Asingle-point of entry into any program or organization represents a standardized mechanism for effectively managing and monitoring all prospective clients seeking access to treatment services. The design of a single access point must reflect the multi-variant needs of both the organization and the client population. Increasingly, payers and clients alike seek providers who demonstrate customer-focused service with emphasis on ease of access, in a cost-effective manner. Many public-sector providers of substance abuse services have faced several challenges related to the design and implementation of a single-point of access. These challenges have included: limited financial and technical resources, multiple service sites and a high client volume with multiple clinical needs. In addition, organizations seeking to successfully implement a single-point of entry are finding a need to make a paradoxical shift from a special populations orientation to a customer satisfaction orientation.

With the primary goal being to determine the impact of a single-point of entry coupled with an integrated management information system on client treatment outcomes, a clinical design and computerized software access system was designed and implemented for a community-based provider of behavioral health services. Human Resources Development Institute Inc. (HRDI), founded in 1974, has serviced the Southside of Chicago, which is the city's most impoverished and under-served alcohol and drug addicted population. In an effort to eliminate barriers experienced by clients seeking treatment services, a need arose to develop a more efficient and cost-effective means of managing a high client volume of alcohol- and drug-addicted clients. Traditionally, clients experienced long waiting periods for treatment due to inefficient client processing and limited community resources. As a result of the aforementioned objectives, HRDI (over a two-year period) worked collaboratively with a local managed care software vendor to develop and create a customized software package that would increase client service efficiencies while improving client treatment outcomes and satisfaction. The vendor, Behavioral Services Inc. (BI) in Geneva, Illinois, developed and created customized software that reflected the manual record-keeping systems of HRDI's conceptual framework of a single-point of entry while also capturing "in-house" administrative data needs.

The focus of this paper is to review the experiences of a community-based provider of behavioral health services and a private software company in designing and implementing a single-point of access system combined with a customized management information system. In addition, a comprehensive design and effective implementation of a single-point of access system and it's impact upon client outcomes will be explored. The findings represent a significant consideration in relation to policy development and funding for substance abuse services in the public sector. Finally, a description of the design will be reviewed as well as the primary objectives of a single-point of access system in a high-risk community.

The core components of a single-point of entry that will be discussed include: a 24-hour telephone client screening and scheduling system; 24- hour triage capabilities; a comprehensive, interdisciplinary behavioral health care assessment; appropriate client-treatment matching for multiple levels of care; integrated utilization management protocols and collaborative referral agreements, and partnerships with other community agencies in an effort to provide a full continuum of services.

Background

The implementation of a single-point of access system represents a crucial milestone for community-based organizations in demonstrating their managed care capabilities. Ironically, this has also proved to be one of the most difficult tasks as well. Many community-based organizations as a result of the increasing trend toward privatization of public sector services have significantly improved their quality of services, utilization management capabilities, and their ability to produce meaningful client and program outcome data. For many organizations a single-point of entry represents the first effort toward integration of multiple organizational systems. Public sector providers generally have a long history of both community acceptance and an understanding of the needs of that community or population. The complexity of a population requiring specialty programs for high risk, high cost patients adds to the challenges of a successful single-point of entry.

Both the current trend toward decreasing public funding for substance abuse programs, as well as the increasing demand for demonstration of managed care capabilities, dictates a need to diversify payers and to attract new sources of revenue. If traditional public sector providers are going to successfully treat this new group of patients, they need to review telephone intake and admission procedures and consider facility upgrades to improve the customer's view of the treatment organization. The implementation of a single-point of entry with emphasis upon timely access, aggressive client tracking and appropriate matching of client need to services were the primary concerns in order to establish a customer-focused orientation. Figure 1: "Impact of a Single-Point of Entry and Management Information System" illustrates how a single-point of entry as well as the automation of this influenced each phase of service delivery. Some of the key design issues of a single-point of entry impacted upon each service phase in an effort to integrate all systems and to guarantee unified efforts in meeting the needs of funding sources and clients.

One of the primary driving forces behind the implementation of a single-point of entry was the need to manage a high-client volume and yet still provide clients with high quality services. Annually, HRDI services approximately 7,000 clients; most present with multiple service needs. Currently, many clients seeking services within community-based organizations experience both long waiting periods for entry, as well as refusal of treatment services due to a lack of funding. The design of a single-point of entry took into account the need to engage clients in a therapeutic process from the onset of their initial call. While motivation in one form or another was a factor in a client initially calling or requesting services, emphasis was placed on rapid engagement and entry prior to that motivation diminishing. In order to accomplish this, clients were assessed within 48 hours of their initial call and for those clients expressing ambivalence or reluctance in receiving treatment, outreach services were provided in or- der to attempt to engage them.

Many of the alcohol- and drug-addicted clients serviced by HRDI are in the middle to late stages of their addiction. Subsequently, due to the chronicity of the client population, many individuals had multiple needs beyond the scope of traditional substance abuse treatment. As a result, the single-point of entry design also focused upon a comprehensive behavioral health assessment identifying needs for medical services, mental health counseling and the like. The assessment process involved mandatory physical exams within the six months prior to admission for all clients.

Approximately 71 percent of all clients receiving a physical had a medical diagnosis, more often than not related to years of substance abuse, which required ongoing medical attention. Many of the physical problems had been previously misdiagnosed by physicians or never diagnosed due to the lack of sufficient medical care. Some of these problems included: ulcers, hypertension, malnutrition, hepatitis, pancreatitis, cirrhosis and other liver ailments, cardiomyopathy, neurological damage, and cancer. As a result of this, substantial emphasis was placed in the design of a single-point of entry to ensure that "linkage" to needed medical resources occurred. In addition to medical services, identification of ancillary services was made for things such as: support groups, job training, literacy programs, GED or other educational opportunities, mental health counseling, and/or other therapeutic or supportive groups.

By and large, the greatest challenge in designing and implementing a successful single-point of entry was to ensure that the management information systems reflected the clinical data capturing needs and allowed for analysis and re-evaluation of the program design. The early stages of computer automation are critical since they establish the scope, structure, timing and cost of the new system and set the stage for all subsequent work. Specifically, the goal of the automation design was to capture data in a way that 1) expedited the admissions process, 2) increased staff efficiency, 3) eliminated duplication of work and 4) resulted in empirical management reports for decision-making purposes. In addition, automation software represented a response to the aforementioned demands placed upon community-based organizations in regards to program effectiveness and accountability within the economic constraints imposed by under-funding. Clearly the way to demonstrate accountability is through sound management techniques and these techniques require large quantities of data that are easy to manipulate and assess. In addition to outcome data, the computer automation increased efficiencies to the extent that it was possible to manage a large client base and respond to referral sources in an efficient and cost-effective manner. In order to achieve this HRDI chose to contract with a software company capable of automating the current record-keeping systems while customizing the design to meet the licensing and clinical needs of an ever-changing behavioral health care field.

Single-Point of Entry and MIS design

The design of a single-point of entry, while having an impact upon all service levels within an organization, is most visible at the pre-admission and admission phases of treatment. Figure 2: "Single-Point of Entry Client Flow" illustrates the significance of the pre-admission and admission phase of a client's experience in accessing treatment services. In addition, this flow chart demonstrates the structure for collection of data. The following is a more specific description of the single-point of entry and integrated MIS design in each of these two areas.

Pre-Admission

At the "pre-admission" phase a client or referring body contacts HRDI requesting services through a 24-hour operated, toll-free number. The primary objective at this point is

1) to complete a brief assessment of whether this is a crisis call or a routine scheduling of an appointment,

2) the collection of initial demographic data, and

3) the scheduling of an appointment time to a service center for an assessment.

In the event that a client is calling in distress or in an emergency situation, an operator will immediately transfer the call to a supervisor or clinician. The importance of this phase can not be overstated as it represents a client's first contact and experience with the service organization. Subsequently, operators are instructed on specific protocols regarding friendliness, dealing with a difficult caller, and attitude. "While you can't train people to have a 'good attitude,' you can train people to perform specific, customer-friendly behaviors and then measure their success factors such as customer service ratings, morale and turnover. By these empirical ratings you will know whether or not your employees have customer-friendly attitudes or not."

The pre-admission phase begins a positive "domino effect" related to the management information system and flow of client data. During a brief telephone screening, client demographics and service requests are input into a "paperless" electronic client file. In addition, brief, clinical data regarding most recent use of alcohol or drugs as well as quantity consumed are taken to determine whether a client requires a referral to detoxification services prior to an assessment. This was a design feature of the single-point of entry system due to the fact that HRDI did not provide either a social or medical detoxification program. In addition, since HRDI's substance abuse programs required 48 hours of sobriety along with no symptoms of withdrawal, early identification and referral of clients requiring this level of care significantly decreased inappropriate client presentations at intake.

Finally, clients are scheduled for an appointment for intake within 48 hours of their call. This process is also automated allowing for instant daily reports of clients scheduled and those failing to attend their appointment. A list of those clients failing to attend their scheduled appointment is given to a case management and outreach team, which aggressively works to engage this population. The benefits of a computerized system at this stage include the ability to effectively track and reach out to a highly unstable and needy client population in a cost-effective manner. Overall efficiencies of managing a large client base improved drastically and were exemplified by things as simple as being able to have a staff person contact via phone clients reminding them of an appointment the next day. Client attendance to an initial intake appointment increased overall by approximately 30 percent.

One of the original automation goals at the preadmission phase was to be able to take all of the client demographic data and presenting problems and instantly evaluate it for administrative purposes. As a result of the computerized software, programmatic improvements can be made to respond to initial data trends both at a clinical and fiscal level. For example, reports can be generated that reflect the service areas by zip code with the largest request for service as well as a client profile of individuals most often seeking assistance. Moreover, this and similar data have been useful in determining where there are service gaps and need for funding to address a priority population or community need.

In addition to basic client demographic data, during the initial collection of data at the pre-admission phase a client profile can be developed regarding a preliminary list of client-presenting problems. During a six-month period from October 1995 to March 1996 the toll-free telephone number received an average of 350 calls per week for a total of 8,436 calls. Of these calls 68 percent represented actual client inquiries for treatment while the others included representatives from referring agencies following-up on a previous referral, collecting data regarding program services and wrong numbers. Of the clients calling requesting services the following represents a break-down of client identified primary and secondary substances of abuse:

These percentages of substance abuse issues is significant for programming and service design purposes, as well as fiscal planning. For example, the figures above represent a significant increase in the number of heroin abusers from a previous reporting period.

One significant by-product of all data entry and dedication to the assessment software should be the easy retrieval of administrative information and reports. For example, as previous data indicated, Derrick and Kushner 1996 suggest that organizations should be able to easily find out: 1) how many clients of what gender, race and background were interviewed and admitted monthly at the treatment site; 2) what changes and trends are occurring; 3) whether clients are appearing with more severe problems; 4) from which zip codes are the clients coming and what referral sources are sending clients; 5) who is conducting interviews and how long are they taking. It was the goal of the pre-admission software design to be able to quickly gather this data at a minimal level, as well as later gather- ing more detailed client information which would improve the ability to treat individuals throughout the overall community.

Intake satisfaction questionnaires were distributed to 100 percent of all clients that received an assessment. This survey was designed to measure client satisfaction at the pre-admission and admission phases of a client's service experience. In addition, client satisfaction data were gathered at random intervals during treatment and at discharge. Figure 3: "Intake Satisfaction Questionnaire" illustrates a summary of those clients that responded to the confidential survey, which was distributed at the end of the interview and placed by the client in a box at the receptionist desk.

The survey results represent 150 client responses during a four-month period from February 15, 1996, to June 15, 1996. Completion of the survey was not mandatory and respondents often did not complete each question as instructed; therefore, the percentages of client responses are based upon the number of 150 respondents that answered any given question. The same survey distributed for a three-month period a year earlier reflected a significant decrease in client satisfaction in relation to Section I pertaining to the pre-admission experiences and overall ratings. The only identifiable variable resulting in this increase in client satisfaction is the implementation of an automated single-point of entry. The survey reflects high client satisfaction in relation to experiences in both the preadmission and admission phases of treatment. The most critical improvement from one year earlier was client responses to the level of satisfaction regarding "the amount of time between your call and scheduled appointment."

Admissions

Derrick and Kushner 1996 describe the automation of any admissions process by stating that assessment software can drastically reduce the time and effort for an evaluation and a full clinical report. However, the software will not reduce the time needed for an interview. The software will also not change a mishandled interview or convert a poor interviewer into a valid, reliable interviewer. The goal of HRDI in automating the admissions process was to eliminate duplication of data collection and improve overall clinical efficiencies. As a cli- ent presented him or herself for an initial interview, staff were able to begin the assessment process having already received the preliminary data gathered over the telephone. This easily retrievable information, provided a background of the client's presenting problem as well as extensive demographic data. Consequently, this allowed the interviewer to confirm the reliability of the data and confront clients on any inconsistent reporting. Having utilized a Local Area Network (LAN) at this project site allowed all clinical staff servicing a client to access and add to a client's electronic file. Updates and clinical notes once entered, were then immediately retrievable for review by any authorized member of the clinical team.

A treatment system with a central intake capability allows for the incorporation of automated, standardized assessment procedures as well as criteria for client placement. The American Society of Addiction Medicine (ASAM) was utilized for developing the assessment instrument. The following six dimensions were evaluated for making patient placement decisions and formulation of individual care plans:

•    Acute intoxification and/or withdrawal potential
•    Biomedical conditions and complications
•    Emotional/behavioral conditions or complications
•    Treatment acceptance/ resistance
•    Relapse potential
•    Recovery Environment

The use of a client treatment matching criteria from the assessment unit is key to the placement of clients within a continuum of care. This design will allow for systemwide evaluation of the objectivity and appropriateness of client assessments and matching to service levels.

The initial interview by a clinician was kept to under one hour and included a comprehensive behavioral health care assessment. A mental health status exam was conducted as well as a thorough substance abuse assessment. The assessment process was designed with several objectives which in- cluded: 1) the initial identification of service needs and treatment care plan goals; 2) an identification of an appropriate level of care; 3) to provide motivational support to begin to engage clients in a therapeutic process; and 4) linkage to appropriate treatment services and resources either internally or externally.

The essential quality assurance elements of an automated intake system should include self-correcting and self-improving capabilities. The quality assurance and improvement system provided information regarding the appropriateness and effectiveness of services. The effectiveness of service delivery should be measured throughout the treatment continuum to allow for ongoing corrective action. The use of Lickert scales provided a standardized measurement tool for monitoring client progress. This data assisted in determining the impact of treatment interventions and modification of individual care plans. Quality assurance reports were continuously generated to monitor client utilization, funding and documentation compliance guidelines. In addition, similar reports were developed to ensure appropriate provision of clinical services specified by the treatment plan.

Findings

The design and implementation of a single-point of entry coupled with a management information system yielded significant data over a two-year period. This has been an ongoing project in various stages with the full impact of this project only now being realized. The most significant impact for this community-based organization was the ability to easily manage and track a large client population base. Clients are assessed in person within 48 hours of their initial phone contact unless they request otherwise. Waiting periods prior to an automated single-point of access ranged from an average of between three to fourteen days. It is also believed that as a result of the reduction in waiting periods, one direct impact has been an increase of clients presenting to their scheduled appointment by approximately 20 percent. This reduction in the no-show rate is due to the rapid engagement of clients, the instant tracking of the computerized software, and aggressive outreach services. In addition, as was illustrated in Figure 3, client satisfaction surveys reported an increase in customer satisfaction particularly in the areas of pre-admission and admission service experiences. Finally, over a one-year period there has been a steady increase in the number of clients that are discharged successfully due to having fulfilled all treatment goals and objectives. It is believed that having automated the treatment process and being able to monitor client progress and/or lack there of has allowed the treatment team the ability to respond to client need in a more timely manner and subsequently act accordingly.

Conclusion

Certainly it would be false to suggest that automation will inherently improve client outcomes or result in "state of the art" clinical service delivery. However, where quality services exist and software automation efforts are made to improve overall -efficiencies, the outcome can only be positive from both a clinical and cost-effectiveness perspective. Many community-based providers similar to HRDI are faced with having to service an extremely large and ever-growing client population while lacking the funding to meet the demand for these services. The concept of a single-point of entry coupled with a management information system is one answer toward ensuring improved clinical efficiencies that result in easily accessible services. In addition, unlike their commercial counterparts, community-based providers are faced with the daunting responsibility to engage and track a large number of non-compliant and under-served alcohol and drug addicted persons. The use of automation in this process promotes the likelihood for more positive treatment results.

Currently most federal, state and local funding for rehabilitation services focuses upon specific programs or levels of care. The concept of a single-point of entry represents a core component to any program and is often an interrelated service but rarely funded or viewed as such. In urban areas such as the Southside of Chicago, an automated single-point of access and triage system is one defense in the difficult task of successfully managing and tracking a highly chronic client population. Subsequently, policy developers and funding sources can not ignore the nontraditional service components that enhance treatment efforts.

Richard E Paul, LCSW, is the director of Behavioral Health Operations at Human Resources Development Institute Inc. Ruby Jones, LCSW, is a vice president at HRDI, which is located at 222 S. Jefferson, Suite 200, Chicago, IL 60661.