Kathleen Grant MDStaff Physician, Omaha VA

Associate Professor, Internal Medicine, UNMC

January 9, 2015

ObjectivesIntroduce recent VA Office of Rural

Health and QUERI-funded SUD projects Review preliminary data from IRI projectReview our process of securing ORH and

QUERI funding

Treatment for SUD

Chronic Diseases not Acute DiseasesEvidence-based Treatment Modalities

PsychotherapyPharmacotherapy

Implementation EBP not consistent

SUD Treatment ApproachIntensive SUD treatment followed by low

intensity treatmentCare transitions to low intensity

“continuing care” treatment are times of high risk for relapseParticipation in continuing care is 1 of 2

significant factors in preventing relapse

Rural SUD UniqueSubstance use different in rural persons

Nicotine use, methamphetamine addiction and binge alcohol drinking higher

Access to careVHA reorganizationSupport groups: AA but less NA, CA, CMA

Psychotherapy studies done in urban settingsSkill set may vary

Cedar

Dixon

Burt

Cuming

Pierce

AntelopeMorrillScotts Bluff

Cheyenne

Deuel

Garfield

Valley Greeley

Madison Stanton

DodgeColfax

Perkins

Chase

Dawson

Red Willow

Phelps

Buffalo Hall

Howard

Adams Clay

Nuckolls

Thayer

Fillmore

Hamilton

Merrick

Jefferson

Polk

York Seward

Butler Douglas

Sarpy

Cass

Otoe

Johnson

Nemaha

Lancaster

Nance

Richardson

Thurston

Washington

Wayne

Number of Licensed Alcohol and Drug Counselors per County in Nebraska 373

10

21

1

4

1

14

11023

3

1

3

3

15

483

2

1

8

2412

Counts Provided by:

STATE OF NEBRASKACredentialing DivisionP.O. Box 94986Lincoln, NE 6850904986402-471-2117 kris.chiles@hhss.ne.gov

Updated 2/6/07

Our records do not indicate a LADC mailing address for the Counties with shaded areas

Note:

Boyd

Dakota

Boone

Saunders

Platte

Saline

Pawnee

Gage

Webster

Gosper

FranklinHarlanFurnasHitchcock

HayesFrontier

WheelerLoupBlaineThomas

LoganMcPherson

Knox

Keya Paha

RockBrown

Hooker

Holt

Grant

Arthur

CherrySheridan

Garden

Kearney1

Sherman

Custer

LincolnKeith

Dundy

Kimball

Banner

Box Butte

Sioux

Dawes

1

21

1

2

1

1

2

2

21

Wheeler

1

14

1

3

2

1

222

2

23

3

2

1

Rural SUD ResourcesContinuing care: limited professionally delivered

servicesSocial support: Self-help group attendance in

veterans may be alternate resourceReduce relapse rates & greater abstinence @ 2

yearsReduce subsequent SUD treatment utilization &

health care costs

Intensive Referral to Support Groups

Dr. Chris Timko developed a 3-session Intensive Referral process

Research conducted @ Palo Alto VAThree key elements

Linked to 12-step meeting volunteer12-step journal completedAsked about 12-step attendance

Improves outcomes24% increase in rates of abstinence @ 12- months

Intensive Referral to Support Groups

StrengthsNo additional costRandomized clinical trialFew exclusionsBrief, feasible intervention: group, individual, phone

sessionsCould be done in primary care, EAP, clergy settings

LimitationsIntensive referral done in outpatients returning home each

day

Intensive Referral DesignUrban Rural

OPT: Home each nightAttend 12-step meetings in

community where treatedAccess to AA/NA/CA/CMAIdentify sponsor (mentor)Some concern anonymitySome concern stigmaAccess mass transportationFamily involved in SUD tx

Residential tx ~ 4 weeksAttend 12-step meetings in

Omaha, Lincoln, GI Some access to AALess likely identify sponsorGreater concern anonymityGreater concern stigmaNo mass transportationLack family involvement SUD tx

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

Rural Veterans”

Funded by VA Office of Rural Health RHRC-CRPilot study of Intensive Referral Intervention

modified for rural veteransAims:

Determine if modified referral increases effectiveness of SUD tx in rural veterans

Determine if trauma/family involvement are factors in responsiveness to modified intervention

Modified Intensive Referral Intervention

12-step liaison introduced upon return homeFamily contacted & educatedEducational material includes concerns

specific to rural veterans:“Drug-related” meetingsAnonymityDistance & transportation

Modified IRIORH RHRC-CR funding 10/1/12-9/30/131/2013 Half of Addiction Therapists

NWI-HCS trained in IRI 3/2013 IRI Intervention initiated

Fidelity measured throughout study3/2013- 12/2014 Enrollment 6-month follow-up ongoing

Modified IRI Baseline Data196 Veterans enrolled & 10 withdrawn prior to follow-upGender:

Female: 8.7% (N=17) Male: 91.3% (N=179)

Race/EthnicityCaucasian: 70.4% (N=138)Hispanic: 5.6% (N=11)African-American: 18.4% (N=36)All others: 5.5% (N=11)

Modified IRI ImplementationOmaha 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%)

QUERI LIP Funding of Intensive Referral Intervention

Alerted to QUERI funding mechanismsEstablished relationship with SUD QUERI

DirectorUnderstudied population: Rural veteransPriority area: Care transitionsObtained SUD QUERI Locally Initiated Project

funding 11/1/2013-2/28/2014

QUERI LIP Funding of IRISpecific 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)

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 guideQuantitative dataQualitative data: analyses ongoing

TrainingStaff generally approved of training (0-5 scale)Training helpful 4.9Satisfied with training 4.4

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

QUERI RRP Funding of Intensive Referral Intervention

Ongoing relationship with SUD QUERI DirectorRequested SUD QUERI Rapid Response

Project fundingImplementation-focused evaluation of IRI to

identify facilitators & barriers to implementation

QUERI RRP Funding of IRISpecific 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

QUERI RRP Funding of IRISets the stage for a submission for

QUERI Service Directed Project

Tailored Tobacco Cessation Tailored Tobacco Cessation Intervention for Rural VeteransIntervention for Rural Veterans

Mark W. Vander Weg, Ph.D., Principal InvestigatorCenter for Comprehensive Access & Delivery Research and

EvaluationIowa City VA Health Care System

Iowa City, IA

Tobacco Use in Rural AreasAccumulating 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.

Treatment for Tobacco UseOne of the factors that appears to contribute to

greater tobacco use and exposure in rural areas is reduced access to treatment

Fewer community resourcesGreater travel distanceLess frequent primary care

Treatment for Tobacco UseOne 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 costUnfortunately, only 1-5% of eligible smokers receive this

type of treatment

Tobacco QuitlinesOur own experiences with QL have been consistent

with the existing literatureIn a study of VA inpatients:

7.8% of smokers were referred to the quitlineOnly 16.7% of those referred received treatment

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

Rational & Elements of Tobacco Cessation Treatment

ApproachGiven 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

Tailored Tobacco Treatment for Rural Smokers

Mark Vander Weg, PhDPrincipal Investigator

Funded by the VA Office of Rural Health

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

Treatment ApproachMedication Management

Shared decision making approach is used to choose from among five first-line medications and combination therapies for smoking cessation

Supplemental Treatment ModulesParticipants 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

Self-reported Tobacco Use Outcomes by Group

(7-day point prevalence abstinence)

OutcomeOutcomeReferral State Referral State

Quitline Quitline % Quit% Quit

VA TailoredVA TailoredQuitline Quitline % Quit% Quit

Odds RatioOdds Ratio (95% CI)(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)

Current Project

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

Funded by the VA Office of Rural Health

Current ProjectPragmatic clinical trial with the same two treatment conditionsIowa City is the Coordinating Center as well as a clinical sitePartnered with four additional sites to roll out the intervention

Ann Arbor, MichiganDenver, ColoradoJackson, MississippiOmaha, Nebraska

Target enrollment is 500 participantsScheduled to go from 4/13 to approximately 12/17

Carolyn Turvey, PHD, Project Lead Carolyn-Turvey@uiowa.eduDawn Klein, Project Manager – Dawn.Klein@va.gov

VIECC GoalsTo improve quality and care coordination for dual

use rural Veterans by using VA’s 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).

VIECC Site Team RolesCollaborate with local/state Health IT contacts and non-VA

community health care partners Provide education to partners on objectives and goals of

VIECCWork with sites to determine workflows for receiving VA CCDs

from VeteransEducate Veterans on using My HealtheVet and how to share

their VA Health Summary with non-VA providers/organizations

Conduct process and outcome evaluations

VHA Office of Rural HealthVeteran Rural Health Resource Center – Central Region

http://www.ruralhealth.va.gov/resource-centersThomas Klobucar, PhD, Interim Director

Thomas.klobucar@va.govM. Bryant Howern, PhD, Deputy Director **

Matthew.howern@va.govMaria Briggs, VISN 23 Rural Health Consultant

Maria.briggs@va.gov

FY 2016 call for proposals to be released in weeks

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.

10 QUERIsChronic Heart

FailureDiabeteseHealthHIV/AIDS/HCVIschemic Heart

DiseaseMental Health

Polytrauma & Blast-related Injury

Spinal Cord InjuryStrokeSubstance Use

Disorders

QUERI http://www.queri.research.va.govAmy Kilbourne, PhD QUERI DirectorEach QUERI has identified Strategic Plan Goals

– priority areasEach QUERI has a director

QUERI FundingLocal Initiated Projects (LIP)

QUERI discretionSmall amount (<$15,000) 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

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

QUERI Local Initiated Projects (LIP)

Mechanism for fundingSend proposal to QUERI Center

2-page narrative:BackgroundObjectives

Specific QUERI Strategic Plan Goal AddressedSpecific objectives relative to work group

MethodsProducts and Potential use/impactBudget and TimelineCo-investigators and staff

SUD-QUERI LIP Funding of IRI“IRI to Improve SUD Treatment Outcomes:

Training & Implementation of Peer Support Specialists & Follow-up”

Train Peer Support SpecialistsMeasure 6-month outcomesDetermine if co-occurring PTSD and/or family involvement

factors in responsiveness to IRIAssess staffs’ and participants’ perception/satisfaction IRIIdentify barriers & facilitators to IRI implementation

QUERI Rapid Response Projects (RRP)

Rapid, flexible mechanism for funding studies1 year projects with max $100,000Lay groundwork for larger implementation

studyAdvance strategic plans of QUERI CentersAddress a short-term issueSet the stage for a larger Service Directed

Project

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

QUERI RRP Letter of Support

The PI should read and understand the SUD-QUERI goals, missions, and objectiveshttp://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-QUERI-RRP-Process.pdf

QUERI RRP Review CriteriaStandard 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

SUD-QUERI RRP Funding of IRI“Evaluation of Implementation of

Intensive Referral Intervention to Support Groups”

Train staff in three additional VISN 23 sitesEvaluate protocol fidelity as staff trained in additional VISN

23 sitesEvaluate clinical staff and site leaders’ satisfaction with IRI

(qualitative and quantitative measures)

QUERI SitesQUERI Website – Funding page:http://www.queri.research.va.gov/funding.cfm

QUERI RFAs (listed under HSR&D):http://vaww.research.va.gov/funding/rfa.cfm

Recently funded QUERI projects (listed with the HSR&D projects):http://www.hsrd.research.va.gov/research/newly_funded.cfm

Current QUERI projects (listed with the HSR&D projects):http://www.hsrd.research.va.gov/research/current.cfm

ORH and QUERI FundingIdentify their priorities

Develop a relationship with leader(s)

Project StaffL. Brendan Young, PhD (Western Illinois

University)Chris Timko, PhD (Palo Alto VA)Cindy Beaumont, CCRCBrian Hirz, PSSPatrick Daly, RAR. Dario Pulido, PhDKathleen Grant, MD

Questions?

Thank YouVA 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