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This poster reports on an initiative to implement HIV rapid testing in substance abuse treatment programs in the state of South Carolina. A multi-agency collaboration between the Single State Authority, the state Health Department, the regional Addiction Technology Transfer Center (ATTC), and one substance abuse treatment program (Lexington-Richland Alcohol and Drug Abuse Council (LRADAC)), facilitated state-wide implementation. LRADAC, a community-based treatment program, was one of twelve sites that participated in the CTN trial on HIV rapid testing (protocol CTN-0032). Upon completion of the trial, LRADAC implemented a rapid HIV testing and counseling program as a clinical service. South Carolina’s previous efforts to implement on-site rapid HIV testing in 10 pilot agencies had less than optimal success due to the absence of a successful model on which agencies could base their implementation plan. With support from the collaborating agencies, staff developed and presented a 2 1/2 day HIV testing and counseling curriculum at the annual SC School of Alcohol and Drug Studies in 2010. Following the successful completion of the course, participants were fully certified to conduct testing and counseling in their local programs. Course participants had the opportunity to learn the counseling and testing procedures that LRADAC staff found successful in implementing their program. Although challenging, implementing HIV testing program in substance abuse treatment programs is feasible for agencies. The multi-agency collaboration in South Carolina supported the development of an HIV testing and counseling course that was team taught and showcased a successful model on which implementation could be based. Consequently, this effort increased the likelihood that additional substance abuse agencies within the state would move forward with implementation.
Related protocols: CTN-0032
Teleconferencing Supervision is a method for training community-based substance abuse clinicians in Motivational Interviewing (MI). In this CTN platform study, 13 clinicians recruited from 3 community treatment programs in the Long Island Node of the Clinical Trials Network attended a 2-day workshop and then received live supervision via telephone during 5 counseling sessions conducted at their community treatment facilities. Clinicians were assessed for skill level at post-workshop, at post-training, and 3 months later; learning was assessed using the MI Treatment Integrity instrument. All summary scores and therapist behavior frequency counts improved by post-training or by the 3 month follow-up, although some gains were not statistically significant.
This study suggests that Teleconferencing Supervision may help facilitate the proficient use of MI community clinicians following workshop instruction. By enabling both clinicians and supervisors to participate from their respective home bases, it is hoped that the TCS model will be able to project training to a broader range of community treatment programs.
The importance of implementing evidence-based practices has taken over health care, whether in the mental health, medical, or substance use treatment realms. While well-intentioned and important, the implementation of evidence-based practices is only one aspect of quality care. In fact, there are many other elements of treatment that are at least as important as offering evidence-based practices, and this is particularly true in levels of care other than traditional outpatient. Other elements of care essential to quality treatment include: 1) Monitoring and ensuring a positive therapeutic alliance between clients and providers – Much research has documented the relationship between positive treatment outcome and a positive therapeutic alliance; 2) Monitoring and ensuring high customer satisfaction: Regardless of the specific treatment offered, it is essential to monitor and address customer satisfaction, as without this, clients will not obtain benefit from treatment; 3) Monitoring administrative discharges – In residential treatment programs, clients are often discharged for non-compliance with treatment. This needs close monitoring, as from experience, administrative discharges have more to do with staff than with clients; 4) Ensuring readily-available treatment access – When individuals are ready to enter treatment, treatment needs to be available. Treatment not being available or long waiting periods to enter treatment will result in lost opportunities; 5) Monitoring no-show rates and overall treatment retention – People have to come to treatment and be retained for treatment to be effective. Thus, a focus on this is necessary; 6) Ensuring clients – multiple treatment needs are addressed – Either in-house or through linkages, clients – other problems need to be addressed; and 7) Ongoing quality improvement – To ensure quality treatment, a culture of continuous quality improvement must be developed.
This presentation will highlight other important aspects of care that must not be forgotten while programs are focused on implementing evidence-based practices.
This is the Primary Outcomes Article for CTN-0091. It has not been published in a peer-reviewed journal.
Practice facilitation is a commonly employed strategy to implement evidence-based programs into primary care settings. Preparing facilitators for this role requires an understanding of their training needs and support. Here we report on the experiences of facilitators who participated in a training program to support efforts to improve opioid medication management in primary care.
Trainees with prior QI experience were recruited for the six-month training program. Each trainee recruited a clinic for which they would serve as an external facilitator to implement the Six Building Blocks program. At the end of the six-months, we conducted two semi-structured interviews with each trainee. The interviews focused on facilitators and barriers that the trainees experienced during the training and support provided. Qualitative content analysis was used to analyze the transcribed interviews.
Three of the five trainees completed the program. In addition to the in-depth understanding of the Six BB program, trainees valued the opportunity to build peer relationships which provided a supportive peer support group. They valued the availability of more experienced facilitators who supported and mentored them. They also mentioned the importance of providing helpful tools and resources and the availability of a clinical expert. Barriers focused on factors internal to the trainees’ clinical setting, the trainees limited clinical knowledge about chronic pain, and difficulty maintaining momentum for change due to the flexible timeline of the program itself.
Conclusions: In addition to training on the content of an evidence-based programs, facilitators valued work with supportive peers and the mentoring of more experienced facilitators. Primary care improvement initiatives employing practice facilitators should consider these training needs and the resources required for this supportive infrastructure.
Related protocols: CTN-0091
This web seminar series had three components:
Introduction to Retention in the NDAT CTN. Presented by Dikla Blumberg, PhD (NDAT CTN Clinical Coordinating Center):
Recruitment and retention are vital aspects of clinical research trials and can factor into the success of a study. Therefore, it is important that researchers understand and identify barriers to meeting recruitment and retention targets and the consequences experienced with poor retention. Additionally, it is helpful to examine historical data available on study retention trends to inform implementation efforts on future studies. Accordingly, this presentation briefly addresses these areas by providing an overview on the topic of study retention, retention within the context of the CTN, and discusses the importance of incorporating strategies and tools for study success.
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The “CHEERS” Principle of Participant Retention: More Than Just Techniques. Presented by Frankie Kropp, MS (OV Node) and Mitra Lewis, MS (NDAT CTN CCC):
Good participant retention involves more than just specific techniques; retention depends on the study staff’s overall philosophy of managing and accommodating study participants. One helpful way to think about participant retention is to insert the “CHEERS” principle into study retention efforts– Customer service, Help overcome barriers, Environment, Excellence, Relationship/Respect, and Search. This 20-minute webinar will provide an overview of the CHEERS principle, including specific examples of what sites can do to maximize participant retention.
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Utilizing a Robust and Comprehensive Locator Form as a Retention Tool. Presented by Phoebe Gauthier, MA, MPH (NE Node) and Dagmar Salazar, MS (NDAT CTN CCC).
Participant recruitment and retention are critical aspects of conducting quality clinical research projects. The National Drug Abuse Treatment Clinical Trials Network (NDAT CTN), which evaluates behavioral, pharmacological, and integrated treatment interventions for substance use disorders, routinely enrolls participants who may be challenging to locate during the treatment and follow-up phase of a trial. This 20-minute presentation will review one tool for increasing retention—an adapted locator form. This locator form is designed to better facilitate locating participants, especially those with unstable living conditions or with limited contact information. Additionally, this presentation will discuss the form elements beyond conventional locator forms and methods for collecting the information to help increase participant retention.
An Institutional Review Board (IRB) provides ethical review of proposed and ongoing clinical research to ensure the rights and welfare of research participants are protected, and that both the study and investigative team adhere to pertinent regulations governing the conduct of clinical trials. Clinical sites wishing to engage in human subjects research must be paired with an IRB registered with the Office of Human Research Protections, thereby ensuring adherence to all tenets of Good Clinical Practice. This pledge is provided in the form of a Federalwide Assurance (FWA) and is one of the central pillars of a clinical trial. This presentation from Eric Hardter, PhD, RAC, Regulatory Affairs Specialist at the NDAT Clinical Coordinating Center, Emmes Corporation, provides an overview of the basis of and need for a FWA as well as the roles and expectations of key stakeholders, including IRBs, institutions, and researchers involved in clinical studies.
Learning Objectives:
- Describe FWAs and FWA provisions.
- Discuss who needs to obtain FWAs, when, and who is covered.
- Consider the expectations and roles for IRBs, institutions, investigators, and researchers that provide oversight and/or engage in clinical research.
New regulations have established the expectation of a single Institutional Review Board (sIRB) to provide ethical review of a clinical research study. The measure is designed to maintain appropriate protection of study participants and yet streamline federally-funded research reviews by eliminating redundancy and avoiding unnecessary administrative burden. Accordingly, CTN researchers must understand the considerations to factor into selecting a sIRB for a multi-center study.
This presentation from Julia Collins, MD, Protocol Specialist at the NDAT Clinical Coordinating Center at the Emmes Corporation, will describe such considerations based on experiences and lessons learned from research teams working with a variety of sIRBs on seven CTN clinical studies.
Learning Objectives:
- Describe types of sIRBs and evaluate suitability for ethical reviews of specific trials.
- Define sIRB selection criteria as applied to studies across disease areas and study designs.
- Discuss other factors to consider and effective processes to implement when selecting a sIRB.
Motivational interviewing (MI) is an evidence-based practice shown to be effective when working with people in treatment for substance use disorders. However, MI is a complex treatment modality optimized by training with feedback. Feedback, assessment, and monitoring of treatment fidelity require measurement, which is typically done using audiotaped sessions. The gold standard for such measurement of MI skill has been an audiotaped interview, scored by a rate with a detailed structured instrument such as the Motivational Interviewing Treatment Integrity 2.0 (MITI 20.0) Coding System. The Helpful Responses Questionnaire (HRQ) is a pen-and-paper test of empathy (a foundational MI skill) that does not require an audiotaped session.
A randomized trial of three different regimens for training counselors in MI (live supervision using teleconferencing, tape-based supervision, and workshop only) offered the opportunity to evaluate the performance of the HRQ as a measure of MI ability, compared to the several MITI 2.0 global scores and subscales. Participants were counselors (N=97) from 26 community-based substance use treatment programs affiliated with the Long Island and New York Nodes of the NIDA Clinical Trials Network, whose MI proficiency was measured at 4 time points: baseline (before an initial 2-day MI workshop), post-workshop, 8 weeks post-workshop (i.e., post-supervision), and 20 weeks post-workshop with both MITI 2.0 and HRQ
HRQ total scores correlated significantly with the Reflection to Question Ratio from the MITI 2.0 at post-workshop, week 8, and week 20, and with the Spirit and Empathy global scores at week 20. Correlations of HRQ with other MITI 2.0 subscales and time points after workshop were small and not significant. As predicted, HRQ scores different between training conditions, with counselors assigned to live supervision achieving better HRQ scores than those in Workshop only.
Conclusions: The HRQ is a modestly accurate measure, mainly of the Reflection to Question ratio, considered a core marker of MI skill. It is sensitive to training effects and may help identify counselors needing more intensive supervision. Given its ease of administration and scoring, HRQ may be a useful marker of MI skill during training efforts.
The CTN webinar “A Practical Guide to Using Brief Addiction Monitor Data in the VA,” was presented by Drs. Dominick DePhilippis and Eric J. Hawkins on August 14, 2017 at 12pm ET.
The Brief Addiction Monitor (BAM) is a tool to support measurement-based care for people with substance use disorders, that was originally developed to assess patient “outcomes” in a valid and efficient manner at the VA. This one-hour webinar looks at its development and features, clinical use of the BAM, programmatic use of the BAM, and implementation history of the BAM at the VA.
Dominick DePhilippis, PhD is the education coordinator for the CESATE at the Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania. He also is a clinical associate in the Department of Psychiatry at the University of Pennsylvania’s Perelman School of Medicine. His areas of professional interest include the dissemination and implementation of measurement-based care and evidence-based treatments, in particular, motivational enhancement therapy and contingency management, in specialty care settings for patients with substance use disorders. He received his PhD in clinical psychology from Hahnemann University.
Eric J. Hawkins, PhD is an Investigator with Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care and the Associate Director of the Seattle Center of Excellence in Substance Abuse Treatment and Education (CESATE), one of two national VA centers devoted to improving the quality of care and clinical outcomes of veterans with substance use conditions. He also is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington and a licensed clinical psychologist in Washington State. His primary research interests include evaluating and improving behavioral health and substance use outcomes of Veterans with alcohol and/or drug misuse conditions. He received his PhD in Clinical Psychology from Brigham Young University.
Additional Resources:
- Download slides (pdf)
The CTN webinar “Measurement-Based Care: Isn’t It About Time We Used It?,” was presented by Dr. A. John Rush, MD, on July 28, 2017 at 1pm ET.
As we continue to provide quality, evidence-based treatment methodologies in healthcare and research, it is important to develop and evaluate the tools used as well as procedures followed in standard care to assess and monitor patient progress. This webinar explored opportunities to improve the development and utilization of measurements to affect patient outcomes. During this one-hour presentation, Dr. Rush defined Measurement-Based Care (MBC), evaluated benefits to using MBC, and discussed application and outcomes focusing on depression as an example to illustrate the use and value of MBC.
A. John Rush, MD is Professor Emeritus, National University of Singapore (Duke-NUS) and holds Adjunct Professorships at Duke University and Texas Tech University medical schools. He has authored over 800 professional publications on the diagnosis, treatment, biology, psychology, and systematic clinical care of persons with mood disorders. As a clinical researcher and practitioner, he is dedicated to advancing science to serve patients who are afflicted with these and related conditions and their families. He was PI of the Texas Medication Algorithm and the STAR*D projects – both of which employed measurement based care. He was recognized as one of the “World’s Most Influential Scientific Minds” by Thomson Reuters in 2014. With prior clinical and research experience with SUD patients, Dr. Rush is a consultant to the CTN.
Additional Resources:
- Download slides (pdf)
In the context of a contingency management (CM) implementation/effectiveness hybrid trial, the post-training implementation domains of direct-care clinicians affiliated with one of the community treatment programs in the Pacific Northwest Node of the NIDA Clinical Trials Network (N=19) were examined in relation to a targeted clinical outcome of subsequently CM-exposed clients. Clinicians’ CM skillfulness, a behavioral measure of their capability to skillfully deliver the intended CM intervention, was found to be a robust and specific predictor of their subsequent client outcomes. Analyses also revealed CM skillfulness to: (1) fully mediate an association between a general therapeutic effectiveness and client outcome; (2) partially mediate an association of in-training exposure to CM and client outcomes; and (3) be composed of six component clinical practice behaviors that each contributed meaningfully to this behavior fidelity index.
Conclusions: Study findings offer preliminary evidence of the predictive validity of post-training CM skillfulness for subsequent client outcomes. This suggests an apparent value in providing skills-focused training in CM, and perhaps other empirically-supported behavior therapies. Skills-focused training does not necessarily preclude trainer use of didactic and discussion elements in CM training curricula, presumably for purposes of enhancing clinician knowledge of core operant conditions principles and practices, as well as to dispel myths and misconceptions that deter adoption readiness. However, current findings provide preliminary evidence to suggest such passive learning strategies are insufficient if the goal of behavior therapy training is to prepare a workforce to effectively implement a new approach.
It is often difficult for evidence-based practices (EBPs) to find their way into addiction treatment programs. One goal of the National Institute on Drug Abuse’s Clinical Trials Network (CTN) is to disseminate these EBPs into community treatment programs. The Southwest Node of the CTN hosted a series of 13 local workshops in EBPs led by experts in the topic areas. Participants (N=327) were asked to complete an online evaluation of the training with a follow-up rate of 75.8%. Respondents reported that the trainings had been applied to their workplace. Qualitative analysis revealed themes of gratitude and a need for additional training opportunities. Participant enthusiasm for training was indicated by the willingness to travel up to a thousand miles and independently pay for travel expenses.
Conclusions: Results suggest that following a workshop training in EBPs, participants reported long-term (14 month) high satisfaction with the training and believed the trainings had been incorporated into their daily practice. Frontline providers are aware of EBPs and eager for further trainings. However, future dissemination studies in front-line settings should involve formal assessments of training needs, objective measures of skill acquisition, and inclusion of training enrichments to supplement the workshop format.
In preparation for the conduct of a clinical trial, investigators must plan for the management of medications used as an intervention or a supportive drug. In setting up for a study, there are various aspects to consider for implementation, tracking, and quality assurance. This one-hour seminar discussed drug management planning and implementation considerations for trials in the CTN.
Additional Resources:
- Download slides (pdf)
- Download handout (pdf)
The NIDA Data Share website was created to make CTN data available to the scientific community and the public at large. These data can be used for secondary analyses and thus serve to increase the contribution of the original studies conducted and extend findings into new areas and knowledge for the benefit of public health. This one-hour webinar, presented by Abigail Matthews, PhD, of the Emmes Corporation, and Dikla Shmueli-Blumberg, PhD, of the CTN Clinical Coordinating Center, focused on an overview of the website, provided highlights of its structure and contents, and detailed the technical procedures involved in utilizing the data for secondary analyses.
Additional Resources:
- Download slides (pdf)
- Download handout (pdf)
The mHealth revolution brings exciting possibilities for both researchers and clinicians, but the use of this technology also raises unique ethical concerns. The purpose of this talk is two-fold. First, we will be discussing some of the most pressing ethical challenges around mHealth. This will involve looking carefully at issues around data ownership, privacy, transparency, and consent. Second, we will introduce some possible solutions. Come discuss what researchers, clinicians, and institutions can do to address ethical risk.
Dr. Tiffany Cvrkel is a bioethicist, philosopher, and lecturer in UCLA’s Department of Molecular, Cell, & Developmental Biology. The primary focus of her work is categorizing the impact and limitations of deliberation as it occurs in the contexts of biomedical ethics. Her particular area of expertise is the ethics of emerging biomedical technologies, including the ethical challenges around mHealth, eHealth, and Big Data. In addition to being an award-winning teacher, she serves as a consultant to scientists and clinicians working with bioethical questions. She specializes in both bringing clarity to bioethical challenges and to assisting in the creation of practical solutions.
Additional Resources:
- Download slides (pdf)