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Technology: The Bridge to Access to Care . Mary R Haack, PhD, RN, FAAN Professor University of Maryland School of Nursing Baltimore, Maryland . Myths about Underserved Patients. Patients will barter or sell phones or computers Patients will not respond truthfully

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Technology the bridge to access to care

Technology: The Bridge to Access to Care

Mary R Haack, PhD, RN, FAAN


University of Maryland School of Nursing

Baltimore, Maryland

Myths about underserved patients
Myths about Underserved Patients

  • Patients will barter or sell phones or computers

  • Patients will not respond truthfully

  • Patients lack technological competence

Technology the bridge to access to care

  • “I will lose my job”

  • “Technology undermines clinical relationships”

Effectiveness of technology and behavioral health
Effectiveness of Technology and Behavioral Health

  • Two decades of research

  • 30 studies show the participants are more likely to respond truthfully to telephone surveys

  • Daily monitoring improves likelihood of early identification of relapse and reduces the length of the relapse

Two pilot studies
Two Pilot Studies

  • Cell phones to monitor medication adherence among homeless

  • Computers to provide counseling to court-involved clients

Baltimore city
Baltimore City

  • 42, 560 people have opioid use disorders

  • 50% suffer from co-occurring psychiatric disorders

Study 1 cell phones to monitor medication adherence
Study 1: Cell Phones to Monitor Medication Adherence

  • Study Partners

    • University of Maryland School of Nursing

    • Health Care for the Homeless Baltimore

University of maryland school of nursing
University of Maryland School of Nursing

  • Founded in 1889

  • Social Justice Mission

  • Ranked seventh in the US

  • 1,600 students

  • Psychiatric Mental Health (PMH) Graduate Faculty lead the project

  • PMH faculty have a clinical faculty practice at HCH

Healthcare for the homeless
Healthcare for the Homeless

  • FQHC in Baltimore City

  • Offers Medical, Psychiatric & Addiction Services in one site

  • Serves the Homeless Adults of Baltimore City

  • HCH served 6,574 individuals in 2008

  • Provides education & advocacy to reduce the incidence & burden of homelessness

Goal of research
Goal of Research

  • Explore the feasibility of using cell phones to monitor medication adherence among homeless patients

  • Increase access to concurrent psychotropic medication and substance abuse treatment for patients with co-occurring disorders

  • Assess use of technology for data collection for a larger study

Cell phones
Cell Phones

  • Provided to 10 patients meeting inclusion criteria

  • Patients given free unlimited phone service for 45 days

  • Computer sent an automated call to the participant at 10 AM every day

  • Patients responded to questions by pressing cell phone keys

  • Computer called missed patients again in the afternoon

Questions asked daily
Questions Asked Daily

  • Salutation

  • Since last call, did you take your medication as prescribed?

    • Yes: press 1

    • No: press 9

  • Are you having any difficulty or side effects from your medication?

    • Yes: press 1

    • No: press 9

  • Exit comments

Inclusion criteria
Inclusion Criteria

  • Ages 21-64

  • Diagnosis of Substance Use Disorder

  • Co-morbid Axis 1 DSM-IV-TR diagnosis

  • Homelessness, based on clinical interview

  • Prescribed a psychotropic medication

  • Willing to receive telephone contact

  • Able to demonstrate ability to use phone

Exclusion criteria
Exclusion Criteria

  • Recent history of violence

  • Active psychosis or acute crisis

  • Unable to follow directions


  • 93% daily response rate

  • When reached, 100% self reported medication adherence

  • Patients reported increase structure

  • Felt cared for by having daily calls

  • Calls were medication reminders

  • Increased contact with families

  • Staff witnessed positive change in subject clinical presentation


  • Cell phones were not lost, bartered or sold

  • Cell phones can monitor adherence

  • Participation rate was high

Study 2 online counseling with computers in the home
Study 2: Online Counseling with Computers in the Home

  • Explore the feasibility of placing computers in the home to improve access to substance abuse counseling

    • Vulnerable populations

    • Underserved areas

    • Court involved

Research partners
Research Partners

  • Essex County Superior Court Juvenile Court in Newark New Jersey

  • Rutgers College of Nursing

  • Alexandria VA Probation Office

  • Others

Essex county new jersey
Essex County New Jersey

  • Essex County estimated 42,516 people in need of SUD treatment

  • Heroin, cocaine and other illicit drugs

  • Newark 4000 child abuse and neglect cases per year

  • 80 to 90% involve substance abuse

  • Children placed in foster care

  • Parents court ordered to treatment

Adoption and safe families act federal law
Adoption and Safe Families Act Federal Law

  • Fate of these families must be decided in 12 to 18 months

  • Parents must meet requirements for reunification: substance abuse treatment and parenting skills training

  • If unable to meet requirements , court terminates the parental rights and child is eligible for adoption

Substance abuse treatment in newark
Substance Abuse Treatment in Newark

  • 6 to 8 weeks waiting list

  • Detox

  • Outpatient counseling 3 X week

Method of recruitment
Method of Recruitment

  • Information was distributed to case managers, halfway houses, and the Court

  • Clients interviewed in person

  • Consent required

    • Patient consent

    • Others living with patient

Inclusion criteria1
Inclusion Criteria

  • 14 years or older

  • Substance abuse problem

  • Members of the household agreed to share the computer and phone line

  • Read and type at high school level

  • Signed release of information for the Court or health care provider for evaluation purposes only

Inclusion criteria2
Inclusion criteria

  • Willing to participate in online counseling for 15 minutes a day

  • Willing to do bi-weekly urine tests

  • Willing to have face to face visit with counselor as needed

Study design
Study Design

  • Participants randomly assigned to experimental or control group

  • Experimental and control group participants received an Internet-ready computer with 1 year access to the Internet

Study design1
Study Design

  • Experimental group received online counseling; control group did not

  • Both groups received Internet service for 12 months

  • Both groups were encouraged to attend self help groups and face to face treatment

Online counseling protocol
Online Counseling Protocol

  • Online motivational counseling

    • Daily triggers: scripted email message broadcasted to all participants in the same stage of recovery every day

    • Prompt: Email message ended with question that served as a prompt to engage the participant in dialogue

    • Freeform dialogue: Addiction counselor maintained daily conversation

  • Counselors helped patients through stages of change

  • In person or on phone meetings when necessary

Example emails
Example Emails

  • Initial Email: “Tell me how is your life?”

    • Patients report various problems

    • More problems reported over time

  • Later email: Why do you think you are having so many difficulties?

    • Patients blame others

    • Patients attribute events to luck

    • Eventually they mention drug use

  • Summary Email: You told me …

  • Counselor changes patient’s stage of change from denial to pre-contemplation

Results daily probability of drug use
Results: Daily Probability of Drug Use

Note: Observed differences are not statistically significant.

Unexpected results
Unexpected results

  • Family members reported to the counselor when the participant was not available

  • Family members wanted to know how they could become a participant

  • Counselors were enthusiastic about the online counseling format

  • Relapses were shorter when counselors had daily contact


  • Cell phones and computers are a feasible as a means of increasing access to care

  • Further research is needed to understand and maximize the potential of cell phones and computers for improving what we already do.


  • Farrokh Alemi, PhD – collaborator in both studies

  • Cell Phone study funded by University of Maryland RIF Program

  • Computer study funded by RWJF


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