VA Office of Rural Health and QUERI-Funded Substance Use Disorders Research

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VA Office of Rural Health and QUERI-Funded
Substance Use Disorders Research

• Kathleen Grant MD
• Staff Physician, Omaha VA
• Associate Professor, Internal Medicine, UNMC
• January 9, 2015

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Objectives

• Introduce recent VA Office of Rural Health and
  QUERI-funded SUD projects
• Review preliminary data from IRI project
• Review our process of securing ORH and QUERI
  funding

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Treatment for SUD

• Chronic Diseases not Acute Diseases
• Evidence-based Treatment Modalities
• Psychotherapy
• Pharmacotherapy
• Implementation EBP not consistent

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SUD Treatment Approach

• Intensive SUD treatment followed by low intensity
  treatment
• Care transitions to low intensity continuing
  care treatment are times of high risk for
  relapse
• Participation in continuing care is 1 of 2
  significant factors in preventing relapse

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Rural SUD Unique

• Substance use different in rural persons
• Nicotine use, methamphetamine addiction and binge
  alcohol drinking higher
• Access to care
• VHA reorganization
• Support groups AA but less NA, CA, CMA
• Psychotherapy studies done in urban settings
• Skill set may vary

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Number of Licensed Alcohol and Drug Counselors
per County in Nebraska 373
Boyd
Keya Paha
Dawes
Cherry
Sheridan
1
1
Cedar
Holt
Knox
1
Sioux
Dixon
3
8
Rock
Brown
2
Dakota
Pierce
Box Butte
1
Thurston
Wayne
4
2
1
3
3
Stanton
Garfield
Madison
Wheeler
Loup
Blaine
Thomas
Hooker
Grant
Wheeler
Burt
Scotts Bluff
Antelope
10
15
2
Morrill
Cuming
Boone
Garden
2
Platte
Dodge
Colfax
Washington
Logan
3
Valley
Greeley
McPherson
Arthur
Banner
1
2
1
Custer
Nance
110
Saunders
1
Douglas
Sherman
Cheyenne
Butler
Keith
Kimball
Howard
Polk
23
1
Lincoln
1
2
Merrick
Sarpy
4
3
Deuel
2
York
Seward
Dawson
Buffalo
Hall
Lancaster
1
4
2
24
12
Perkins
Cass
83
3
Hamilton
Otoe
Fillmore
1
Saline
Frontier
Kearney 1
Adams
Clay
Chase
Phelps
14
Hayes
2
2
Gage
Johnson
1
2
Gosper
Nemaha
2
Richardson
1
Pawnee
Webster
2
Thayer
Franklin
Harlan
Furnas
Dundy
1
Red Willow
Hitchcock
2
1
Jefferson
Nuckolls
Counts Provided by STATE OF NEBRASKA Credentiali
ng Division P.O. Box 94986 Lincoln, NE
6850904986 402-471-2117 kris.chiles_at_hhss.ne.gov
Updated 2/6/07 Our records do not indicate a LADC
mailing address for the Counties with shaded
areas
Note
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Rural SUD Resources

• Continuing care limited professionally delivered
  services
• Social support Self-help group attendance in
  veterans may be alternate resource
• Reduce relapse rates greater abstinence _at_ 2
  years
• Reduce subsequent SUD treatment utilization
  health care costs

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Intensive Referral to Support Groups

• Dr. Chris Timko developed a 3-session Intensive
  Referral process
• Research conducted _at_ Palo Alto VA
• Three key elements
• Linked to 12-step meeting volunteer
• 12-step journal completed
• Asked about 12-step attendance
• Improves outcomes
• 24 increase in rates of abstinence _at_ 12- months

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Intensive Referral to Support Groups

• Strengths
• No additional cost
• Randomized clinical trial
• Few exclusions
• Brief, feasible intervention group, individual,
  phone sessions
• Could be done in primary care, EAP, clergy
  settings
• Limitations
• Intensive referral done in outpatients returning
  home each day

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Intensive Referral Design

• Urban

• Rural

• OPT Home each night
• Attend 12-step meetings in community where
  treated
• Access to AA/NA/CA/CMA
• Identify sponsor (mentor)
• Some concern anonymity
• Some concern stigma
• Access mass transportation
• Family involved in SUD tx

• Residential tx 4 weeks
• Attend 12-step meetings in Omaha, Lincoln, GI
• Some access to AA
• Less likely identify sponsor
• Greater concern anonymity
• Greater concern stigma
• No mass transportation
• Lack family involvement SUD tx

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Intensive Referral Intervention to Improve SUD
Treatment Outcomes among Rural and Highly Rural
Veterans

• Funded by VA Office of Rural Health RHRC-CR
• Pilot study of Intensive Referral Intervention
  modified for rural veterans
• Aims
• Determine if modified referral increases
  effectiveness of SUD tx in rural veterans
• Determine if trauma/family involvement are
  factors in responsiveness to modified intervention

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Modified Intensive Referral Intervention

• 12-step liaison introduced upon return home
• Family contacted educated
• Educational material includes concerns specific
  to rural veterans
• Drug-related meetings
• Anonymity
• Distance transportation

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Modified IRI

• ORH RHRC-CR funding 10/1/12-9/30/13
• 1/2013 Half of Addiction Therapists NWI-HCS
  trained in IRI
• 3/2013 IRI Intervention initiated
• Fidelity measured throughout study
• 3/2013- 12/2014 Enrollment
• 6-month follow-up ongoing

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Modified IRI Baseline Data

• 196 Veterans enrolled 10 withdrawn prior to
  follow-up
• Gender
• Female 8.7 (N17)
• Male 91.3 (N179)
• Race/Ethnicity
• Caucasian 70.4 (N138)
• Hispanic 5.6 (N11)
• African-American 18.4 (N36)
• All others 5.5 (N11)

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Modified IRI Implementation
Omaha Lincoln Grand Island Total
Participants Received Session 1 29/54 (54) 2/3 (67) 24/48 (50) 55/105 (52)
Participants Received Session 2 18/54 (33) 2/3 (67) 13/48 (27) 33/105 (31)
Participants Received Session 3 12/54 (22) 1/3 (33) 5/48 (10) 18/105 (17)
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QUERI LIP Funding of Intensive Referral
Intervention

• Alerted to QUERI funding mechanisms
• Established relationship with SUD QUERI Director
• Understudied population Rural veterans
• Priority area Care transitions
• Obtained SUD QUERI Locally Initiated Project
  funding 11/1/2013-2/28/2014

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QUERI LIP Funding of IRI

• Specific Aims
• Train Peer Support Specialists in GI, L, O
  (completed)
• Measure 6- month outcomes (ongoing)
• Determine if PTSD and family involvement factors
  in responsiveness to IRI (ongoing)
• Assess Clinicians and Patients
  perceptions/satisfaction with IRI (clinicians
  completed patients ongoing)
• Identify barriers and facilitators to IRI
  implementation (clinicians completed patients
  ongoing)

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Clinicians Perceptions/Satisfaction with IRI

• Interviewed all Site Leaders, Addiction
  Therapists and Peer Support Specialists at GI, L
  and Omaha who participated in the IRI training
  and implementation
• Semi-standardized interview guide
• Quantitative data
• Qualitative data analyses ongoing
• Training
• Staff generally approved of training (0-5 scale)
• Training helpful 4.9
• Satisfied with training 4.4

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Clinicians Perception/Satisfaction with IRI
Implementation
  Helpful Satisfactory
Brochures 4.9 3.8
Client Sessions 4.6 3.4
Meeting Identification 4.7 4.6
Liaison Identification 4.7 4.3
Self-Help Journal 3.8 3.2
Client Follow-up 3.7 3.9
Family Outreach 4.2 4.0
Overall Evaluation 4.1 4.8
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QUERI RRP Funding of Intensive Referral
Intervention

• Ongoing relationship with SUD QUERI Director
• Requested SUD QUERI Rapid Response Project
  funding
• Implementation-focused evaluation of IRI to
  identify facilitators barriers to implementation

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QUERI RRP Funding of IRI

• Specific Aims
• Evaluate modified protocol fidelity as Peer
  Support Specialists trained in Minneapolis, Iowa
  City and Des Moines (ongoing)
• Evaluate PSS satisfaction with IRI (Qualitative
  Quantitative data) to be done 3/2015
• Evaluate site leaders satisfaction with IRI
  (Qualitative Quantitative data)to be done
  3/2015

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QUERI RRP Funding of IRI

• Sets the stage for a submission for QUERI Service
  Directed Project

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Tailored Tobacco Cessation Intervention for Rural
Veterans

• Mark W. Vander Weg, Ph.D., Principal Investigator
• Center for Comprehensive Access Delivery
  Research and Evaluation
• Iowa City VA Health Care System
• Iowa City, IA

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Tobacco Use in Rural Areas

• Accumulating evidence suggests that tobacco use
  is significantly elevated in people who live in
  rural areas
• People in rural communities also appear more
  likely to be exposed to secondhand smoke.

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Treatment for Tobacco Use

• One of the factors that appears to contribute to
  greater tobacco use and exposure in rural areas
  is reduced access to treatment
• Fewer community resources
• Greater travel distance
• Less frequent primary care

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Treatment for Tobacco Use

• One approach that has been widely- advocated for
  addressing barriers to care is the use of tobacco
  quitlines (QL)
• Each state has a dedicated QL through which
  residents can receive counseling at no direct
  cost
• Unfortunately, only 1-5 of eligible smokers
  receive this type of treatment

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Tobacco Quitlines

• Our own experiences with QL have been consistent
  with the existing literature
• In a study of VA inpatients
• 7.8 of smokers were referred to the quitline
• Only 16.7 of those referred received treatment

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Tobacco CessationConcerns Comorbidities

• Treatment responsive to the unique needs of
  individual patients
• Depression and substance use disorders not
  addressed
• Weight concerns are barrier to quitting and
  trigger for relapse and are not addressed

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Rational Elements of Tobacco Cessation
Treatment Approach

• Given the high prevalence of tobacco use and
  reduced access to care, design a phone-based
  treatment approach for rural Veterans
• Rather than rely on outside providers using a
  cumbersome referral process, intervention
  delivered by VA personnel
• Designed supplemental treatment modules to
  address alcohol use, mood management, and weight
  gain

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Tailored Tobacco Treatment for Rural Smokers

• Mark Vander Weg, PhD
• Principal Investigator
• Funded by the VA Office of Rural Health

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Pilot Study

• Design Randomized controlled trial
• Participants 63 Veteran smokers receiving
  treatment through the ICVAHCS or affiliated CBOC
  proactively recruited via mailings.
• Treatment Conditions Referral to state tobacco
  QL vs. tailored tobacco cessation intervention.
  Both groups received pharmacotherapy
• Outcomes Self-reported tobacco use at the end of
  treatment and six months

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Treatment Approach

• Medication Management
• Shared decision making approach is used to choose
  from among five first-line medications and
  combination therapies for smoking cessation
• Supplemental Treatment Modules
• Participants also screened for presence of risky
  alcohol use, elevated depressive symptoms and
  weight concerns and offered additional behavioral
  treatment to address these issues
• Supplemental treatment delivered concomitantly
  during smoking cessation calls

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Self-reported Tobacco Use Outcomes by
Group(7-day point prevalence abstinence)
Outcome Referral State Quitline Quit VA Tailored Quitline Quit Odds Ratio (95 CI)
Post treatment penalized imputation 25.0 38.7 1.90 (0.65-5.57)
Post treatment complete case 26.7 52.2 3.00 (0.95-9.49)

6 months penalized imputation 28.1 29.0 1.05 (0.35-3.12)
6 months - complete case 36.7 39.1 1.11 (0.36-3.40)
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Current Project

• In December, 2012, the Office of Rural Health
  contacted PI about extending the project

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Tailored Tobacco Cessation Intervention
Implementation StudyMark Vander Weg PhD
Funded by the VA Office of Rural Health
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Current Project

• Pragmatic clinical trial with the same two
  treatment conditions
• Iowa City is the Coordinating Center as well as a
  clinical site
• Partnered with four additional sites to roll out
  the intervention
• Ann Arbor, Michigan
• Denver, Colorado
• Jackson, Mississippi
• Omaha, Nebraska
• Target enrollment is 500 participants
• Scheduled to go from 4/13 to approximately 12/17

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Veteran Initiated Electronic Care Coordination
Pilot (VIECC) Overview for Non-VA Partners
Carolyn Turvey, PHD, Project Lead
Carolyn-Turvey_at_uiowa.edu Dawn Klein, Project
Manager Dawn.Klein_at_va.gov
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VIECC Goals

• To improve quality and care coordination for dual
  use rural Veterans by using VAs My HealtheVet
  Blue Button capability to facilitate transfer of
  health information to non-VA providers for
  healthcare.
• To evaluate if availability of VA health
  information at non-VA points of care impacts care
  received (medication discrepancies, duplicative
  tests, cost).

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Participating Locations
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VIECC Site Team Roles

• Collaborate with local/state Health IT contacts
  and non-VA community health care partners
• Provide education to partners on objectives and
  goals of VIECC
• Work with sites to determine workflows for
  receiving VA CCDs from Veterans
• Educate Veterans on using My HealtheVet and how
  to share their VA Health Summary with non-VA
  providers/organizations
• Conduct process and outcome evaluations

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VHA Office of Rural Health

• Veteran Rural Health Resource Center Central
  Region
• http//www.ruralhealth.va.gov/resource-centers
• Thomas Klobucar, PhD, Interim Director
• Thomas.klobucar_at_va.gov
• M. Bryant Howern, PhD, Deputy Director
• Matthew.howern_at_va.gov
• Maria Briggs, VISN 23 Rural Health Consultant
• Maria.briggs_at_va.gov
• FY 2016 call for proposals to be released in
  weeks

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VA Quality Enhancement Research Initiative (QUERI)

• Unique research-operations partnership funded
  through VHA special purpose funds
• Mission is to improve care by studying and
  facilitating the adoption of new evidence-based
  treatments, tests, and models of care into
  routine clinical practice.

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10 QUERIs

• Chronic Heart Failure
• Diabetes
• eHealth
• HIV/AIDS/HCV
• Ischemic Heart Disease
• Mental Health

• Polytrauma Blast-related Injury
• Spinal Cord Injury
• Stroke
• Substance Use Disorders

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QUERI

• http//www.queri.research.va.gov
• Amy Kilbourne, PhD QUERI Director
• Each QUERI has identified Strategic Plan Goals
  priority areas
• Each QUERI has a director

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QUERI Funding

• Local Initiated Projects (LIP)
• QUERI discretion
• Small amount (lt15,000) over 1 year
• Rapid Response Projects (RRP)
• 100,000 over 1-2 years
• Service Directed Research/Projects (SDP/SDR)
• 1.1 million over 3-4 years

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QUERI Local Initiated Projects (LIP)

• Contribute specific QUERI Center Strategic Plan
  goals
• Self-contained research projects, pilot or
  supplementary data to projects, lead to proposals
• 2,000-15,000 range.
• Projects completed funds must be obligated by
  September 15th

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QUERI Local Initiated Projects (LIP)

• Mechanism for funding
• Send proposal to QUERI Center
• 2-page narrative
• Background
• Objectives
• Specific QUERI Strategic Plan Goal Addressed
• Specific objectives relative to work group
• Methods
• Products and Potential use/impact
• Budget and Timeline
• Co-investigators and staff

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SUD-QUERI LIP Funding of IRI

• IRI to Improve SUD Treatment Outcomes Training
  Implementation of Peer Support Specialists
  Follow-up
• Train Peer Support Specialists
• Measure 6-month outcomes
• Determine if co-occurring PTSD and/or family
  involvement factors in responsiveness to IRI
• Assess staffs and participants
  perception/satisfaction IRI
• Identify barriers facilitators to IRI
  implementation

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QUERI Rapid Response Projects (RRP)

• Rapid, flexible mechanism for funding studies
• 1 year projects with max 100,000
• Lay groundwork for larger implementation study
• Advance strategic plans of QUERI Centers
• Address a short-term issue
• Set the stage for a larger Service Directed
  Project

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QUERI RRP Application

• Requires an Intent to Submit to QUERI Center
• NIH Application through e-commons
• Ensure specific aims align with QUERI Goals
• One resubmission allowed

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QUERI RRP Letter of Support

• The PI should read and understand the SUD-QUERI
  goals, missions, and objectives
• http//www.queri.research.va.gov/sud/
• Guidelines for obtaining a letter of support from
  SUD QUERI
• http//www.queri.research.va.gov/sud/docs/SUD-QUER
  I-RRP-Process.pdf

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QUERI RRP Review Criteria

• Standard criteria
• Alignment of specific aims with QUERI and VHA
  Partner goals
• Evidence base is adequate for implementation OR
  if pre-implementation, there is a plan describing
  how this project will lead to implementation of
  an intervention
• Likely Impact and Potential for Sustainability

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SUD-QUERI RRP Funding of IRI

• Evaluation of Implementation of Intensive
  Referral Intervention to Support Groups
• Train staff in three additional VISN 23 sites
• Evaluate protocol fidelity as staff trained in
  additional VISN 23 sites
• Evaluate clinical staff and site leaders
  satisfaction with IRI (qualitative and
  quantitative measures)

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QUERI Sites

• QUERI Website Funding page
• http//www.queri.research.va.gov/funding.cfm
• QUERI RFAs (listed under HSRD)
• http//vaww.research.va.gov/funding/rfa.cfm
• Recently funded QUERI projects (listed with the
  HSRD projects)
• http//www.hsrd.research.va.gov/research/newly_fun
  ded.cfm
• Current QUERI projects (listed with the HSRD
  projects)
• http//www.hsrd.research.va.gov/research/current.c
  fm

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ORH and QUERI Funding

• Identify their priorities
• Develop a relationship with leader(s)

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Project Staff

• L. Brendan Young, PhD (Western Illinois
  University)
• Chris Timko, PhD (Palo Alto VA)
• Cindy Beaumont, CCRC
• Brian Hirz, PSS
• Patrick Daly, RA
• R. Dario Pulido, PhD
• Kathleen Grant, MD

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Questions?
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Thank You

• VA NWI-HCS Research Leadership Staff
• VA Office of Rural Health
• Veterans Rural Health Resource Center-CR
• Iowa City VA
• Substance Use Disorders Quality Enhancement
  Research Initiative