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

精神健康(MH)和物质使用障碍(SUD)在病毒感染者中很常见 不受抑制的艾滋病毒携带者(PWH)，并改善“难以触及”人群的健康结果将 需要新的方法来整合艾滋病毒、MH和SUD的治疗。华盛顿州西雅图的Max诊所 是一种新的“低屏障”诊所，成功地提高了复合体对PWH的病毒抑制 医疗和社会需求。扩大低障碍护理是西雅图/金县结束艾滋病毒的核心 流行病计划，美国其他城市也在实施类似的诊所，但MH和SUD不足 治疗是该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 建议是制定可复制的战略，实施协作护理管理(CoCM) 瑞安·怀特资助的低障碍艾滋病毒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在初级保健中改善抑郁症的治疗和管理 接受护士护理经理的治疗。据我们所知，CoCM还没有在患者身上进行研究 具有复杂共病和社会需求的人群，以及合作医疗对心理健康和/或心理健康的影响 在美国的PWH中还没有研究过抑制病毒的SUD条件。我们的方法是由 环境规划信息系统框架(探索、规划、实施、维持)。对于目标1，我们将开发一个CoCM 将抑郁症和OUD治疗整合到为没有抑郁症的患者提供低障碍艾滋病毒护理环境的模式 在过去的一年里一直在抑制病毒。我们将使用战略汇编来实施 模型(包括规划、重组和教育战略)和利益相关者的意见将指导迭代 模型的精细化。对于目标2，我们将评估以下项目的可行性、可接受性和适当性 在低障碍诊所中采用CoCM模型并评估以下人群行为健康结果的变化 患者在6个月后进入CoCM。我们将招募35名患者参加CoCM，作为标准护理的一部分 授权期。为了评估可行性、可接受性和适当性，我们将进行定性 前后对MAX诊所患者(N=15)和服务交付利益相关者(N=15)的访谈 CoCM的实施。为了评估CoCM是否在MAX诊所的设置中保持其有效性， 我们将评估干预对登记的患者中抑郁和OUD结果的影响。 CoCM在6个月时。为了改进工具和流程，以便为将来的研究收集感兴趣的数据，我们将注册 在一项研究中，40名患者在基线和6个月的随访中评估了以下因素：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、与健康相关的生活质量， 急诊室和医院的使用率。这些研究将产生关键的初步数据，以设计 未来在多个环境中的研究。

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.