Are Walk-in Services at KW Counselling Services Clinically

Effective and Cost-effective?

Carol A. Stalker, PhD, Sue Horton, PhD, Cheryl-Anne Cait, PhD, Leslie Josling, MSc, RSW

Walk In Counselling Clinic

• Launched 2007 in response to a waiting list of 981 clients

• Operates every Thursday from noon-8pm• Average wait for service 20 minutes• 20 minute intake and initial screening• 1.5-2 hour session• Serves approximately 30 clients/week• Serves couples, families, individuals (all ages)

Rationale

• By responding to clients in their moment of need we will capitalize on their “readiness to change” and improve outcomes

• Quick and easy access to service speaks to current culture

• Eliminates “no shows’• Provide a ‘cadillac’ session knowing many

clients only ever come for one session

Staffing

• Approximately 75 hours professional staff time/week (including intake and director) or 12 individuals/week

• Approximately 60 hours of student (graduate level) time/week (9 individuals/week)

Approach

• Structured intervention from screening through assessment to treatment.

• Screening and standardized assessment for suicidality, homicidality, addictions, intimate partner violence

• Intervention builds on client/family strength/capacity

• Client walks away with concrete agreed upon plan

Follow up

• If deemed high risk, client offered immediate follow up appointment

• Other clients are asked to ‘work the plan’• Clients invited to call for ongoing therapy or

return to Walk In Counselling Clinic• Walk In Counselling Clinic has effectively

eliminated the waiting list

Literature Review

• 18 studies• Only two randomized controlled trials• Outcomes assessed included:– client perception of sufficiency of the single

session– problem improvement – satisfaction with the service– aspect of the service that was most helpful

Literature Review (cont’d)• Many methodological limitations:– Little consistency in how outcomes are measured–Many studies used non-standardized measures– Small samples– Involvement of therapists in collection of outcome

data– Some studies used only client satisfaction measures

• Majority of clients studied reported the single session to be sufficient and helpful; they also indicated satisfaction, especially with the accessibility of the service

1) Is the walk-in approach clinically effective in terms of reducing psychological distress and reducing the use of health and social services?

2) Who benefits most from the single-session approach? Are there differences in terms of sociodemographics, nature of presenting problem, initial level of psychological distress, or"readiness for change” (using Transtheoretical Model of Change, Prochaska & DiClemente, 1982)?

3) Is the walk-in approach cost-effective?

   

Research Questions

1) Invite all walk-in clients 16 years of age and over to participate in the study over a period of 13 weeks (May 27-Aug 26, 2010)

2) Invite all new clients coming for first session of traditional counselling to participate (control group)

3) Collect follow-up data at one month after walk-in or first scheduled session and two months later by mail.

Our Plan

Psychological distress – General Health Questionnaire-12 (Goldberg, 1972)

Readiness for Change – Stages of Change Questionnaire (Bellis, 1994) (18 items)

Use of health and social services and number of days lost from employment – designed by us (9 questions)

Socio-demographic information – 10 questions

Measures

All walk-in clients given Letter of Information and questionnaire when they registered for walk-in

Research Assistants in waiting room on walk-in days to answer questions

Locked box in the wait room for completed questionnaires

Receptionists asked to give clients with first scheduled session the research package.

One administrative worker responsible for sending out follow-up questionnaires.

Procedures

Walk-in clients: 225 clients out of a total of 362 (62%) agreed

to complete the Time One Questionnaire. 153 (68% of 225) consented to receive follow-

up questionnaires. 28 (12% of 225) returned the follow-up data at

one-month follow-up.Control group: 14 clients (36%) agreed to participate, 7/14

(50%) agreed to follow-up; no one returned one-month follow-up questionnaire.

Participation Rates

We decided that an incentive was necessary to encourage increased response rate for follow-up points

Added a four month follow-up with permission of REB

Offered $10.00 Tim Horton’s gift certificate 24 individuals responded (15 had previously

responded after one month: in total 38 different individuals responded at least once)

Change in Methods

Sample Characteristics

Walk-in clients (n= 225)

Marital status◦ 36% married/common law◦ 41% single◦ 15% separated/divorced

Work status◦ 36% full time◦ 15% part time◦ 24% unemployed◦ 11% disability◦ 16 % other (school etc)

90% first language English

Presenting issue◦ 28% depression◦ 22% couple relationship◦ 17% depression + other◦ 5% parent/child conflict◦ 4% family conflict

Sample Characteristics

n= 225

Household income◦ 44% <$19,999◦ 26% $20,000 – 39,999◦ 13% $40,000 – 59,999◦ 16% >$60,000

Source of referral◦ 17% Agency web-site◦ 15% Friend◦ 15% Family member◦ 10% Physician◦ 39% Other – court, Ontario

Works, hospital, other counselling agencies, co-worker etc.

Readiness to Change (walk-in clients only) (n= 225)

Precontemplation

Contemplation Action Maintenance

3.6 8.5 7.8 7.3

Precontemplation (“I don’t really think I am part of the problem”) Contemplation (“I have been thinking I might want to change something about myself”) Action (“I am finally working on things that concern me”)Maintenance (“I am working to prevent myself from having a relapse”)Score: 1=lowest (disagree most), 10=highest (agree most)

All 1 mo. follow-up

4 mo.follow-up

Sample size 225 28 24

% female 54% 71% 54%

Mean age 33 40 36

GHQ (0=best, 12=worst) 7.4 8.1 7.5

Health prevented usual activities (previous month)

53% 79%* 63%

Health prevented work (if worked) 32% 38% 20%

Had used emergency (past month)

15% 11% 8%

Saw doctor/walk-in (past month) 44% 61% 52%

Had used other services 45% 46% 29%

# of other services used 3.6 3.0 3.0

Characteristics at Baseline of all Participants and Those who Followed Up

* Significantly different, 5%

Baseline After 1 month

GHQ (0=best, 12=worst) 8.1 3.3*

Health prevented usual activities 79% 36%*

Health prevented work 38% 13%*

Days lost/person (if worked) 3.12 0.25

Had used emergency (past month) 11% 7%

Saw doctor/walk-in in past month 61% 50%

Had used other services (past month)

46% 61%

# of other services used (users only)

3.0 3.8

Before/After Comparison for Those who Returned One Month Follow-up (n= 28)

* Significantly different, 5%

Baseline After 4 months

GHQ (0=best, 12=worst) 7.5 2.8*

Health prevented usual activities 63% 33%*

Health prevented work (if worked) 20% 10%

Days lost/person (if worked) 2.0 0.2

Had used emergency 8% 13%

Saw doctor/walk-in in past month 52% 50%

Had used other services 29% 50%

# of other services used 3.0 3.7

Before/After Comparison for Those who Returned Four month Follow-up (n=24)

*significantly different, 5%

Relationship between Stages of Change and Age, Gender and Change on GHQ-12

at One-Month Follow-up

*Correlation is significant at the .05 level (2-tailed)**Correlation is significant at the .01 level (2-tailed)

Precontemp Contempla-

tion

Action Maintenance Gender Age Change on

GHQ

Precontemp 1.00

Contemplat .201 1.00

Action .179 .840** 1.00

Maintenance .202 .838** .814** 1.00

Gender -.242 .047 .019 .120 1.00

Age -.038 -.378* -.481** -.365 -.002 1.00

Change on

GHQ

-.202 .458* .302 .479** .168 .048 1.00

Relationship between Stages of Change and Age, Gender and Change on GHQ-12

at Four-Month Follow-up *Correlation is significant at the .05 level (2-tailed)

**Correlation is significant at the .01 level (2-tailed)

Precontemp Contempla-

tion

Action Maintenance Gender Age Change on

GHQ

Precontemp1.00

Contemplat-.674** 1.00

Action-.433* .456* 1.00

Maintenance-.450* .451* .783** 1.00

Gender-.266 .215 .264 .307 1.00

Age.156 .240 .091 -.052 -.115 1.00

Change on

GHQ

-.389

Sig. (2-tailed) .060

.382

Sig. (2-tailed) .065

.224 .162 -.202 .145 1.00

Is walk-in effective? GHQ (all walk-in sample) 7.4 at baseline Drops significantly to 3.3 (1 month) and 2.8 (4

months) (score <3 is not a “case”) Almost as large as the improvement in scores

seen for Health Connect clients (with traditional counselling) at closure after (8 sessions)

Increase in proportion able to resume work/normal activities – also significant

Need a control group!

Preliminary Conclusions: 1

Who benefits most?◦ No differences by age, gender◦ Scores on contemplation, action and maintenance

positively related to improvement in GHQ◦ Score on precontemplation negatively related to

improvement in GHQ◦ Correlation highest with contemplation score:

significant (p<0.05) at 1 month and 4 months

Preliminary Conclusions: 2

Who benefits most? (cont) Correlation between Contemplation score and change

on GHQ at one month follow-up r = .46 p<.05

Correlation between Contemplation score and change on GHQ at four month follow-up

r = .38 p<.065

Correlation between Precontemplation score and change on GHQ at four month follow-up

r = -.39 p< .06

Preliminary Conclusions: 3

Is walk-in cost-effective? Cost of 1 session walk-in $120 Cost of emergency visit: $225 for assessment, plus

minimum $150 in follow-up Cost of doctor’s visit: $150 for assessment, plus cost of

follow-up 19% of the baseline sample said without walk-in, they

would have gone to emergency, 8% to doctor: walk-in saved $90/person

Value of 0.9 extra day worked/person after walk-in on average is $70 (using minimum wage) or more

Walk-in clients used more community services- hard to assign cost

Preliminary Conclusions: 4

Response rates were low (summer; methods)

Control group did not work well Need control group: even if untreated,

people will recover somewhat Have applied for a CIHR grant to do larger

study Hope to compare walk-in to those on a

waitlist at another site (in general waitlists > 1 month)

Limitations: Next Steps

What is the experience of Family Services with Walk In?

What are the implications of our learnings? What are the opportunities if any?

Discussion