February 2007

Grant Results

SUMMARY

The Center for Health Systems Research and Analysis (CHSRA) at the University of Wisconsin, Madison, convened two meetings in November 2004 and May 2005 on the application of technological innovations to the diagnosis and treatment of substance abuse disorders (SUDs).

Key Results
During the first meeting, held in Chicago in 2004, experts in technology heard from people with personal knowledge of the SUD treatment system about their encounters with the barriers to good care the current system erected.

This meeting led to planning for the workshop, held May 5–6, 2005 at RWJF in Princeton, N.J. At the meeting substance abuse treatment practitioners and several technology experts identified opportunities for improvement in three key areas:

  • Understanding addiction and strategies for prevention among children, parents and policy-makers.
  • Proactive identification of people at risk (and linking this into the medical care system).
  • Personal case management and ongoing support of people in recovery.

Key Conclusion
Summing up, the technologies will be able to help with relapse prevention — identifying and responding to triggers that lead a person with a chronic disease (i.e., SUD) to initiate counterproductive behavior, or to counteract the effect of these triggers. These new technologies will turn patients and their families into their own case managers.

Funding
The Robert Wood Johnson Foundation (RWJF) sponsored the two meetings with two grants totaling $163,793. Of this, $65,000 was reprogrammed from a grant (ID# 052450) to the national program office of the Paths to Recovery national program, which managed this project.

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THE PROBLEM

Few people access substance abuse treatment and even fewer receive high quality care (based on evidence, proven practices, etc.). There are, however, promising technologies that have the opportunity to dramatically improve the cost effectiveness of treatment and could also improve the quality of care and access to care. This project is intended to better understand what those technologies are and what role they might play in SUD treatment.

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RWJF STRATEGY

RWJF seeks to improve the quality of care in SUD treatment and has identified three main objectives for this work:

  • To improve the ability of the SUD treatment system to measure the quality of the care it provides, by documenting evidence-based practices for treatment and developing widely accepted indicators to measure the use of these practices.
  • To enhance the capacity of state governments to use their roles as purchasers and licensers of care to support the implementation of these evidence-based practices.
  • To identify innovations that will help the SUD treatment delivery system put these proven practices to use.

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THE PROJECT

In April 2004, RWJF awarded a grant to the Center for Health Systems Research and Analysis (CHSRA) to assist RWJF program staff on the Addiction Prevention & Treatment Team to identify opportunities for improving the quality of care provided by the current SUD treatment system. In November 2004, the center convened the first of two-part series of meetings.

During this first meeting, experts in technology heard from people with personal knowledge of the SUD treatment system about their encounters with the barriers to good care the current system erected. With this background, the participants then discussed the technological innovations that might, over roughly a 20-year time frame, offer ways to improve the system.

This meeting led to planning for a workshop in May 2005 at which SUD treatment practitioners would work with a few of the technology experts to identify changes that could be implemented over a shorter period of time.

The center's staff and RWJF's program team established three goals for the May workshop:

  • To identify a set of technological innovations that will substantially improve addiction treatment, and will be practical to implement within three to five years.
  • To clarify when and how these innovations can be put to use.
  • To identify the next steps needed to make these innovations real, and thereby to improve the overall quality of SUD care.

The participants in the workshop from the addiction treatment field had a variety of experience and included the head of a state mental health agency, a senior manager from a managed care behavioral health program, a person recovering from an SUD who directs a counseling facility and the scientific director of an addiction treatment research institute.

Those who knew about technological innovations included medical school faculty, health care futurists, experts in the application of these technologies to industries outside of health care and those who have worked to apply technology to improve the quality of care for other conditions, including cancer care.

A core underlying belief at the workshop was that addiction is, in fact, a chronic disease, and as with any chronic disease, relapses are to be expected. Understanding addiction as a chronic disease permits the use of the Chronic Care Model as defined by Ed Wagner in "Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness?" (published in Effective Clinical Practice, (1):2–4, 1998) as a framework for thinking about addiction treatment. The Chronic Care Model recognizes that an effective care system involves the coordination of an informed and active consumer and that consumer's family, effective design of the delivery system, prepared practice teams and a prepared community, and supportive technology.

The center's staff structured the workshop to allow for work that, first, promoted divergent thinking and creativity, what the facilitator called "connecting and rearranging knowledge — among people who think flexibly — to generate new, surprising ideas that people will find useful." To strengthen the notion that the ideas be "found useful," the divergent thinking then was followed by work to promote convergent thinking in order to harvest, refine and adapt these ideas so they could conceivably be implemented.

Specifically, through the two days of the workshop participants spent time:

  • Hearing from patients and family members about actual experiences with the addiction treatment system, understanding where the existing system had failed and conceptualizing the places in the diagnostic and treatment processes where changes could have led to improvements in care (the "if-onlys").
  • Using this information to set priorities about what consumers need and what parts of the SUD treatment system should be changed (using the elements of the Chronic Care Model as a framework).
  • Learning about technical innovations — what's out there that could be helpful — and selecting the most promising innovations.
  • Creating, and telling the story of, interventions involving a package of technological innovations that have great potential to improve the SUD treatment system.
  • Identifying what to do next.

These tasks were conducted primarily in small groups, each containing a particular mix of expertise, and at other times they were randomly selected. In all cases, each group had members from both the addiction treatment and technology sectors. Each of these groups considered three areas for opportunities for improvement:

  • Understanding addiction and strategies for prevention among children, parents and policy-makers.
  • Proactive identification of people at risk (and linking this into the medical care system).
  • Personal case management and ongoing support of people in recovery.

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RESULTS

On each of these areas of improvement, the work groups discussed possible solutions and improvements.

  • Understanding addiction and strategies for prevention. For example, the work groups proposed developing a Web-based game with a narrative designed to build a range of life skills, treating addiction as one component. The game could initially be targeted to 6–11 year-olds with the idea that "the game grows with you," with issues and decisions becoming more complex as the children age and move up to more advanced levels. In addition to building skills among the players, the game also would provide the opportunity to involve parents; the game could be designed to emphasize children interacting with their parents and thereby help parents identify potential problems as they assess the decisions made by their children. Finally, the aggregate information gathered from thousands of players of the game could become a valuable source of information for policy-makers, public health officials and providers about how children make decisions on substance use. This technology can also be applied to the other areas.
  • Proactive identification of people at risk of developing SUDs. Workshop participants built on the idea of using "push technologies" to insure that both people at risk of developing SUDs, their families and their providers receive evidence-based information on appropriate care and actions "at the right time, in the right place and in the right way." Vehicles for this push technology could include cell phones, wearable technology and electronic medical records that contain flagged messages and links to information on evidence-based care. Persons especially at risk for developing SUDs could be further diagnosed using existing brain scanning technology, and in the future, as implantable "chips" become available, information about a person's activities could be used to inform the feedback received by both the patient and his/her provider. The workshop participants who developed this idea highlighted its potential to normalize the identification of risk factors and triggers for SUDs. Primary care providers currently do very little in this area, and a major improvement in the delivery system would come from integrating this activity into regular medical care.
  • Personal case management and ongoing support of people in recovery. Recovery is a lifelong effort, and much of the discussion in the workshop involved the implications of recognizing addiction as a chronic illness with the concomitant recognition that relapses are inevitable. Much of the current SUD treatment system is not geared to this outlook, so several of the working groups addressed how technology can support a new point of view in the management of recovery — not just for the SUD client but for family and larger support systems as well who are providing "case management" to the SUD client. One group looked specifically at the immediate follow-up to residential treatment, a second considered support networks for those in rural and other isolated settings, and a third considered recovery over the long term. Whatever the setting, the stories the groups created focused on making better and more coherent use of the wide range of communications technologies: from low-tech television, through cell phones, PDAs, GPS, the Internet, videoconferencing and electronic medical records, up to the more nascent technologies of body media ("smart shirts") and artificial intelligence/virtual counseling.
  • The core needs of the target groups — both consumers and providers — include:
    • First, having immediate access to valid and reliable information. Consumers need to know about their options, and providers need to know about the physiologic state and current environment of the consumer they are trying to support (as the technology of implantable chips develops in the next few years, more such information will be able to be sent).
    • Second, the need for technology to guide behavior change (e.g., by early identification of relapse tendencies and using virtual reality to help people practice how to deal with high risk situations. For example, technologies will allow clients not only to know that they are getting anxious (a key predictor of possible relapse) but a warning system (triggered by wearable sensors) can trigger the initiation of a biofeedback system to help prevent a relapse.
    • Third, the great opportunity technology offers to create virtual communities and to strengthen the personal interaction among people in recovery, which has powerful potential. Any such efforts must, however, be tailored to the consumer's level of comfort with technology. There will be an ongoing need for a range of levels of sophistication in the technological support. Finally, increased access to information requires careful management or consumers and providers may become overwhelmed by sheer volume. The workshop participants cited the importance of artificial intelligence tools and their ability to help target the information provided to a specific situation.

Summing up, the technologies will be able to help with relapse prevention — identifying and responding to triggers that lead a person with a chronic disease (i.e., SUD) to initiate counterproductive behavior, or to counteract the effect of these triggers. These new technologies will turn patients and their families into their own case managers.

Workshop participants hoped these ideas could have broad application to other chronic illnesses, and also serve to reinforce understanding of addiction as a chronic illness.

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AFTER THE GRANT

As a result of the meeting, some treatment agencies have already begun to initiate some new interventions. For example, a treatment agency is now moving to long-distance counseling using low-tech video conferencing.

At the same time, workshop participants identified a number of considerations that must be taken into account as actions are taken. First, any efforts to improve the identification of people with the potential to develop addiction disorders, and tracking information about the actions of those in the treatment system, raises ethical and legal issues about confidentiality and the use or potential abuse of this information. These issues must be addressed; a necessary first step is to ensure that funding is available to support the research and policy development required.

People in the field need to develop a better understanding of how to make technological innovations work in real practice. This will involve bringing not just software developers and other experts in technology into the discussion, but also consumers and their families, and providers. Consumers need also to be involved consistently and iteratively as any actual tools or games are designed.

Designing the algorithms that will govern the "virtual counselors" and clarifying the evidence-based information that will be "pushed" to providers (especially primary care providers) and consumers/families is a big job, still to be done: "The research may be there but it's not aggregated," as one participant said.

Participants urged RWJF's Addiction Prevention & Treatment Team and staff at the center to think creatively about how this work might be funded. Becoming involved in this work could bring substantial long-term gains to software developers, for example, and there is no reason not to take advantage of this.

Finally, as people design these technological innovations, they need to be aware that the SUD treatment workforce and consumers of these services need to be ready to use these technologies. As the field moves to incorporate more and more technological resources into diagnosis, treatment and recovery, people need to realize that education in technology must, in the future, become an active part of SUD treatment.

Meanwhile, RWJF has made another grant (ID# 055304) to the University of Wisconsin, Madison, Center for Health Systems Research and Analysis to disseminate a blueprint of the addiction treatment system of the future. The goal of the collaborative project is to stimulate interest in developing and testing technology-based systems, create a prototype system, and attract support for ongoing work from government agencies and philanthropic organizations.

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GRANT DETAILS & CONTACT INFORMATION

Project

Developing a Blueprint of the Addiction Treatment System of the Future

Grantee

University of Wisconsin, Madison, Center for Health Systems Research and Analysis (Madison,  WI)

  • Amount: $ 98,793
    Dates: April 2004 to December 2004
    ID#:  049911

Contact

David H. Gustafson
(608) 263-4882
dhgustaf@facstaff.wisc.edu

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Report prepared by: Katherine Garrett
Reviewed by: Molly McKaughan
Program Officer: Kristin B. Schubert

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