First request for service

In establishing its nine Paths to Recovery NIATx set the goal of bringing patients into treatment within 24 hours. It alsoestablished the goal of improving engagement (a key role in first contact). The issue of how to improve engagement is a Path untoitself and will thus receive limited attention here. Hence the focus of this review will be on the evidence supporting the needand methods for rapid access to treatment.

One of the project aims of the Network for the Improvement of Addiction Treatment is to increase the proportion of callers whoenter treatment within 24 hours of first request.

The assumption is that when someone breaks through denial and reaches out for help, they have not experienced a permanent changein attitude. If not engaged almost immediately, they will soon return to old patterns and convince themselves that things are notas bad as they previously thought. In order to engage the largest amount of clients in substance abuse treatment, organizationsshould be able to schedule initial appointments within 24 hours of first contact. This accelerated intake will greatly increase thenumber of clients who show up for that initial appointment. For this study accelerated intake will be defined as having the abilityto schedule an intake appointment within 24 hours of the clients’first contact with the organization.

There has been a fair amount of research into the effectiveness of accelerated intake in reducing the number of noshows for their initial appointment. This research has shown that when one is able to schedule clients within 24 hours of their firstcontact, the likelihood that they will show up for the intake is increased greatly. In fact, research by Kirby et al (1997) showsthat even a delay of one day increases the number of no shows as the percentage of clients attending the initial appointment at acocaine outpatient treatment facility dropped from 83% to 57%.

This research expanded on the work of Festinger et al (1996) which studied same day intake compared to standard intake (1 to 7day delay between first contact and appointment). Again, clients in the accelerated group had a higher percentage of attendance, 59% to33%. The immediacy of the response for the accelerated group was seen as positive feedback for the client which likely increasedmotivational levels to attend the appointment.

Early research into the inverse effect of appointment delay and initial attendance has come to the same conclusion. The fasteran organization can schedule an appointment, the better the chances of the client showing up. Woody et al (1975) examined anaccelerated intake program instituted at an outpatient treatment facility at a VA hospital in Philadelphia. Intake procedures weremodified so that the entire process (first contact, assessment and start of treatment) was completed in one day. 55% of patientsinitiated treatment under the accelerated intake program as opposed to 30% from the normal intake group.

Hyslop et al (1981) observed an increase in attendance rates from 53% to 70% when waiting times were reduced to under seven daysat an outpatient alcohol referral clinic and Fleming et al (1987) reported an increase in initial appointment failure rates whenwaiting time increased to more than two weeks at an alcohol treatment facility.

Stark et al (1990) examined this relationship in an outpatient community drug treatment agency in Portland, OR andfound similar results. Clients were given the opportunity to enter treatment“as soon as possible”or scheduled for an appointment an average of 9.7 days later. 55% kept the acceleratedintake appointment while only 41% kept the standard intake appointment.

These studies were able to show that clients given the option of accelerated intake attend their initial appointment in higherpercentages than clients using standard intake procedures. Festinger et al (2002) attempted to determine the specific delayinterval that creates the greatest rates of initial attendance. Clients at an outpatient cocaine addiction treatment facility wererandomly assigned appointments within the same day, one day later, three days and seven days later. 72% of subjects scheduled one daylater attended their appointment. This was greater then same day (55%), three days later (41%),or seven days later (38%). This studysuggests that appointments scheduled 24 hrs from the first request for service are optimum.

Stasiewicz and Stalker (1999) performed a study to determine how accelerated intake compared to 2 other types ofmissed-appointment interventions. The research, conducted at an outpatient substance abuse clinic, assigned clients to one of 4appointment groups: accelerated intake, appointment 5 days later with no reminder, appointment 5 days later with a mailedappointment card and appointment 5 days later with a reminder phone call. The study found that the only impact on attendance wasaccelerated intake. 71% of patients scheduled within 48 hours actually attended. For the rest of the groups attendance wasapproximately 50%.

All these studies indicate that there are steps that clinics can unilaterally take to increase the number of clients attendingtreatment after first contact. Accelerated intake has proven to be the one consistently successful missed appointment intervention inall these studies. It has even been shown that the optimal amount of treatment delay is specifically 24 hours or one day.