Implementing an mHealth system for substance use disorders in primary care: a mixed methods study of clinicians’ initial expectations and first year experiences

Abstract

BackgroundMillions of Americans need but don’t receive treatment for substance use, and evidence suggests that addiction-focused interventions on smart phones could support their recovery. There is little research on implementation of addiction-related interventions in primary care, particularly in Federally Qualified Health Centers (FQHCs) that provide primary care to underserved populations. We used mixed methods to examine three FQHCs’ implementation of Seva, a smart-phone app that offers patients online support/discussion, health-tracking, and tools for coping with cravings, and offers clinicians information about patients’ health tracking and relapses. We examined (a) clinicians’ initial perspectives about implementing Seva, and (b) the first year of implementation at Site 1.MethodsPrior to staggered implementation at three FQHCs (Midwest city in WI vs. rural town in MT vs. metropolitan NY), interviews, meetings, and focus groups were conducted with 53 clinicians to identify core themes of initial expectations about implementation. One year into implementation at Site 1, clinicians there were re-interviewed. Their reports were supplemented by quantitative data on clinician and patient use of Seva.ResultsClinicians anticipated that Seva could help patients and make behavioral health appointments more efficient, but they were skeptical that physicians would engage with Seva (given high caseloads), and they were uncertain whether patients would use Seva. They were concerned about legal obligations for monitoring patients’ interactions online, including possible “cries for help” or inappropriate interactions. One year later at Site 1, behavioral health care providers, rather than physicians, had incorporated Seva into patient care, primarily by discussing it during appointments. Given workflow/load concerns, only a few key clinicians monitored health tracking/relapses and prompted outreach when needed; two researchers monitored the discussion board and alerted the clinic as needed. Clinician turnover/leave complicated this approach. Contrary to clinicians’ initial concerns, patients showed sustained, mutually supportive use of Seva, with few instances of misuse.ConclusionsResults suggest the value of (a) focusing implementation on behavioral health care providers rather than physicians, (b) assigning a few individuals (not necessarily clinicians) to monitor health tracking, relapses, and the discussion board, (c) anticipating turnover/leave and having designated replacements. Patients showed sustained, positive use of Seva.Trial registrationClinicalTrials.gov (NCT01963234).

Implementing a Mobile Health System to Integrate the Treatment of Addiction Into Primary Care: A Hybrid Implementation-Effectiveness Study

“…We do not know how Seva might function in a primary care clinic without designated behavioral health staff. Although Seva was somewhat integrated into behavioral health, it did not deeply penetrate physicians' treatment of patients, as reported previously about Site 1 [ 26 ] and observed in Sites 2 and 3, perhaps reflecting the deep divides between primary care and behavioral health mentioned in the Introduction [ 15 ].…”

“…This paper reports quantitative and observational results. Selected qualitative results were reported separately [ 26 ].…”

Detecting Recovery Problems Just in Time: Application of Automated Linguistic Analysis and Supervised Machine Learning to an Online Substance Abuse Forum

“…In addition, although peers can offer first-hand experience related to coping and recovery, they may lack expertise necessary to guide decision making about clinical issues [ 30 ]. In contrast, moderators often have knowledge of intervention components and health behavior change processes and may recognize instances where contact or treatment is appropriate [ 31 , 32 , 10 ]. Moderators may additionally engage in pseudo-therapeutic activities such as offering emotion-focused support or assisting participants in reassessing dysfunctional perspectives [ 11 ] and may be more effective than peers in motivating individuals earlier in their behavior change process [ 33 ].…”

Detecting Recovery Problems Just in Time: Application of Automated Linguistic Analysis and Supervised Machine Learning to an Online Substance Abuse Forum (Preprint)

“…In addition, while peers can offer first-hand experience related to coping and recovery, they may lack expertise necessary to guide decision-making about clinical issues [30]. In contrast, moderators often have knowledge of intervention components and health behavior change processes, and may recognize instances where contact or treatment is appropriate [31,32,10]. Moderators may additionally engage in pseudo-therapeutic activities like offering emotion-focused support or assisting participants in reassessing dysfunctional perspectives [11], and may be more effective than peers in motivating individuals earlier in their behavior change process [33].…”