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Local governments play an important role in improving substance abuse and mental health services. The structure of the local learning collaborative requires careful attention to old relationships and challenges local governmental leaders to help move participants from a competitive to collaborative environment. This study describes one county's experience applying the NIATx process improvement model via a local learning collaborative. Local substance abuse and mental health agencies participated in two local learning collaboratives designed to improve client retention in substance abuse treatment and client access to mental health services. Results of changes implemented at the provider level on access and retention are outlined. The process of implementing evidence-based practices by using the Plan-Do-Study-Act rapid-cycle change is a powerful combination for change at the local level. Key lessons include: creating a clear plan and shared vision, recognizing that one size does not fit all, using data can help fuel participant engagement, a long collaborative may benefit from breaking it into smaller segments, and paying providers to offset costs of participation enhances their engagement. The experience gained in Onondaga County, New York, offers insights that serve as a foundation for using the local learning collaborative in other community-based organizations.

A shift from traditional approaches in chemical dependency treatment to the use of evidence-based practices (EBPs) presents opportunity and challenge for treatment providers. Efforts to change how institutions and individuals deliver care are often hampered by the day-to-day responsibilities of delivering treatment. Access to trainings is a barrier to EBP implementation and such meetings may take away from direct-service time with clients (Ruzek & Rosen, 2009). While training workshops can improve skills (Miller, Yahne, Moyers, Martinez, & Pirritano, 2004) and confidence (Bennett-Levy & Beedie, 2007), the process of incorporating new methodologies and ways of approaching treatment can require considerable investment on the part of practitioners. Additionally, fewer client hours during transition and planning times can have financial repercussions for individuals and treatment centers. Concern about administrative and executive support can also influence willingness to engage in process improvement. Researchers have suggested different potential frameworks for advancing implementation science (Damschroder et al., 2009, Fixsen et al., 2005 and Wandersman et al., 2008). These frameworks highlight the importance of leadership engagement, resource support, internal opinion leaders and champions, and training opportunities to build knowledge and skills, which are supported by consultation, and coaching to support innovation implementation. A multi-organizational learning collaborative focused on improvement is a mechanism that helps accelerate the diffusion of innovations (Wilson, Berwick, & Cleary, 2003). The use of a learning collaborative to improve the quality of care can exist at the local, regional, or national level. States have used a regional learning collaborative approach to improve services in mental health (Cohen, Adams, Dougherty, Clark, & Taylor, 2007); the public health department (Kushion et al., 2007 and Riley et al., 2009) and substance abuse treatment agencies (Rutkowski et al., 2010). However, fewer examples illustrate how county-based or local learning collaboratives improve services. One such collaborative sought to improve maternal and child health services. Their work highlighted the importance of partnerships with local funders, stakeholder involvement, barrier identification by local providers, and learning from other promising national and local initiatives as key steps in redesigning local systems of care (Keyser et al., 2010). In 2006, leaders in the Onondaga County Department of Mental Health (OCDMH) created a local learning collaborative to support the implementation of evidence-based clinical practices in their chemical dependency programs and evidence-based business practices to improve client access to mental health services. A local learning collaborative is a data-driven network of change teams from organizations within a single system of care that work collectively to enhance performance through process improvement. OCDMH's prior experience with the NIATx (Formerly the Network for the Improvement of Addiction Treatment, now simply NIATx) process improvement model prompted their decision to use a local learning collaborative. This model also supports the ongoing development of a person-centered service delivery system in Onondaga County. The local learning collaborative brought together key stakeholders to support providers interested in making content and process changes to their programming that would improve the quality of care in Onondaga County. The stakeholder groups included licensed chemical dependency and mental health treatment providers in Onondaga County, the Office of Alcoholism and Substance Abuse Services (OASAS, the single state agency), and Onondaga County as the local funder of services. Since 2006, these organizations have used the local learning collaborative model to support EBP implementation and improve access to mental health services. The purpose of this paper is to discuss the use of a local learning collaborative approach to support the implementation of evidence-based clinical and business practices to improve the quality of care. The lessons learned may be particularly relevant to states and counties interested in facilitating a collaborative approach among community-based treatment providers. It may also offer guidance on how to implement a local learning collaborative. 1.1. Local learning collaborative in chemical dependency When the pilot began, Onondaga County, as a member of the Western New York Care Coordination Program (www.carecoordination.net), was already developing a person-centered, service-delivery system with emphasis on natural supports, individualized recovery approaches, and client choice (Raskin and Rogers, 1995 and Schwartz et al., 2000). Primarily applied within the mental health service system, this person-centered approach fosters communication between chemical dependency and mental health treatment providers while offering comprehensive support to clients seeking services for co-occurring chemical dependency and mental illness. Person-centered planning is a comprehensive, life-planning approach originally developed to meet the needs of developmentally disabled adults. At its core, person-centered planning is about developing services and supports based upon the needs of the individual. This is in contrast to a traditional-service approach that enrolls individuals into pre-existing service elements that often provide a poor fit and yield modest progress toward recovery. Recovery management emphasizes partnerships between clients and providers, while focusing on long-term-care management (Scott et al., 2005 and White et al., 2003). The recovery-management approach is familiar to the chemical-dependency treatment community, and its values and practices align with the person-centered planning model. More recently, recovery management (RM) has been promoted as a parallel approach for the chemical dependency service system, with comparable values regarding individualized recovery-oriented approaches (Adams & Grieder, 2005). Therefore, recovery management became a stepping-stone to the person-centered approach for participating chemical-dependency treatment providers. To encourage collaboration between providers while offering a common understanding of person-centered treatment principles, participating providers received training in person-centered planning and recovery management. These trainings provided a basis for implementing EBPs within a person-centered treatment system. The “Evidence-Based Practice in Chemical Dependency” local learning collaborative was a service enhancement project of the Onondaga County Department of Mental Health. It was designed to improve chemical dependency services through the following four goals: (a) encourage person-centered/recovery-management approaches and values; (b) increase the utilization of evidence-based practices, (c) foster collaboration among providers and (d) encourage a process improvement approach using rapid cycle change. Providers in this local learning collaborative focused on the implementation of three evidence based practices: Contingency Management, Seeking Safety and Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency. 1.2. Contingency Management OCDMH's first EBP priority was testing a method to decrease no-show rates and increase persistence in treatment. Based upon a review of EBPs in this area and a dialogue to build consensus, the collaborative selected Contingency Management (CM) as the first EBP to implement (Petry, 2000). CM is a behavioral therapy that supports treatment goals with incentives and consequences (Prendergast, Podus, Finney, Greenwell, & Roll, 2006). Previous studies reveal significant increases in attendance, abstinence, and treatment compliance using CM (Carroll and Rounsaville, 2007, Lott and Jencius, 2009 and Petry et al., 2000). The use of CM has successfully increased abstinence among such diverse populations as cocaine abusers, drug dependent pregnant and post-partum woman, and in a community-based marijuana treatment program (Budney et al., 2000, Petry et al., 2007 and Silverman et al., 2001). 1.3. Seeking Safety Seeking Safety is a manual-based treatment for clients with a dual diagnosis of Post-Traumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD) (Najavits, 2002). The treatment methodology is group-based and uses principles of Cognitive Behavioral Therapy to address both PTSD and substance abuse simultaneously. PTSD is significantly more common in SUD populations and is linked to higher rates of treatment noncompliance and relapse (Jacobsen, Southwick, & Kosten, 2001). Several studies show integrative treatment of PTSD and SUD, in general, and with Seeking Safety in particular, to have positive outcomes in areas of client satisfaction, treatment compliance, increase in abstinent behaviors, and reduction in PTSD symptoms (Cohen and Hien, 2006, Desai et al., 2008, Hien et al., 2004, Morrissey et al., 2005 and Najavits et al., 2006). The selection of Seeking Safety is due, in part, to a perceived positive outcome from an existing Seeking Safety group already active in one of the partner organizations. Analysis of the current group demonstrated that patients completed treatment at higher rates than the general treatment population. Attendance and patient-reported satisfaction within the Seeking Safety group were consistently positive. This result led to the selection of Seeking Safety as a means of targeting rates of treatment completion among clients with co-current experiences of trauma and substance abuse. The collaborative contracted with the author of Seeking Safety, to conduct a two-day workshop on the model. Subsequently, all four provider–partners began a Seeking Safety group (Najavits, 2004). 1.4. Motivational Interviewing Assessment: STEP Based on the work of the SAMHSA/NIDA Blending Team Initiative, Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA: STEP) is designed to assist counselors in the use of motivational interviewing skills during assessments. It includes tools to aid in clinical supervision and is for direct use by practitioners (Martino et al., 2006, Martino et al., 2008 and Martino et al., 2010). Initially, providers participated in two MIA: STEP training workshops. A wide variability among practitioners’ knowledge of motivational interviewing techniques and therefore their ability to apply those techniques in clinical practice was apparent, and two levels of training were required. Level one addressed basic MI concepts and skills, while the second level focused on the supervisory and advanced skills needed to implement MIA: STEP. Currently the EBPs used in chemical-dependency treatment provider organizations are in varying stages of MIA: STEP implementation. Some have implemented MIA: STEP, while others have engaged in MIA: STEP-informed practice. 1.5. Local learning collaborative for clinic access Buoyed by their success, Onondaga County Mental Health Department decided to implement a second local learning collaborative with their mental-health providers. The Clinic Access Project's (CAP) focus was to use the NIATx Plan-Do-Study-Act model to implement person-centered, family-driven changes that increase clinic access. This focus area was selected to help minimize sizeable waiting lists and related access challenges for mental health therapy and outpatient psychiatric services throughout the community. 1.6. Role of process improvement In a recent article, McCarty, Gustafson, Capoccia, and Cotter (2009) state how the NIATx process improvement model provides a framework for meeting the Institute of Medicine (IOM) goals to improve the quality of behavioral health care. However, organizational effort to begin a change process can be daunting. It is often difficult to identify and prioritize an agency's treatment needs and subsequently connect those needs with the implementation of specific evidence-based practices. Using a learning collaborative approach, the NIATx process improvement model integrates five key principles of organizational change with the use of PDSA change cycles (Capoccia et al., 2007). The NIATx learning collaborative approach (including the key values of transparent dialogue and collective learning) allows providers to come together for collective benefit, despite a history of competition for funding and program support (Evans, Rieckmann, Fitzgerald, & Gustafson, 2008). Treatment agencies have used the NIATx model to focus their efforts on implementation of business practices to reduce waiting times and increase continuation in treatment (Hoffman et al., 2008, McCarty et al., 2007 and Wisdom et al., 2009). The NIATx model has also helped improve patient care in behavioral health systems (Prescott, Madden, Dennis, Tisher, & Wingate, 2007). A recent NIATx initiative, Advancing Recovery, expanded the NIATx model to test its usefulness in the implementation of evidence-based practices (EBPs) related to pharmacological and behavioral therapies among chemical dependency providers and to create changes at state and payer levels that would encourage EBP adoption (Bornemeier, 2010). The local learning collaborative in Onondaga County used the NIATx (www.niatx.net) rapid cycle change model as the vehicle to assist providers in rapidly implementing various targeted EBPs. It was offered to providers as the best way to insure their investment because the model uses clear data to fuel decision making (Wisdom et al., 2006). County leaders pointedly conveyed the message that if properly implemented EPBs did not yield results, providers would not have to continue them.

Theuniquestructureof thelocallearningcollaborativerequires attention to old relationships. The challenge for leaders is moving participants from a competitive to collaborative environment through transparency. In developing a culture of collaboration, providers have to move toward an altruistic viewpoint and understand that this collaboration is a means to improve behavioral health services in their locality. Achieving this level of transparency represents a unique challenge. It is individual and organizational shame that drives us to hide flaws rather than openly share them. This resulted in missed opportunities for change, as organizations, especially with local peers, are fearful of asking for support and acknowledging errors or imperfections. When an organization blames individuals for problems, it discourages transparency. When an organization encourages open sharing, team members can come together without shame to explore potential improvements. As a result, team members begin to notice flaws in the process and are encouraged to call attention to these valuable improvement opportunities. In Onondaga County, the collaborative approach fostered transparent collaboration, resulting in a significant cultural shift that enhanced lines of communication between the participating organizations. The flexibility of a local learning collaborative offersopportunities for small, local, in-person gatherings that foster cooperation across treatment providers and with their peers, leveragetheiractionstoimproveservicedelivery.OnondagaCounty leadership also had an important role in modeling and encouraging the value of collaboration and transparency; in this case, leading by example is crucial. One noted example of role modeling was OCDMH’s rapid acknowledgement and repair efforts related to an unsuccessful training session. Participants appreciated this, and OCDMH’s example helped cultivate the transparent collaboration necessaryfortheprojecttobesuccessful.Withouttransparency,the potential for improvements may be non-existent. Now more than ever, fiscally tough times require efficient and effective tools for navigation and bringing change to the treatment system.InOnondagaCounty,providersneededtodevelopeffective and efficient practices and work to abandon traditional practices that do not achieve measurable recovery goals. It is important to use the local government unit as a mechanism to support change through rapid cycle leadership and the local learning collaborative appears to be an effective system to bring about change. The local governmentunitrepresentsachangeinfrastructurethatisflexible, cost efficient, self-sustaining and ripe with local knowledge; consideritasapowerfulplatformofinnovationandspringboardto EBP implementation. Using the NIATx approach to support the local learning collaborative not only will help bring about effective change, but will establish an infrastructure to improve the quality of the local delivery system.