Collaborative Care Management for Integrated Mental Health and Substance Use Treatment in Low-Barrier HIV Care

同时发生的精神健康（MH）和物质使用障碍（SUD）在病毒感染者中很常见。 未受抑制的艾滋病毒感染者（PWH），并改善"难以接触"人群的健康结果， 需要新的方法来整合艾滋病毒，MH和SUD的治疗。位于华盛顿西雅图的马克斯诊所 是一种新型的"低屏障"诊所，成功地增加了病毒抑制PWH与复杂的 医疗和社会需求。低障碍护理的扩展是西雅图/金郡结束艾滋病毒的核心 流行病计划，类似的诊所正在美国其他城市实施，但MH和SUD不足 治疗是这一模式的一个关键缺陷，必须加以解决。这两年R34的总体目标是 建议是制定一个可复制的战略，实施协作护理管理（CoCM）， 在Ryan White资助的低障碍HIV诊所治疗抑郁症和阿片类药物使用障碍（OUD）。CoCM是 有强有力的证据支持，可以改善初级保健中抑郁症的治疗和管理OUD 与护理经理一起治疗。据我们所知，CoCM尚未在患者中进行研究。 具有复杂合并症和社会需求的人群，以及CoCM对心理健康和/或 SUD条件对病毒抑制的影响尚未在美国PWH中进行研究。 EPIS框架（勘探、规划、实施、维持）。对于目标1，我们将开发CoCM 将抑郁症和OUD治疗整合到低障碍艾滋病毒护理环境中的模式， 在过去的一年里一直在抑制病毒我们将使用一系列战略来实施 模型（包括规划、重组和教育战略）和利益相关者的投入将指导迭代 模型的细化。对于目标2，我们将评估 在低障碍诊所中采用CoCM模型，并评估 6个月后入组CoCM的患者。我们将在CoCM中招募35例患者，作为标准治疗的一部分， 补助期。为了评估可行性、可接受性和适当性，我们将进行定性分析。 与Max Clinic患者（N = 15）和服务提供利益相关者（N = 15）在治疗前后进行访谈 实施COCM。为了评估CoCM在Max Clinic的设置中是否保持其有效性， 我们将评估干预对入选研究的患者的抑郁和OUD结局的影响。 6个月时的CoCM。为了完善收集未来研究所需数据的工具和流程，我们将招募 一项研究中的40例患者，在基线和6个月随访时评估以下因素：物质使用其他 比阿片类药物，焦虑症状，住房稳定性，监狱监禁，就业，健康相关的生活质量， 以及急诊室和医院的利用率。这些研究将产生关键的初步数据，以设计一个 未来的研究在多个设置。

Co-occurring mental health (MH) and substance use disorders (SUD) are common among virally unsuppressed people with HIV (PWH), and improving the health outcomes of “hard-to-reach” populations will require new approaches to integrating treatment for HIV, MH and SUD. The Max Clinic in Seattle, Washington is a novel “low-barrier” clinic that has successfully increased viral suppression among PWH with complex medical and social needs. Expansion of low-barrier care is central to Seattle/King County’s Ending the HIV Epidemic plan, and similar clinics are being implemented in other U.S. cities, but inadequate MH and SUD treatment is a critical deficit of the model that must be addressed. The overall goal of this two-year R34 proposal is to develop a replicable strategy of implementing collaborative care management (CoCM) for the treatment of depression and opioid use disorder (OUD) in a Ryan White-funded low-barrier HIV clinic. CoCM is supported by robust evidence for improving the treatment of depression in primary care and for managing OUD treatment with a nurse care manager. To our knowledge, CoCM has not yet been studied in patient populations with complex comorbidities and social needs, and the impact of CoCM for mental health and/or SUD conditions on viral suppression has not been studied among PWH in the U.S. Our approach is guided by the EPIS framework (exploration, planning, implementation, sustainment). For Aim 1, we will develop a CoCM model to integrate depression and OUD treatment into a low-barrier HIV care setting for patients who have not had continuous viral suppression in the past year. We will use a compilation of strategies to implement the model (including planning, restructuring, and education strategies), and stakeholder input will guide iterative refinement of the model. For Aim 2, we will evaluate the feasibility, acceptability, and appropriateness of the adapted CoCM model in a low-barrier clinic and assess changes in behavioral health outcomes among patients enrolled in CoCM after 6 months. We will enroll 35 patients in CoCM as part of standard care during the grant period. To evaluate feasibility, acceptability, and appropriateness, we will conduct qualitative interviews with Max Clinic patients (N=15) and service delivery stakeholders (N=15) before and after implementation of CoCM. To assess whether CoCM retains its effectiveness in the setting of the Max Clinic, we will evaluate the impact of the intervention on depression and OUD outcomes among patients enrolled in CoCM at 6 months. To refine tools and processes for collecting data of interest for a future study, we will enroll 40 patients in a study to assess the following factors at baseline and 6-month follow-up: substance use other than opioids, anxiety symptoms, housing stability, jail incarceration, employment, health-related quality of life, and emergency room and hospital utilization. These studies will generate crucial preliminary data to design a future study in multiple settings.