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Technology: The Bridge to Access to Care

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

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  1. Technology: The Bridge to Access to Care Mary R Haack, PhD, RN, FAAN Professor University of Maryland School of Nursing Baltimore, Maryland

  2. Myths about Underserved Patients • Patients will barter or sell phones or computers • Patients will not respond truthfully • Patients lack technological competence

  3. Fear • “I will lose my job” • “Technology undermines clinical relationships”

  4. 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

  5. Two Pilot Studies • Cell phones to monitor medication adherence among homeless • Computers to provide counseling to court-involved clients

  6. Baltimore City • 42, 560 people have opioid use disorders • 50% suffer from co-occurring psychiatric disorders

  7. Study 1: Cell Phones to Monitor Medication Adherence • Study Partners • University of Maryland School of Nursing • Health Care for the Homeless Baltimore

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. Exclusion Criteria • Recent history of violence • Active psychosis or acute crisis • Unable to follow directions

  15. Characteristics of the Subjects

  16. Demographics/Co-Occurring Disorders

  17. Results: Percent of Subjects Reached per Day

  18. Results • 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

  19. Conclusion • Cell phones were not lost, bartered or sold • Cell phones can monitor adherence • Participation rate was high

  20. 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

  21. Research Partners • Essex County Superior Court Juvenile Court in Newark New Jersey • Rutgers College of Nursing • Alexandria VA Probation Office • Others

  22. 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

  23. 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

  24. Substance Abuse Treatment in Newark • 6 to 8 weeks waiting list • Detox • Outpatient counseling 3 X week

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. Characteristics of Study Population

  33. Results: Daily Probability of Drug Use Note: Observed differences are not statistically significant.

  34. 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

  35. Conclusions • 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.

  36. Acknowledgements • Farrokh Alemi, PhD – collaborator in both studies alemi@cox.net • Cell Phone study funded by University of Maryland RIF Program • Computer study funded by RWJF

  37. References Alemi F, Haack MR, Nemes S, Aughburns R, Sinkule J, Neuhauser D. Therapeutic emails. Substance Abuse Treatment, Prevention, and Policy 2007, 2:7 Tate DF, Wing RR, Winett RA. Using Internet technology to deliver a behavioral weight loss program. JAMA. 2001, 285:1172–1177. Tate DF, Jackvony EH, Wing RR. Effects of Internet behavioral counseling on weight loss in adults at risk for type 2 diabetes: a randomized trial. JAMA. 2003, 289(14):1833-1836. Squires DD, Hester RK. Using technical innovations in clinical practice: the Drinker's Check-Up software program. J Clin Psychol. 2004, 60(2):159-169. Ruggiero KJ, Resnick HS, Acierno R, Coffey SF, Carpenter MJ, Ruscio AM, Stephens RS, Kilpatrick DG, Stasiewicz PR, Roffman RA, Bucuvalas M, Galea S. Internet-based intervention for mental health and substance use problems in disaster-affected populations: a pilot feasibility study. BehavTher. 2006, 37(2):190-205. Epub 2006 Mar 27. Japuntich SJ, Zehner ME, Smith SS, Jorenby DE, Valdez JA, Fiore MC, Baker TB, Gustafson DH. Smoking cessation via the internet: a randomized clinical trial of an internet intervention as adjuvant treatment in a smoking cessation intervention. Nicotine Tob Res. 2006, 8 Suppl 1: S59-67. Linke S, Murray E, Butler C, Wallace P. Internet-based interactive health intervention for the promotion of sensible drinking: patterns of use and potential impact on members of the general public. J Med Internet Res. 2007, 8;9(2): e10. Ondersma SJ, Chase SK, Svikis DS, Schuster CR. Computer-based brief motivational intervention for perinatal drug use. J Subst Abuse Treat. 2005, 28(4): 305-12. Hester RK, Delaney HD. Behavioral Self-Control Program for Windows: results of a controlled clinical trial. J Consult Clin Psychol. 1997, 65(4):686-93. Handmaker NS, Hester RK, Delaney HD. Videotaped training in alcohol counseling for obstetric care practitioners: a randomized controlled trial. Obstet Gynecol. 1999, 93(2):213-8. Kivlahan DR, Marlatt GA, Fromme K, Coppel DB, Williams E. Secondary prevention with college drinkers: evaluation of an alcohol skills training program. J Consult Clin Psychol. 1990, 58(6):805-10. Collins SE, Carey KB, Sliwinski MJ. Mailed personalized normative feedback as a brief intervention for at-risk college drinkers. J Stud Alcohol. 2002, 63(5):559-567. Alemi F, Stephens RC, Javalghi RG, Dyches H, Butts J, Ghadiri A. A randomized trial of a telecommunications network for pregnant women who use cocaine. Medical Care 1996, 34 (10 Supplement):OS10-OS20. Alemi F, Stephens RC, Mosavel M, Ghadiri A, Krishnaswamy J, Thakkar H. Electronic Self Help and Support Groups: A Voice Bulletin Board. Medical Care 1996, 34(10 Suppl):OS32-OS44. Mosavel M. The use of a telephone-based communication tool by low-income substance abusers. Journal of Health Communications. 2005, 10(5):451-63. Burda, C, Haack, M, Duarte, A, Alemi, F. (In press) Medication Adherence among Homeless Patients: A Pilot Study of Cell Phone Effectiveness. Journal of the American Academy of Nurse Practitioners.

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