Telehealth Technologies: The Portal to Expanding Treatment &

Recovery Services Terra Hamblin, MA, NCC, DCC

ATTC Network Coordinating Office

10 Regional Centers

National Frontier & Rural

ATTC

National American Indian & Alaska Native

ATTC National SBIRT ATTC

National Hispanic & Latino

ATTC

4 ATTC National Focus Centers

SERVE as the national subject expert and key resource to PROMOTE the awareness and implementation of telehealth technologies.

PREPARE pre-service addiction

treatment and allied health students on using telehealth

technologies by developing and disseminating academic

curricula for infusion into existing courses.

CREATE addiction treatment telehealth competencies and develop policy recommendations for national license portability to encourage the addiction treatment and recovery workforce to ADOPT the use of telehealth services.

USE state-of-the-art culturally-relevant training and technical assistance activities to help the frontier/rural addiction treatment and recovery workforce IMPLEMENT telehealth services.

What would you say if you could.

.easily expand your Treatment services?

.provide supportive services to your patients 24/7?

.expand the reach of your Treatment services?

.provide patients with additional personalized feedback?

.clinically fill some of the hours for your intensive outpatient patients?

.help patients increase their knowledge about their chronic condition (SUDs)

.connect your patients with other patients with similar conditions outside of

the treatment provider

.ensure that patients had the time to really learn about relapse and relapse prevention strategies

Technology Assisted Care

Presentation Outline Technology and the General Public Use of TAC Interventions Characteristics of TACs TACs in Other Systems of Care Utility of TACs Research on TACs Administrative Issues Conclusion Resources

Expose participants to Technology Assisted Care

interventions and showcase two

interventions validated recently through NIDA

Technology has invaded our lives. and our profession

and its Creeping into clinical practice (Mishna et al., 2012)

87% of Americans use the Internet

(Fox & Rainie-Pew Report,2014)

90% of American adults have cell phones

58% have smart phones (Pew Report, 2012)

No matter a persons salary. more people OWN cell phones than USE the internet

(Fox, 2013)

29% of Americans own a tablet

The average American owns FOUR technology devices

(Digital Consumer Report, 2013)

80% send and receive text messages

(Pew Report, 2012)

Perpetual texters.

adolescents (aged 1317) sending or receiving 3,339 texts a month(six texts per waking hour)

young adults (aged 1824) sending or receiving 1,630 (three texts per waking hour)

DIGITAL DIVIDE

(McClure et al., 2012)

Survey of 8 urban drug treatment clinics in Baltimore (266 patients)

Clients had access to - Mobile Phone (91%) - Text Messaging (79%) - Internet/Email/Computer (39 - 45%)

What do we know about the use of technology among our clients?

Another study found that 95% of teens receiving treatment at emergency rooms had access to mobile

phones and participated in text messaging.

(Ranney et al., 2012)

Text message-based behavioral interventions were shown to be acceptable, valid, and reliable with

teens on a variety of sensitive topics.

Have you ever Booked travel arrangements online Purchased an item costing more than $100 online Checked bank account information or moved money between accounts online Applied for a credit card online Signed up for insurance online Signed up for telephone, cable services, or utilities online Paid a bill online Owned a Kindle or iPad Owned access to an electronic book to read on your computer Purchased audio files (e.g., music, books) online Purchased/rented video media (e.g., movies, TV shows) online Owned a cell phone with a digital camera or smart phone with Internet access Owned a robotic cleaning device (e.g., Roomba) Filed your taxes online Used a bank that was online only (i.e., one with no physical structure) Owned or interested in owning a vehicle with voice activation technology for cell

phone use and/or interfacing with stereo or comfort control systems

To date, more than 100 different computer-assisted therapy programs have been developed for a

range of mental disorders and behavioral health problems

(Klein, et al., 2012; Marks et al., 2007; Moore, et al., 2011) (Klein, et al., 2012; Moore, et al., 2011)

Encouraging evidence suggests positive

treatment outcomes

(Bickel et al., 2008; Carroll & Rounsaville, 2010)

In general, technology-based behavioral health interventions have

been shown to be well accepted, efficacious and cost effective, especially

when compared to standard care

(Aronson, Marsch, & Acosta, 2013)

More Specifically there are meta-analytic evaluations of

technology assisted care programs for a range of Psychiatric Disorders

Depression and Anxiety (Spek et al., 2007; Andrews et al., 2010) Illicit Drug Use (Tait, 2013) Smoking (Rooke, 2010) Alcohol Use (Khadjesari, 2011)

The Rise of TAC is supported by the

number studies NIDA and SAMHSA

are collaborating on to assist SUD

treatment programs in adopting and

implementing TACs. (Campbell, A. 2014)

USE of TACs and Devices

Computers

Tablets

Web-based Screeners

Web-Based Support Groups

Interactive Voice Response

Virtual Reality

Video Games

Mobile Phones

CHARACTERISTICS of TAC Interventions

TAC Interventions may consist of text, audio, video,

animations, and/or other forms of multimedia

use information from medical records, physiological data capture devices, or other sources

may be interactively customized, or tailored, to an individual users needs Aronson, Marsch, & Acosta, 2013

Enable anonymity

Marsch, 2012

Are Cost Effective

Marsch, 2012

TACs are flexible by providing automated and tailored information

(Moyer & Finney, 2004/2005; Fotheringham et al., 2000)

Transcend Geographical Boundaries

Marsch, 2012

Facilitate Linkages to Services in Ones Community

Marsch, 2012

With TACs, clinicians have the opportunity to extend their reach by offering

additional resources and support outside of normal clinic hours

TACs could serve as a proverbial foot in the door for clients who are uneasy about seeking SUD treatment

(Rummel & Joyce, 2010)

TACs 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

Utility of TAC Interventions

Could they help Increase the Number of Individuals Entering SUD Treatment?

3.3%

19.3 million people needed but did not receive treatment for illicit drug or alcohol use

Did not feel they needed

treatment

(NSDUH, 2011)

In 2011, 20.6 million people aged 12 or older met the criteria for substance use disorders

Felt they needed treatment Did not

make an effort

Felt they needed treatment Did make an effort

Reasons why people dont enter treatment

alcohol treatment is only for real alcoholics treatment wouldn't work for me treatment would hurt my career not believing that the problem was serious enough

for treatment believing that they should be able to handle the

problem on their own believing the problem would get better on its own liked to drink too much to quit

Stecker, McGovern, & Herr, 2012

Worried about feeling discomfort in treatment, including both physical and psychological discomfort- (e.g., dying from withdrawals, having to face old trauma, trusting someone new, etc.)

Fears about admitting that they had a

problem with alcohol (i.e., Everyone would be surprised to learn that I had a drinking problem) Stecker, McGovern, & Herr, 2012

TACs. Could help providers implement EBPs

A recent meta-analysis (n=2,340) demonstrated that nearly 2.5 times as many substance-users who

received evidence-based psychosocial treatment achieved post-treatment and/or clinically

significant abstinence, compared to those who received non-evidence-based psychosocial treatment

or no psychosocial treatment

Dutra et al., 2008

Some EBPs are Complex require considerable staff training

And Include Issues related to

Fidelity and Supervision

Costs Associated with EBPs. Staffing, Equipment, Incentives

Structuring/Scheduling treatment sessions according to EBPs when.

Travel to treatment may decrease treatment participation

Examples of EBPs Used by TACs

Cognitive Behavioral Therapy Community Reinforcement Approach Contingency Management Motivational Enhancement Motivational Interviewing Brief Intervention Screening Relapse Prevention

TAC Interventions

Serve as adjuncts to standard treatment Save clinician time Extend clinician expertise Integrate other EBPs to provide additional services

to clients with co-morbid conditions Provide access to computerized smoking

cessations programs or other health-related conditions

(Carroll & Rounsaville, 2010)

Models of Integration for TAC Interventions Brief Intervention - particularly in settings where

SUD treatment services are limited (e.g., primary care settings [FQHCs], mental health, etc.)

Could improve motivation and/or readiness? Stand Alone Treatment - comprehensive service

(up to 65 modules available) delivered over a structured period of time (e.g., 12 weeks)

Clinician Extender - administered as an adjunct to treatment whereby clinicians prescribe TACs (or portions of) to enhance therapeutic intervention.

TACs are Embedded Within Other Systems Medical Settings

emergency rooms primary care offices health clinics

Criminal justice Settings probation and parole offices jails prisons

Educational Settings colleges schools

Public Schools- SBIRT- Web-Based Curtis, McLellan, & Gabellini, 2014

TACs to Reduce College Student Drinking Carey et al., 2012

Emergency Rooms- Using IVR or Web-based SBIRT

Choo et al., 2012

Prison Settings TES-Computer-based Intervention

TES used in 10 prisons in 4 states (Chaple, 2012; Blenko, 2012; & Chaple et al. 2013)

MAPIT-Computer-based Intervention (Walters et al., 2014)

TACs in different settings

CBT4CBT (Carroll et al., 2008) Outpatient clients CBT + 6 computer modules on CBT

TES [Therapeutic Education System] (Marsch & Bickel, 2004) Community Reinforcement Approach + Incentives HIV/AIDS Intervention-Opioid treatment clients (2004) Outpatient Opioid Treatment- TAU + TES (2008) Outpatient Treatment-2hrs per week of TES + TAU (2012)

Outpatient Opioid Treatment (2014)

Ondersma (2005/2007) single-session computer-delivered MI intervention reduced drug

use among postpartum women

Examples of TACs

Web-Based Support Groups http://aa-intergroup.org www.AlcoholHelpCenter.net www.smartrecovery.org http://www.cyberrecovery.net/forums http://www.addictiontribe.com www.NAChatroom.org

Podcasts/Radio Shows www.12stepradio.com

https://itunes.apple.com/us/podcast/aa-on-air-wellington/id465173613?mt=2

https://itunes.apple.com/us/podcast/smart-recovery-podcasts/id433764979?mt=2

https://itunes.apple.com/us/podcast/online-recovery-support/id317380341?mt=2

https://itunes.apple.com/us/podcast/getting-to-recovery/id455357559?mt=2

Computer Simulation Games

Male Veterans adjunct to treatment focused on relapse prevention Played computer simulation game for 8 weeks no different in relapse rates results show decreases in craving and

increases in self efficacy

(Verduin et al., 2012)

Guardian Angel

Examples of Web-based Screeners Drinkers Checkup http://drinkerscheckup.com Moderate Drinking

http://www.moderatedrinking.com Rethinking your Drinking

http://rethinkingdrinking.niaaa.nih.gov Check your Drinking www.checkyourdrinking.net

Web-Based Screeners for College Students

www.CheckYourDrinkingU.net www.eCHUG.com http://www.collegebingedrinking.net

Alcohol-Comprehensive Health Enhancement Support System

(ACHESS) Theoretical Design (Self Determination Theory) RCT Results: Reduced number of Risky Drinking days by half and increased the odds of total abstinence Available commercially soon

ACHESS

The ACHESS intervention is explicitly designed to address the three constructs

coping competence social support autonomous motivation

Primary hypothesis is that ACHESS will reduce

risky drinking days

ACHESS employs these concepts in the following ways to prevent relapse

1. develop/maintain autonomous motivation to prevent relapse (autonomy supportiveness)

2. offer resources to cope with pressures to relapse, e.g., cravings, withdrawal symptoms, high risk situations (competence)

3. provide access to social support to persevere (relatedness)

(Gustafson, et al., 2011)

ACHESS Monitoring and alerts Reminders Autonomous motivation Assertive outreach Care coordination Medication reminders Peer & family support Relaxation Locations tracking Contact with professionals Information

Boston University Slideshow Title Goes Here

C.A.S.A. CHESS Comunicando A travs de Smartphone Apoyo

Computer-based Intervention

Technology-Assisted Care Interventions have been validated recently through

NIDA research

Therapeutic Education System (TES)

An interactive, web-based psychosocial intervention for SUDs, grounded in:

Community Reinforcement Approach (CRA)

+ Cognitive Behavioral Therapy (CBT)

+ Contingency Management (CM)

What Do People Say About TES?

Features of TES

Consists of 65 interactive, multimedia modules Self-directed, evidence-based program with skills

training, interactive exercises, and homework Audio component accompanies all module content Electronic reports of patient activity available Contingency Management Component tracks

earnings of incentives dependent on some defined outcome (e.g., urine results confirming abstinence)

Prize-based incentives, virtual fishbowl, intermittent schedule of reinforcement

TES Incentive System

Based on: Abstinence Module Completion

TES doubled the odds of abstinence among clients who

tested positive for substances

TES improved retention (48% of TES clients stayed in Treatment

for 12 months compared to 40% of TAU)

Findings suggest that TES can be substituted for a portion of face-to-face counseling and

produce better outcomes (i.e., abstinence and retention)

Other TES Findings

In outpatients with opioid dependence, computer-administered CRA with vouchers produced similar abstinence weeks and longer continuous abstinence than therapist-administered CRA with vouchers and reduced therapist time.

(Bickel et al., 2008)

Other TES Findings

For youth in substance abuse treatment, TES was an effective adjunct to HIV prevention education (Marsch et al., 2011)

In MMTP program, TES plus counseling produced greater 12-month abstinence than counseling alone (Marsch et al., 2011)

In a prison population, TES was as effective as standard treatment in reducing drug use, HIV risk and self-reported

criminal behavior at 3- and 6-months post-release and resulted in greater treatment satisfaction and completion

(Chaple et al., 2013)

CBT4CBT CBT4CBT is a computer-based version of cognitive

behavioral therapy (CBT) used in conjunction with clinical care for current substance users

Six modules and follow up assignments focus on key concepts in substance use, including cravings,

problem solving and decision making skills The multimedia presentation, based on elementary

level computer learning games, requires no previous computer experience.

www.cbt4cbt.com

CBT4CBT was more positively evaluated by participants

Completion of homework assignments in CBT4CBT was significantly correlated with outcome and a significant predictor of Tx

involvement.

Conclusion CBT4CBT plus clinical practice is more effective in reducing drug use during

treatment than standard therapy alone.

Administratively.

The key is to select TAC interventions that support the

organizations future strategy and add perceived value to customers both

consumers and payers (Adler, 2013)

While TAC Interventions are not currently reimbursable, they could provide a return by:

Reducing the cost of service per unit the cost of service per case

Improving payer preference consumer preference operating performance consumer outcome or functioning

Facilitating a new consumer service a new payer relationship

(Adler, 2013)

Customer Demand

Although reimbursement structures for technology-mediated services under both private and public health insurance plans

are emerging, depending on State licensing and reimbursement policies

providers may try to recapture their costs in other ways.

the use of TAC interventions may be incorporated as a value-added

service that assists providers in meeting other contractual obligations,

such as the use of EBPs.

For example

Start-Up Costs

Equipment including computers, tablets, and servers

Allocating and configuring space, cabling and other communications

lines, building reconfiguration, equipment, and cooling systems

Internet Provider Fees

Legal and Liability Consultation (e.g., sufficient and explicit insurance coverage)

What does the TAC vendor provide? Software

encryption systems, virus protection, applications, storage, and security systems

Consultation in technology Content development

clinical materials, protocols, procedures that will support and guide implementation

informed consent forms and privacy disclosures

Initial staff training - including staff & expert trainer time

Costs of Ongoing Maintenance Equipment maintenance, insurance, and replacement costs Ongoing internet provider fees Annual licensing or hosting fees Expert consultation and/or troubleshooting Training for new staff and refresher training Content refinement and updating of materials Legal and accounting consultation Inclusion of extra client data and client

privacy/consent management information

Privacy, Security, & Confidentiality

Unique Considerations for TACs Self-directed therapeutic websites/applications

typically hosted by third-party vendors (HIPAA business agreement may be required) Organizations will typically purchase a license for a

group of clients, and the clients are each provided with a unique user ID and password

(HIPAA compliant portal ask that question) Applications vary in terms of data security and the

amount of personal information entered (typically, personal information is not required)

(Personal health information collected or not)

TES: An Example Password protected for each participant Self-directed via computer (no therapist) Clinical information is not stored,

participation is tracked (i.e., specific modules completed)

No personal information is collected Transfer of information is not required Clinician would merely document the use of

TAC in the record (Tx plan, progress notes)

CBT4CBT: An Example Access to the CBT4CBT program was on a dedicated

computer in a private room within the clinic Research Assistant showed patients how to use program Patients accessed the program through a log-in and

password system to protect confidentiality CBT4CBT is user friendly as no previous experience with

computers or reading skills is necessary (i.e., material presented in text is also read by a narrator)

Collects NO protected private health information

(Carroll et al., 2014)

Summary of TAC Interventions

Promising TAC Interventions exist to treat alcohol, tobacco, gambling, & illicit drug use

TES & CBT4CBT are two interventions that are currently leading the way

Clinicians & administrators need to think through how they can use these new technologies in clinical treatment

Delivery of CBT could be subcontracted to the computer..

(Carroll & Rounsaville, 2010)

TACs may replace a portion of clinicians typical interaction with clients which may

allow a treatment provider

to treat more clients with the same number of clinicians

free-up clinicians to have more time to manage client crises or spend more time with those with the greatest need for more intensive care.

more effectively manage high patient caseloads

Clinical Considerations for TAC Integrating into the treatment plan

Use in individual therapy Use in group therapy Select relevant order and content of modules Use for homework assignments

Orienting client to system, its purpose and use Processing experience with clients Documentation in progress notes Tracking participation

NOT THIS

Or This

Clinician Extenders

(Bickel et al., 2008; Carroll & Rounsaville, 2010; Des Jarlais et al., 1999; Marsch, 2011)

Professionals will need to view technology as a powerful partner in improving quality and productivity of behavioral healthcare

Marsch & Gustafson, 2013

Whether its Group Counseling

Like This or Like This

or Client Homework Like This

or Like This

TACs are in ClientsBest Interest

Expanding Access

Enhancing Treatment Services

SUDTECH.ORG

Center for Technology and Behavioral Health

Treatment Improvement Protocol (TIP) Using Technology-Based Therapeutic Tools

in Behavioral Health Services

Coming Soon

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857

The vital question for this field is

not Do computer-assisted therapies work?

but..

(Kiluk et al., 2011)

which specific computer-assisted therapies, delivered under what conditions to which populations,

exert effects that approach or exceed those of standard

clinician-delivered therapies?

(Kiluk et al., 2011)

Thank you National Frontier and Rural ATTC

nfarattc.org

Slide Number 1Slide Number 2Slide Number 310 Regional Centers4 ATTC National Focus CentersSERVE as the national subject expert and key resource to PROMOTE the awareness and implementation of telehealth technologies. Slide Number 7Slide Number 8Slide Number 9What would you say if you could..easily expand your Treatment services?.provide supportive services to your patients 24/7?.expand the reach of your Treatment services?.provide patients with additional personalized feedback?.clinically fill some of the hours for your intensive outpatient patients?.help patients increase their knowledge about their chronic condition (SUDs).connect your patients with other patients with similar conditions outside of the treatment provider.ensure that patients had the time to really learn about relapse and relapse prevention strategiesSlide Number 19Presentation OutlineSlide Number 21Slide Number 22 and its Creeping into clinical practice87% of Americans use the Internet90% of American adults have cell phonesNo matter a persons salary. more people OWN cell phones than USE the internet Slide Number 27Slide Number 2880% send and receive text messages Perpetual texters.Slide Number 31Slide Number 32Slide Number 33Slide Number 34Slide Number 35(McClure et al., 2012)Slide Number 37Slide Number 38To date, more than 100different computer-assisted therapy programs have been developed for a range of mental disorders and behavioral health problems Encouraging evidence suggests positive treatment outcomesIn general, technology-based behavioral health interventions have been shown to be well accepted, efficacious and cost effective, especially when compared tostandard careMore Specifically there are meta-analytic evaluations of technology assisted care programs for a range of Psychiatric DisordersSlide Number 43USE of TACs and DevicesComputersTabletsWeb-based ScreenersWeb-Based Support GroupsInteractive Voice ResponseVirtual RealityVideo GamesSlide Number 52CHARACTERISTICS of TAC InterventionsTAC InterventionsEnable anonymity Are Cost Effective TACs are flexible by providing automated and tailored informationTranscend Geographical BoundariesFacilitate Linkages to Services in Ones Community With TACs, clinicians havethe opportunity to extend their reach by offering additional resources andsupport outside of normal clinic hoursTACs could serve as a proverbial foot in the door for clients who are uneasy about seeking SUD treatmentTACs may also be offered as stand-alone interventions, which may be particularly relevant in rural or other settings where access to care may be limitedSlide Number 63Could they help Increase the Number of Individuals Entering SUD Treatment?Slide Number 65Reasons why people dont enter treatmentSlide Number 67TACs.Could help providers implement EBPsA recent meta-analysis (n=2,340) demonstrated that nearly 2.5 times as many substance-users who received evidence-based psychosocialtreatment achieved post-treatment and/or clinically significant abstinence, compared to those who received non-evidence-based psychosocial treatment or no psychosocial treatment Some EBPs are Complexrequire considerable staff trainingAnd Include Issues related to Fidelity and SupervisionCosts Associated with EBPs.Staffing, Equipment, IncentivesStructuring/Scheduling treatment sessions according to EBPs when.Travel to treatment may decrease treatment participationExamples of EBPs Used by TACsTAC InterventionsModels of Integration for TAC InterventionsTACs are Embedded Within Other Systems Public Schools- SBIRT- Web-BasedCurtis, McLellan, & Gabellini, 2014TACs to Reduce College Student DrinkingCarey et al., 2012Emergency Rooms- Using IVR or Web-based SBIRTChoo et al., 2012Prison SettingsTACs in different settingsExamples of TACsWeb-Based Support GroupsPodcasts/Radio ShowsComputer Simulation GamesExamples of Web-based ScreenersWeb-Based Screeners for College StudentsAlcohol-Comprehensive Health Enhancement Support System (ACHESS)ACHESSACHESS employs these concepts in the following ways to prevent relapseACHESSC.A.S.A. CHESSComunicando A travs de Smartphone ApoyoSlide Number 94Slide Number 95Therapeutic Education System (TES)What Do People Say About TES? Features of TESTES Incentive SystemTES doubled the odds of abstinence among clients who tested positive for substancesTES improved retention (48% of TES clients stayed in Treatment for 12 months compared to 40% of TAU)Findings suggest that TES can be substituted for a portion of face-to-face counseling and produce better outcomes (i.e., abstinence and retention)Other TES FindingsOther TES FindingsIn a prison population, TES was as effective as standard treatment in reducing drug use, HIV risk and self-reported criminal behavior at 3- and 6-months post-release and resulted in greater treatment satisfaction and completion (Chaple et al., 2013)CBT4CBTwww.cbt4cbt.comCBT4CBT was more positively evaluated by participants Completion of homework assignments in CBT4CBT was significantly correlated with outcome and a significant predictor of Tx involvement.ConclusionCBT4CBT plus clinical practice is more effective in reducing drug use during treatment than standard therapy alone.Administratively.The key is to select TAC interventions that support the organizations future strategy and add perceived value to customers both consumers and payers While TAC Interventions are not currently reimbursable, they could provide a return by:Slide Number 114Slide Number 115Slide Number 116 the use of TAC interventions may be incorporated as a value-added service that assists providers in meeting other contractual obligations, such as the use of EBPs. Slide Number 118Slide Number 119Slide Number 120Slide Number 121Start-Up CostsEquipment including computers, tablets, and serversAllocating and configuring space,cabling and other communications lines, building reconfiguration, equipment, and cooling systemsInternet Provider FeesLegal and Liability Consultation (e.g., sufficient and explicit insurance coverage)What does the TAC vendor provide? Costs of Ongoing MaintenanceSlide Number 129Unique Considerations for TACsTES: An ExampleCBT4CBT: An Example Summary of TAC InterventionsDelivery of CBT could be subcontracted to the computer..TACs may replace a portion of clinicians typical interaction with clients which may allow a treatment providerClinical Considerations for TAC NOT THISOr ThisClinician ExtendersProfessionals will need to view technology as a powerful partner in improving quality and productivity of behavioral healthcare Whether its Group Counselingor Client HomeworkTACs are in ClientsBest Interest Slide Number 144Slide Number 145SUDTECH.ORG Center for Technology and Behavioral Health Slide Number 148Coming SoonSlide Number 150Slide Number 151Slide Number 152Slide Number 153The vital question for this field is not Do computer-assisted therapies work? but.. which specific computer-assisted therapies, delivered under what conditions to which populations, exert effects that approach orexceed those of standard clinician-delivered therapies?Slide Number 156