Care Integration for Hepatitis C Virus Treatment Through Facilitated Telemedicine Within Opioid Treatment Programs: Qualitative Study

Background Telemedicine has the potential to remove geographic and temporal obstacles to health care access. Whether and how telemedicine can increase health care access for underserved populations remains an open question. To address this issue, we integrated facilitated telemedicine encounters for the management of hepatitis C virus (HCV), a highly prevalent condition among people with opioid use disorder (OUD), into opioid treatment programs (OTPs). In New York State, OTPs are methadone-dispensing centers that provide patient-centered, evidence-based treatment for OUD. We investigated the integration and impact of facilitated telemedicine into OTP workflows in these settings. Objective This study aims to understand OTP staff experiences with integrating facilitated telemedicine for HCV treatment into OTPs, including best practices and lessons learned. Methods We conducted semistructured interviews with 45 OTP staff members (13 clinical, 12 administrative, 6 physicians, and 14 support staff members) at least one year after the implementation of facilitated telemedicine for HCV management. We used hermeneutic phenomenological analysis to understand OTP staff experiences. Results We identified 4 overarching themes illustrating the successful integration of facilitated telemedicine for HCV care into OTPs. First, integration requires an understanding of the challenges, goals, and values of the OTP. As OTP staff learned about new, highly effective HCV therapies, they valued an HCV cure as a “win” for their patients and were excited about the potential to eliminate a highly prevalent infectious disease. Second, the integration of facilitated telemedicine into OTPs fosters social support and reinforces relationships between patients and OTP staff. OTP staff appreciated the ability to have “eyes on” patients during telemedicine encounters to assess body language, a necessary component of OUD management. Third, participants described high levels of interprofessional collaboration as a care team that included the blurring of lines between disciplines working toward a common goal of improving patient care. Study case managers were integrated into OTP workflows and established communication channels to improve patient outcomes. Fourth, administrators endorsed the sustained and future expansion of facilitated telemedicine to address comorbidities. Conclusions OTP staff were highly enthusiastic about facilitated telemedicine for an underserved population. They described high levels of collaboration and integration comparable to relevant integrative frameworks. When situated within OTPs, facilitated telemedicine is a high-value application of telemedicine that provides support for underserved populations necessary for high-quality health care. These experiences support sustaining and scaling facilitated telemedicine in comparable settings and evaluating its ability to address other comorbidities. Trial Registration ClinicalTrials.gov NCT02933970; https://clinicaltrials.gov/study/NCT02933970

The table below illustrates how and where (when applicable) our study addresses each item in the COREQ checklist.
"The multidisciplinary analysis team included a hermeneutic phenomenology expert (SSD), a social psychologist (AV), and a case manager (SJG) who performed the initial thematic coding.Subsequently, the study principal investigator (AHT) and study director (AD) joined the analysis team for the final coalescence of themes."Relationship with participants 6. Relationship established Was a relationship established prior to study commencement?
Yes, all interviewed participants were staff who participated in a study sponsored by the Patient-Centered Outcomes Research Institute (PCORI) comparing hepatitis C virus (HCV) treatment through facilitated telemedicine integrated into opioid treatment programs (OTPs) to offsite referral.The study was conducted in 12 OTPs throughout New York State.All interviewed staff participated in the facilitated telemedicine encounters (i.e., clinical staff), supported patients undergoing HCV treatment through telemedicine (i.e., patient engagement staff), or were responsible for HCV medication dispensing or side effect management (i.e., nursing staff).We also interviewed OTP administrators who were responsible for study planning, implementation, and conduct at their sites.

Participant knowledge of the interviewer
What did the participants know about the researcher?e.g.personal goals, reasons for doing the research-Yes, all interviewed participants were aware of the intent of the research from their involvement in the randomized clinical trial that was initiated in 2017.During the conduct of the randomized trial, we conducted a variety of activities to increase site engagement including annual learning and staff appreciation lunches at each site that fostered awareness of the trial among all site staff.We also actively educated all site staff about the basics of HCV.

Interviewer characteristics
What characteristics were reported about the interviewer/ facilitator?e.g.bias, assumptions, reasons and interests in the research topic Dr. Dickerson explained that she is a Professor of Nursing and that she has been working with the study team for several years.She explained that her initial experience with the study team commenced in 2017 when she participated in a thematic analysis of people with opioid use disorder testimonials of hepatitis C virus (HCV) treatment through telemedicine integrated into OTPs.Since that time, Dr. Dickerson has been a co-author on six additional publications including the current manuscript.  2 Yes, quotations are presented and are identified as to whether they were derived from a staff member or an administrator to protect participant identity.Since many sites have only one person per job category (i.e., one administrator), we were concerned that even the use of a study number might not preclude identification of the interviewee.This concern is augmented since the names and locations of the sites participating in the randomized trial are publicly available.The lack of explicit indication of the speaker's location reduces the likelihood of identification.

Data and findings consistent
Was there consistency between the data presented and the findings?Manuscript, pages 3-10 The interpretation was warranted, and exemplary themes provide evidence of the interpretation.

Clarity of major themes
Were major themes clearly presented in the findings?Manuscript, pages 3-10 "Participant interviews revealed four themes related to integration of facilitated telemedicine into a behavioral setting (Figure 1)." 32.Clarity of minor themes Is there a description of diverse cases or discussion of minor themes?Manuscript, pages 3-10 Yes, minor themes are discussed when adding understanding to the main theme and are supported by quotations.There were no diverse cases.