Background
Integration of treatment for unhealthy alcohol use into HIV clinics
The innovation: integrated stepped care for unhealthy alcohol use in HIV clinics
Methods
Study overview
Study design and participants
HIV clinic characteristics | Social worker | Psychologist | Addiction psychiatrist | Additional considerations |
---|---|---|---|---|
Site 1 | Yes | No | No | n/a |
Site 2 | Yes | Yes | No | n/a |
Site 3 | No | Yes | No | n/a |
Site 4 | No | No | No | n/a |
Site 5 | No | No | No | Providers at geographically dispersed VA-based locations |
Data collection
Focus group procedures
Intervention Characteristics
: Can you tell me about your experiences with treating HIV-infected patients for their unhealthy alcohol use in the context of the
STEP Trials
?
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How does the integrated stepped care approach compare to other treatment approaches? |
What made it easier? |
What make it more difficult? |
Does the intervention feel like something you would create? How would you change it? |
Intervention Characteristics:
How did you find the patients responded to your treatment and the integrated stepped care treatment approach, in general?
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How motivated were patients to participate? |
What seemed to impact their motivation? |
How could this have been improved? |
Characteristics of the Individuals:
What was your experience with delivering the intervention?
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What aspects did you find most effective? |
What aspects did you find least effective? |
How did it fit in with your other roles and responsibilities? |
How comfortable are you in delivering this type of intervention? |
What changes would you make in the training materials to increase their usability? |
Inner Setting:
Can you tell me more about how you communicated with others involved in the care of your patients with unhealthy alcohol use?
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What about social workers/psychologists/psychiatrists? |
What about the patients’ primary care provider? |
Inner Setting:
How important is treating unhealthy alcohol use to your supervisor? To the VA?
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Does this get measured in any way? |
What kinds of resources are dedicated to this? |
Do you think your supervisor would support you to do this kind of work even after the trial ends? |
Describe some of the complexities in implementing this treatment model with regards to the duration, scope, disruption of other activities, number of steps. |
Qualitative analysis
Results
Domain | Definition |
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I. Intervention characteristics: integrated stepped care for unhealthy alcohol use
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Evidence strength & quality | Providers’ perception of the quality and validity of evidence supporting the belief that integrated stepped care for unhealthy alcohol use will lead to decreased unhealthy alcohol use |
Relative advantage | Providers’ perception of the advantage of implementing integrated stepped care for unhealthy alcohol use versus an alternative solution |
Adaptability | The degree to which integrated stepped care for unhealthy alcohol use can be adapted, tailored, refined, or reinvented to meet local needs |
Complexity | Perceived difficulty of implementation, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement |
Design quality & packaging | Perceived excellence in how integrated stepped care for unhealthy alcohol use is bundled, presented, and assembled |
II. Inner domain: HIV clinics
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Networks and communications | The nature and quality of webs of social networks and the nature and quality of formal and informal communications within VA-based HIV clinics and across providers |
Implementation climate | The absorptive capacity for change, shared receptivity of involved individuals to integrated stepped care for unhealthy alcohol use and the extent to which use of it will be rewarded, supported, and expected within the VA |
Tension for change | The degree to which providers perceive the current situation as intolerable or needing change |
Compatibility | The degree of tangible fit between meaning and values attached to integrated stepped care for unhealthy alcohol use by involved individuals, how those align with individuals’ own norms, values, and perceived risks and needs, and how this treatment model with existing workflows and systems |
Relative priority | Individuals’ shared perception of the importance of the implementation within the VA-based HIV clinics |
Readiness for implementation | Tangible and immediate indicators of organizational commitment to its decision to implement integrated stepped care for unhealthy alcohol use |
Available resources | The level of resources dedicated for implementation and on-going operations, including money, training, education, physical space, and time |
Access to knowledge & information | Ease of access to digestible information and knowledge about the intervention and how to incorporate it into work tasks |
III. Characteristics of individuals: providers
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Self-efficacy | Providers’ belief in their own capabilities to execute courses of action to achieve implementation goals |
Individual stage of change | Characterization of the phase a provider is in, as he/she progresses toward skilled, enthusiastic and sustained use of integrated stepped care for unhealthy alcohol use |
Characteristic | Overall (n = 9) | Social workers (n = 4) | Psychologists (n = 2) | Addiction psychiatrists (n = 3) |
---|---|---|---|---|
Age, mean (SD) in years | 44 (11) | 35 (8)* | 54 (1) | 45 (11) |
Race (%) | ||||
White | 78 | 100 | 50 | 67 |
Black | 11 | 0 | 50 | 0 |
Asian | 11 | 0 | 0 | 33 |
Ethnicity, Hispanic (%) | 11 | 25 | 0 | 0 |
Gender, Female (%) | 89 | 100 | 100 | 67 |
Average number weekly patients, mean (SD) | 23 (20) | 20 (18) | 23 (18) | 29 (29) |
Number HIV-infected, mean (SD) | 8 (11) | 15 (14) | 2 (1) | 2 (1) |
Number with an alcohol use disorder or alcohol related problem, mean (SD) | 12 (12) | 5 (5) | 16 (20) | 17 (14) |
Years in current role, mean (SD), [range] | 8 (8), [1–24] | 5 (7), [1–15] | 6 (4), [3–9] | 14 (10) |
Intervention Characteristics Domain: Integrated Stepped Care Model
Evidence strength and quality
I come from an addiction background before coming to the Infectious Disease clinic, and my mental health background. So motivational interviewing is kind of like magic dust \(\ldots\)
I was thinking about the COMBINE Study and the medical management was a very powerful intervention \(\ldots\) I recall from Project COMBINE that included recommendations of going to AA, but it also included me prescribing medication.
Relative advantage
The one where it talked about your drinking [compared to norms], in both my cases they were surprised by the results. It was palpable. You could tell. They \(\ldots\) you know. What do you think of what I’ve just said in terms of, this shows there is such—this high percentile [compared to] drinking [norms] the language is–was surprising to them.
Adaptability
The one thing I probably would change, I think I would want more than, maybe just a little more than four sessions, for me \(\ldots\) My guys worked, so we had to kind of shuffle around to get ‘em in on off days, so committing to 4 sessions was easy. But I felt like they—you were just at that point where you’re holding your kids’ hips as he’s bicycling without training wheels and I just let him go, and he was just taking off—Session number 4. Done. And if I only had just a 5th, maybe just a 5th session, would be the one thing that I would change \(\ldots\) [But] I’m all for \(\ldots\) therapy ending.
\(\ldots\) you start to build a [rapport], and then, because of this session slots issue you cannot see him anymore.
The only other thing too that I also thought about in terms of I think all of our patients, we’re only focusing on alcohol use \(\ldots\) we have like a huge crack epidemic too \(\ldots\) So it’s also interesting to me that we’re only talking to them about how alcohol impacts their body, and I’m ignoring the fact \(\ldots\) he’s like, “No, I did not drink, I just smoked crack yesterday.” Great. You know.
I mean, talking about the relationship between your sex practices and your substance use, talking about the relationship between lack of condom use and substance use, that’s all huge in our clinic. There’s a huge correlation between that. Even to asking them about, are you disclosing your sex—when they go to sex parties, there’s a whole, that’s a whole ‘nother-\(\ldots\) I would totally be interested in seeing how we could do best practices in the VA with prevention positives.
Complexity
Yeah, unless you had, when they come to the clinic, you provide them with a packet of paperwork for them to fill out, and you have the AUDIT-C or whatever other screening tools you’re using, I think it’s going to be difficult to implement.
Somebody would have to be tracking to make sure that it went the right way. There’s gotta be a way \(\ldots\) in terms of tracking someone would have to be responsible for it. It might be unrealistic to think that with 1100 or 1500 person caseloads, a Social Worker would really be able to do that well. I mean, things would fall through the cracks.
I think the word “brief” can be deceiving sometimes \(\ldots\) I don’t think that 20 min which I think was the original design was always necessarily [enough time]- I think sometimes it drags out more so to 40 something to really bring ‘em around. And then the phone booster depending on, same thing, like the resource needs, can be a challenge. And in my real world I think scheduling a phone appointment, if it’s not [the research coordinator] reminding me that I have to do the phone appointment, and me finding it on my Outlook is challenging, just because I have walk-in clinics.
\(\ldots\) it’s not like we’re seeing this huge amount of patients. But I think that when you’re presenting it to people \(\ldots\) it’d be helpful to kind of inform them of that up front \(\ldots\) but it’s not that big of a workload difference.
Design quality and packaging
Social Worker 1: This is more structured, I didn’t have readiness tools and things like that, but, which are great.Social Worker 2: I also like the feedback tool, because we don’t always have like their levels right in front of us, I mean we can obviously click through the whole chart and look at all of their labs \(\ldots\) So it puts it in a nice neat package in terms of providing them with the feedback and having all the normative data and everything else.
Psychologist 1: One, we sent them home with a sort of a homework form [and we said, bring it back]. I think that has the effect in some ways of sort of holding them accountable, when you have to write down what you’ve done. Write your sins down.Psychologist 2: In my experience, the feedback form was absolutely helpful, and because it allowed them to—both of them to, whether they wanted to see how much they were drinking or not, and related it to specific incidents, that allowed them to see those triggers.
I think you can—just by acknowledging, “you’re probably already using these, and you’re probably already doing this, we just want to give you a format and kind of keep track of it.” Because you’re not indicating that you’re adding any more work on \(\ldots\) So you’re not adding on anything more on their caseloads. Especially like if you’re doing it within the ID clinic, and the social workers within the clinic are already meeting with these patients. So, I think it’s just acknowledging that.
For some of my patients, not just in the trial, they’ve had prior experience with disulfiram. And they don’t want to go there. And they lump all the medicines together into I’m talking to them about disulfiram. It doesn’t matter what I say, it’s just like the Charlie Brown, waw waw, waw waw, waw waw. They thinking in their mind, disulfiram, if I slip up I’m going to get sick and die, I can’t take medication. It would be nice to have like a table or something to say, “This is this medicine, it’s what it does; this is this medicine, this one’s different” \(\ldots\)
Inner Setting Domain: HIV Clinics
Networks and communications
And the doctors refer as they’re seeing patients that have the social work-related concerns, as needed.
One thing I would like is \(\ldots\) a local call—a local meeting—that would be very helpful too. See what’s going on \(\ldots\) It would be nice to hear what’s going on.
Social Worker 1: I know we’re all only a phone call away but we don’t—also if you have elevators at that level where they’re seeing the addiction psychiatrist, they’re not necessarily having contact with us anymore, so there’s not that communication on that level.Social Worker 2: Oh yeah, we work as a team. I knock on their door, they knock on my door, no, we definitely work as a team, except, the same thing, the addiction psychiatrist is in a separate part of—you know, our building is very large.
Implementation climate
Tension for change
That’s something if a position can be carved out \(\ldots\) and there is a need. There is such a need. Because I get so many phone calls.
I would say we’d be supported at the national level \(\ldots\) But right now, frankly our challenge is getting—where we’ve been focusing our energy is getting the specialty programs to prescribe medication for alcohol dependence or use disorders. The uptake is really low, nationally.
Compatibility
It’s basically what we—I mean, at least me, what I have been doing.
The way that we operate is, I see all of our new patients ideally like when either they’re newly diagnosed [with HIV] or new to our clinic. Ideally before their initial physician’s appointment, when they come in and get their initial lab work done? I see them, do a comprehensive bio-psychosocial assessment, and or provide like post-HIV diagnosis counseling, and then see them as needed from there on out, depending on what their resource needs are and psychosocial stressors. And the patients that are long established, I see them either when they come as a walk-into see me because they need something, or because the doctors think that they need to see me, or the nurse or the pharmacist or whomever in the clinic.
I think it would be a great \(\ldots\) the PACT teams all have now a social worker, a nurse. I think that would be where \(\ldots\) And everybody’s supposed to have a primary care. Should be assigned a primary care. So I think adding this [intervention] in that team, would be \(\ldots\) you would catch the majority of people.
So they would be more integrated and they would work more like a team, as opposed to being a group practice of independent providers which is how most mental health clinics are now. And so they’ve been rolling this out for about a year or so, and part of what they’ve talked about is how would you integrate addiction treatment into that.
Relative priority
But we still, like even before this study I was gonna—we used this framework. You know, when you’re dealing with somebody who’s, for example, you go into one of the [clinic] meetings and they’re not taking their HIV meds like they’re supposed to, and they’re developing all this resistance and one of the identified reasons is alcohol, I call them in, talk to them and then hopefully it leads to a referral \(\ldots\) but as our role as social workers to the clinic we’d be neglecting a lot of the other important information if we solely focused on the alcohol without addressing all of the other psychosocial stressors and concerns.
Readiness for implementation
Available resources
We have nurses but our nurses are really directed in nature versus like looking at a framework. This is a lot more probing, and our nurses are much more prescriptive and directive in nature. I don’t know if that’s across the board though.
Access to knowledge and information
But something, I mean it makes sense—pharmaceutical companies don’t just create something and publish some papers and let it go at that. In order to get people to uptake it they do proactively go out and detail. So we really shouldn’t be surprised if we publish a paper and people don’t uptake it either \(\ldots\) if we could convince the ID docs to at least initiate it, to talk about naltrexone a little bit, and maybe we don’t have to burden them with managing it. But if we could get them to just sell it a little better.
Addiction Psychiatrist 1: One guy came almost every session. Unfortunately he just said, “I like to talk to you, not like to take medicine from you.”Addiction Psychiatrist 2: I have been more successful prescribing SSRI’s and [tricylics rather than acamprosate]. There’s a fair bit of resistance [to pharmacotherapy] \(\ldots\) It’s like, some of—a good number of them have been in AA, so you don’t need a pill—it’s-anything. That resistance, I don’t know—I don’t need a pill to–I can do it on my own. A lot of patients, it’s from the AA end. And probably some of the pressure is also from… their primary care docs or their cardiologists have never thought about naltrexone.
Characteristics of Individuals Domain: Providers (i.e. Social Workers, Psychologists and Addiction Psychiatrists)
Self-efficacy
I’d be seeing them anyways. And so I’m glad to know that you have educated me, and it fits. It definitely fits with what we’re doing.
I think level of engagement has something to do with it. When we talked, I—the first client that I had was just so into it that by the time the second session, he was way ahead, way ahead, and so all I could do was affirm what he was doing.
And there’s too much time in between [patients]. It’s almost like having to relearn it every [time].
Individual stage of change
But if it’s such a brief thing, and they already have a relationship with their physician, doesn’t it make sense to have the physician do this, and then they have the MET with a social worker, I feel like most social workers that I come cross in the VA, could probably do the MET [stuff].
I think that it could also be powerful if the medication was coming from the Infectious Disease doc, the person who saved my life saying, I think it’s important for your health and your management of your HIV disease, that you stop drinking, and I’m willing to work with you \(\ldots\) I do think that there’s something powerful when the doc who’s saved your life says, “I think you should do something.” That carries a lot of weight. As opposed to this other person I referred you to. So that would be my only suggestion. But I don’t know if you could get ID docs to \(\ldots\) I would submit that they have great motivational skills, because if they can get folks to take HIV meds, then they know how to motivate people.