Transcript Monitoring Medication Adherence among Homeless Patients:

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
 Patients lack technological
competence
Fear
 “I will lose my job”
 “Technology undermines clinical
relationships”
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
Two Pilot Studies
 Cell phones to monitor medication
adherence among homeless
 Computers to provide counseling to
court-involved clients
Baltimore City
 42, 560 people have opioid use
disorders
 50% suffer from co-occurring
psychiatric disorders
Study 1: Cell Phones to Monitor
Medication Adherence
 Study Partners
 University of Maryland School of Nursing
 Health Care for the Homeless Baltimore
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





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
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
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
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
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
Exclusion Criteria
 Recent history of violence
 Active psychosis or acute crisis
 Unable to follow directions
Characteristics of the Subjects
Characteristics of 10 homeless subjects
Mean / Standard
Percent deviation
Percent male
80%
0.16
Percent black
80%
0.16
Average age
46.90
8.80
Modified Mini Screen for Mental Illness
12.60
3.17
Center for Epidemiological Studies Depression
Scale
29.70
10.95
Lifetime years of cocaine use
10.95
9.45
Lifetime years of heroin use
6.20
7.90
23.60
9.43
Life time years of alcohol use at more than 3
times/week
Demographics/Co-Occurring Disorders
Age
Gender
Diagnosis
Substance
46
Female
Bipolar Mixed, Severe,
Psychotic Behavior
Poly
43
Male
57
Female
MDD , Psychotic Features
MDD Recurrent, Severe,
Psychotic Features
49
Male
Bipolar I
ETOH
Opioid dep, on
Suboxone
45
Male
Schizoaffective
Cocaine & ETOH
49
Female
Bipolar D/O
Crack, ETOH, & Heroin
46
Male
MDD, Psychotic Features
ETOH & Cocaine
24
Male
Bipolar
Oxycontin & ETOH
49
Male
Bipolar Mixed
ETOH
53
Male
Schizoaffective
ETOH & Cocaine
ETOH
Results: Percent of Subjects
Reached per Day
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
Conclusion
 Cell phones were not lost, bartered or
sold
 Cell phones can monitor adherence
 Participation rate was high
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
Research Partners
 Essex County Superior Court Juvenile
Court in Newark New Jersey
 Rutgers College of Nursing
 Alexandria VA Probation Office
 Others
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
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
Substance Abuse Treatment in
Newark
 6 to 8 weeks waiting list
 Detox
 Outpatient counseling 3 X week
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
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
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
Study Design
 Participants randomly assigned to
experimental or control group
 Experimental and control group
participants received an Internetready computer with 1 year access to
the Internet
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
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
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
Characteristics of Study
Population
Number of cases
Number of experimental cases
10
5
30
15
17
9
22
10
Halfway
house &
family court
13%
Probation
agency
Percent White
Indian
Reservation
clinic
0%
6%
Substance abuse &
mental health
clinic
18%
Percent Black
0%
83%
88%
59%
Percent Hispanic
Percent Indian
Percent male
0%
100%
40%
3%
0%
10%
6%
0%
71%
14%
9%
50%
Average years of education
(st. dev.)
Percent days worked in last 30
days
Percent on probation
12.0
(.9)
26%
11.9
(1.9)
12%
12.6
(2.1)
39%
12.6
(2.2)
48%
30%
20%
100%
27%
Percent with medication for
psychological problems
10%
20%
12%
32%
Referral source
Results: Daily Probability of
Drug Use
Experimental
Control
8.95%
25.35%
6.94%
7.01%
2.36%
1.75%
+Urine test
Drug
Self-reported use
Use
in last 30 days
Self-reported Alcohol Use
Note: Observed differences are not statistically significant.
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
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.
Acknowledgements
 Farrokh Alemi, PhD – collaborator in
both studies [email protected]
 Cell Phone study funded by University
of Maryland RIF Program
 Computer study funded by RWJF
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