It's 4 a.m. and in a crime-ridden neighborhood of Wilmington, Delaware, Charles, a heroin addict, is curled up in his blankets in a doorway, clutching a baseball bat to protect himself and his wife who is sleeping beside him in an old lawn chair. People in passing cars think they see another couple of homeless people, but what they don't realize is they're witnessing the desperate state of America's drug treatment system. Charles isn't looking for a fix; in fact, he's doing what a man in Wilmington needs to do if he's serious about getting treatment for a drug addiction: he is staking out his spot at a treatment center whose waiting list is so long that people have taken to literally camping out in front of their door in hopes of getting in for treatment.

James, the director of Wilmington's Brandywine Counseling, is painfully aware of the desperate need for treatment in his community. He's kept up at night thinking about the people sleeping in front of his agency hoping for treatment, and knowing that many will be turned away because there are simply not enough resources, staff, and time in the day to treat them all. Brandywine reflects the incredible demand for treatment nationwide. Some 26 million Americans are in need of treatment for alcohol or drug addictions, but only 25% are able to get access to the treatment they need. Unfortunately, shrinking budgets and declining funding prohibit providers from hiring additional staff or acquiring additional space to expand their treatment capacity.

Because of growing demand and shrinking resources, the Network for the Improvement of Addiction Treatment (NIATx) was formed. Comprised of 29 addiction treatment agencies nationwide, NIATx is training providers how to evaluate and change their organizational processes in order to do more with less. Much more, in fact. The 29 model agencies are decreasing wait times for treatment, decreasing appointment no-show rates, increasing continuation rates, and increasing admissions -- and making access and retention improvements is actually helping their bottom line, thus ensuring that these improvements are sustainable.

As one of the 29 agency "Change Leaders," James encourages his staff to form a "change team" that includes someone from every role in the agency: doctors, nurses, counselors, outreach, admissions, administration, management, a client, and the client's mother -- each has a different perspective on the agency and how to improve it. Through weekly meetings this team comes up with all kinds of ideas; they plan and implement them, tracking data to see if the changes are actually improvements. Some change ideas are tried and discarded, others become new company policy.

For instance, they know that part of their problem is that they only have enough staff to do treatment orientation twice a week, which creates a bottleneck early in the process. Someone suggests videotaping an orientation session and letting incoming clients watch it with one counselor rather than using the entire orientation team. This actually does allow more people each day to come in for an assessment, begin orientation, and start treatment. Unfortunately, the time spent with additional clients, and the extra paperwork it entails, severely overburdens the intake staff.

So the intake counselors start meeting for ten minutes at the end of their hectic days to debrief, and they come up with ideas for improving the agency's changes. Soon outreach workers take over leading clients through the video orientation, allowing the intake counselors time to complete the necessary client paperwork - and admit 50% more clients into the methadone treatment program! This allows more people to enter treatment, distributes the extra work more equitably among staff, and brings more revenue into the agency: an overall improvement for clients, staff, and the bottom line.

Before you know it, a revolution has begun. Seriously. There are signs in the hallways and lobby stating, "Paths to Recovery: it's a Revolution! Ask me about it." Staff, clients, and family members alike ask what it's all about, and are encouraged to offer suggestions and to hold Brandywine accountable for the improvements they're claiming to make. A climate of change slowly begins to pervade the whole agency.

Sometimes things aren't smooth: clients get angry if they don't see the `revolutionary change' the posters advertise; staff get frustrated because they have to keep changing the ways things are done, but they're told it is part of the process. The whole agency is making changes, changes in the way they've always done things; changes, James reminds them, not unlike the changes they're asking their clients to make. This notion helps keep their perspective. Change is difficult. But in the long run, just as clients are turning their lives around, the 29 change teams are turning around their addiction treatment systems.

James and the rest of the Brandywine change team are reminded that they've been doing the right thing when a heroin addict comes in one morning, saying, "I heard on the street that you can get me started on methadone today . I'm ready." They know that the difficult process of change has been worth it when one person said that the factor that most helped get him on the road to recovery was being able to start treatment the very day he decided to look for it. One changed life makes it worth the struggle. Yet word of same day treatment is slowly starting to spread around Wilmington, and more come looking for it. Brandywine is but one of the 29, and these 29 agencies who are piloting a new way of thinking for addiction treatment agencies are hopefully just the beginning...

Reprinted with permission from the Network for the Improvement of Addiction Treatment.