Transcript The Therapeutic Education System (TES)

Transforming Health and Health Care
via Technology
Lisa A. Marsch, Ph.D.
Director, Center for Technology and Behavioral Health
Dartmouth Psychiatric Research Center
Department of Psychiatry
Dartmouth College
www.c4tbh.org
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)
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.
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
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)
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%.
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).
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.
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).
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.)
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.
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)
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.).
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
List of Module Topics in Therapeutic Education System (TES)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Training Module
What is a Functional Analysis?
Conducting a Functional Analysis
Self-Management Planning
Drug Refusal Skills Training
Awareness of Negative Thinking
Managing Negative Thinking
Managing Thoughts About Using
Managing Negative Moods and Depression
Introduction to Problem Solving
Effective Problem Solving
Progressive Muscle Relaxation Training
Receiving Criticism
Seemingly Irrelevant Decisions
Other Drug Use
Coping with Thoughts About Using
Introduction to Assertiveness
How to Express Oneself in an Assertive Manner
Introduction to Anger Management
How to Become More Aware of the Feeling of Anger
Coping with Anger
Introduction to Relaxation Training
Progressive Muscle Relaxation Generalization
Introduction to Giving Criticism
Steps for Giving Constructive Criticism
Receiving Criticism
Giving and Receiving Compliments
Sharing Feelings
Vocational Counseling
Naltrexone
31
32
Limited Alcohol Use
Financial Management
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
Insomnia
Time Management
Relationship Counseling
Part 1
Relationship Counseling
Part 2
Relationship Counseling
Part 3
Alcohol and Disulfiram
Communication Skills
Nonverbal Communication
Social Recreational Counseling
Attentive Listening
HIV and AIDS
Sexually transmitted infections (STIs)
Hepatitis
Sexual transmission of HIV and STIs
The Female Condom
Birth control use and HIV and STIs
Drug Use, HIV and Hepatitis
Alcohol use and risk for HIV, STIs and hepatitis
Getting Tested for HIV, STIs and Hepatitis
Finding More HIV, STI and Hepatitis Information
Negotiating Safer Sex
Decision-Making
Skills
Identifying/managing triggers for risky sex
Identifying and Managing Triggers for Risky Drug Use
Increasing Self-Confidence
in Decision Making
Taking Responsibility for Choices
Living with Hep C: Managing Treatment, Promoting Health
Living
Living
Living
Living
Living
Living
with Hep C: Coping Skills
with HIV: Coping skills and managing stigma
with HIV: Comm. skills for disclosing HIV status
with HIV: Managing treatment and medications
with HIV: Drug use and Immune System
with HIV: Daily routines to promote health
Sample Screens from TES
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 objectivelyverified drug abstinence among individuals in outpatient buprenorphine
treatment (Bickel, Marsch et al., 2008).
12
a
10
Treatment Weeks
•
a
8
6
b
4
2
0
Continuous Abstinence from
Opioids and Cocaine
Standard
Therapist
Computer
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%
Percent Weeks
Opioid Abstinent
•
50%
40%
30%
20%
10%
0%
TES with
reduced TAU
Treatment
as Usual (TAU)
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.
Illegal Drug Use
Percent
Criminal Activity
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 phonebased intervention during times of heightened risk for drug use.
Treatment Retention
Mobile Psychosocial Treatment
(Chi-square = 4.7; p=.031)
100
Percent Retained
90
84%
80
70
56%
60
50
40
30
20
10
0
Mobile
Intervention
Standard
Treatment
Objectively Measured Opioid Abstinence Mobile
Psychosocial Treatment
(t (48) = -1.97; p= .055)
Weeks of Opioid Abstinence
7
6
5
4
3
2
1
0
Mobile
Intervention
Standard
Treatment
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
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
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
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
Center for Technology and
Behavioral Health
www.c4tbh.org
[email protected]