RESUMEN
BACKGROUND AND AIMS: Therapist characteristics may be associated with variation in consistency, quality and effectiveness of treatment delivery. We examined associations between treatment fidelity and therapist education, experience, treatment orientation and perceived skills in a randomized, multi-site trial of Twelve Step Facilitation (TSF). METHODS: Raters scored audio-recorded, TSF sessions (n = 966; 97% of TSF sessions) from 32 community-based, trained therapists for adherence, competence, empathy and global session performance. RESULTS: Therapists with graduate degrees had significantly higher adherence and global performance fidelity ratings. Therapists reporting more positive attitudes toward 12-Step groups had lower adherence ratings. Being in recovery was associated with lower fidelity in univariate tests, but higher adherence in multivariate analysis. Fidelity was higher for therapists reporting self-efficacy in basic counseling skills and lower for self-efficacy in addiction-specific counseling skills. Fidelity was also superior in group relative to individual TSF sessions. CONCLUSIONS: Results have implications for therapist selection, training and supervision in community-based, effectiveness trials and community implementation of evidence-based treatments. To obtain high fidelity and improve outcomes, it may be preferable to choose masters level therapists who are open to learning new treatments and have good, general counseling skills.
Asunto(s)
Servicios Comunitarios de Salud Mental/organización & administración , Consejo/organización & administración , Grupos de Autoayuda , Trastornos Relacionados con Sustancias/rehabilitación , Adulto , Actitud del Personal de Salud , Competencia Clínica , Consejo/educación , Consejo/normas , Práctica Clínica Basada en la Evidencia/métodos , Femenino , Estudios de Seguimiento , Adhesión a Directriz , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Relaciones Profesional-Paciente , Centros de Tratamiento de Abuso de SustanciasRESUMEN
BACKGROUND: Training research staff to implement clinical trials occurring in community-based addiction treatment programs presents unique challenges. Standardized patient walkthroughs of study procedures may enhance training and protocol implementation. OBJECTIVES: Examine and discuss cross-site and cross-study challenges of participant screening and data collection procedures identified during standardized patient walkthroughs of multi-site clinical trials. METHOD: Actors portrayed clients and "walked through" study procedures with protocol research staff. The study completed 57 walkthroughs during implementation of 4 clinical trials. RESULTS: Observers and walkthrough participants identified three areas of concern (consent procedures, screening and assessment processes, and protocol implementation) and made suggestions for resolving the concerns. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Standardized patient walkthroughs capture issues with study procedures previously unidentified with didactic training or unscripted rehearsals. Clinical trials within the National Drug Abuse Treatment Clinical Trials Network are conducted in addiction treatment centers that vary on multiple dimensions. Based on walkthrough observations, the national protocol team and local site leadership modify standardized operating procedures and resolve cross-site problems prior to recruiting study participants. The standardized patient walkthrough improves consistency across study sites and reduces potential site variation in study outcomes.
Asunto(s)
Simulación de Paciente , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Proyectos de Investigación , Trastornos Relacionados con Sustancias/rehabilitación , Servicios de Salud Comunitaria/métodos , Recolección de Datos , Femenino , Humanos , Masculino , Estudios Multicéntricos como Asunto/métodos , National Institute on Drug Abuse (U.S.) , Estados UnidosRESUMEN
OBJECTIVES: Effective January 2008, state Medicaid plans may reimburse for screening and brief intervention for alcohol and drug misuse. This study assessed state Medicaid activity to implement Healthcare Common Procedure Code System codes and pay for screening and brief intervention. METHODS: State and District of Columbia Medicaid representatives (N=44) participated in semistructured telephone interviews (N=37) or provided e-mail correspondence (N=7) about implementation of reimbursement codes. Confirmatory Web searches of Medicaid fee schedules supplemented findings and provided information for the remaining seven states. RESULTS: More than half the states (N=28) list designated screening and brief intervention codes in their state Medicaid fee schedules; 19 of those states are capable of reimbursing for the codes. Qualitative analysis examined the challenges in choosing codes, assigning reimbursement rates, and working within constrained Medicaid budgets. CONCLUSIONS: Implementation of billing codes appears to be an insufficient policy mechanism to promote utilization of screening and brief intervention for treating substance use.
Asunto(s)
Tamizaje Masivo/economía , Medicaid , Psicoterapia Breve/economía , Mecanismo de Reembolso/organización & administración , Trastornos Relacionados con Sustancias/diagnóstico , Humanos , Entrevistas como Asunto , Estados UnidosRESUMEN
The current climate of increasing performance expectations and diminishing resources, along with innovations in evidence-based practices (EBPs), creates new dilemmas for substance abuse treatment providers, policymakers, funders, and the service delivery system. This paper describes findings from baseline interviews with representatives from 49 state substance abuse authorities (SSAs). Interviews assessed efforts aimed at facilitating EBP adoption in each state and the District of Columbia. Results suggested that SSAs are concentrating more effort on EBP implementation strategies such as education, training, and infrastructure development, and less effort on financial mechanisms, regulations, and accreditation. The majority of SSAs use EBPs as a criterion in their contracts with providers, and just over half reported that EBP use is tied to state funding. To date, Oregon remains the only state with legislation that mandates treatment expenditures for EBPs; North Carolina follows suit with legislation that requires EBP promotion within current resources.
Asunto(s)
Práctica Clínica Basada en la Evidencia/normas , Implementación de Plan de Salud/métodos , Política de Salud , Centros de Tratamiento de Abuso de Sustancias/normas , Trastornos Relacionados con Sustancias/terapia , Alcoholismo/terapia , Actitud del Personal de Salud , Práctica Clínica Basada en la Evidencia/tendencias , Encuestas de Atención de la Salud , Administradores de Instituciones de Salud , Humanos , Entrevistas como Asunto , Centros de Tratamiento de Abuso de Sustancias/organización & administración , Centros de Tratamiento de Abuso de Sustancias/tendencias , Estados UnidosRESUMEN
Clinician training and supervision are needed to transfer evidence-based practices to community-based treatment organizations. Standardized patients (SPs) are used for clinician training and evaluating. However, to be effective for substance abuse counselors, SPs must realistically portray substance abuse treatment clients. The current study assessed authenticity of SPs as substance abuse treatment clients. Twenty-one substance abuse counselors interviewed SP(s) with differing profiles. Counselors provided quantitative and qualitative ratings of SP authenticity. Counselor responses to the study procedures were analyzed as well. Quantitative results include high-authenticity ratings for the SPs but counselors' subjective responses varied. Counselor's rated the experience of participating in the study positively and provided constructive comments for future applications of this methodology. Results support future work on SPs as teaching and evaluation tools in substance abuse counseling. Findings also illustrate the need to refine definitions of authenticity for SPs as substance abuse clients.
Asunto(s)
Alcoholismo/rehabilitación , Consejo/educación , Simulación de Paciente , Trastornos Relacionados con Sustancias/rehabilitación , Adulto , Alcoholismo/psicología , Trastornos Relacionados con Anfetaminas/psicología , Trastornos Relacionados con Anfetaminas/rehabilitación , Actitud del Personal de Salud , Curriculum , Medicina Basada en la Evidencia , Femenino , Dependencia de Heroína/psicología , Dependencia de Heroína/rehabilitación , Humanos , Capacitación en Servicio , Entrevista Psicológica , Masculino , Metanfetamina , Proyectos Piloto , Trastornos Relacionados con Sustancias/psicologíaRESUMEN
This report describes a standardized patient (SP) walk-through to facilitate implementation of a clinical trial within the National Drug Abuse Treatment Clinical Trials Network (CTN). SPs are actors trained to portray a set of symptoms consistently across interactions with multiple clinicians. The Oregon/Hawaii Node of the CTN employed one SP to pilot participant screening processes in a study testing a combined pharmacological and behavioral therapy for women and men dependent on prescription opioid analgesics. The SP mimicked an individual seeking treatment and "walked" through study intake processes. Findings such as study staff members' inadequacy in describing issues of patient confidentiality and problems explaining the Health Insurance Portability and Accountability Act led to modifications to the clinical implementation of the study. Research coordinators and the staff found the use of an SP to be highly effective. The node is now making routine use of SPs in the implementation of CTN protocols.