Retention & Engagement: It's the Relationship

Last month I focused on the interplay between retention and engagement (the top two priorities emerging from ContinuumCloud’s 2024 Behavioral Health Industry Trends Report) at a macro level. This month I want to focus on relationship as the lynchpin for, and the link between, both. Among the most recognized and widely used tools to measure employee engagement is the Gallup Q12. The 12 items can be viewed in clusters that reveal employees’ perceptions about work-related basic needs, individual contribution, teamwork, and growth. As such, they reflect the employees’ perceived relationship to their supervisor and organization. Additionally, the strength of the therapeutic alliance has a long history of being found to predict therapy outcomes, regardless of a clinician’s approach or theoretical orientation. Thus, the research strongly supports the importance of relationship in both employee and patient engagement.

Building Relationships to Improve Employee Retention

It has long been said that employees leave supervisors not organizations. The Gallup questions highlight this. At the basic needs level, questions focus on whether the staff has the information and tools to do the job; all of which depend on a supervisor’s direction and support. Individual contribution-related questions are all relationship driven: being given the opportunity to shine, being recognized, cared about, and encouraged. Teamwork items include being able to meaningfully share opinions, valuing the mission, believing in one’s team, and having a “best friend” in the workplace, thus describing relationships among co-workers. Lastly, the two growth items reflect the communication about progress, learning, and development. Retention among organizations with high engagement is roughly 20% higher than in low scoring organization. The deeper the connection within the team; the more engaged and effective the team and the employee become.

Improving the Client Experience & Outcomes

While therapeutic alliance – aka the relationship between patient and therapist – predicts outcome at the individual level, that relationship starts with the process for entering treatment. Many organizations report 50% no-show rates for first appointments, meaning engagement has failed at the front door. Data shows that many patients attend zero or one session or drop out after a very few. It is critical to evaluate these processes from the patients’ point of view. Most people seek counseling at a time of crisis, transition, and significant stress. Therapeutically, this is a time where change is most likely to succeed. Barriers to access narrow this window of opportunity. Managing the enrollment (separate from Intake) seamlessly – verifying insurance, establishing fees, scheduling, understanding transportation or other barriers that a patient will need to overcome – should be as seamless and easy as possible. Cultural competence, ensuring that clinicians are trained and that patients are assigned in ways that are sensitive to both the presenting problem and the individual seeking care, also builds patient engagement.

The intake process at many organizations is designed to satisfy numerous bureaucratic requirements, often at the expense of the patient’s perceived need to have the problem that motivated them to seek care addressed immediately. Streamlining the process, setting expectations (describing therapy and how it works) and ensuring that treatment occurs within the assessment can build patient commitment to the work of treatment. EHRs can ensure that information moves seamlessly between providers, that redundant questions can be eliminated, and that patient self-report information can be brought into the EHR directly and be easily viewed. The clinician process needs to be such that the clinician can absorb this information easily and timely.

The Impact of Clinician Retention on Patient Attrition

Ensuring that the processes and the technology used by the organization are effective can satisfy many of the clinician’s basic needs that contribute to positive engagement. Less staff turnover contributes to better patient engagement as well. Over the years, one of the frequent complaints by patients and referral sources about behavioral health organizations, especially those that are publicly funded, is that treatment is often interrupted by staff departures. This impacts the therapeutic alliance and causes the patient to both retell their story and build a new trusting relationship. If this is repeated, patients give up on therapy and on the organization. This, in turn, erodes the organization’s clinicians’ sense of their own work. Demoralized staff find work increasingly challenging. Creating more turnover.

Supervisors need the same levels of support and engagement as staff. They too need to see basic needs met, individual contribution recognized, a team and network with which to connect, and a sense that they are valued, and will be able to grow professionally. Too often, these needs are ignored as “good” clinicians are promoted into management jobs with little support or training.

Valuing Employee Retention to Improve the Patient Experience

Understanding the relationship base for both retention and patient engagement can lead an organization to better align its process and technology to build ease of work and access to care. Ensuring that supervisors focus on the needs, value, and growth of their individual staff and team can create a virtual spiral of staff and patient engagement, replacing the vicious cycle of staff turnover and client loss.