How do we best address growing opioid abuse nationwide? It’s a question that many health care organizations have been asking with increasing urgency. Solutions must include changing the way we prescribe opioids as well as better supporting recovery and reducing relapse. A plethora of programs exist that address opioid addiction recovery, but the challenge will be how efficiently existing programs can be scaled to meet the needs of an ever-growing population of people struggling with substance use disorder.
In light of the need for inexpensive, scalable solutions, we propose the widespread use of automated, bidirectional SMS (text)- and phone call–based mobile health systems that seamlessly integrate into existing community substance abuse recovery programs. They will allow providers to expand their services to larger populations without putting additional strain on care managers.
Here’s how it’s being done at a community-based health care organization in Missouri.
Preferred Family Healthcare (PFH) is a nonprofit organization with dozens of locations throughout the Midwest, providing mental health, substance use, and developmental disability care, as well as employment and social services. In Missouri, PFH identifies clients with a history of substance use disorder who have had more than $20,000 in Medicaid costs in a year and offers these patients a wide range of treatment and support services, including housing assistance, telecoaching, employment services, budgeting programs, and more.
A major limitation on PFH’s efforts is the demand on resources and the oversight needed to meet the needs of this growing patient population. That’s where the Technology Assisted Care Coordination (TACC) project comes in.
TACC’s goal is to improve the efficacy of PFH’s services and reduce costs by utilizing mobile health in three ways:
- Triage patients instantly and alert care managers to the patients who need attention most acutely
- Provide care managers with more efficient ways to communicate/form relationships with patients
- Give patients a “panic button” — the ability to proactively alert care managers when they need the most help — for supportive therapy for opioid use, or for other needs like medical care and food
Patient Outreach via Text
The technology that supports TACC was developed by Epharmix, a digital health care company established by Washington University in St. Louis researchers and alumni, which leverages mobile health technologies to better manage chronic health conditions. Epharmix worked closely with PFH to develop and implement an intervention that allows care managers to efficiently and effectively manage a large cohort of patients by tailoring interventions to patients’ needs. Because 23% of Americans still don’t have smartphones, Epharmix chose an SMS- and automated phone call–based system, EpxSubstanceUse, which can be used on any phone. The TAAC pilot was funded through a grant from the Substance Abuse and Mental Health Services Administration.
Previously, Preferred Family Healthcare staff would monitor patients’ opioid use behaviors through individual phone calls and in-person appointments every month or so. Now, monitoring can be done as frequently as daily, using texts that ask patients whether they have used in the last day or had the urge to use, a cost- and time-efficient system because the messages are automatically generated. For those who report they are struggling, follow-up questions are automatically sent, and a three-tiered triage system assesses patient risk and instantly generates messages to care managers to alert them to intervene via a phone call (through the mobile health platform) or an in-person appointment, as appropriate. The system also queries patients about other factors protective against substance use, such as whether they’re attending support groups.
Time and Dollars Saved
Twenty-one patients were initially enrolled in the program in early 2017, with about 100 expected to participate by early 2019. Patients remain in the program for anywhere from a few months to years, depending on the length of their recovery. Generally, patient response rates to Epharmix text messages start strong and decline over time, as expected, as the novelty wears off. But contact has been maintained with more than 60% of users after 3 months. When polled, most participants indicated that their relationship with their care manager improved, with a median score of 6 out of 9, with 1 meaning that relationships with care managers had worsened, 5 being neutral, and 9 meaning the relationship had significantly improved. Patients have reported that the regular contact is reassuring, with one participant saying, “It’s comforting to know that someone cares and that help is immediately available at the other end if I need it.” Similarly, care managers feel reassured in knowing with greater certainty how patients are doing between in-person visits.
Data collected via the text messaging service revealed that at the time of enrollment, 42% of patients reported substance use in the past 3 days, 41% reported no use, and the remainder didn’t respond. Substance use trended downward over the first 3 months and by week 13, only 12% of patients reporting using, 50% reported no use, and 38% didn’t respond.
A return-on-investment analysis showed a 19% per patient cost savings thanks to reduced staff time needed to monitor patients. Each patient with a substance use disorder costs PFH approximately $926 per year in care management costs alone. On average, the mobile service replaces 15 minutes of check-in time per client per week. Staff average around 30 clients each, which amounts to 450 minutes (7.5 hours) per week in mobile health–associated time savings. Thanks to this extra time, each staff member can see approximately 23% more patients each week, which reduces per patient care management costs by $173 (19%) per year. Additional statewide and federal cost savings are expected through reduced Medicaid spending thanks to better patient outcomes.
Mobile health interventions have the potential to drive efficient expansion of services that combat the opioid crisis in the United States. While no amount of automated text messaging can substitute for human contact between patient and provider, mobile platforms can seamlessly connect patients to care managers, peer support groups, doctors, helplines, and other services more quickly and cost-effectively than can be achieved otherwise.
Preferred Family Healthcare intends to continue growing its Technology Assisted Care Coordination project, which is showcasing how to effectively build mobile interventions into the existing framework of community care management programs. The experiment has demonstrated how these technologies can improve patient-caregiver relationships, reduce per patient workload, and, we hope, eventually assist in long-term recovery.
Acknowledgements: We would like to acknowledge the expertise and oversight of Sally Haywood and Shawn Billings of the Behavioral Health Network of Saint Louis, as well as the tireless work of all care managers at Preferred Family Healthcare. We would also like to thank Michael Veshkini and the rest of the Epharmix team for development of the mobile health solution. Finally, we would like to thank Will Ross, MD, MPH, for his continued mentorship.