Technology Assisted=Care for Substance Use Disorders
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Training Goals: 1. Improve awareness of and receptivity to using Technology-Assisted Care (TAC) for the treatment of Substance Use Disorders (SUDs) 2. Identify effective TAC interventions for SUDs 3. Demonstrate exemplary TAC interventions 4. Identify strategies/approaches for adoption and integration of TAC into routine clinical practice 5. Explore implementation and integration challenges (e.g., cost, reimbursement, security)
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Technology Assisted=Care for Substance Use Disorders
- 2. Training Goals • Improve awareness of and receptivity to using Technology-Assisted Care (TAC) for the treatment of Substance Use Disorders (SUDs) • Identify effective TAC interventions for SUDs • Demonstrate exemplary TAC interventions • Identify strategies/approaches for adoption and integration of TAC into routine clinical practice • Explore implementation and integration challenges (e.g., cost, reimbursement, security) 2
- 3. Introductions • Name • Organization • Position/Title/Job Responsibility • Icebreaker (next page) 3
- 4. 4 Have you ever … • Booked travel arrangements online • Purchased an item costing more than $100 online • Checked bank account information or moved money between accounts online • Applied for a credit card online • Signed up for insurance online • Signed up for telephone, cable services, or utilities online • Paid a bill online • Owned a Kindle or iPad • Owned access to an electronic book to read on your computer • Purchased audio files (e.g., music, books) online • Purchased/rented video media (e.g., movies, TV shows) online • Owned a cell phone with a digital camera or smart phone with Internet access • Owned a robotic cleaning device (e.g., Roomba) • Filed your taxes online • Used a bank that was online only (i.e., one with no physical structure) • Owned or interested in owning a vehicle with voice activation technology for cell phone use and/or interfacing with stereo or comfort control systems
- 5. Technology Adoption • Adoption Research is concerned with identifying the factors that influence user acceptance of technological innovations 5 (Van Slyke et al., 2004; Corneille et al., 2014)
- 6. (1) Optimisim - How beneficial will this new technology be once I start using it? (2) Proficiency - How difficult will it be for me to learn to use it properly? 6 Contributing Factors towards Technology Adoption (Van Slyke et al., 2004; Corneille et al., 2014)
- 7. (1) Dependence - How individuals might feel enslaved by technology (2) Vulnerability - How technology may increase the chances of being victimized OR distrust of technology and its ability to work properly/function as intended 7 Inhibiting Factors towards Technology Adoption (Van Slyke et al., 2004; Corneille et al., 2014)
- 8. Any of these positive and negative factors may influence consumers' expectations of how much benefit (if any) they will gain from technology use, and thus their propensity to adopt new technologies. 8(Van Slyke et al., 2004; Corneille et al., 2014)
- 10. help participants understand the benefits, ease of use and clinical application to enhance treatment services AND to be aware of the positive and negative factors that impact adoption 10 This training is designed to introduce participants to two validated TAC interventions in order to
- 11. Module 1 Technology & Everyday Life
- 12. Technology use has invaded our lives 12
- 13. 87%of Americans use the Internet (Fox & Rainie, Pew Report, 2014) 13
- 14. 91% of American adults have cell phones 58% have smart phones (Pew Report, 2014) 14
- 15. No matter a person’s salary… more people own cell phones than use the internet 15 (Fox, 2013)
- 16. 29% of Americans own a tablet The average American owns four technology devices (Digital Consumer Report, 2013) 16
- 18. 18
- 19. Technology in the Workplace 19
- 20. Activity #1 Break into small groups: Thinking of the technological innovations that you have used at work, please identify the ways in which these various tools have: • Facilitated your work/introduced efficiencies? • Impeded your work/created challenges? 20
- 21. Module 2 Technology & Treatment
- 23. PURPOSE: This blending product will introduce two Technology Assisted Care (TAC) interventions that have demonstrated utility as an adjunct to treatment services in specialty drug treatments programs. Historically, TACs have been used in general health care settings to treat other chronic medical conditions (e.g., diabetes, heart disease, asthma, etc.) 23
- 24. Blending Team Members SAMHSA CSAT-ATTC Traci Rieckmann, Ph.D. – Northwest ATTC Michael Chaple, Ph.D. – Northeast & Caribbean ATTC Richard Spence, Ph.D. – South Southwest ATTC Nancy Roget, M.S. – National Frontier and Rural ATTC Michael Wilhelm – National Frontier and Rural ATTC Paul Warren, LMSW – Northeast & Caribbean ATTC Phillip Orrick – South Southwest ATTC NIDA Edward Nunes, Ph.D. – Columbia University/NY State Psychiatric Institute Aimee Campbell, Ph.D. – Columbia University/NY State Psychiatric Institute Gloria Miele, Ph.D. – Columbia University 24
- 25. 20.2 million people needed but did not receive treatment for illicit drug or alcohol use (NSDUH, 2011) In 2013, 22.7 million people aged 12 or older met the criteria for substance use disorders 25 95.3% 2.9% 1.6% Did Not Feel They Needed Treatment Felt They Needed Treatment and Did Not Make an Effort Felt They Needed Treatment and Did Make an Effort
- 26. Common Beliefs among Users • treatment is only for “alcoholics” or “addicts” • treatment is too expensive, I can’t afford it • treatment doesn’t work (for me) • treatment would be detrimental to my career • this problem isn’t serious enough for treatment • can handle this problem on my own • like to drink/use drugs too much to quit • treatment will be physically (i.e., withdrawals) and psychologically uncomfortable (i.e., traumatic) • be embarrassed if others knew I had a problem (Stecker, McGovern, & Herr, 2012) 26
- 27. Client Barriers to Accessing Treatment • Transportation • Time away from home • Child care • Employment • Lack of available services • Stigma/confidentiality • Other client barriers? 27
- 28. Program Barriers to Delivering Care • Large caseloads • Administration of EBPs with fidelity • Lack of standardized practice in service delivery • Limited resources (time/money) • Limitations regarding clinical skill sets • Burden of training/supervision • Complex cases with multiple needs • Other program barriers? 28
- 29. (McClure et al., 2012) • Survey of 8 urban drug treatment clinics in Baltimore (266 patients) • Clients had access to - Mobile Phone (91%) - Text Messaging (79%) - Internet/Email/Computer (39 - 45%) What do we know about the use of technology among our clients? 29
- 30. 30 Another study found that 95% of teens receiving treatment at emergency rooms had access to mobile phones and participated in text messaging. (Ranney et al., 2012) Text message-based behavioral interventions were shown to be acceptable, valid and reliable with teens on a variety of sensitive topics.
- 31. “Delivery of CBT could be subcontracted to the computer …” (Carroll & Rounsaville, 2010) 31
- 32. Technology Assisted Care Use of technology devices to deliver some aspects of psychotherapy or behavioral treatment directly to patients via interaction with a web-based program32
- 33. To date, more than 100 different technology-assisted care programs have been developed for a range of mental disorders and behavioral health problems (Klein, et al., 2012; Marks et al., 2007; Moore, et al., 2011)(Klein et al., 2012; Moore et al., 2011)
- 34. More Specifically… there are meta-analytic evaluations of technology assisted care programs for a range of Psychiatric Disorders • Depression and Anxiety (Spek et al., 2007; Andrews et al., 2010) • Illicit Drug Use (Tait, 2013) • Smoking (Rooke, 2010) • Alcohol Use (Khadjesari, 2011) 34
- 35. Technology-Assisted Care Interventions • may consist of text, audio, video, animations, and/or other forms of multimedia • use information from medical records, physiological data capture devices, or other sources • may be interactively customized, or tailored, to an individual user’s needs (Aronson, Marsch, & Acosta, 2013) 35
- 37. Technology-Assisted Care Interventions offer many advantages… 37
- 38. Technology-Assisted Care Interventions are flexible in their administration and their ability to provide automated and tailored information. (Moyer & Finney, 2004/2005; Fotheringham et al., 2000) 38
- 39. Allow for on-demand access to therapeutic support outside of formal care settings anytime/anywhere (Marsch, 2012) 39
- 41. Are Potentially Cost Effective (Marsch, 2012) 41
- 42. Facilitate Linkages to Services in One’s Community (Marsch, 2012) 42
- 43. TAC Interventions could increase RECEPTIVITY to care by serving as a proverbial “foot in the door” for clients who are uneasy about seeking SUD treatment. (Rummel & Joyce, 2010) 43
- 45. TAC Interventions can improve organizational capacity to provide evidence-based practices and thereby enhance the reach of EBPs (Marsch, 2012) 45
- 46. EBPs Administered via Technology- Assisted Care Interventions • Cognitive Behavioral Therapy • Community Reinforcement Approach • Contingency Management • Motivational Enhancement • Motivational Interviewing • Screening • Brief Intervention • Relapse Prevention
- 47. Encouraging evidence suggests positive treatment outcomes (Bickel et al., 2008; Carroll & Rounsaville, 2010) 47
- 48. A recent meta-analysis (n=2,340) demonstrated that nearly 2.5 times as many substance-users who received evidence-based psychosocial treatment achieved post-treatment and/or clinically significant abstinence, compared to those who received non-evidence-based or no psychosocial treatment. (Dutra et al., 2008) 48
- 49. Clinician turnover - 31% Clinical Supervisor turnover - 19% (Gardner et al, 2012) 49
- 50. In summary, professionals can view technology as a powerful partner in improving quality and productivity of behavioral healthcare (Marsch & Gustafson, 2013) 50
- 51. not THIS … … or THIS 51
- 52. Clinician Extenders (Bickel et al., 2008; Carroll & Rounsaville, 2010; Des Jarlais et al., 1999; Marsch, 2011) But this… 52
- 53. Module 3 TAC Interventions for SUD
- 55. Technology-Assisted Care Interventions have been developed to target Addictive Disorders including: • Alcohol Use • Tobacco Cessation • Gambling • Illicit Drug Use 55
- 56. In general, technology-based behavioral health interventions have been shown to be well accepted, efficacious, and cost effective, especially when compared to standard care. (Aronson, Marsch, & Acosta, 2013) 56
- 57. 57 Technology-Assisted Care Interventions have been validated recently through NIDA research TES and CBT4CBT
- 58. Therapeutic Education System (TES) An interactive, web-based psychosocial intervention for SUDs, grounded in: Community Reinforcement Approach (CRA) + Contingency Management (CM) 58
- 59. What Do People Say About TES? 59
- 60. Features of TES • Consists of 65 interactive, multimedia modules • Self-directed, evidence-based program with skills training, interactive exercises, and homework • Audio component accompanies all module content • Electronic reports of patient activity available • Contingency Management Component tracks earnings of incentives dependent on some defined outcome (e.g., urine results confirming abstinence) 60
- 61. TES modules can be broadly classified as: • Substance Use/Abuse (e.g., drug refusal skills, coping with thoughts about using, identifying/managing triggers) • Risk Reduction for HIV, AIDS & STIs (e.g., drug use, HIV and hepatitis, identifying/managing triggers for risky sexual behaviors) • Cognitive and Emotional Regulation (e.g., managing negative thinking, anger management) • Psychosocial Functioning (e.g., effective problem solving, communication skills) Optional modules provide more advanced information on risk reduction and psychosocial functioning 61
- 62. Prize-based incentives, virtual “fishbowl,” intermittent schedule of reinforcement TES Incentive System Based on: • Abstinence • Module Completion 62
- 63. To evaluate the effectiveness of including an interactive, web-based version of the Community Reinforcement Approach (CRA) plus incentives targeting drug abstinence and treatment participation as part of community-based, outpatient substance abuse treatment Primary Objective of CTN-0044: Multi-site Effectiveness Trial of TES 63
- 64. Study Design & Participant Flow 12 Weeks Within 30 days of CTP enrollment Screening N=1,781 Baseline N=523 Randomization N=507 TAU N=252 TES N=255 3-Mo Post Treatment Follow-up N=225 Ineligible N=850 Eligible/Not Interested N=130 Eligible/Didn’t attend BL N=278 Ineligible N=4 Failed to Return N=7 Declined N=3 Clinical Reasons N=2 3-Mo Post Treatment Follow-up N=224 6-Mo Post Treatment Follow-up N=228 6-Mo Post Treatment Follow-up N=231 Stratified by: a) Site b) Urine drug screen at baseline (positive vs. negative) c) Primary substance (Stimulants vs. Other) I) Primary OUTCOMES: a) Abstinence (illicit drugs/heavy drinking days) based on TLFB, urine drug screen b) Treatment Retention II) Secondary OUTCOMES: a) HIV Risk Behavior b) Psychosocial Functioning c) Treatment Acceptability TES Substituted for 2 hours of clinician time (Campbell et al., 2014)
- 65. doubled the odds of among clients who tested positive for substances upon entry into the study 65
- 66. improved retention (48% of TES clients stayed in Treatment for 12 months compared to 40% of TAU) 66
- 67. Findings suggest that can be substituted for a portion of face-to-face counseling and produce better outcomes (i.e., abstinence and retention). 67
- 68. CBT4CBT CBT4CBT is a computer-based version of cognitive behavioral therapy (CBT) used in conjunction with clinical care for current substance users Six modules and follow up assignments focus on key concepts in substance use, including cravings, problem solving and decision making skills The multimedia presentation, based on elementary level computer learning games, requires no previous computer experience.
- 70. CBT4CBT Study Design Randomized Controlled Trial: 77 Individuals Seeking Treatment in an Outpatient Setting Standard Treatment Standard Tx plus bi-weekly access to CBT4CBT
- 71. CBT4CBT Outcomes 71 • Participants assigned to the CBT4CBT condition submitted significantly more urine specimens that were negative for any type of drugs, especially cocaine and tended to have longer continuous periods of abstinence during treatment • The number of days abstinent was not significantly different between groups, nor was the retention rate between conditions. (Carroll et al., 2014
- 72. CBT4CBT was more positively evaluated by participants 72 (Carroll et al., 2014
- 73. Completion of homework assignments in CBT4CBT was significantly correlated with outcome and a significant predictor of Tx involvement. 73(Carroll et al., 2014
- 74. Conclusion CBT4CBT plus clinical practice is more effective in reducing drug use during treatment than standard therapy alone. 74(Carroll et al., 2014
- 75. Summary of TAC Interventions • Promising TAC Interventions exist to treat alcohol, tobacco, gambling, & illicit drug use • TES & CBT4CBT are two interventions that are currently leading the way • Clinicians & administrators need to think through how they can use these new technologies in clinical treatment 75
- 76. Activity #2 “Profiles” of Evidence-based TAC Interventions Group 1: CBT4CBT Group 2: Therapeutic Education System Review your assigned “profile” and prepare the following to be presented to the larger group: 1. Description of the intervention (how it works) 2. Key outcomes of particular interest to clinicians 3. Initial impressions of potential utility in care 76
- 78. I’m interested in using TAC interventions to enhance our services, but how would I go about integrating this type of intervention into the flow of clinical services? 78
- 79. “Models” of Integration for TAC Interventions • Brief Intervention - particularly in settings where SUD treatment services are limited (e.g., primary care settings [FQHCs], mental health, etc.) • Stand alone treatment - comprehensive service (up to 65 modules available) delivered over a structured period of time (e.g., 12 weeks) • Clinician extender - administered as an adjunct to treatment whereby clinicians “prescribe” TBIs (or portions of) to enhance therapeutic intervention. 79 Hasin et al., 2013; Ranney et al., 2014; Rose et al., 2010; Chaple et al., 2014, Chaple et al; in press Marsch et al., 2014; Campbell et al., 2014
- 80. TAC interventions may replace a portion of a clinician’s typical interaction with clients, which may allow a treatment provider: • to provide more treatment and treat more clients with the same number of clinicians • to free up clinicians to spend time with those with the greatest need for more intensive care • to more effectively manage high patient caseloads 80 Marsch et al., 2014; Campbell et al, 2014
- 81. Clinical Considerations for TAC • Integrating into the treatment plan – Use in individual therapy – Use in group therapy – Select relevant order and content of modules – Use for homework assignments • Orienting client to system, its purpose and use • Processing experience with clients • Documentation in progress notes • Tracking participation 81
- 82. TES Module Demonstration Substance Use Refusal Skills 82
- 83. Access TES Module Pair up or use your own laptop/tablet http://train.healthsim.com username: train1 to train20 password: train1 to train20 site ID: 1 Activity #3 83
- 84. TES Modules for Exercise Introduction to Behavior Chains Analyze Your Own Behavior Chains 84
- 85. Consider These Questions • How is the content clinically relevant to support the work you do? • How could this intervention be used to enhance what you do in clinical practice? • How could this intervention be used to offset some of the work that you do? • How might clients enjoy this technology? 85
- 87. The keyis to select TAC interventions that support the organization’s future strategy and add perceived value to customers – both consumers and payers (Adler, 2013) 87
- 88. Administrative Considerations • Reimbursement • Return on Technology Investments • Staff Turnover • Budgeting Considerations • Start-Up Costs • Ongoing Maintenance Costs • Privacy and Security • Implementation Strategies 88
- 89. While TAC Interventions are not currently reimbursable, they could provide a return by: • Reducing – the cost of service per unit – the cost of service per case • Improving – payer preference – consumer preference – operating performance – consumer outcome or functioning • Facilitating – a new consumer service – a new payer relationship (Adler, 2013) 89
- 91. Although reimbursement structures for technology-mediated services under both private and public health insurance plans are emerging, depending on State licensing and reimbursement policies providers may try to recapture their costs in other ways. 91(McGinty et al., 2006)
- 92. … the use of TAC interventions may be incorporated as a value-added service that assists providers in meeting other contractual obligations, such as the use of EBPs. For example … 92 (McGinty et al., 2006)
- 93. Budgeting Considerations • The costs associated with various types of technology-mediated interventions vary widely • Need to project for infrastructure development (startup) along with cost of ongoing maintenance • Investment in the initial infrastructure is costly and not typically reimbursable • As the use of technology to deliver health services explodes, States and payers are scrambling to establish regulations to keep pace (McGinty et al., 2006) 93
- 95. Equipment including computers, tablets, and servers95
- 96. Allocating and configuring space, cabling and other communications lines, building reconfiguration, equipment, and cooling systems 96
- 98. Legal and Liability Consultation (e.g., sufficient and explicit insurance coverage) 98
- 99. What does the TAC vendor provide? • Software – encryption systems, virus protection, applications, storage, and security systems • Consultation in technology • Content development – clinical materials, protocols, procedures that will support and guide implementation – informed consent forms and privacy disclosures • Initial staff training, including staff time, expert trainer time 99
- 100. Costs of Ongoing Maintenance • Equipment maintenance, insurance, and replacement costs • Ongoing internet provider fees • Annual licensing or hosting fees • Expert consultation and/or troubleshooting • Training for new staff and refresher training • Content refinement and updating of materials • Legal and accounting consultation • Inclusion of extra client data and client privacy/consent management information 100
- 101. Privacy, Security, & Confidentiality 101
- 102. Unique Considerations for TAC • Self-directed therapeutic websites/applications typically hosted by third-party vendors (HIPAA business agreement may be required) • Organizations will typically purchase a license for a group of clients, and the clients are each provided with a unique user ID and password (HIPAA compliant portal ask that question) • Applications vary in terms of data security and the amount of personal information entered (typically, personal information is not required) (Personal health information collected or not) 102
- 103. TES: An Example • Password protected for each participant • Self-directed via computer (no therapist) • Clinical information is not stored, participation is tracked (i.e., specific modules completed) • No personal information is collected • Transfer of information is not required • Clinician would merely document the use of TAC in the record (Tx plan, progress notes)103
- 104. CBT4CBT: An Example • Access to the CBT4CBT program was on a dedicated computer in a private room within the clinic • Research Assistant showed patients how to use program • Patients accessed the program through a log-in and password system to protect confidentiality • CBT4CBT is user friendly as no previous experience with computers or reading skills is necessary (i.e., material presented in text is also read by a narrator) • Collects NO protected private health information 104 (Carroll et al., 2014)
- 105. Module 6 Adoption & Implementation
- 106. Implementing New Practices Adoptionis the process of deciding whether to use an innovation, which may or may not lead to implementation. Implementationis the incorporation of an innovation into routine practice. • ideally includes a range of strategies designed to address individual, organizational, and systemic characteristics 106
- 107. Adoption/Implementation Process • Some organizations struggle with the implementation of EBPs. Diffusion of an innovation is a slow process (up to 17 years) and success varies (Balas & Boren, 2000). • Lack of understanding of organizational context – effective interventions are not necessarily generalizable to other settings. • Need to carefully examine & account for interacting contextual variables (e.g., work setting, organizational culture) that could potentially impact implementation efforts. • Theoretical models have been developed to help guide and evaluate implementation efforts. 107
- 108. Comprehensive Framework • Intervention Characteristics (evidence strength and quality, relative advantage, adaptability, complexity, cost) • Outer Setting (patient needs and resources, peer pressure, external policy and incentives) • Inner Setting (organizational structure, culture and climate; compatability, relative priority, and organizational incentives) • Characteristics of Individuals (self-efficacy, individual stages of change, identification with organization, personal attributes) • Processes (planning, staff engagement, execution, evaluation) (CFIR; Damschroder et al., 2009) 108
- 109. 3 Diffusion of Innovation Constructs • Relative Advantage • Complexity • Compatibility Most relevant constructs to technology adoption research 109 (Van Slyke et al., 2004; Corneille et al., 2014) (Rogers, 1995)
- 110. DOI Construct Definitions (Van Slyke et al., 2004; Corneille et al., 2014) Relative advantage refers to the belief that a new system has benefits above and beyond the current system. Someone who believes that a text message based intervention is more useful than existing interventions will be more likely to adopt this innovation. Complexity refers to perceptions of difficulty associated with adopting a system. Someone who believes that a text-message based intervention will be easy to use will be more likely to accept this technology. Compatibility posits that one will be more likely to adopt an innovation if it is consistent with his values, views, beliefs, and customs. Someone who uses her mobile phone to participate in other electronic services (view banking information, receive promotional notices) will be more likely to adopt a TAC program. 110
- 111. Activity #4 Discuss the 3 DOI constructs relating to technology adoption 111 Break into Small Groups
- 112. 112 (Rogers, 1995) Use these questions as a guide for your discussion… • What advantages would TES and CBT4CBT provide to your organization? • Do TES and CBT4CBT seem easy to use? • How well would TES and CBT4CBT fit into your agency’s existing treatment model, including your culture and values?
- 113. 113
- 114. ATTC Network Coordinating Office 10 Regional Centers 2012 – 2017
- 115. National Frontier & Rural ATTC National American Indian & Alaska Native ATTC National SBIRT ATTC National Hispanic & Latino ATTC 4 ATTC National Focus Centers
- 116. www.nfarattc.org 116
- 117. 117
- 118. 118
- 119. SUDTECH.ORG 119
- 120. 120
- 121. Center for Technology and Behavioral Health 121
- 122. 122
- 123. Treatment Improvement Protocol (TIP) XX Using Technology-Based Therapeutic Tools in Behavioral Health Services Coming Soon… U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 123
Editor's Notes
- Ask each participant to read through the list and identify and count how many of the behaviors listed they have participated in. Report out in introductions.
- About 87% of Americans currently use the Internet at least occasionally. However, there are people who live in rural and remote areas that at times have difficulty accessing it. Terms like the “broadband divide” mean that some people still do not have access to the Internet, which is an issue. Source: Fox, S. & Rainie, L. (2014). The Web at 25 in the U.S. Pew Research Center’s Internet & American Life Project.
- According to a report published by the Pew Research Center, 91% of American adults have cell phones and 58% of the population in the US have smart phones Source Fox, S. & Rainie, L. (2014). How the internet has woven itself into American life. Pew Research Center’s Internet & American Life Project.
- The Digital Consumer Report (2013) found that Americans on average own at least four technology devices. Ask participants how many tech devices they own (e.g., iPods or MP3 players; smart phones, computers, laptops, tablets, phones, etc.). Once again, the point is that the use of technology devices is increasing and customers will expect (or demand) that technology options be available to address both administrative and clinical issues in behavioral health treatment. Some participants may ask questions about data on the tech devices owned and used by clients. Recently, a study conducted with eight treatment clinics in inner city Baltimore found that clients did have access to tech devices, with the most common being a cell phone. Although most clients did not have smart phones, well over a third had access to the Internet through computers (McClure, Acquanta, Harding, & Stitzer, In Press). In addition, this study found that a majority of clients used cell phones for text messaging. Source: McClure, E., Acquavita, Harding, E., Stitzer, M. (2012). Utilization of communication technology by patients enrolled in substance abuse treatment. Drug and Alcohol Dependence, 129(1-2), 145-50. Nielsen. (2014). The Digital Consumer Report. Retrieved from http://www.nielsen.com/us/en/reports/2014/the-us-digital-consumer-report.html
- As indicated in the slide, 35% of American adults have gone online to try to figure out what medical condition they may have. In an online heath survey conducted by the Pew Research Center, those that searched the Internet for answers were dubbed “online diagnosers.” Also noted in the survey, in the past year 59% of American adults searched online for health information; 53% talked to a clinician about what they found online and; 41% of the online diagnosers had their condition confirmed by a clinician. Source: Fox, S. & Duggan, M., (2013). Health Online 2013. Pew Research Center’s Internet & American Life Project.
- To be discussed in a large group Electronic Medical Records, telephone, email, online resources, etc. Have participants look at both the positives and the negatives of using technology in the workplace Wrap up activity and module summarizing the positive and negative aspects of using technology, emphasizing that these methods are here to stay and are being adopted more and more and therefore we should be focusing our energy on how to most efficiently and comfortably incorporate these technological tools into the everyday flow of our work
- According to the National Survey on Drug Use and Health (NSDUH, 2011), more than 20.6 million people aged 12 or over met the criteria for substance use disorders. 95%, or 19.2 million, did not feel they needed treatment, and 3% felt they needed treatment but did not make an effort to get it. This is an important issue to discuss and reflect upon as a significant amount of people met the criteria for substance use disorders (almost 20 million) but didn’t feel like they needed treatment. Is this due to the stigma that still exists regarding addiction treatment; lack of access to treatment; the costs and hassles related to attending treatment, or other barriers? Nonetheless, there are a number of factors that serve as barriers to individuals accessing treatment services. Source Substance Abuse and Mental Health Services Agency (SAMHSA). (2011). The NSDUH Report: Alcohol treatment: Need, utilization, and barriers. Rockville, MD.
- What are some barriers that keep clients from treatment? Facilitate as a group discussion All of these involve access to care.
- What are some program barriers to providing evidence-based practices including TBIs? Facilitate as a group discussion
- When we talk about access to the internet, we need to look at what clients have access to. The data presented here are from a recent study that examined technology use among clients in urban drug treatment clinics in Baltimore. 266 patients were surveyed regarding their access to technology 91% had access to a mobile phone (in this particular study the mobile phones were most often the prepaid/disposable type) 79% of these particular patients did text messaging a much smaller rate had access to the Internet, email, or a computer This is important to keep in mind when we are thinking about telehealth and how to expand access for clients. Also important to keep in mind these data were collected a few years ago, so, like all other technology use, it is probable that these rates have increased since then. Source McClure, E., Acquavita, Harding, E., Stitzer, M. (2012). Utilization of communication technology by patients enrolled in substance abuse treatment. Drug and Alcohol Dependence, 129(1-2), 145-50.
- Carroll & Rounsaville (2010) in their journal article suggested that Cognitive Behavioral Therapy (CBT) could be delivered by computer (subcontracted to the computer), which would allow providers to save clinician time while still providing clients with exposure to an evidence-based practice or approach. While this comment might have been made in a ‘tongue and cheek’ manner it is important for treatment providers to consider this idea. This would allow the client to spend more time practicing a particular counseling skill when the clinician may not be available. Note to Trainer We chose this picture because back in the day when computers were new and very large no one considered that one day more powerful computers could fit in the palm of your hand. The same may be true regarding the use of computer-based interventions in SUD treatment. Source Carroll, K.M. & Rounsaville, B.J. (2010). Computer-assisted therapy in psychiatry: Be brave-It’s a new world. Current Psychiatry Reports, 12, 426-432.
- There is extensive literature showing the use and effectiveness of computer-based interventions in other disciplines. Computer-delivered therapy is a computer-based media that provides users with information designed to supply therapeutic treatment Currently, there are computer-based interventions that are downloaded as software on individual computers at treatment sites. However, more recently, most computer-based interventions are accessed through a web portal that includes a log-in. Treatment providers buy a licensing fee and then give clients access to these interventions while receiving services at a treatment program. Soon this term will subsumed and everything will be called web-based interventions using different platforms or devices (computers, mobile phone, and tablets). Think of it this way - right now your bank probably offers online banking. How you conduct online banking using whatever tools you have available doesn’t matter. The issue is that you can do your banking online. Source Carroll, K.M. & Rounsaville, B.J. (2010). Computer-assisted therapy in psychiatry: Be brave-It’s a new world. Current Psychiatry Reports, 12, 426-432.
- Computer based intervention programs have been around for some time and used to treat a variety of physical and mental health disorders (e.g., cancer, diabetes, heart disease depression, anxiety, poor nutrition, and sexual risk behaviors) with positive outcomes (Klein, et al., 2012; Moore, et al., 2011). However, the literature for using computer-based interventions to treat substance use disorders is more recent. (See the reference section for full citations). Cancer - Gustafson, D. H., McTavish, F. M. et al. (2005). Diabetes - Glasgow, R. E., Nutting, P. A. et al. (2005); Williams, G. C., Lynch, M. et al. (2007); Montani, S., Bellazzi, R. et al. (2001). Heart Disease - Verheijden, M., Bakx, J. C. et al. (2004) Mood Disorders - Farvolden, P., Denisoff, E. et al. (2005) Depression/Anxiety - Cavanagh, K., & Shapiro, D. A. (2004); Kaltenthaler, E., Parry, G. et al. (2008); Reger, M. A. & Gahm, G. A. (2009); Spek, V., Cuijpers, P. et al. (2007) Poor Nutrition - Portnoy, D. B., Scott-Sheldon, L. A. J. et al. (2008) Sexual Risk Behaviors - Ybarra, M. L., & Bull, S. S. (2007); Marsch L. A. & Bickel W. K. (2004) Sources Klein, A.A. et al. (2012). Computerized continuing care support for alcohol and drug dependence: A preliminary analysis of usage and outcomes. Journal of Substance Abuse Treatment, 42, 25-34. Marks, I.M., Cavanagh, K., & Gega, L. (2007). Computer-aided psychotherapy: Revolution or bubble? The British Journal of Psychiatry, 191(6), 471-473. Moore, B.A., Fazzino, T., Garnet, B., Cutter, C.J., & Barry, D.T. (2011). Computer-based interventions for drug use disorders: A systematic review. Journal of Substance Abuse Treatment, 40, 215-223.
- TBI’s can be placed on a variety of devices!!!
- Most computer-based interventions have the capability to tailor their programs to meet each clients’ specific treatment or recovery needs. This is based upon clients’ responses to educational materials included as part of the community-based intervention. For example, a client is working on a module on drug refusal skills and based upon their responses to various questions and exercises the computer program will change accordingly to provide another review or educational activity on drug refusal skills or will move the client on to the next module. Source Moyer, A. & Finney, J. (2004/2005). Brief interventions for alcohol problems: Factors that facilitate implementation. Alcohol Research and Health, 28(1), 44-50. Fotheringham, M., Owies, D., Leslie, E., & Owen, N. (2000). Interactive health communication in preventive medicine: Internet-based strategies in teaching and research. American Journal of Preventive Medicine, 19(2), 113-120.
- Can be customized to include
- There is encouraging evidence that suggests positive treatment outcomes with computer-based interventions, which will be reviewed in this training
- Clinicians often feel overloaded, which may lead to increased staff turnover. TBIs could free up some clinician time, improving their job satisfaction and potentially longevity
- Serve as adjuncts to standard treatment Save clinician time Extend clinician expertise Integrate other EBPs to provide additional services to clients with co-morbid conditions Provide access to computerized smoking cessation programs or other health-related conditions Given the difficulty of being trained in every single EBP, Computer-based Interventions can help save clinician time and extend their expertise. For example, most addiction treatment provides need to concurrently address clients use of nicotine while in substance abuse treatment. The following data supports that point: Many computer-based interventions are designed to serve as an adjunct to treatment services, thereby extending the work of the clinician. For example, a computer-based intervention may be used instead of a group counseling session. The client works on a module, learns about drug refusal skills and practices them through a series of learning experiences rather than attending the group session. This allows the counselor to spend their time with clients who may be dealing with other more pressing problems or issues that require their immediate attention. The term clinician extenders appears in journal articles authored by Lisa Marsch, Warren Bickel, and Kathy Carroll. This is about helping counselors, not replacing them, as well as enhancing treatment services. The anonymity of this approach might be appealing to some individuals when dealing with substance abuse and other risk behaviors. These tools can have a significant public health impact by reaching frontier and rural areas, and may be used in a wide variety of settings such as: Web-based interventions offered in the home Community organizations Schools Emergency rooms, Health care providers’ offices Mobile devices Source Bickel, W.K., Marsch, L.A., Buchhalter, A.R., & Badger, G.J. (2008). Computerized behavior therapy for opioid-dependent patients: A randomized controlled trial. Experimental and Clinical Psychopharmacology, 16(2), 132-143. Carroll, K.M. & Rounsaville, B.J. (2010). Computer-assisted therapy in psychiatry: Be brave-It’s a new world. Current Psychiatry Reports, 12, 426-432. Des Jarlais, D.C., Paone, D., Miliken, J. et al. (1999). Audio-computer interviewing to measure risk behaviour for HIV among injecting drug users: A quasi-randomised trial. Lancet, 353(9165), 1657-1661. Marsch, L. (2011). Technology-based interventions targeting substance use disorders and related issues: An editorial. Substance Use & Misuse, 46(1), 1-3.
- The remainder of this module presents an overview of the available literature on the available technology-based interventions for alcohol use, tobacco cessation, gambling and illicit drug use. We focus on those with empirical evidence and that have been rigorously tested.
- The Community Reinforcement Approach (CRA) is a comprehensive behavioral program for treating substance-abuse problems. It is based on the belief that environmental contingencies can play a powerful role in encouraging or discouraging drinking or drug use. Consequently, it utilizes social, recreational, familial, and vocational reinforcers to assist consumers in the recovery process. Its goal is to make a sober lifestyle more rewarding than the use of substances. Although CRA has been cited among approaches with the strongest evidence of efficacy, very few clinicians who treat consumers with addictions are familiar with it. Cognitive behavioral therapy (CBT) is a psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviors and cognitive processes through a number of goal-oriented explicit and systematic procedures. This technique acknowledges that there may be behaviors that cannot be controlled through rational thought. Thus, CBT is “problem focused” (undertaken for specific problems) and “action-oriented” (therapist tries to assist the client in selecting specific strategies to help address those problems). Contingency Management is a strategy used in behavioral health treatment to encourage positive behavior change in patients (e.g., abstinence) by providing reinforcing consequences when patients meet treatment goals and by withholding those consequences (or providing more punitive measures) when patients engage in the undesired behavior (e.g., drinking or drug use). Positive consequences of abstinence may include receipt of vouchers that are exchangeable for retail goods, whereas negative consequences may include the withholding of those same vouchers or in some instances the loss of previously obtained rewards. By most evaluations, contingency management procedures produce some of the largest effect sizes.
- Clients can earn draws based on the number of urine toxicology tests that come back negative and/or the number of TES modules completed. This can be customized for each program and can be run without incentives as well. For more on information on motivational incentives, refer to the PAMI blending product: http://www.attcnetwork.org/explore/priorityareas/science/blendinginitiative/pami/ Note: Prior research has generally shown that this kind of incentive system is not a trigger for those with gambling disorders (Petry, ref)
- Add description of CRA and CM After a number of studies demonstrated the efficacy of TES in a variety of settings, NIDA’s Clinical Trials Network funded an effectiveness trial to see how TES could be used in clinical practice. The primary objective of the trial, known as CTN-0044, was to evaluate the effectiveness of including TES as part of outpatient substance abuse treatment.
- Emphasize that the effect of TES was greater among patients who tested positive for substances at baseline whereas TES was equally effective to TAU in clients who were abstinent at baseline. This suggests that TES was most effective with those clients that presented with more challenges/active use.
- Emphasize that the effect of TES was greater among patients who tested positive for substances at baseline whereas TES was equally effective to TAU in clients who were abstinent at baseline. This suggests that TES was most effective with those clients that presented with more challenges/active use.
- CTN Ancillary Study Results: Explored acceptability among a sample of 40 AI/AN enrolled in 2 outpatient treatment programs. Results show overall good acceptability, with highest ratings for modules addressing STDs and drug use triggers. Client feedback suggested modifications, such as using more native language or slang, references to spirituality and the natural world, and native actors. Assessed the influence of practitioner attitudes & norms on intention to use web-based interventions. Results show that social norms are the primary influence on intention to use while workforce and organizational variables had little influence on counselor intentions. Results suggest that social normative interventions are needed to support adoption of new technologies. Findings from other TES Studies: Among a sample of outpatients with opioid dependence, computer-assisted CRA with vouchers produced similar abstinence weeks and longer continuous abstinence than therapist-administered CRA with vouchers (Bickel et. al., 2008). TES was demonstrated to be an effective adjunct to HIV prevention education for youth in substance abuse treatment (i.e. TES plus counseling produced greater 12-month abstinence than counseling alone) (Marsch et al., 2011) Administered in prison to substance abusing offenders, TES was as effective as standard treatment in: reducing drug use, HIV risk, and self-reported criminal behavior at 3- and 6-months post-release; reducing recidivism at 12-months post-release; and greater reported treatment satisfaction and completion (Chaple et al., 2013; 2014)
- Carroll, K.M., Ball, S.A., Martino, S. Nich, C., Gordon, M.A., Portnoy, G.A. & Rounsaville, B.J. (2008). Computer-assisted delivery of cognitive behavioral therapy for addiction: A randomized trial of CBT4CBT. The American Journal of Psychiatry, 165:7, 881-889. PMCID: PMC2562873. Carroll, K.M., Ball, S.A., Martino, S., Nich, C., Babuscio, T. A. & Rounsaville, B.J. (2009). Enduring effects of a computer-assisted training program for cognitive behavioral therapy: A six-month follow-up of CBT4CBT. Drug and Alcohol Dependence, 100, 178-181. PMCID: PMC2742309
- Segway to demonstrations and clinical integration discussion
- Groups review detailed profiles of TES or CBT4CBT. Within each group discuss the intervention, how it works, the key outcomes of particular interest and impressions of potential utility in standard practice
- Trainer will walk through the drug refusal skill module. Demonstrate login and navigation through the module. Cover as much as possible, walking through as many of the features of the system as reasonable (e.g., audio, video, learning exercises, etc.). Use audio to hear narration and video dialogue. Navigate through ending questions and competency activity. Explain that questions are repeated, are presented more quickly and change order to ensure comprehension. This guided learning approach has been shown to be effective and comes from learning theory. TES uses “fluency-based” Computer-Assisted Instruction (CAI), grounded in the “precision teaching” approach (e.g., Binder, 1993) to assess a patient’s grasp of the material and adjust the pace and level of repetition of material in order to promote mastery of the skills and information being taught.
- Let people know that there may be buffering issues - Participants work independently or in pairs, sharing devices when needed. Trainer walks around to help those who need it. Display next slide for questions people should consider while navigating the module
- Conduct this exercise with both the recently viewed modules and videos in mind. Both should provide the necessary context for participants to comment on the potential utility of TES/TBIs.
- ALTHOUGH, there are some private insurers that are paying for it and some state agencies are contracting for these types of services, there is increased public demand. Customer demand is starting to drive telehealth technologies which in turn is changing how insurance companies reimbursement policies. According to an article posted by the Wall Street Journal, “Virtual doctor visit services—which connect the patient form their homes with physicians whom they meet via online video or phone—are moving into the mainstream, as insurers and employers are increasingly willing to pay for them.” Source Mathews, A.W., Wall Street Journal (Online), New York, N.Y. December 21, 2012
- ***NEED A TRAINER NOTE***
- Each provider is different, so users should check on what the vendor provides in each of these areas
- In the past this is how we thought about protecting Patient Health Information (The federal confidentiality rules and regulations require that patient treatment records be kept in a locked room inside a locked file cabinet ensuring that the general public does not have access). When considering the use of telehealth technologies, it is important to understand that both HIPAA Rules on Privacy and Security, and the Federal Confidentiality Rules and Regulations 42 CFR Part 2 apply. Addiction treatment providers must be adhere to both the Federal Confidentiality Rules and Regulations and HIPAA Privacy and Security Act, complying with the more stringent of the two codes whenever the codes differ, or in other words, whatever regulations provides the patient with the most privacy. Note to Trainer The following identifies resources that participants can access that compares 42 CFR Part 2 to the HIPAA Privacy and Security Rules, and the use of 42 CFR Part 2 with Health Information Exchanges. These resources may be shared with the participants at a break if need be, but are not part of the topics covered in this presentation. SAMHSA has a well written document that compares the two. That document, The Confidentiality of Alcohol and Drug Abuse Patient Records Regulation and the HIPAA Privacy Rule: Implications for Alcohol and Substance Abuse Programs (2004) can be found at http://www.samhsa.gov/HealthPrivacy/docs/SAMHSAPart2-HIPAAComparison2004.pdf. More recent documents include two FAQ sheets: Applying the Substance Abuse Confidentiality Regulations http://www.integration.samhsa.gov/financing/SAMHSA_42CFRPART2FAQII_-1-,_pdf.pdf Applying the Substance Abuse Confidentiality Regulations to Health Information Exchange (HIE) http://www.samhsa.gov/healthPrivacy/docs/EHR-FAQs.pdf.
- Changing practices to incorporate telehealth technologies – or any other new practice – is multi-level and multi-faceted. Not only do organizations need to have a commitment and shared resolve for change and an effective strategy for managing the change process, organizations need to pay attention to the components of adoption and implementation of a telehealth technology. The new field of implementation science studies the effects of individual, organizational, and systemic characteristics on the process of implementation of new programs or practices. There is now an open source (free access) online journal called “Implementation Science” that is devoted to this type of research.
- Many organizations struggle with the implementation of Evidence-Based Practices (EBPs). In fact, research has frequently demonstrated that diffusion of an innovation is a slow process (up to 17 years) and success varies (Balas & Boren, 2000). Much of the difficulty stems from a lack of understanding of organizational context—an intervention shown to be effective in one unit is not necessarily generalizable to other settings. The complexity of healthcare delivery stresses the need to carefully examine and then account for interacting contextual variables (e.g., work setting, organizational culture) that could potentially impact implementation efforts. A number of theoretical models have been developed to help guide and evaluate implementation efforts.
- Relative advantage refers to the belief that a new system has benefits above and beyond the current system. Someone who believes that a text message based intervention is more useful than existing interventions will be more likely to adopt this innovation. Complexity refers to perceptions of difficulty associated with adopting a system. Someone who believes that a text-message based intervention will be easy to use will be more likely to accept this technology Compatibility posits that one will be more likely to adopt an innovation if it is consistent with his values, views, beliefs, and customs. Someone who uses her mobile phone to participate in other electronic services (view banking information, receive promotional notices) will be more likely to adopt a TAC program
- See next slide for questions for this activity related to relative advantage, complexity and compatibility.
- As you’ve seen, the web site is a great resource for you to become more familiar with technology-based interventions, including videos, literature reviews and demonstrations of various technologies for substance abuse treatment. (Show different tabs and what’s included as needed)