Presentation on theme: "NIDA Interests: Focus on Addiction Health Services"— Presentation transcript:
1NIDA Interests: Focus on Addiction Health Services Tisha Wiley, Ph.D.Service Research BranchDivision of Epidemiology, Services, and Prevention ResearchNational Institute on Drug AbuseAugust 14, 2012CALDAR Early Career TrackCheck the subtitle on this
2range of problems improve public health. Division of Epidemiology, Services and Prevention Research (DESPR): NIDA’s Public Health DivisionEPIDEMIOLOGY RESEARCH BRANCHDESPR promotesepidemiology, services &prevention research tounderstand and address therange of problemsrelated to drug abuse, in order toimprove public health.PREVENTION RESEARCH BRANCHSERVICES RESEARCH BRANCH2
3range of problems improve public health. Division of Epidemiology, Services and Prevention Research (DESPR): NIDA’s Public Health DivisionEPIDEMIOLOGY RESEARCH BRANCHDESPR promotesepidemiology, services &prevention research tounderstand and address therange of problemsrelated to drug abuse, in order toimprove public health.PREVENTION RESEARCH BRANCHSERVICES RESEARCH BRANCH3
4Service Research Branch Mission Support rigorous research to improve the quality of addiction treatment and recovery support servicesSERVICES: Drug, alcohol, nicotine disorder services & HIV/HCV services for drug-involved individualsDELIVERY SYSTEMS: Specialty treatment programs, general health care settings, criminal justice settings, social service agencies, etc.QUALITY: effective services for all who need them at reasonable a costAvailability, access, appropriateness, effectiveness, safety, efficiency, cost
5Our Research VisionNIDA’s Services Research Branch supports science that leads addiction treatment services toward the highest possible levels of quality, efficiency, & economy.
6About NIDA’s Service Research Branch 238 Active Grants (as of August 2012)$75m in Direct Costs83% of funding goes to Research Project GrantsR01, R21, R03s, etc.
7Services Research Continuum Defining service needsRefining practices for real-world useTesting service delivery modelsPre-implementation researchImplementation TrialsPIPELINEMeasures/methodsSeek, Test, Treat, RetainCJDATS (U01)SRB GRANT TOPICSCo- & Multi-morbidityAlternative service modelsJustice Involved Adolescents (U01)Drug use trajectoriesPrimary CareCJ servicesTx engagement/retentionOther D&I TrialsSBIRTEBP uptakeHealth disparitiesWorkforceUse of technology in treatmentSystems Overlap (e.g., child welfare)
8Selected SRB Areas of Interest Technology & MethodologyImplementation, Sustainability & Outcomes of EBP’sSpecial Settings: Criminal Justice, Juvenile Justice, Child WelfareHealthcare Reform Impact
9Methodology & Technology Relevant Funding AnnouncementsSRB Flagship PA’sPA (R01) – 5 years, unlimited*PA (R21) – 2 years, $275k direct totalPA (R03) – 2 years, $100k direct totalPA (R34) – 3 years, $435 direct totalTechnology/HIV PA’sPA (R01)PA (R34)
10Methodology & Technology Health Services and Economic Research on the Prevention and Treatment of Drug, Alcohol, and Tobacco Abuse (R01, R21, & R03)Our “Flagship” PA’sPA (R01)Supports “developing, refining, and validating new approaches for conducting treatment and prevention services research”Study DesignsMeasurement ToolsSimulation ModelingQuality/Performance MeasuresStatistical ModelsPA (R21)PA (R03)
11Methodology & Technology Technology-Based Interventions to Promote Engagement in Care and Treatment Adherence for Substance Abusing Populations with HIV (R01, R34)Use of technology to directly improve patient-level outcomes (i.e., adherence)Capacity of HIV treatment providers and related service delivery organizations to adopt and integrate such technologies to promote HIV treatment outcomes;Use of technology to improve the organization and delivery of HIV treatment and services.
13Implementation Science PA (R34): Building System Capacity for Implementing EBPsOrganizational and/or systems-level interventions that may optimize access, utilization, delivery, quality, and/or cost of treatment services through the use of EPBsOrganizational and/or systems-specific adaptations to existing EBPsNovel service delivery models to be pilot tested in preparation for larger-scale effectiveness trials
14Implementation Science PA (R34): Building System Capacity for Implementing EBPsHypothesis-driven research that:Addresses systems-level implementation research questionsBuilds provider/funder capacity for conducting research beyond life of the grantDesigned to implement (not develop) evidence-based drug treatment or prevention practicesIdeally, projects will involve:One or more treatment or prevention settingsAn external agency that impacts their services (e.g., SSA, SMA)An academic partner experienced in doing NIH research
15Implementation Science Implementation science isnot intended to test interventions,but to study howto get evidence-based interventions adopted, adapted, & sustained.Our view of implementation science is NOT about effectiveness or efficacy trials
16Implementation Research: Studying the Technology Transfer Process How do we move EBP’s into everyday use?How do we organize treatment to support EBPs?How do we train and supervise staff to use EBPs?How do we change business practices to value EBPs?Client-level outcomes are NOT the focal outcome.Research questions are about finding effective implementation strategies.
17What are implementation strategies? Determining organization’s needs and alternative solutionsSTRATEGIC PLANNINGDetermining organization’s readiness for changeREADINESS ASSESSMENTMonitoring and modifying organizational processes and procedures to implement and sustain new practices (e.g., NIATx)PROCESS IMPROVEMENTWho is trained (e.g., clinical staff, correctional staff, administrative staff), on what, and required resources?TRAINING AND SUPERVISIONModifying what information is collected, how it is accessed and used to support decision-making.INFORMATION SYSTEMSHow can organizational culture be changed to support the infrastructure needed to maintain new services?ORGANIZATIONAL CULTUREYou can use slide 8 or this slide.
18Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare Relevant Funding AnnouncementsFlagship PATRIALS (RFA-DA )Deadline: November 28, 2012Relevant Funded ProjectsCJ-DATS (U01, 10 Research Centers)Seek, Test & Treat: Addressing HIV in the Criminal Justice System (R01s, 13 awards)Data Harmonization
19Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare RFA-DA (U01): Translational Research on Interventions forAdolescents in the Legal System: TRIALSPurposeTest implementation strategies and associated measures to improve the continuum of substance abuse prevention and treatment services delivered to youth under juvenile justice supervisionStructureMultisite collaborative AgreementTwo Types of ApplicationsCoordinating CenterResearch Center
20Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare RFA-DA (U01): Translational Research on Interventions forAdolescents in the Legal System: TRIALSNeedYouth and adolescents in juvenile justice system at high risk and need effective drug use prevention and treatment servicesMost juvenile justice systems do not provide adequate servicesOpportunityWe have effective, evidence-based prevention and treatment interventions for adolescentsInvolvement in the juvenile justice system provides window to intervene with drug abuse & HIVResearchers can partner with juvenile justice agencies:Adolescent drug courts; truancy, teen, family courtsJuvenile detentionJuvenile probation
21Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare CJ-DATS4/14/2017Special Settings: Criminal Justice, Juvenile Justice, & Child WelfareKey Features of CJ-DATS-2 ( )Focus on implementation researchTransfer of evidence-based practicesCriminal justice re-entry-systems improvementCorrectional Facilities, Probation, & ParoleTest of different implementation & quality improvement strategies
22Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare Key Features of CJ-DATS-2 ( )3 Research Protocols10 Research Centers62 Correctional Facilities11 States2 NIDA FTEs$26.8 million over 5 years$2.7 million from CSAT and DOJ co-funders
23Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare Key Features of CJ-DATS-2 ( )MATDoes strategic planning intervention + staff training improve MAT utilization?HIVDoes a local change team improve utilization of HIV services along the continuum of care?AssessmentDoes a local change team improve the case planning process?
25Healthcare Reform Impact Relevant ACA Provisions & Environment:Expands coverage to more than 30 million individuals, many at high risk for drug abuseFundamentally changes the way many drug abuse prevention and treatment services are financedEmphasizes central role of primary care settingsFocuses on screening and preventionPromotes use of electronic health records
26Healthcare Reform Impact Relevant RFA: RFA-DA (R21/R33)Closes August 22, but still an area of interestResearch Topic Examples:Uptake rate for insurance among those with drug use disorders and related conditions and how this is affected by outreach and types of offered coverageResponsiveness of demand for services among the newly coveredEffect on types and quantity of services sought and responses by payersEffect on financing and cost of treatment
27Other FOAsTime-Sensitive Drug Abuse Research (R01) PAR“Rapidly evolving areas where opportunities for empirical study are, by their very nature, only available through expedited review and award of support.”3 Criteriascientific value and feasibility are clear,rapid review and funding are requiredknowledge gained from the study is time-sensitive –regular review cycle = missed opportunity
28Other FOAs Drug Abuse Dissertation Research (R36) PAR-10-020 Last receipt date: October 20122 years, $50k in direct costsSupports research on:EpidemiologyPreventionServicesWomen and Sex/Gender Differences
29Other Areas of Interest Clinical Quality ImprovementAdaptive service delivery strategies to adjust level, dosage, and type of intervention in response to changing needsContinuity of care within and across settingsIntegrated addiction and other medical treatmentPerformance measurement and managementImpact of IT systems and system changes
30Other Areas of Interest Services Organization and ManagementService delivery models (e.g. collaboration, co-location)Management and human resources (e.g. recruitment, training, retention)Business practices
31Other Areas of Interest EconomicsFinancing, e.g.Effect of health insurance on demand for treatmentEffect of reimbursement mechanisms on supply of treatmentEconomic incentives for quality improvementEconomic evaluation (CEA, CUA, CBA)Economic efficiency
32SRB: We are here to help! Contact Us: (301) 443-6504 Branch ChiefRedonna Chandler, Ph.D.Medication-assisted treatment, SBIRT, NIDA-MEDRichard Denisco, M.D.Organization & management, implementation scienceLori Ducharme, Ph.D.Economics research, performance measurementSarah Duffy, Ph.D.HIV, vulnerable populationsDionne Jones, Ph.D.HIV prevention & adherence, child & adolescent drug treatmentShoshana Kahana, Ph.D.Science Officer for CJDATS; criminal justice research, methodologyTisha Wiley, Ph.D.
33Unanswered Research Questions How can HIV services be integrated across the criminal justice system?What is the resistance?What organizational change is needed?What workforce is needed?What implementation strategies work?What will it cost and is it cost-effective?What interventions are needed to reduce stigma associated with drug use, HIV, criminal justice involvement?
34Potential Research Areas for Networks Innovative business practices to improve efficiency & effectiveness of treatmentEffectiveness of commonly used interventions & practicesStrategies promoting diffusion, adoption & sustainability of EBP’sEffectiveness of treatment in a range of settingsYou can use slide 5 or this slide.Studying effects of organization/ management, economics & policies on implementation & effectiveness of EBP’sCost, cost-benefit & cost-effectiveness34
35Recent Funding Initiatives Seek, Test & Treat: Addressing HIV in the Criminal Justice SystemRFA-DA (13 awards)Seek, Test, Treat & Retain: Addressing HIV among Vulnerable PopulationsRFA-DA (10 awards)Economic Studies of Health Insurance Coverage on Drug Abuse Treatment Availability, Access, Costs and QualityRFA-DA (2 awards)Integration of Drug Abuse Prevention and Treatment in Primary Care SettingsRFA-DA ; Applications reviewed March 1, 2012
36Developing an intervention is only one part of translating research into practice. Accessand EngagementProvider knowledge and behaviorOrganization Structure and ClimateExternal Environment (e.g., stigma, financing)INTERVENTION36
37Patient Outcomes can be Improved by: Developing interventions that are highly effective as delivered.DBNBRDPMCBITBCTNDeveloping interventions that are highly effective as delivered.DBNBRDPMCBITBCTNImplementing effective interventions more widely.CTNOSPCDESPR3737
39Other SRB Research Informs Moving Intervention into Practice 16
40An Alternative Model for Intervention Development BasicResearchPracticeEfficacyResearchServicesResearchQuestions(Type II)ServicesResearchQuestionsSystemsResearchSmall-scaleEffectivenessResearchLarge-scaleEffectivenessResearchRobertson, 2002, Schematic Conceptualization of Prevention Science1740
41Conceptual Model of CJ-DATS 2 Implementation Research Implementation StrategiesIntervention StrategiesOutcomesSystems EnvironmentOrganizationalGroup/LearningSupervisionIndividual Providers/ConsumersImplementation OutcomesFeasibilityFidelityPenetrationAcceptabilitySustainabilityUptakeCostsService Outcomes*EfficiencySafetyEffectiveness EquityPatient- centerednessTimelinessClient OutcomesSatisfactionFunctionSymptomatologyEvidence- Based Practices* IOM Standards of CareImplementation Research MethodsSource: Proctor et al., Adm Policy Ment Health 2009;36:24-34.
42Drug Treatment Services & Health Screening in Adult CJ % Facilities Providing ServiceDrug / Alc EducationStandardized SA AssessmtTC (Segregated)Case Mgmt/ TASCTuberculosis ScreeningMental Health AssessmentHIV TestingHIV Tmt, CounselingPrisonJailCommunity CorrectionsSource: Taxman et al., JSAT 2007;32: and Crim Just Beh 2007;34:
43Step’N Out: Implementing Contingency Management Working Alliance# Parole SessionsPOTmtAvg TotalFace- to-FaceParole & Tmt Same Day% Parole SessionsAll p<.01Collaborative Behavioral MgmtStd ParoleSource: Friedmann, et al., J Exp Criminol 2009; 32:
44CJ-DATS-2 Structure (2008-2013) NIDACoordinating CenterPrincipal InvestigatorsSteering CommitteeCo-PIs (CJ Partners)SC Work Groups Data Management Core Measures Publication/Dissemination QualitativeNIDA ScientistStudy 1 Work GroupStudy 2 Work GroupStudy 3 Work GroupStudy Management SubgroupPublicationsProtocol DevelopmentQualitative MeasuresOutcome MeasuresStudy Management SubgroupPublicationsProtocol DevelopmentQualitative MeasuresOutcome MeasuresStudy Management SubgroupPublicationsProtocol DevelopmentQualitative MeasuresOutcome Measures
46Percentage of Inmates Who Filled an ART Prescription Within 60 Days of Release 100Only a small percentage of Texas prison inmatesReceiving ART whileincarcerated filled an initial ART prescriptionwithin 60 days of their release8060Percent4030%17.7%205.4%Had prescriptionfilled within:10 days30 days60 daysBaillargeon J et al., JAMA 301(8): , 2009.
47Life Course View of Addiction Refines Understanding of Recovery & Benefit Cost Multiple treatment episodes is the norm.27 years = Median time from first to last drug use9 years = Median time from first treatment episode to last useDennis, Scott, Funk, & Foss. (2005). The duration & correlates of addiction & treatment. JSAT, 28, S51-S62.Benefit CostZarkin, Dunlap, Hicks, & Mamo. (2005). Benefits & costs of methadone treatment: results from a lifetime simulation model. Health Economics, 14,
48Programs often LACK Evidenced Based Assessment to Identify and Practices to Treat: Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environmentCommon mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self-mutilation and suicidal thoughts)Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime)HIV risk behaviors (needle use, sexual risk, victimization)Child maltreatment (physical, sexual, emotional)Recovery environment and peer risk
49Other Structural Challenges to Delivery of Quality Care in Behavioral Health Systems High turnover workforce with variable education background related to diagnosis, placement, treatment planning and referral to other servicesHeterogeneous needs and severity characterized by multiple problems, chronic relapse, and multiple episodes of care over several yearsLack of access to or use of data at the program level to guide immediate clinical decisions, billing and program planningMissing, bad or misrepresented data that needs to be minimized and incorporated into interpretationsLack of Infrastructure that is needed to support implementation and fidelity