Transforming Health and Health Care via Technology

1. Transforming Health and Health Care via Technology Lisa A. Marsch, Ph.D. Director, Center for Technology and Behavioral HealthDartmouth Psychiatric Research Center Department of Psychiatry Dartmouth College www.c4tbh.org

2. Promise of Applying Technology to Health • Technologies (e.g., web-, mobile phone) offer considerable promise for impacting the spectrum of health and wellness, ranging from assessment, prevention, treatment, and recovery support • Assessment and Monitoring Tools: increase standardization and accuracy of data collection in a wide array of settings in real time • Interventions: e.g., Prevention interventions; Computer-assisted behavior therapies; Self-management tools; Decision Support Systems in areas of mental health, substance use, medication-taking, treatment selection, health promotion, and other areas of behavioral health • Applications for clinical populations as well as prevention/wellness promotion (e.g., “quantified self movement” of behavioral tracking to increase self-knowledge via data)

3. Promise of Applying Technology to Health • Technology-based therapeutic tools offer great promise for enabling the widespread dissemination of evidence-based interventions targeting health behavior. • Technology-based interventions may be delivered anytime/anywhere and reduce barriers/disparities in access to care. • These tools deliver care with fidelity, in a manner that does not require time or training of clinicians, and in a manner that is responsive to each individual’s profile of needs, preferences, and level of cognitive functioning. • They offer the potential to enable individuals (and optionally an extended support network) to play leading roles in their own care management.

4. Promise of Applying Technology to Behavioral Health • Research on technology-based tools targeting behavioral health has demonstrated that these tools (if developed well and in collaboration with the target audience): • Can be highly useful and acceptable to diverse populations • Have a large impact on health behavior and health outcomes • Increase quality, reach, and personalization of care • Can be cost-effective • Can prevent costly escalation of problems and unnecessary healthcare utilization (via on-demand, “just in time” therapeutic support) • Can be responsive to individuals’ health behavior trajectory over time

5. Prevalence and Significance of Behavioral Health Disorders • Mental health and substance use disorders are common in the U.S. • Approx. 1 in 4 to 1 in 5 adults are diagnosable with one or more mental health disorders • Approx. 1 in 10 adults are diagnosable with one or more substance use disorders • Persons with behavioral health disorders are among the most frequent and costliest utilizers of health care services. • Overall annual economic cost of mental health disorders estimated at over $300 billion (increased from $35 billion in 1996) • WHO estimates that mental illness accounts for more disability in developed countries than other groups of illnesses (including cancer and heart disease)

6. The Role of Behavioral Health in Chronic Disease Management • Behavioral Health Disorders are highly prevalent among Clinical Populations with Chronic Physical Health Conditions • (approx. 133 million Americans, accounting for over 75% of health care costs) • e.g., Persons with diabetes have 40-72% incidence of depression; 50% incidence anxiety • Behavioral Health Disorders Typically Complicate and Worsen the Course and Treatment of Chronic Medical Illnesses. • Lower quality of life, poorer response to treatment, worse medical and psychiatric outcomes, higher mortality and higher costs of care. • e.g., when depression co-occurs with diabetes, health care costs increase by 50-75%.

7. Integration of Physical and Behavioral Health in evolving U.S. Healthcare System • Technology-based approaches targeting behavioral health are particularly timely and offer promise for meeting a tremendous need as the healthcare delivery requirements of the Affordable Care Act (ACA) are implemented nationally. • e.g., • Increased focus on integrating care for physical health conditions and substance use • mental health disorders. • Providers are responsible for the entirety of patients’ care. • Medicaid eligibility will expand and provide coverage for the first time to an estimated 32 • million (many are poor, unemployed, and have disproportionately high rate of behavioral • health problems).

8. Unprecedented Opportunities for Effective and Cost-effective Technology-based Solutions • Technology offers great promise for helping to realize the integration of behavioral and physical health in a manner that increases quality of care while containing costs. • Mobile communication technologies that embraces the behavioral dimensions of multiple chronic-condition care can dramatically decrease barriers to successful management • Health information and communication technologies may transform health care service delivery models.

9. Ubiquity of Technology • Access to the Internet and mobile devices has been growing at extraordinary rates. • Over 80% of Americans currently have Internet access, about 90% subscribe to mobile phone services, and about 66% participate in online social networks (Pew Research Center, 2012). • Over 90% of individuals worldwide have access to mobile phone services, totaling about 6 billion mobile phone subscriptions worldwide (ITU, 2012). • Importantly, Internet and mobile access is also high and growing among even the most traditionally underserved and vulnerable populations (Gibbons et al., 2001), including among persons with substance use disorders (e.g., McLure et al., 2013).

10. Implementation of Technology-based Therapeutic Tools • Technology-based therapeutic tools may be deployed via numerous flexible models and may enable entirely new models of delivering behavioral health care (e.g., treatment of substance use disorders). • Technology-based therapeutic tools may be used along with more traditional models of intervention delivery (e.g., offered as an adjunct to substance abuse treatment). • In a “clinician-extender” model, clinicians have the opportunity to extend their reach by offering these additional resources to their clients to support their clients outside of their direct interchange with their clinician (e.g., as a supplement to clinician-delivered therapy, pharmacological treatments, etc.)

11. Implementation of Technology-based Therapeutic Tools • Alternatively, these therapeutic tools may replace a portion of their typical interaction with clients with a technology-based intervention. • This may allow a treatment program to treat more clients with the same number of clinicians and/or free-up clinicians to have more time to manage client crises or spend more time with clients in greatest need of more intensive care.

12. Implementation of Technology-based Therapeutic Tools • These tools 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 or for individuals who do not wish to engage in traditional models of care. (e.g., 90% of persons with substance use and/or mental health disorders are not in treatment)

13. Examples of Various Models of Deployment:The Therapeutic Education System (TES) as an Exemplar • Therapeutic Education System (TES),an interactive, behavioral therapy intervention for substance use disorders, grounded in the Community Reinforcement Approach (CRA) + Contingency Management Behavior Therapy + HIV Prevention • Employs informational technologies of demonstrated effectiveness • Available on multiple platforms (including web-based desktop computers, Android smartphones, iPhones, iPads, etc.).

14. Therapeutic Education System (TES) for Substance Abuse & HIV Prevention Composed of 65 interactive modules grounded in the effective Community Reinforcement Approach (CRA) psychosocial intervention Program is self-directed & includes a Training Module Therapists/Patients can use “customization plan” to establish individualized treatment plan for patients based on treatment needs Patients complete evidence-based program modules on skills training, interactive exercises and homework in accordance with their plan All module content includes accompanying audio Electronic reports of patients’ activity available to therapists New content can be readily added to the content delivery system

15. List of Module Topics in Therapeutic Education System (TES) 33 Insomnia 1 Training Module 34 Time Management 2 What is a Functional Analysis? 35 Relationship Counseling Part 1 - 3 Conducting a Functional Analysis 36 Relationship Counseling Part 2 - 4 Self - Management Planning 37 Relationship Counseling Part 3 - 5 Drug Refusal Skills Training 38 Alcohol and Disulfiram 6 Awareness of Negative Thinking 39 Communication Skills 7 Managing Negative Thinking 40 Nonverbal Communication 8 Managing Thoughts About Using 41 Social Recreational Counseling 9 Managing Negative Moods and Depression 42 Attentive Listening 10 Introduction to Problem Solving 43 HIV and AIDS 11 Effective Problem Solving 44 Sexually transmitted infections (STIs) 12 Progressive Muscle Relaxation Training 45 Hepatitis 13 Receiving Criticism 46 Sexual transmission of HIV and STIs 47 The Female Condom 14 Seemingly Irrelevant Decisions 48 Birth control use and HIV and STIs 15 Other Drug Use 49 Drug Use, HIV and Hepatitis 16 Coping with Thoughts About Using 50 Alcohol use and risk for HIV, STIs and hepatitis 17 Introduction to Assertiveness 51 Getting Tested for HIV, STIs and Hepatitis 18 How to Express Oneself in an Assertive Manner 52 Finding More HIV, STI and Hepatitis Information 19 Introduction to Anger Management 53 Negotiating Safer Sex 20 How to Become More Aware of the Feeling of Anger 54 Decision-Making Skills - 21 Coping with Anger 55 Identifying/managing triggers for risky sex 22 Introduction to Relaxation Training 56 Identifying and Managing Triggers for Risky Drug Use 23 Progressive Muscle Relaxation Generalization 57 Increasing Self-Confidence in Decision Making - 24 Introduction to Giving Criticism 58 Taking Responsibility for Choices 25 Steps for Giving Constructive Criticism 59 Living with Hep C: Managing Treatment, Promoting Health 26 Receiving Criticism Living with Hep C: Coping Skills 60 27 Giving and Receiving Compliments 61 Living with HIV: Coping skills and managing stigma 62 Living with HIV: Comm. skills for disclosing HIV status 28 Sharing Feelings 63 Living with HIV: Managing treatment and medications 29 Vocational Counseling 64 Living with HIV: Drug use and Immune System 30 Naltrexone 65 Living with HIV: Daily routines to promote health 31 Limited Alcohol Use 32 Financial Management

16. Sample Screens from TES

17. Partial Replacement Model in Specialty Addiction Treatment – Efficacy Trial • An NIDA-funded randomized, controlled trial (n=135) demonstrated that TES was as efficacious as comparable CRA + CM therapy, delivered by highly trained therapists, and better than standard treatment in promoting objectively-verified drug abstinence among individuals in outpatient buprenorphine treatment (Bickel, Marsch et al., 2008). 12 12 Standard Therapist a a 10 10 Computer 8 8 b Treatment Weeks 6 6 4 4 2 2 0 0 Continuous Abstinence from Opioids and Cocaine

18. Partial Replacement Model in Addiction Specialty Treatment – Effectiveness Trial • Another NIDA-funded trial (n=160; 12 month participation) demonstrated that TES enhances opioid abstinence rates in outpatient addiction treatment when a TES substitutes for a portion of standard counseling (Marsch, 2013) 70% 60% 50% Percent Weeks Opioid Abstinent 40% 30% 20% 10% 0% TES with reduced TAU Treatment as Usual (TAU)

19. Multi-Site Evaluation of TES in prisons: Comparative Effectiveness • Employed random assignment of male and female inmates with substance use disorders (N=513) to (E) TES (N=258),or(C) Clinician-Delivered Care (N=255) across 10 sites in 4 research centers linked to the NIDA-funded CJDATS network (in CO, WA, PA and KY). • The prospective, longitudinal study design consisted of three assessment points —baseline and 3- and 6- months post prison release.

20. Illegal Drug Use

21. Criminal Activity Percent

22. Example of a Mobile Psychosocial Intervention as an Adjunct to Care Random assignment of 50 new intakes in outpatient addiction treatment to: (1) standard care or (2) mobile phone/web-based psychosocial treatment for 12 weeks The mobile intervention demonstrated good feasibility and acceptability: Participants typically maintained their mobile phones for the duration of the treatment, used the mobile program and reported high levels of acceptability of the program (e.g., how useful, how easy to use, etc.). Qualitative data indicate that several participants reported using the mobile phone-based intervention during times of heightened risk for drug use.

23. Treatment Retention Mobile Psychosocial Treatment (Chi-square = 4.7; p=.031) 100 90 84% 80 Percent Retained 70 56% 60 50 40 30 20 10 0 Mobile Intervention Standard Treatment

24. Objectively Measured Opioid Abstinence Mobile Psychosocial Treatment (t (48) = -1.97; p= .055) 7 Weeks of Opioid Abstinence 6 5 4 3 2 1 Mobile Intervention Standard Treatment 0

25. Implementation Science Study- Integrating Treatment of SUDs into Primary Care • Stepped Wedge Design (staggered implementation across sites) evaluating a technology-based addiction/treatment recovery support system within FQHCs • Focus on integrated care using personalized technology-based therapeutic support system available on mobile devices and care coordination with FQHC clinicians • Focus largely on organizational-level outcomes

26. Opportunities for a Science-Informed Strategy for ‘Scaling up’ the Application of Technology to the Transformation of Health Care Systems Opportunities in Technology Development • Ensuring health systems considerations drive how technology is employed • Breaking down siloed, disorder-specific approaches to the development of technology-based health systems • Promoting Partnerships among Academic-Foundation-Industry partners • Engaging consumers as the main driver of development (e.g., to provide greater patient choice and access; greater engagement in their own health and greater opportunity to engage an extended support network) • Employing fundamental mechanisms of behavior change in the development of technology-based interventions

27. Opportunities for a Science-Informed Strategy for ‘Scaling up’ the Application of Technology to the Transformation of Health Care Systems • Opportunities in Evaluation • Opportunities within domains of measurement, experimental design, data analytics, and data visualization • Comprehensive focus on service delivery models and accompanying payment models concurrently (e.g., obtaining data from all relevant stakeholders) • Importance of an interdisciplinary team to inform adoption and sustained implementation (e.g., experts in clinical care, health economics, financing, technologists) • Understanding trajectories of consumer engagement (e.g., the role of incentives as well as considerations re: consumer adherence vs. strategic episodic use) • Models that enable ongoing evaluation and rapid iteration in real-world implementation efforts

28. Opportunities for a Science-Informed Strategy for ‘Scaling up’ the Application of Technology to the Transformation of Health Care Systems • Opportunities for Models of Deployment: • Technology as Clinician-Extender via a “Prescription” Model (e.g., Opportunity for Increasing Reach and Service Capacity) • Stepped Care models with centralized technology support banks • Technology Solutions Direct to Consumer • Technology as Minimally Disruptive Health Care (to reduce burden of illness as well as burden of treatment) • Opportunities for Global Health

29. Center for Technology and Behavioral Health www.c4tbh.org Lisa.A.Marsch@Dartmouth.edu