Expanding access to substance use services and mental health care for people with HIV in Alabama, a technology readiness assessment using a mixed methods approach

Abstract

Background Alabama is one of seven priority states for the National Ending the HIV Epidemic Initiative due to a large rural burden of disease. Mental health (MH) and substance use disorders (SUD) represent obstacles to HIV care in rural areas lacking Medicaid expansion and infrastructure. Evidence-informed technologies, such as telehealth, may enhance SUD and MH services but remain understudied in rural regions. Methods We conducted a readiness assessment using a mixed methods approach to explore opportunities for enhanced SUD and MH screening using electronic patient reported outcomes (ePROs) and telehealth at five Ryan White HIV/AIDS Program-funded clinics in AL. Clinic providers and staff from each site (N = 16) completed the Organizational Readiness to Implement Change (ORIC) assessment and interviews regarding existing services and readiness to change. People with HIV from each site (PLH, N = 18) completed surveys on the acceptability and accessibility of technology for healthcare. Results Surveys and interviews revealed that all clinics screen for depression annually by use of the Patient Health Questionnaire-9 (PHQ9). SUD screening is less frequent and unstandardized. Telehealth is available at all sites, with three of the five sites beginning services due to the COVID-19 pandemic; however, telehealth for MH and SUD services is not standardized across sites. Results demonstrate an overall readiness to adopt standardized screenings and expand telehealth services beyond HIV services at clinics. There were several concerns including Wi-Fi access, staff capacity, and patients’ technological literacy. A sample of 18 people with HIV (PWH), ages 18 to 65 years, participated in surveys; all demonstrated adequate technology literacy. A majority had accessed telehealth and were not concerned about it being too complicated or limiting communication. There were some concerns around lack of in-person interaction and lack of a physical exam and high-quality care with telehealth. Conclusion This study of PWH and the clinics that serve them reveals opportunities to expand SUD and MH services in rural regions using technology. Areas for improvement include implementing routine SUD screening, expanding telehealth while maintaining opportunities for in-person interaction, and using standardized ePROs that are completed by patients, in order to minimize stigma and bias.

Delivery of the HIV Service and Telemedicine Through Effective Patient-Reported Outcomes (+STEP) Intervention to Increase Screening and Treatment of Mental Health and Substance Use Disorders for People Living With HIV in Alabama: Protocol for an Effectiveness-Implementation Study (Preprint)

“…In 2019, there were 4065 persons living with HIV receiving care at one of the participating +STEP sites. Initial findings from aim 1 of this study are available at BMC Health Services Research [42]. Using data from patient surveys and key staff members' qualitative interviews, this study found that all participating RWHAP-funded clinics were ready and willing to implement and integrate ePRO screening for MH and SUD followed by telehealth services as part of their treatment strategy.…”

Delivery of the HIV Service and Telemedicine Through Effective Patient-Reported Outcomes (+STEP) Intervention to Increase Screening and Treatment of Mental Health and Substance Use Disorders for People Living With HIV in Alabama: Protocol for an Effectiveness-Implementation Study

“…Initial findings from aim 1 of this study are available at BMC Health Services Research [ 42 ]. Using data from patient surveys and key staff members’ qualitative interviews, this study found that all participating RWHAP-funded clinics were ready and willing to implement and integrate ePRO screening for MH and SUD followed by telehealth services as part of their treatment strategy.…”

“…Interviews with key staff explored technological capacity and organizational readiness for change using the CFIR. Additional methodological details for aim 1 have been published in BMC Health Services Research [ 39 ]. The Implementation data will be abstracted from scheduling logs, training logs, and the electronic medical record (EMR) at each clinic site every 2 months to characterize the clinic and patient adoption and penetration of +STEP.…”

Evaluating Clinical Outcomes in Patients Being Treated Exclusively via Telepsychiatry

“…Although effective treatment is available for both these chronic conditions, access to these treatments can be a challenge, which has led to significant gaps in treatment [6–8]. Difficulties in access to treatment can stem from physical distances from a treatment site, difficulties with arranging for time away from home or work to attend clinical appointments, prohibitive treatment costs, and the paucity of specialist care [9,10]. Remarkably, 27% of the counties in the US are characterized by the complete absence of psychiatrists [11].…”

“…Remarkably, 27% of the counties in the US are characterized by the complete absence of psychiatrists [11]. Rural residents are noteworthy for having limited access to in person psychiatric care [9,11]. Even more troubling, it appears that issues of access occur independently of the patients’ health insurance status.…”