Technology: The Bridge to Access to Care

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

11. 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

12. 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

13. 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

14. 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

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

16. Characteristics of the Subjects

17. Demographics/Co-Occurring Disorders

18. Results: Percent of Subjects Reached per Day

19. 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

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

21. 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

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

23. 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

24. 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

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Characteristics of Study Population

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

35. 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

36. 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.

37. 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

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