development of an ‘in-home’ telehealth substance abuse management program for veterans with...
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Development of an ‘In-Home’ Telehealth Development of an ‘In-Home’ Telehealth Substance Abuse Management Program for Substance Abuse Management Program for
Veterans with Substance Use DisordersVeterans with Substance Use Disorders
Elizabeth J. Santa Ana, Ph.D.Elizabeth J. Santa Ana, Ph.D.Research Psychologist, Charleston VA Medical Center
Assistant ProfessorClinical Neuroscience Division, Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
Scientific Retreat on Telemedicine11/19/10
The ‘In-Home’ Messaging Device (IHMD)The ‘In-Home’ Messaging Device (IHMD)The Health Buddy® appliance
Bosch-Health Hero
The Viterion V100 appliance
Panasonic
Commonly used in internal Commonly used in internal Medicine for patients with:Medicine for patients with:
-Hypertension Psychiatry:Psychiatry:-Diabetes -Post-Traumatic Stress Disorder-Congestive heart failure -Depression-Lung disease -Schizophrenia-Spinal cord injury -Traumatic brain injury
Connected via landline phone to a secure server which Connected via landline phone to a secure server which provides assessment and disease ‘self-management’ provides assessment and disease ‘self-management’ education to patients in their homes education to patients in their homes (Darkins et al., 2008). (Darkins et al., 2008).
IHMDs contain text-based messages delivered through a IHMDs contain text-based messages delivered through a messaging window or screen.messaging window or screen.
Patients push buttons on the device to proceed through the Patients push buttons on the device to proceed through the disease management protocol.disease management protocol.
Patient responses to protocol questions are electronically Patient responses to protocol questions are electronically recorded and made available to recorded and made available to Care CoordinatorsCare Coordinators (e.g., (e.g., nurses, social workers, dieticians, nurse practitioners) on nurses, social workers, dieticians, nurse practitioners) on their computer desktop.their computer desktop.
IHMD FeaturesIHMD Features
Care Coordination Home Telehealth (CCHT) Care Coordination Home Telehealth (CCHT) manages the Veterans Administration national manages the Veterans Administration national home telehealth program. home telehealth program.
Goal is to provide home telehealth treatment and Goal is to provide home telehealth treatment and disease management technologies to patients disease management technologies to patients with chronic conditions with chronic conditions (Darkins et al., 2008). (Darkins et al., 2008).
Prevents unnecessary hospital admissions or Prevents unnecessary hospital admissions or long-term institutional care.long-term institutional care.
Assists patients to live independently at home. Assists patients to live independently at home.
What is Care Coordination?What is Care Coordination?
The Alert System:The Alert System:
Patient responses are risk stratified or color coded (e.g., Patient responses are risk stratified or color coded (e.g., redred, , yellowyellow, , greengreen) to triage particular “out of parameter” behaviors (e.g., binge ) to triage particular “out of parameter” behaviors (e.g., binge drinking, illicit drug use, withdrawal symptoms) requiring immediate drinking, illicit drug use, withdrawal symptoms) requiring immediate attention or intervention.attention or intervention.
The Care Coordinator may contact the patient directly or refer the The Care Coordinator may contact the patient directly or refer the patient to his/her primary care provider to help build the patient’s patient to his/her primary care provider to help build the patient’s self-management skills, provide case management, or evaluate for self-management skills, provide case management, or evaluate for more intensive services or intervention.more intensive services or intervention.
Questions and treatment information designed with Questions and treatment information designed with expanding branching logic for individualized assessment expanding branching logic for individualized assessment and intervention and intervention (will provide example).(will provide example).
Daily dialogues are Daily dialogues are << 10 minutes in length. 10 minutes in length.
IHMD FeaturesIHMD Features
IHMD Advantages IHMD Advantages Simple, Simple, user-friendly,user-friendly, readily visible readily visible Provides care coordinator with Provides care coordinator with a daily stream of a daily stream of
data data regarding the patient’s health problemregarding the patient’s health problem Gets patients to Gets patients to self-monitorself-monitor and consider issues and consider issues
related to self-managing their health problem related to self-managing their health problem each dayeach day
Motivates and Motivates and educates patients on how to educates patients on how to improve improve their health problemtheir health problem
May be used alone May be used alone for patients not engaged in for patients not engaged in formal treatment programs formal treatment programs or as an add-on or as an add-on to to program servicesprogram services
Delivers Delivers evidence-based treatment evidence-based treatment components components to patients at hometo patients at home
May provide May provide opportunities for targeted outreach opportunities for targeted outreach (during periods of lapses and relapses)(during periods of lapses and relapses)
Supports patient care in least restrictive settingSupports patient care in least restrictive setting
Efficacy-IHMD’sEfficacy-IHMD’s IHMDs reduced total number of inpatient hospital stays among veterans IHMDs reduced total number of inpatient hospital stays among veterans
with with chronic heart failure chronic heart failure (Schofield et al., 2005).(Schofield et al., 2005).
IHMDs improved recovery outcomes (symptom evaluation and IHMDs improved recovery outcomes (symptom evaluation and postoperative problems) among elderly postoperative problems) among elderly coronary artery bypass coronary artery bypass patients patients (Zimmerman et al., 2004).(Zimmerman et al., 2004).
50% reduction in the proportion of 50% reduction in the proportion of diabeticdiabetic patients who were patients who were hospitalized and an 11% reduction in emergency room use (Chumbler et hospitalized and an 11% reduction in emergency room use (Chumbler et al. 2005).al. 2005).
High satisfaction (94%) among 791 chronic medical and 120 mental High satisfaction (94%) among 791 chronic medical and 120 mental health patients who have used IHMDs (Ryan et al. 2003).health patients who have used IHMDs (Ryan et al. 2003).
Systematic development and randomized controlled Systematic development and randomized controlled evaluation of IHMDs for use with patients with substance use evaluation of IHMDs for use with patients with substance use disorders disorders has not occurred previouslyhas not occurred previously. .
BackgroundBackground Of the estimated 25 million U.S. veterans,
approximately 11% are dependent on or abusing alcohol and illicit drugs.
Only 0.8% of patients receive specialty treatment for these substance use disorders (Office of Applied Studies, 2005).
Roadblocks:
-Lack of transportation-The elderly-Physical challenges-Many returning OEF/OIF veterans unable to attend outpatient services.-Rural living (too far away from nearest VA hospital)-Stigma (especially for those who remain in active
duty) 2007: VA Office of Telehealth requests IHMD program development for
veterans with substance use disorders to enhance their access to supportive treatment services.
Substance Use Disorder Program (SUD)Substance Use Disorder Program (SUD)
I. I. Daily assessment Daily assessment (repeated (repeated daily)daily) Alcohol use Alcohol use (craving and commitment)(craving and commitment)
Drug use Drug use (craving and commitment)(craving and commitment)
Acute risk Acute risk (withdrawal sx, suicidality)(withdrawal sx, suicidality)
II. II. Self-Management Skills Self-Management Skills (unique)(unique) Building Motivation Modules (8)Building Motivation Modules (8) Coping and Skills Training Modules Coping and Skills Training Modules
(10)(10) Social and community Support Group Social and community Support Group
Skills Building Modules (9)Skills Building Modules (9)
I. I. Daily assessment Daily assessment Based on practitioner guidelines from the National Institute on Alcohol Abuse and Alcoholism (NIAAA; U.S. Department of Health and Human Services, 1995)
World Health Organization (Henry‐Edwards, Humeniuk, Ali, Poznyak, &
Monteiro, 2008) for screening patients for alcohol and drug use problems.
II. II. Self-Management SkillsSelf-Management SkillsBased on substance abuse behavioral intervention from the Combined Behavioral Intervention Manual (CBI; Miller, Moyers, & Arciniega, 2005) utilized in the Combining Medications and Behavioral Interventions study (COMBINE; Anton et al., 2006).
CBI manual:Empirically supported psychotherapy intervention. Adapted from three treatments:
-Motivational enhancement therapy-Cognitive behavioral skills training-Twelve-step facilitation and recovery support
Substance Use Disorder Program (SUD)Substance Use Disorder Program (SUD)
SUD Alcohol Use AssessmentSUD Alcohol Use AssessmentHow many alcohol drinks did you drink in the past 24 hours? (1 alcohol drink = 12 ounces of beer, 3.5 ounces of wine or 1.5 ounces of 80 proof spirits)
0 1 2 3 4 5 6 7 8 9 10 11 12+
Great! You’re meeting your goal of not drinking.
On the scale below, please rate your level of craving to drink alcohol today.
0 1 2 3 4 5 6 7 8 9 10 No craving at all Extreme Craving
On the scale below, please rate how committed you are to NOT drink today.
0 1 2 3 4 5 6 7 8 9 10
Not at all committed Extremely committed
Stay home and avoid situations in which you or others could get hurt. Please don’t drive at this time. If you are having a medical emergency, please call 911 immediately.
Are you currently intoxicated from drinking?
If > 4 (High alert)
Your goal is to not drink. You drank very heavily. Use your <in home program> to help you not drink again. Follow up with your Care Coordinator.
If 2-3 (Moderate alert)
Your goal is to not drink. You drank quite a bit. Use your <in home program> to help you not drink again. Follow up with your Care Coordinator.
If 1 (Low alert)
Your goal is to not drink. You had a slip. Use your <in home program> to help you not drink again.
The Care Coordinator, using clinical judgment, will contact veteran for combination of cravings > 8 and commitment to remain alcohol free < 3.
> 1
0
Yes
The “Alert” indicator is for the Care Coordinator staff member. High alert triggers a call from the Care Coordinator. Moderate alert will trigger a call back if the patient calls, or the care coordinator may call based on clinical judgment. Care Coordinator may or may not call for low alert based on clinical judgment.
SUD 27 Daily Self-Management Skills SUD 27 Daily Self-Management Skills ModulesModules
I.I. Daily Assessment Dialogues Daily Assessment Dialogues:: Alcohol Use Assessment Alcohol Use Assessment Drug Use Assessment Drug Use Assessment Risk Assessment Risk Assessment
II.II. Building Motivation Modules: Building Motivation Modules:
Importance RulerImportance Ruler Values sortValues sort Pros and Cons: Benefits of stopping usePros and Cons: Benefits of stopping use Pros and Cons: Costs of continuing to usePros and Cons: Costs of continuing to use Personal strengthsPersonal strengths Past successesPast successes Confidence rulerConfidence ruler Change planningChange planning
II. II. Coping and Skills Training Modules Coping and Skills Training Modules
Recognizing triggersRecognizing triggers
What I do to no drink or use drugsWhat I do to no drink or use drugs
Coping with craving and urges to use (Day 1)Coping with craving and urges to use (Day 1)
Coping with craving and urges to use (Day 2)Coping with craving and urges to use (Day 2)
Mood managementMood management
Changing automatic negative thoughtsChanging automatic negative thoughts
Assertive communication in conflict situations (Day 2)Assertive communication in conflict situations (Day 2)
Assertive communication: General skills (Day 1)Assertive communication: General skills (Day 1)
Alcohol refusal skills for handling social pressure (Day 1)Alcohol refusal skills for handling social pressure (Day 1)
Alcohol refusal skills for handling social pressure (Day 2)Alcohol refusal skills for handling social pressure (Day 2)
II. II. Social and community Support Group Skills Social and community Support Group Skills Building ModulesBuilding Modules
Enjoyable activitiesEnjoyable activities
Self-help support groupsSelf-help support groups
Supportive personSupportive person
Social supportSocial support
Case management needsCase management needs
Treatment participation, Pros of AttendingTreatment participation, Pros of Attending
Treatment participation, Overcoing obstaclesTreatment participation, Overcoing obstacles
Medication AdherenceMedication Adherence
Continuing recovery and Wrap upContinuing recovery and Wrap up
RelapseRelapse
SUD Qualitative PilotSUD Qualitative Pilot
Primary AimPrimary Aim: : To preliminarily test To preliminarily test SUDSUD for use with for use with IHMDs and to establish initial acceptability and IHMDs and to establish initial acceptability and feasibility when delivered by Care Coordinators to feasibility when delivered by Care Coordinators to patients with substance use disorders.patients with substance use disorders.
ParticipantsParticipants: : Six volunteer participants were referred Six volunteer participants were referred by their primary care clinician between November 2009 by their primary care clinician between November 2009 and March 2010 to Care Coordination Home Telehealth and March 2010 to Care Coordination Home Telehealth (CCHT) services. (CCHT) services.
Inclusion criteriaInclusion criteria: :
History of and/or current alcohol, drug, or poly-History of and/or current alcohol, drug, or poly-substance dependence. substance dependence.
Currently being followed by a VA primary care clinician Currently being followed by a VA primary care clinician for substance dependence/abuse. for substance dependence/abuse.
Enrollment in a VA intensive outpatient substance Enrollment in a VA intensive outpatient substance abuse program for current alcohol and/or drug abuse program for current alcohol and/or drug dependence.dependence.
Age (years) 57.3+ 6.3
Race 4 Caucasian / 2 African American
Sex 6 (100%) Male
DSM-IV Alcohol Dependence 5 (83%)
DSM-IV Cocaine Dependence 1 (16%)
Time in recovery
6 mos to ≤ 1 yr 2 (33%)
2 yrs 1 (16%)
0 yrs 2 (33%)
3 yrs, recently relapsed 1 (16%)
Demographic Variables/Participant Characteristics Demographic Variables/Participant Characteristics (n = 6)(n = 6)
Quantitative AssessmentQuantitative Assessment
Likert scale from ‘1 = not at all helpful/not at all easy’ to ‘10 = extremely helpful/extremely easy’:
1. How helpful was SUD in supporting your effort to not drink and/or use drugs?
2. How easy it was to understand the SUD material and to use the IHMD device?
3. How easy it was to set up your IHMD.
From ‘1 = not at all satisfied’ to ‘10 = extremely satisfied’:
4. How satisfied were you were with SUD in addressing your substance use problem?
5. Average number of days and time participants logged onto their device during the 27 day program was recorded .
Qualitative AssessmentQualitative Assessment
Likert-type response scale‘ from ‘not at all, mildly, moderately, strongly, very strongly’:
6. How strongly did SUD motivate you to address your substance use problem?
7. How much did SUD assist you to cope with and manage your substance use problem?
8. To what degree did the daily assessment help you to monitor your substance use?
9. To what degree would you recommend SUD to others?Data analysis involved descriptive statistics using SPSS version 17.0
Variables Average of 1-to-10 (not at all helpful/not at all easy- to-extremely helpful/extremely easy) Likert-Scale Response
Quantitative Results: SUD level of helpfulness in supporting effort to not drink/use drugs
Ease of understanding SUD material
Ease of using IHMD device
Ease of setting up IHMD
Satisfaction with SUD in addressing substance use problem
Mean (SD)/Range
8.2 (.57)/6.0 to 10.0
9.4 (.12)/8.0 to 10.0
9.2 (.29) /8.0 to 10.0
10.0
8.2 (.29)/6.0 to 10
Qualitative Results: SUD enhanced level of motivation to address substance use problem
SUD enhanced level of assistance to cope with and manage substance use problem
SUD daily assessment level of helpfulness in monitoring substance use
Would recommend SUD to others
% Moderately (n) %Strongly (n) %Very Strongly (n)
33% (2) 17% (1) 50% (3)
50% (3) --- 50% (3)
33% (2) 17% (1) 50% (3)
---- 50% (3) 50% (3)
SUD Qualitative Pilot Results
Summary from the SUD Pilot StudySummary from the SUD Pilot StudyIHMDs for Substance Use Disorders:
1. Offers a practical, accessible, feasible, acceptable, and supportive intervention when layered onto existing substance abuse outpatient treatment for patients with substance use disorders.
2. Participants reported that SUD was easy to use and understand, enhanced motivation to address substance use problems, provided helpful self-management skills for maintaining recovery, and enhanced the ability to cope with, monitor, and manage substance use problems. 3. Participants reported high satisfaction with the support SUD provided for addressing substance use problems, and most participants recommended SUD to others with a substance use problem.
4. Compliance rate was high (92%).
Does the SUD-IHMD lead to a significantly Does the SUD-IHMD lead to a significantly greater reduction in alcohol /drug use and an greater reduction in alcohol /drug use and an increase in treatment engagement outcomes increase in treatment engagement outcomes by 3-month follow-up compared to participants by 3-month follow-up compared to participants in treatment as usual (TAU)?in treatment as usual (TAU)?
Hypothesis: Participants who receive the SUD-Hypothesis: Participants who receive the SUD-IHMD will consume less alcohol /illicit drugs IHMD will consume less alcohol /illicit drugs and will be engaged in and attend more and will be engaged in and attend more continuous aftercare treatment than continuous aftercare treatment than participants in TAU by the 3-month follow-up .participants in TAU by the 3-month follow-up .
Current InvestigationCurrent Investigation
A randomized-controlled trial evaluating SUD is currently being conducted at the Charleston VAMC. (Results of this RCT are pending).
Interactive Voice Response Interactive Voice Response Technology via cell phones may be Technology via cell phones may be approved within the VA in the next 6 approved within the VA in the next 6 to 12 months to 12 months (as yet, no prior vendors have (as yet, no prior vendors have created a secure cellular network for VA data transmission)created a secure cellular network for VA data transmission)
Wireless IHMDs: ViterionWireless IHMDs: Viterion
Palliative care management protocolsPalliative care management protocols
What’s in the Future for Home-based Tele-What’s in the Future for Home-based Tele-mental Health Care? mental Health Care?
Use of IHMDs may be a Medicare/Medicaid covered Use of IHMDs may be a Medicare/Medicaid covered service in other health care agenciesservice in other health care agencies
Medicare/Medicaid may cover the cost of:Medicare/Medicaid may cover the cost of: CCHT staff supportCCHT staff support Transmission chargesTransmission charges EquipmentEquipment
Centers for Medicare and Medicaid Services:Centers for Medicare and Medicaid Services:https://www.cms.gov/Telemedicine/https://www.cms.gov/Telemedicine/
http://www.cahabagba.com/part_b/education_and_outreach/http://www.cahabagba.com/part_b/education_and_outreach/
general_billing_info/telehealth.htmgeneral_billing_info/telehealth.htm
Nancy Cox (BoschNancy Cox (Bosch): ): Reimbursement issues (856) 723-2522Reimbursement issues (856) 723-2522
Can this be reimbursed in other health agencies?Can this be reimbursed in other health agencies?
For more information on IHMD program For more information on IHMD program design: design:
Elizabeth J. Santa Ana, Ph.D.Elizabeth J. Santa Ana, Ph.D.
(843) 789-7168(843) 789-7168
AcknowledgementsAcknowledgements
This work supported by This work supported by VA Clinical Science VA Clinical Science Research & Development (CSR&D) through a CDA-2 Research & Development (CSR&D) through a CDA-2 (CDA-2-016-08S) (CDA-2-016-08S) awarded to Dr. Elizabeth Santa awarded to Dr. Elizabeth Santa Ana. Ana.
Special thanks to the Charleston VAMC Care Special thanks to the Charleston VAMC Care Coordination Home Telehealth Services: Coordination Home Telehealth Services:
Maureen Distler, RN, BSNMaureen Distler, RN, BSN Kelly Artigues, BSNKelly Artigues, BSN Linda Godleski, MD Linda Godleski, MD (VA National Telehealth Lead)(VA National Telehealth Lead)