Journal of Substance Abuse Treatment 37 (2009) 101–109

Brief article

Results of a statewide evaluation of “paperwork burden” inaddiction treatment

Deni Carise, (Ph.D.)a,b,⁎, Meghan Love, (B.S.)a, Julia Zur, (B.A.)a,A. Thomas McLellan, (Ph.D.)a,b, Jack Kemp, (M.S.)a,c

aTreatment Research Institute, 600 Public Ledger Building, 150 South Independence Mall West, Philadelphia, PA 19106-3475, USAbUniversity of Pennsylvania, Center for Studies of Addiction, Philadelphia, PA 19104, USAcDelaware Division of Substance Abuse and Mental Health, New Castle, DE 19720, USA

Received 12 September 2008; accepted 6 October 2008

Abstract

This article chronicles three steps taken by research, clinical, and state staff toward assessing, evaluating, and streamlining clinical andadministrative paperwork at all public outpatient addiction treatment programs in one state. The first step was an accounting of all paperworkrequirements at each program. The second step included the development of time estimates for the paperwork requirements; synthesis ofinformation across sites; providing written evaluation of the need, utility, and redundancy of all forms (paperwork) collected; and suggestionsfor eliminating unused or unnecessary data collection and streamlining the remaining data collection. Thirdly, the state agency hosted ameeting with the state staff, researchers, and staff from all programs and agencies with state-funded contracts and took action. Paperworkreductions over the course of a 6-month outpatient treatment episode were estimated at 4 to 6 hours, with most of the time burden beingeliminated from the intake process. © 2009 Elsevier Inc. All rights reserved.

Keywords: Addiction treatment; Clinical information systems; Electronic records; Evaluation; Paperwork

1. Introduction

Substance abuse treatment providers are inundated withreporting requirements (McLellan, Kleber, & Carise, 2003).The burden of excessive paperwork in the health care field iswell documented, and many studies have demonstrated itsnegative impact on the well-being of health care profes-sionals. For example, a study of professional psychologistsfound that increased administrative and paperwork hourswere associated with greater emotional exhaustion andburnout (Rupert & Morgan, 2005). Other studies have foundthat paperwork was among the greatest stressors (Rupert &Baird, 2004) and challenges (Kantorowski, 1992) reportedamong professionals in the mental health field.

Many studies have also documented the degree to whichpaperwork is associated with job dissatisfaction. In a study ofmental health professionals, 50% of those surveyed reported

⁎ Corresponding author. Tel.: +215 399 0980x102; fax: +215 399 0987.E-mail address: dcarise@tresearch.org (D. Carise).

0740-5472/08/$ – see front matter © 2009 Elsevier Inc. All rights reserved.doi:10.1016/j.jsat.2008.10.009

dissatisfaction with the amount of time they spent onpaperwork. When asked to choose from a list of jobresponsibilities, mental health nurses identified paperwork asbeing the one item with which they were most dissatisfied(Robinson, Murrells, & Smith, 2005). Cypres, Landsberg,and Spellmann (1997) also surveyed mental health profes-sionals and found that paperwork was one of the greatest jobcomplaints because counselors reporting it compromised theamount of time they were able to spend with their clients.

Paperwork burden problems are not unique to the nursingor mental health fields. Counselors in the substance abusetreatment field frequently report being inundated bydocumentation requirements. The burden of these require-ments was a pervasive complaint reported by a sample of 175substance abuse treatment programs in a telephone survey oninformation collected in the course of their day-to-day work.Numerous programs cited paperwork burdens of 4 hours ormore at patient admission simply to collect data required bystate agencies and multiple managed care organizations(McLellan et al., 2003).

102 D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109

In other studies, 38% of substance abuse treatment casemanagers reported spending more than 20% of their workweek completing paperwork (Brindis & Theidon, 1997), andMcDaniel, Spieglman, and Beattie (2006) also documentedthe dissatisfaction substance abuse treatment providersreported with the increased paperwork requirements result-ing from managed care.

Substance abuse treatment programs collect data foraccreditation, managed care, research, and outcomes report-ing purposes. State offices, accrediting agencies, managedcare organizations, and other regulatory agencies (includingbut not limited to drug courts, parole, welfare, and childwelfare) each demand collection of specific information ordata. Perhaps most important in this regard is that much ofthis data collection is considered nothing more than “paper-work” by the counselors and other personnel within theprograms that collect it because the information collected inmost of these forms is not inherently useful for clinical caredecisions. Adding to the burden and the resentment causedby these multiple reporting requirements is the frustratingand often substantial overlap in the nature of the informationrequested by the various agencies and organizations.

The focus of our original work with the Delaware Divisionof Substance Abuse and Mental Health (DSAMH) was toassist with the design and evaluation of a new statewide,performance-based contracting (PBC) system. All outpatientabstinence-oriented adult substance abuse treatment pro-grams were required to provide treatment services at aminimum of 90% capacity. In addition, they were required tocollect standard admission data on all clients and to rapidlyreport client attendance data during treatment as well as typeand date of discharge. The data reported were audited foraccuracy and capacity, and rates of attendance became centraldeterminants of reimbursement for the programs. As a resultof this project, those programs that were able to retain clientsin active participation longer received performance incen-tives, whereas programs that were not able to retain clientsdid not receive these incentives (McLellan, Kemp, Brooks, &Carise, 2008). This contracting effort, although purposelyquite simple, led to significant increases in client census andin lengths of stay in the participating programs—as well asincreased income.

In addition to the measures associated with PBC,DSAMH was interested in initiating a pilot project withthe assistance of the Treatment Research Institute (TRI) tointroduce the collection of key clinical data items bycounselors in face-to-face treatment sessions during thecourse of outpatient treatment. The collection of theseadditional client status measures on all clients at multipletimes over the course of treatment (called concurrentrecovery monitoring [CRM]; McLellan, McKay, Forman,Cacciola, & Kemp, 2005) threatened to impose still moredata collection on the already burdened clinical staff at thesetreatment programs. Although clinical staff were notconceptually against CRM—and indeed, even endorsed it—there was understandable frustration regarding how this

additional data collection of client-level behavioral measuresat each individual session would actually be accommodated.

Acknowledging that these clinically meaningful activitieswould also result in additional data collection and reporting,TRI conducted a “Paperwork Burden” assessment todetermine the nature, volume, and extent of overlap amongthe multiple data collection demands currently affecting allstate-funded outpatient substance abuse treatment programs.If it were not possible to eliminate at least the same amountof data collection, time and effort required for the proposedCRM procedure, it seemed unfair to ask the programs toparticipate in the CRM study.

Therefore, this article describes this systematic evaluationof the data collection and reporting requirements at thesetreatment programs and reports the administrative changes(to decrease paperwork) resulting from this evaluation.

2. Methods

The director of the research team had several years ofprior experience working with the State Director andindirectly with the treatment programs. The investigator ofthis project met with the State Director and asked if hewould be interested in piloting the Paperwork Burden studyand if he felt this would be of interest to the state-fundedoutpatient, substance abuse treatment programs. Withinterest and approval from the State Director, during aregularly scheduled quarterly meeting with the providersand state director, the investigator described the PaperworkBurden evaluation (and the larger study) to the providers(primarily program directors and supervisors). The provi-ders were enthusiastic and agreed to participate. Toimplement the paperwork reduction assessment, 2 seniorTRI research staff traveled to each of the 11 state-funded,adult outpatient substance abuse treatment programs for ahalf-day meeting (approximately 5 hours) with various staffmembers. The purpose of this in-person site meeting was toassemble a complete inventory of all data collectioninstruments and forms. This paperwork assessment wasnot confined to the paperwork required by the state drugand alcohol agency because each of these 11 programs hadclient referral arrangements with other state agencies (e.g.,Probation/Parole, Child Protective Services, and so forth),managed care organizations, and private insurance carriers.In addition, programs received referrals from managed careorganizations that also required various information andreports. Finally, the documentation also included datacollection requirements of nongovernmental organizationssuch as Joint Commission on Accreditation of HealthcareOrganizations (JCAHO).

The study was approved by the Institutional ReviewBoards at both Treatment Research Institute and the DelawareHealth and Social Services. Because participating in thePaperworkBurden reviewwas completely voluntary for staff,did not involve patients, and collected no identifying

103D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109

information from staff, informed consent was not required.The Paperwork Burden assessment was conceptually verysimple but procedurally quite demanding. It required 6months to complete and initially consisted of the 5-hour in-person visits to each site by two senior TRI research staff whomet with the program directors, administrative and clinicalstaffs to compile every form and piece of information requiredby any of the agencies described above. The evaluationincluded all forms required by any of the above agencies ororganizations on clients at admission, during the course oftreatment, at discharge/transfer, and at follow-up. This part ofthe evaluation resulted in a spreadsheet identifying all formscollected by program. These spreadsheets were sent via emailto each site where they were inspected by participating sitestaff followed by several additional interactions generally byphone but occasionally in person with staff to assure theaccuracy and completeness of our reports. In this regard, staffat the programs often had mixed opinions about which datacollection activities were required, by whom, and for whichclients. It was regularly the case that clinical staff at a program(who actually collect the data) would say that, “we use the‘XYZ’ form, it's required”; however, their supervisor wouldsay, “we don't use the ‘XYZ’ form, it hasn't been required forseveral years” or vice-versa. In these cases, we entered intoour spreadsheets all those forms that were actually used indata collection by at least one staff member but recorded allthe comments from both supervisors and direct care staff. Webelieve this method provided the most realistic appraisal ofthe actual paperwork collected. We provided these finalreports to the State Substance Abuse Director, other DSAMHstaff, and to all treatment programs. The State Director,treatment providers, and research staff met as a group oncemore when the Director dedicated 3 hours of their regularlyscheduled quarterly meeting to reviewing the results of thesefindings deciding on a course of action.

2.1. Description of treatment programs

All outpatient substance abuse treatment programs thathad contracts with DSAMH (n = 11) participated in thepaperwork reduction assessment project. We used theAddiction Treatment Inventory (ATI) to measure programcharacteristics. The ATI is a semistructured interviewcompleted with treatment program directors. It is designedto provide standard information on the staffing profile,treatment orientation, organizational structure, financing,and services delivered in all modalities of addictiontreatment programs (Carise, McLellan, & Gifford, 2000).

2.2. Program organization

The 11 outpatient programs in this review were actuallyrun by four “parent” agencies. Nonetheless, resultsreported here refer to the 11 treatment programs becauseeven those programs within parent agencies routinely differin their characteristics.

2.3. Frequency of group and individual counseling

In 8 of the 11 sites (73%), clients attended grouptreatment twice a week and had individual counselingsessions about once a month. At the remaining 3 sites (27%),clients attended group once per week and saw a counselor onan individual basis twice a month.

2.4. Intake scheduling

Six of the sites (55%) accepted only scheduled clients foradmissions, whereas two sites (18%) had no scheduledappointments—all admissions completed via “walk-in”procedures. The remaining three sites (27%) accepted bothwalk-in and scheduled clients.

2.5. Accreditation

Of the 11 sites, 6 (55%), were accredited by the JCAHO,and 2 sites (18%) were in the process of obtaining JCAHOaccreditation. Five sites (45%) reported being accredited bythe Commission on Accreditation of Rehabilitation Facilities(CARF). Four sites (36%) were accredited by both CARFand JCAHO.

3. Results

3.1. Organizing forms

All sites used the following three organizing forms—although it later emerged that only one form, the ClientService Record, was required by the state.

3.1.1. Intake log/schedule bookAll sites had a log or sign-in book to document who

entered care and at what date. Time required is 1 to 2 minutesper client.

3.1.2. Client service recordDocumentation of services provided to all clients was

required by DSAMH's licensing standards. This formdocumented the dates and duration of services providedsuch as preadmission/evaluation meetings, individual/family, mental health/psychiatric, group sessions, and casemanagement session for an individual client through theircourse of treatment. All sites used this state-required form.Time required is 3 to 5 minutes per contact per session.

3.1.3. Checklist of Required FormsAll sites had one or more forms to assure inclusion of all

required forms in each client chart. According to stateauthorities, these forms were intended to assist staff as areminder of items that needed clinical review or updating.However, some sites reported completing this form atdischarge suggesting that they may be using it simply as

104 D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109

an administrative checklist. Time required is 10 to 20minutes total when done throughout treatment; however,some sites reported the form took 60 minutes whencompleted at or after discharge.

3.1.3.1. Organizing forms suggestions. The intake log/schedule book carries only a minimal burden of 1 to 2minutes per client, and the Client Services Record (the onlyrequired document in this category) takes only 3 to 5minutes per contact or session)—no changes are suggested.The problematic form was the Checklist of RequiredForms. Although it is often useful for agencies to have achecklist to make certain all required forms have beencompleted, filling out the Checklist after the patient has lefttreatment diminishes its usefulness and presents a sig-nificant time burden to the counselor. As a result, westrongly recommended that if sites wanted to continue

Table 1Time reductions by type of paperwork

Paperworkprior to st

Range (m

Intake/Admission forms (3 components)1. Organizing formsIntake log/schedule book 1–2Client service record 3–5Checklist of Required Forms 10–60Total organizing forms 14–672. Client administrative formsClient rights, confidentiality, HIPAA 10–20Consent and release of information 5–10Program description and rules 5Total client administrative forms 20–353. Intake assessment formsCRF 10–15ASI 45–60ASAM PPC-2R 30SOGS 10MAST 7–10Interpretive summary 30–45Assessment summary 30–45Other info for JCAHO 15–30Total intake assessment forms 177–245Intake paperwork tally/reduction 211–347

During treatment and treatment planning formsASI update every 3 months 30–45ASAM update every 3 months 10–15Subtotal 40–60Treatment paperwork tally/reduction (6-month treatment episode) 80–120

Discharge formsCRF 5–10ASI at discharge 30–45ASAM at discharge 10–20Discharge paperwork tally/reduction 45–75

Overall paperwork reductionsTotal paperwork reduction (in minutes) 336–542Total paperwork reduction (in hours) 5.6–9.0

using the Checklist of Required Forms for their ownassurance purposes, that they collect this informationduring the course of treatment, not at discharge. With thatprovision, the average amount of time taken for organizingforms could go from an average of 14 to 67 minutes downto 14 to 27 minutes, decreasing the paperwork burdenbetween 0 and 40 minutes depending upon the currentpractice at the site (see also Table 1).

3.2. Client administrative forms at intake

The great majority of client data collection for allprograms surveyed was completed at intake/admission. Ofthe 11 sites, 6 reported that intake data collection require-ments could be completed in one session (approximately 2–3hours), whereas 5 of 11 sites reported that intake requirementscould take two to three separate sessions and up to 7 hours.

burdenudy

Recommendchange

Paperwork burdenafter study Burden reduction

inutes) Range (minutes) Range (Minutes)

No 1–2 0No 3–5 0Do during 10–20 0–40

14–27 0–40

No 8–18 2–2Combine 4–7 1–3Combine 3–5 2–0

15–30 5–5

No 10–15 0No 45–60 0Yes 0 30Screener 2–10 8–0Yes 0 7–10Yes 0 30–45Yes 0 30–45No 10–20 5–10

67–105 110–14096–162 115–185

Yes 0 30–45Yes 0 10–15

0 40–600 80–120

No 5–10 0Yes 0 30–45Yes 0 10–20

5–10 40–65

101–172 235–3701.7–2.9 3.9–6.2

105D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109

The administrative portion of the intake paperworkrequirements included (a) client protection and rights forms(including confidentiality and protection of informationprocedures), (b) consent for treatment and release ofinformation forms, and (c) documents describing theprogram, its rules, fee agreement, and grievance policy.

3.2.1. Client protection and rights, statement of confidentiality,and HIPAA

These forms are required by DSAMH licensing standards,and all sites had forms related to these issues; however, therewas significant variability across sites in the application ofthese forms. Each site was missing some of the componentsof Health Insurance Portability and Accountability Act(HIPAA) requirements, including specific information onexpiration dates of consents; a statement of the individual'sright to revoke his or her authorization and how to do so;whether treatment, payment, enrollment, or eligibility ofbenefits could be conditioned on authorization; or astatement of the potential risk that personal health informa-tion may be redisclosed by the recipient. Time required is 10to 20 minutes.

3.2.2. Consent and release of information formsAll sites had consent forms. All but 1 site had emergency

contact releases, 6 combined this information with otherforms, and 4 had separate forms. All sites had forms for theDSAMH requirements of (a) for DSAMH to let the treatmentprogram know if a client is covered by state funding and (b)for treatment programs to bill DSAMH for covered servicesprovided by the treatment program. Of the 11 sites, 6 had twoseparate forms for this purpose, whereas the other 5 sitescombined the forms into a single consent. Combined releaseforms and to/from releases are accepted as long as the consentis completed correctly according to Federal Law require-ments (SAMHSA, 2004). Time required is 5 to 10 minutes.

3.2.3. Documents on program descriptions and rulesOf the 11 sites, 9 (82%) had program descriptions, rules,

and schedules on separate forms—each of which requiredpatient signatures. These were local forms not required byState licensing, but they did inform clients about relevantaspects of the programs' operations. Of the 11 sites, 7(64%) had a Client Handbook that included all client-relevant forms and schedules. Of the 11 sites, 9 (81%) hadformal grievance policies, with 4 sites (36%) havingincluded this information in their HIPAA forms. Therewas some confusion regarding a “Client Choice” documentdesigned to ensure notification to the client of alternatetreatment options. Six sites (55%) thought it was requiredand included it, whereas 5 others did not. We confirmed forsites that this form was not required, and severalimmediately stopped using it. There were 2 sites (18%)that continued to use this form because they felt that it wasimportant for clients to be aware of other treatment options.All sites had multiple fee agreement forms including a Fee

Collection Sheet, Sliding Scale Fee Guideline form, and FeeSchedule. Time required is 5 minutes.

3.2.3.1. Client administrative forms suggestions. We devel-oped a HIPAA form that could be used by all sites that fullycovered all requirements for HIPAA authorization. We alsorecommended that all programs combine their Consent andInformation Release forms into a single form that wouldservice all state agencies and that could accommodatesending of information in both directions between the stateagencies and the programs. So, for example, whereas mostsites currently had one form to allow the treating agency tosend intake information to DSAMH as required and anadditional form for clients to allow DSAMH to sendinformation to the treating agency to identify if the clientwas covered by the state for the treatment services provided,they now use a single form.

We also recommended that the four sites that did notprovide a Client Handbook begin doing so because this is away to provide relevant information in one document.Finally, we recommended the consolidation of the FeeCollection Sheet, Sliding Scale Fee Guideline form, and theFee Schedule form into one form, thereby reducing thenumber of forms to review with the client. Program staffestimated that completion of Client Administrative IntakeForms averaged 20 to 35 minutes per client. By followingour recommendations, the time to complete this category ofpaperwork would be reduced to 15 to 30 minutes per client,decreasing paperwork burden by 5 minutes.

3.3. Intake assessment forms

Perhaps the most time-consuming forms collected werethose for client assessment. All sites were required to collectdata on the State's Consumer Reporting Form (CRF). Inaddition, at admission and again at various times during theclient's treatment, administration of the Addiction SeverityIndex (ASI) and the American Society of AddictionMedicine (ASAM) client placement criteria were required.In addition to these, sites also collected various otherassessments or biopsychosocial instruments either of localinterest or required by various managed care organizations.Some of these included the Michigan Alcoholism ScreeningTest (MAST), the South Oaks Gambling Screen (SOGS),and several nonstandardized forms.

3.3.1. Delaware's CRFThe CRF was the core instrument required by DSAMH to

begin the process of registering the client as having entered thetreatment system and to collect basic client level data, much ofwhich is required by the Substance Abuse Prevention andTreatment Block Grant. Time required is 10 to 15 minutes.

3.3.2. Addiction Severity IndexThe State required the ASI (McLellan et al., 1992) be

completed upon intake for all clients. Most of these sites

106 D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109

(10/11) used the Drug Evaluation Network System'scomputer-assisted version of the ASI. The DENS versionof the ASI requires appreciably less time than the standardpaper-and-pencil interview and also produces a narrativesummary of the information and the beginnings of a basictreatment plan (Carise, Gurel, Kendig, & McLellan, 2002).Time required is 45 to 60 minutes.

3.3.3. The ASAM Patient Placement CriteriaThe ASAM Patient Placement Criteria (PPC) is a set of

guidelines used for placement, continued stay, and dischargeof clients with alcohol and other drug problems into fivebroad levels of care from Early Intervention to MedicallyManaged Inpatient Treatment to aftercare (ASAM, 2006;http://www.asam.org/ppc/ppc2.htm). Time required is 30minutes if client is not transferring to a higher level of care.

3.3.4. Additional forms

3.3.4.1. South Oaks Gambling Screen. The SOGS is a briefself-report questionnaire designed to detect gamblingproblems (Lesieur & Blume, 1987; Stinchfield, 2002)that was used by all treatment programs, as it had beenrequired by DSAMH several years earlier. Time required is10 minutes.

3.3.4.2. Michigan Alcoholism Screening Test. This is a briefself-report questionnaire designed to detect alcoholism(Selzer, 1971). It is widely used in clinical and researchsettings. The 24 scored items assess symptoms andconsequences of alcohol abuse. Of the 11 sites, 4 reportedusing the MAST to fulfill requirements by the state or itslicensing board. Time required is 7 to 10 minutes toadminister and score.

3.3.4.3. The interpretive summary. Five sites wrote a specific“interpretive summary,” essentially a clinical impression ofthe data collected at admission assessment. Time required is30 to 45 minutes.

3.3.4.4. The assessment summary. Of the 11 sites, 10 werealso doing an assessment summary of the ASI and ASAMdata. Time required is 30 to 45 minutes.

3.3.4.5. Miscellaneous forms. There were also itemscollected on the following topics: Spirituality, Leisure timeactivities, HIV/Risk Assessment, Nutritional Screening, andQuality of Life information. Much of this appeared to beclinically important as well as necessary for JCAHOrequirements. Time required is 15 to 30 minutes total.

3.3.4.6. Intake assessment suggestions3.3.4.6.1. Consumer Reporting Form and Addiction

Severity Index. We recommended no changes to Delaware'sState Intake form (CRF), recognizing that a change in thisform would necessitate a complete overhaul of the state-

administered computerized data collection system. Inaddition, we recommended no overall changes to the ASIform because this too would leave 10 of the 11 sites withoutcomputerized capability for collecting this data.

3.3.4.6.2. American Society of Addiction Medicine.Because the programs in this evaluation were outpatientprograms and there is almost never a challenge on treatmentneed for this level of service, the ASAM criteria may not beessential, particularly if traditional outpatient care wasdetermined to be the level of care needed. However, it wasacknowledged that the ASAM criteria might be necessary forthose patients seeking transfer to a higher level of care.DSAMH agreed to the use of ASAM criteria only for higherlevels of care, and this saved approximately 30 minutes onintake paperwork.

3.3.4.6.3. South Oaks Gambling Screen. The requirementto complete the SOGS was clinically sensible but notnecessary for all clients. A two-question screener (taking nomore than 1–2 minutes to administer) was designed toidentify patients who had never gambled. Only a positivescreen to these two questions led to administration of the fullSOGS. Therefore, if the client had never gambled (and asignificant proportion had not), the SOGS was notadministered. This decision rule led to a time savings ofapproximately 8 minutes.

3.3.4.6.4. Michigan Alcoholism Screening Test. Althoughthe MAST is a useful clinical tool, the evaluation uncoveredthat it was not required byDSAMH (as programs had thought)and that it did not collect substantially different informationthan was already being collected at intake. As a result,treatment programs decided to eliminate it from the standarddata collection, resulting in a savings of 7 to 10 minutes.

3.3.4.7. Assessment and interpretive summaries. Most siteswere completing an Assessment Summary and an “Inter-pretive Summary.”We checked to see if DSAMH preferred aparticular style or content for client admission interview andsummary (other than requiring the ASI and CRF) and foundthat these two documents were not required and that allmethods of other assessment and intake summaries wereacceptable. Because more than half of the sites wereinterested in JCAHO accreditation and because JCAHOrequired a narrative intake summary, we suggested that sitesuse the automated DENS-ASI summary, which contains allrelevant information in a computer generated, narrativereport and has been used successfully in many JCAHOaccredited sites (10/11 sites were using the DENS ASIsoftware). DSAMH agreed to accept the DENS-ASInarrative relieving the programs of the “InterpretiveSummary” and the “Assessment Summary,” and resulted ina total time savings of 60 to 90 minutes (30–45 minutes weretypically needed to write each summary).

3.3.4.8. Miscellaneous forms. As noted above, manyprograms were using their own forms for additional questionsabout leisure time activities, quality of life, pain assessments,

107D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109

family, nutritional, and HIV assessment. Because the formswere used randomly by different sites and counselorsreported that they served a specific purpose, we did notrecommend deletions here. Instead, we recommended thatprograms retain those forms they found useful but produce acommon battery of these forms in standard formats so thatthey were all collecting the information in the same way andconsolidate these questions into one form. These proceduresresulted in a 5- to 10-minute decrease in paperwork.

In summary, prior to the implementation of our sugges-tions, completing the intake assessment forms took from justunder 3 hours to just over 4 hours (177–245 minutes) tocomplete (depending upon site procedures and inclusions).Per our suggestions, the elimination of the ASAM for thoseentering traditional outpatient care, the MAST, and theInterpretative and Assessment summaries; the adoption of aSOGS screener; and the consolidation of miscellaneousforms resulted in a reduction of 1.8 to 2.3 hours (110–140minutes) in paperwork. Intake assessment now takes onaverage 1.1 to 1 3/4 hours (67–105 minutes) to complete.See Table 1 for a tabular representation of the findings.

3.4. During treatment documentation

Treatment planning and treatment documentation paper-work was much more variable across the 11 programs, andthere were fewer requirements by the state and lessstandardization. Most treatment programs reported that anadministration of the ASI was required every 3 monthsthroughout the course of treatment. This was actually not thecase, but it was essentially a widespread misunderstandingcausing most programs to spend 30 to 45 minutes per client,every 3 months completing an updated ASI. Similarly,programs believed the ASAM client placement summarieswere also required for all clients every 3 months, althoughDSAMH reported that this requirement had been eliminatedsome time prior to this evaluation. ASAM summariescontinued to be required only if the client was moving to adifferent level of care. Time required for repeated ASAMplacement criteria was approximately 10 to 15 minutes perclient—repeated every 3 months.

3.4.1. During treatment documentation suggestionsReadministering the complete ASI every 90 days for

clinical purposes during the course of treatment is notnecessary. In addition, as indicated previously, reevaluatingthe ASAM placement criteria may only be desirable in thecase of client transfers to more intensive levels of care. Thus,we recommend that DSAMH clarify that they had indeedpreviously eliminated both the ASI and ASAM administra-tion requirements for during-treatment reporting and that amore streamlined client “checkup” form be pilot tested toachieve the same purposes. Based upon this recommenda-tion, DSAMH reiterated that ASI and ASAM updates werenot required during treatment with one exception—ASAMsummaries continue to be required to refer a client in

outpatient treatment to a DSAMH-funded residentialprogram. This resulted in a net time savings of 40 to 60minutes every 3 months or 1 1/4 to 2 hours over the course ofa 6-month treatment episode.

3.5. Discharge paperwork

3.5.1. Delaware's CRF at dischargeA second CRF form is required to be completed and sent

to DSAMH to document the date and nature of the client'sdischarge from the treatment system. Time required is 5 to10 minutes.

3.5.2. Addiction Severity IndexAll programs were required to collect a final ASI at the

time of discharge on all clients. Time required is 30 to 40minutes per client.

3.5.3. American Society of Addiction Medicine PatientPlacement Criteria

All programs were required to collect a final ASAM PPCform at the time of discharge. Time required is 10 to 20minutes per client.

3.5.3.1. Discharge paperwork suggestions. Based on thereasoning noted in Section 3.4 regarding the use of the ASIand ASAM PPC-2R during treatment, DSAMH eliminatedthe collection of the ASI and ASAM PPC at discharge aswell. This led to a reduction of an additional 40 to 60 minutesof paperwork at discharge while still obtaining all of theinformation that they were actually using from the state CRFform that is readministered at discharge.

3.6. Follow-up meeting/action plan

As noted above in Methods, after providing the finalreports to all participants, the State Director, treatmentproviders, and research staff met as a group once more whenthe Director dedicated 3 hours of their regularly scheduledquarterly meeting to reviewing the results of these findingsdeciding on a course of action. Representatives of all treatmentprograms, the researchers involved, the State SubstanceAbuseDirector, and other DSAMH staff, including representativesfrom the licensing unit, were in attendance.

This meeting began with a presentation of the findingsfrom the paperwork assessment that highlighted each form,the amount of time taken to complete the form, the numberof sites completing the form, and whether they believed theform was required. For each form, the group entered intodiscussion regarding the use of the data, the State Directordiscussed reasons for requiring the form (if applicable), theresearch staff presented reasons for and against the collectionof the data (i.e., we were against the collection of the ASIand ASAM every 90 days and provided both a scientific andpractical basis for our reasoning), the provider staffdiscussed their experience with collecting the information

108 D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109

and the group, led by the State Director, came to a decisionregarding whether the form/data collection was valuableclinically or administratively.

Interestingly, one of the most compelling findings was theextent of misunderstanding regarding what was required bythe various funding and regulatory agencies (e.g., DSAMH,criminal justice and child protective agencies, JCAHO, andCARF) and the rationale for why information was collected.In general, many forms that programs believed to be requiredwere no longer used nor required. Moreover, some of theforms that were required did not actually result inadministrative action or decision support and thus were notreally useful to those who were requesting them. Based uponthe findings gathered in the evaluation, most of therecommendations for elimination and consolidation ofreporting were accepted and put into place immediately.

In summary, data collection time was reduced byapproximately 2 to 3 hours per patient at intake/admission,approximately 1 to 2 hours per patient during the course ofan average 6 month outpatient treatment episode, andapproximately 40 to 60 minutes at treatment discharge. Areasonable estimate of total time saved per patient over thecourse of a 6-month treatment episode is 4 to 6 hours.

4. Discussion

We believe the Paperwork Burden Assessment led to amore streamlined and efficient data collection process thatimportantly has not eliminated any useful information.Moreover, this effort was seen as a good faith effort toacknowledge and address the legitimate time constraints onthese programs—paving the way for a collaborative effort toimprove clinically and administratively relevant data collec-tion for improved accountability. We believe the implicationsare significant for other administrators and public authoritiesto give them a tangible estimate of the data collection burdenthat affects so many programs as well as one reasonable wayto add the collection of new, important variables. That is, ifnew measures or data collection items are to be added, thevalue and necessity of collection of older items or measuresshould be reviewed. Whenever possible, do not add to datacollection without taking away something that is alreadybeing collected. Equally important, do not collect data thatare not being used, and show providers the utility and valueof the data by providing results back to those you are askingto collect the data. Once clinical staff see the use of the dataand maybe even begin to use it clinically, their investment incollecting accurate and timely data will increase.

It is likely that the history of this group (providers,researchers, and the State Director) working together was animportant factor in the success of this meeting; however, theimportance of the willingness and openness of the StateDirector in discussing the data collection and makingchanges to the current requirements cannot be under-estimated. This activity simply could not have been

successful without the State Director's willingness to makechanges, to hear the treatment providers concerns andsuggestions, and to trust the research group's scientificopinions. The level of interest in program improvement canalso be seen by the participation of two treatment programsinvolved in the Network for the Improvement of AddictionTreatment projects as well as the State's participation in theRobert Wood Johnson Foundation's Advancing Recoveryinitiative. Both of these programs have goals of improvingsystems of care that are consistent with this project.

The Paperwork Burden assessment was an important andvaluable activity for the state, its substance abuse treatmentproviders, and the participating researchers. It was rewardingto see such a significant impact from such a basic endeavor.These activities positively affected the relationship betweenthe state agency and the treatment providers and between thetreatment providers and the researchers and led to a numberof basic gains for all involved.

First, it created a stronger collaborative atmosphere for allconcerned—the state agency, the state-funded treatmentproviders, and the researchers working within the state.Providers saw that both research and state agency staffs werelistening to them and were responding to their concerns. Inaddition to increasing collaboration and goodwill betweenthe parties, these activities generated a new way of thinkingabout paperwork and data collection within the state. Itbecame clear that that data should only be collected if itcould produce meaningful information. The process hasreoriented thinking on the part of programs and DSAMHleading to a better understanding of the need to have aspecific reason for collecting each form and each piece ofdata. The state is more cognizant of only requiring thoseitems that they believe are essential for client care or thosethey will actually use for some specific purpose in the future.Likewise, treatment programs report feeling more acceptingof the data collection required, knowing that there is apurpose to each requirement. Finally, they are more likely toview data collection as part of good clinical management—not just paperwork. Put simply, there is no longer a feeling ofadministering forms simply to collect data.

Directors of several other states have expressed interestedin replicating this work in their state systems, and althoughthese states are much larger than the pilot state, it isincumbent upon us to find a way to assist states, agencies,providers, and programs of every size to easily collect theinformation they need; to have the ability to use thatinformation for decision making at the program, agency, andstate level; and not to be sidetracked by collection ofextraneous data that serves neither the state policy makers,the program directors, nor the patient.

Acknowledgments

Work on this project was supported by National Instituteof Drug Abuse Grants R21 DA 19787, RO1 DA13134, andR01 DA015125. The authors would like to thank Amy

109D. Carise et al. / Journal of Substance Abuse Treatment 37 (2009) 101–109

Camilleri for her help in preparation of this manuscript. Wewould also like to thank the staff of the outpatient substanceabuse treatment programs in the state of Delaware and KimBeniquez at the DSAMH. Early results of this work havebeen presented at several conferences/meetings including theNational Institute on Drug Abuse Division of EpidemiologyServices Prevention Research Branch State Grantee Meetingin January 2008, the College on Problems of DrugDependence June 2007 and June 2008, and the CaliforniaState Agency/University of California Los Angeles Summit:Using Performance and Outcomes Measures to ImproveTreatment in March 2008.

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