Process improvement for behavioral health

Identify Clients at Risk for Leaving and Intervene


Clients often threaten to leave treatment and yet there is no follow-up to see what’s wrong and to help solve the problems.


Get feedback from clients regularly so that you can identify clients who are at risk for leaving and intervene so that they stay engaged.

Featured Stories

Bridge House in New Orleans, Louisiana, increased continuation rates from 48 percent to 63 percent by implementing weekly check-ins, asking clients to rate on a scale of 1-10:

  1. How willing are you to continue treatment here?
  2. How important is it for you to stay in treatment?
  3. How motivated are you to stay?
  4. How strong has your urge to use been this past week?

A high rating on “How strong has your urge to use been this past week?” was the best predictor that a client would quit treatment. They also scheduled weekly continuation staffings so that counselors could discuss continuation issues and how to intervene with clients at risk for leaving treatment. The counselors used Motivational Interviewing guidelines to motivate patients to stay in treatment. Each counselor planned one specific change to motivate the patient to continue and assessed whether it worked using PDSA cycles. For more information, see the Bridge House Continuation case study.

Sinnissippi Centers in Dixon, Illinois increased continuation through the first four sessions from 0 to 100 percent by using the Outcome Rating Scale/Session Rating Scale (ORS/SRS) with intensive outpatient clients and addressed problems that were identified. After using the SRS for six months, the counselors found that they could get the same results without the paperwork by having informal one-to-one discussions about whether weekly goals were being met. They have continued to sustain the high continuation rates. For more information, see the Sinnissippi Change Bulletin.

Gosnold, Inc. in Falmouth, Massachusetts increased completion rates by 10 percent by implementing an “R Board” system to discretely identify detox patients at risk for leaving. Any staff member could put an “R” on the chart next to the client’s name. Other staff members were notified of the potential risk and at least five staff members, including nurses, counselors, and counselor aids, talked to the patient about his feelings and talked about why he should remain in the program. For more information, see the Gosnold Change Bulletin.

Lessons Learned

  • Expect that clients will think about quitting treatment.
  • Create ways for counselors to exchange ideas about how to intervene. In addition to benefiting clients, this may help counselors feel supported and prevent burnout.
  • Analyze your data to determine the most common points that clients are likely to leave treatment—often during the first week and at 30 days. Watch clients more closely at these times and plan ways of intervening.
  • Create a system so that staff can communicate with each other about clients who show signs of leaving.
  • Use the Session Rating Scale or an agency-specific scale on a weekly basis to identify clients at risk for leaving.
  • Have counselors develop PDSA Cycles to test ideas for intervening.
  • Use Motivational Enhancement Techniques to re-engage clients. These include openended questions, affirmations, reflective listening, summarizing statements, and the creation of discrepancy between the client’s urge to use and the desire to continue in treatment.

Tracking Measures

Cycle Measure

No-show rate for treatment sessions

Data Collection Form

No Show Tracking Spreadsheet



  • 1. Select a counselor who is willing to test this change with one group.
  • 2. Decide how to get feedback from clients. For example, have the counselor ask clients to check in each week by answering the following questions with a rating from 1-10.
    • How willing are you to continue treatment here?
    • How important is it for you to stay in treatment?
    • How motivated are you to stay?
    • How strong has your urge to use been this past week?
  • 3. Collect baseline data for no-show rates for the selected group before making any changes.


  • 4. Get feedback from clients for the next 2 weeks.
  • 5. Use the responses to these questions to identify clients who may be at risk for leaving treatment and track them individually.
  • 6. Identify and intervene to keep these clients in treatment.
  • 7. Track and calculate the no-show rate for the selected group for another two weeks.


  • 8. Check the fidelity of the change. Was the change implemented as planned?
  • 9. Evaluate the change:
    • Did the no-show rate for the group decrease after implementing the weekly check-in?
    • Did the check-in help identify clients at risk for leaving?
    • Were counselors able to identify ideas for intervening with clients at risk for leaving?
    • Did clients who were identified as being at risk for leaving continue in treatment?


  • 10. Adjust the check-in method or try other ideas for intervening when clients are identified as being at risk for leaving and re-test this promising practice for an additional two weeks.

Repeat this series of steps until you have refined your approach to getting feedback from clients and engaging clients at risk for leaving. Have all counselors use this approach so that all of the clients that may quit treatment are identified and reengaged in treatment. Continue to experiment with different ways for counselors to exchange ideas about how to intervene.

Related Information

More Stories

STEPS at Liberty Center in Wooster, Ohio increased continuation rates by holding a special group for clients at high risk for dropping out of treatment.

Daybreak Youth Services in Spokane, Washington increased continuation rates in the adolescent residential program beyond 30 days, from 55 percent to 72 percent by implementing a client feedback survey that allowed adolescents to rate their relationship with the staff by asking:

  1. Is the staff member able to help you with your skills?
  2. Is the staff member easy to talk to?
  3. Does the staff member validate you?
  4. Does the staff member make you feel heard, understood and respected?
  5. Does the staff member seem to use the skills when talking to you.

They provided each staff member with the feedback. The client feedback survey was initially sent out every 60 days, and later changed to every six months. They also used a shift debriefing form for staff to assess how well they’d engaged with clients that day.

Vanguard in Arlington, Virginia consistently maintained continuation rates in their adult and adolescent residential programs above 90 percent after implementing an unplanned discharges form so that their counselors could review what happened when a client left treatment early and think about how to prevent it from happening again.

Women’s Recovery Association in Burlingame, California, uses the weekly risk assessment & progress notes to assess client risk.

Prairie Ridge Addiction Treatment in Mason City, Iowa, had their clinical supervisors play an active role to ensure that counselors and patients are a good match. They assigned counselors who were more experienced to the less motivated patients.