Uvu hamblin 2015_presentation_for_posting

Telehealth Technologies:
The Portal to Expanding Treatment &
Recovery Services
Terra Hamblin, MA, NCC, DCC

ATTC Network
Coordinating Office
10 Regional Centers

National
Frontier & Rural
ATTC
National
American Indian & Alaska Native
ATTC National
SBIRT
ATTC
National
Hispanic & Latino
ATTC
4 ATTC National Focus Centers

SERVE
as the national subject expert
and key resource to PROMOTE
the awareness and
implementation of
telehealth technologies.

PREPARE
pre-service addiction
treatment and allied health
students on using telehealth
technologies by developing
and disseminating academic
curricula for infusion into
existing courses.

CREATE
addiction treatment telehealth
competencies and develop
policy recommendations for
national license portability to
encourage the addiction
treatment and recovery
workforce to ADOPT the
use of telehealth services.

USE
state-of-the-art culturally-relevant
training and technical assistance
activities to help the frontier/rural
addiction treatment and recovery
workforce IMPLEMENT
telehealth services.

What would you
say if you could….

….easily expand your Treatment
services?

….provide supportive services to your
patients 24/7?

….expand the reach of your Treatment
services?

….provide patients with additional
personalized feedback?

….clinically fill some of the hours for your
intensive outpatient patients?

….help patients increase their knowledge
about their chronic condition (SUDs)

.…connect your patients with other
patients with similar conditions outside of
the treatment provider

….ensure that patients had the time to really learn
about relapse and relapse prevention strategies

Presentation Outline
• Technology and the General Public
• Use of TAC Interventions
• Characteristics of TACs
• TACs in Other Systems of Care
• Utility of TACs
• Research on TACs
• Administrative Issues
• Conclusion
• Resources

Expose participants to
Technology Assisted Care
interventions and
showcase two
interventions validated
recently through NIDA

Technology has invaded our lives…. and
our profession

… and it’s Creeping into clinical practice
(Mishna et al., 2012)

87%of Americans
use the Internet
(Fox & Rainie-Pew Report,2014)

90% of American adults
have cell phones
58% have smart phones (Pew Report, 2012)

No matter a person’s salary…. more people
OWN cell phones than USE the internet
(Fox, 2013)

29% of Americans own a tablet
The average American owns
FOUR technology devices(Digital Consumer Report, 2013)

80%send and receive
text messages
(Pew Report, 2012)

Perpetual texters….
• adolescents (aged 13–17) sending or receiving
3,339 texts a month(six texts per waking hour)
• young adults (aged 18–24) sending or
receiving 1,630 (three texts per waking hour)

(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?

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.

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

To date, more than 100
different computer-assisted therapy
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)

Encouraging evidence
suggests positive
treatment outcomes
(Bickel et al., 2008; Carroll & Rounsaville, 2010)

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)

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)

“The Rise of TAC
is supported by the
number studies
NIDA and SAMHSA
are collaborating on
to assist SUD
treatment programs
in adopting and
implementing TACs.”
(Campbell, A. 2014)

CHARACTERISTICS
of TAC Interventions…

TAC 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

Are Cost Effective
Marsch, 2012

TACs are flexible by providing
automated and tailored information
(Moyer & Finney, 2004/2005; Fotheringham et al., 2000)

Transcend Geographical
Boundaries
Marsch, 2012

Facilitate Linkages to Services
in One’s Community
Marsch, 2012

With TACs, clinicians have
the opportunity to extend their reach by offering
additional resources and
support outside of ‘normal clinic hours’

TACs could serve as a proverbial
“foot in the door” for clients who are
uneasy about seeking SUD treatment
(Rummel & Joyce, 2010)

TACs may also be offered as stand-alone
interventions, which may be particularly
relevant in rural or other settings where
access to care may be limited

Utility
of TAC Interventions…

Could they help Increase the Number of
Individuals Entering SUD Treatment?

3.3%
19.3 million people needed but did not receive treatment
for illicit drug or alcohol use
Did not feel
they needed
treatment
(NSDUH, 2011)
In 2011, 20.6 million people aged 12 or older met
the criteria for substance use disorders
Felt they needed
treatment – Did not
make an effort
Felt they needed
treatment – Did
make an effort

Reasons why people
don’t enter treatment…
• alcohol treatment is “only for real alcoholics”
• “treatment wouldn't work for me”
• “treatment would hurt my career”
• not believing that the problem was serious enough
for treatment
• believing that they should be able to handle the
problem on their own
• believing the problem would get better on its own
• liked to drink too much to quit
Stecker, McGovern, & Herr, 2012

• Worried about feeling discomfort in
treatment, including both physical and
psychological discomfort- (e.g., dying
from withdrawals, having to face old trauma,
trusting someone new, etc.)
• Fears about admitting that they had a
problem with alcohol (i.e., “Everyone would
be surprised to learn that I had a drinking
problem”) Stecker, McGovern, & Herr, 2012

TACs….
Could help providers implement EBPs

A recent meta-analysis (n=2,340) demonstrated
that nearly 2.5times 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 psychosocial treatment
or no psychosocial treatment
Dutra et al., 2008

Some EBPs are Complex……
require considerable staff training

And Include
Issues related to
Fidelity and
Supervision…

Costs Associated with EBPs….
Staffing, Equipment, Incentives

Structuring/Scheduling treatment sessions
according to EBPs when….
Travel to treatment may decrease
treatment participation

Examples of EBPs Used by TACs
• Cognitive Behavioral Therapy
• Community Reinforcement Approach
• Contingency Management
• Motivational Enhancement
• Motivational Interviewing
• Brief Intervention
• Screening
• Relapse Prevention

TAC Interventions
• 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
cessations programs or other health-related
conditions
(Carroll & Rounsaville, 2010)

“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.)
Could improve motivation and/or readiness?
• 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” TACs (or
portions of) to enhance therapeutic intervention.

TACs are Embedded Within Other Systems
• Medical Settings
– emergency rooms
– primary care offices
– health clinics
• Criminal justice Settings
– probation and parole offices
– jails
– prisons
• Educational Settings
– colleges
– schools

Public Schools- SBIRT- Web-Based
Curtis, McLellan, & Gabellini, 2014

TACs to Reduce College Student Drinking
Carey et al., 2012

Emergency Rooms- Using IVR or
Web-based SBIRT
Choo et al., 2012

Prison Settings
• TES-Computer-based Intervention
– TES used in 10 prisons in 4 states
(Chaple, 2012; Blenko, 2012; & Chaple et al. 2013)
• MAPIT-Computer-based Intervention
(Walters et al., 2014)

TACs in different settings…
• CBT4CBT (Carroll et al., 2008)
• Outpatient clients
• CBT + 6 computer modules on CBT
• TES [Therapeutic Education System] (Marsch & Bickel, 2004)
• Community Reinforcement Approach + Incentives
• HIV/AIDS Intervention-Opioid treatment clients (2004)
• Outpatient Opioid Treatment- TAU + TES (2008)
• Outpatient Treatment-2hrs per week of TES + TAU (2012)
Outpatient Opioid Treatment (2014)
• Ondersma (2005/2007)
• single-session computer-delivered MI intervention reduced drug
use among postpartum women

Web-Based Support Groups
• http://aa-intergroup.org
• www.AlcoholHelpCenter.net
• www.smartrecovery.org
• http://www.cyberrecovery.net/forums
• http://www.addictiontribe.com
• www.NAChatroom.org

Podcasts/Radio Shows
• www.12stepradio.com
• https://itunes.apple.com/us/podcast/aa-on-air-
wellington/id465173613?mt=2
• https://itunes.apple.com/us/podcast/smart-
recovery-podcasts/id433764979?mt=2
• https://itunes.apple.com/us/podcast/online-
recovery-support/id317380341?mt=2
• https://itunes.apple.com/us/podcast/getting-to-
recovery/id455357559?mt=2

Computer Simulation Games
• Male Veterans
– adjunct to treatment
– focused on relapse prevention
– Played computer simulation game for 8 weeks
– no different in relapse rates
– results show decreases in craving and
increases in self efficacy
(Verduin et al., 2012)
Guardian Angel

Examples of Web-based Screeners
• Drinkers Checkup
http://drinkerscheckup.com
• Moderate Drinking
http://www.moderatedrinking.com
• Rethinking your Drinking
http://rethinkingdrinking.niaaa.nih.gov
• Check your Drinking
www.checkyourdrinking.net

Web-Based Screeners for College Students
• www.CheckYourDrinkingU.net
• www.eCHUG.com
• http://www.collegebingedrinking.net

Alcohol-Comprehensive Health
Enhancement Support System
(ACHESS)
Theoretical Design
(Self Determination Theory)
RCT Results: Reduced number of
Risky Drinking days by half and
increased the odds of total
abstinence
Available commercially soon

ACHESS
The ACHESS intervention is explicitly designed to
address the three constructs
– coping competence
– social support
– autonomous motivation
Primary hypothesis is that ACHESS will reduce
risky drinking days

ACHESS employs these concepts in the
following ways to prevent relapse
1. develop/maintain autonomous motivation
to prevent relapse (autonomy
supportiveness)
2. offer resources to cope with pressures to
relapse, e.g., cravings, withdrawal
symptoms, high risk situations (competence)
3. provide access to social support to
persevere (relatedness)
(Gustafson, et al., 2011)

ACHESS
• Monitoring and alerts
• Reminders
• Autonomous motivation
• Assertive outreach
• Care coordination
• Medication reminders
• Peer & family support
• Relaxation
• Locations tracking
• Contact with professionals
• Information

Boston University Slideshow Title Goes Here
C.A.S.A. CHESS
Comunicando
A través de
Smartphone
Apoyo

Technology-Assisted Care Interventions
have been validated recently through
NIDA research

Therapeutic Education System (TES)
An interactive, web-based psychosocial
intervention for SUDs, grounded in:
Community Reinforcement Approach (CRA)
+
Cognitive Behavioral Therapy (CBT)
+
Contingency Management (CM)

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)

Prize-based incentives, virtual fishbowl,
intermittent schedule of reinforcement
TES Incentive System
Based on:
• Abstinence
• Module Completion

TES doubled the odds of
abstinence among clients who
tested positive for substances

TES improved retention
(48% of TES clients stayed in Treatment
for 12 months compared to 40% of TAU)

Findings suggest that TES can be substituted
for a portion of face-to-face counseling and
produce better outcomes
(i.e., abstinence and retention)

Other TES Findings
In outpatients with opioid dependence, computer-administered
CRA with vouchers produced similar abstinence weeks and longer
continuous abstinence than therapist-administered CRA with
vouchers and reduced therapist time.
(Bickel et al., 2008)

Other TES Findings
• For youth in substance
abuse treatment, TES was
an effective adjunct to HIV
prevention education
(Marsch et al., 2011)
• In MMTP program, TES plus
counseling produced greater
12-month abstinence than
counseling alone
(Marsch et al., 2011)

In a prison population, TESwas as effective as standard
treatment in reducing drug use, HIV risk and self-reported
criminal behavior at 3- and 6-months post-release and
resulted in greater treatment satisfaction and completion
(Chaple et al., 2013)

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.

CBT4CBT was more positively
evaluated by participants

Completion of homework assignments in
CBT4CBT was significantly correlated with
outcome and a significant predictor of Tx
involvement.

Conclusion
CBT4CBT plus clinical practice is more
effective in reducing drug use during
treatment than standard therapy alone.

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)

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)

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.

… 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 …

Equipment
including computers, tablets, and servers

Allocating and configuring space,
cabling and other communications
lines, building reconfiguration,
equipment, and cooling systems

Legal and Liability Consultation
(e.g., sufficient and explicit insurance coverage)

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 & expert
trainer time

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

Privacy, Security, & Confidentiality

Unique Considerations for TACs
• 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)

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)

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
(Carroll et al., 2014)

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

“Delivery of CBT could be subcontracted to the
computer…..”
(Carroll & Rounsaville, 2010)

TACs may replace a portion of clinician’s
typical interaction with clients which may
allow a treatment provider
• to treat more clients with the same number of
clinicians
• free-up clinicians to have more time to manage
client crises or spend more time with those with the
greatest need for more intensive care.
• more effectively manage high patient caseloads

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

Clinician
Extenders
(Bickel et al., 2008; Carroll & Rounsaville, 2010; Des
Jarlais et al., 1999; Marsch, 2011)

Professionals will need to view technology
as a powerful partner
in improving quality and productivity of
behavioral healthcare Marsch & Gustafson, 2013

Whether its Group Counseling
Like This or Like This

or Client Homework
Like This
or Like This

TACs are in Clients’Best Interest
Expanding
Access
Enhancing
Treatment Services

Center for Technology and Behavioral Health

Treatment Improvement Protocol (TIP)
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

The vital question for this field is
not
“Do computer-assisted therapies work?”
but…..
(Kiluk et al., 2011)

“which specific computer-assisted
therapies, delivered under what
conditions to which populations,
exert effects that approach or
exceed those of standard
clinician-delivered therapies”?
(Kiluk et al., 2011)

Thank you
National Frontier and Rural ATTC
nfarattc.org

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