Co-morbid substance use is widespread among Veterans with hepatitis C virus (HCV). Of the more than 147,000 Veterans with chronic HCV in VHA care in 2008, 55% reported a history of alcohol abuse. Among Veterans with chronic HCV infection, less than a third has received antiviral therapy. Active substance use disorder (SUD) is a major barrier to receipt of HCV antiviral therapy. Patients respond better to antiviral therapy if they abstain from drinking. Thus, patients with SUDs are typically referred to SUD treatment, but many do not follow through with referrals.
The overarching goal of this Phase 1 Pilot was to improve the delivery of integrated mental health care for patients with SUDs in HCV clinics, and ultimately to increase their access to HCV treatment by referring them to mutual-help groups such as Alcoholics Anonymous. The study sought to determine whether an evidence-based 3-Step Mutual-Help Referral Method that has been tested in SUD specialty treatment settings could be successfully implemented in HCV clinics. Study objectives were to: (1) Implement the 3-Step Mutual Help Referral Method in three HCV Clinics, and (2) Use formative evaluation methods to: (a) identify mutual-help referral practices in the HCV clinics, (b) identify system and provider barriers and facilitators to implementing the 3-Step Mutual Help Referral Method, and (c) solicit feedback from patients on factors influencing their decision to accept or decline referral to a mutual help group and factors influencing their involvement in them.
During pre-implementation visits to three HCV clinics in California, we observed clinic operations, interviewed key informants, and identified clinic providers who would implement the 3-Step Mutual-Help Referral Method. Use of this referral method involved providers giving patients mutual-help brochures and a journal, connecting them with a volunteer at a local Alcoholics Anonymous (AA) meeting, and making two follow-up calls to discuss and encourage meeting attendance. To address study objectives, we conducted monthly telephone interviews with clinic staff to obtain their feedback on implementing the mutual-help referral method, address issues that arose, and make adaptations as needed. We also conducted semi-structured telephone interviews with patients to obtain feedback on factors influencing their decisions to accept or reject mutual-help group referral, their current involvement in the groups, and how the referral process worked for them.
Atlas.ti qualitative software was used to code the data and aid in the identification of themes. The PI and research staff met to develop initial codes for the interviews. Interviews were coded independently by two project staff who resolved coding inconsistencies through mutual discussion.
We completed a total of 21 monthly interviews with five HCV clinic providers over a 5-month implementation period. A key barrier that staff identified in using the 3-Step Mutual-Help Referral Method was insufficient time during clinic visits to discuss mutual-help with patients, connect them to an AA volunteer, and make follow-up calls. However, staff reported that making a 3-Step referral only took an extra 5-10 minutes beyond the time they typically spent referring a patient to AA. Other barriers to staff referring patients were staff assumptions that patients would not benefit from referral to AA because they were not interested in stopping drinking, or conversely, that they had already cut back or stopped drinking, or were in outpatient treatment.
Of the 15 patients to whom providers offered mutual-help referral, 12 agreed to be contacted by research staff, and nine completed interviews. Six of the patients who were interviewed accepted referral to AA, and three declined referral. All patients who were interviewed had experience attending Alcoholics Anonymous or other mutual-help groups prior to being offered referral to AA by their HCV clinic provider. Four of nine patients also had prior treatment for substance use disorders.
Patients who accepted referral made only limited use of the 3-Step Mutual-Help Referral materials (self-help brochures and journal) that clinic providers gave them, and none of the patients made contact with an AA volunteer, called the AA hotline, or attended meetings that providers suggested. Patients' reasons for not contacting a volunteer or hotline included: discomfort around strangers, preferring one-on-one interactions to meetings, wanting to handle things on their own, relying on support from a family member who had stopped drinking, and already attending AA meetings.
The reasons that patients gave for declining mutual-help group referral included: not being ready to quit drinking, believing that they didn't have a problem, or feeling that they could change their drinking habits on their own.
Despite patients' limited engagement in the 3-Step Mutual-Help Referral Method, all patients who were drinking reduced their consumption of alcohol after their HCV clinic provider talked to them about their need to cut back or stop drinking and offered them referral. Patients cut back on the number of days and/or the amount that they drank. Thus, it is possible that the 3-step method may have worked similarly to a brief alcohol intervention
Project findings highlight potential provider and patient barriers to implementing the 3-Step Mutual-Help Referral Method in HCV clinics that will need to be addressed in order to successfully implement the 3-Step Mutual-Help Referral Method in HCV clinics.
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