Patient navigation is a patient-centered approach to care coordination that helps people overcome barriers to receiving and adhering to health care. Patient navigation has been effective in linking people to HIV care, but some people who have both untreated HIV concurrently and a substance use disorder may need additional support.
Contingency management (CM) is a system of delivering incentives to increase the frequency of desired behaviors. It has demonstrated effectiveness in improving substance use-related outcomes and adherence to treatment.
Project HOPE (CTN-0049) combined these two approaches in a novel way to engage patients with co-occurring HIV and substance use disorders. This ancillary study aimed to examine patient navigator views about how contingency management interacted with and impacted their navigation process.
Twenty-two patient navigators from the original 10 Project HOPE study sites were interviewed, with questions addressing descriptions of the participant population, substance use disorder vs. HIV treatment entry and engagement issues, and the use of CM within the navigation service delivery protocol.
In the interviews, patient navigators reported that the CM intervention used in Project HOPE, which involved escalating financial incentives, helped motivate participant attendance at navigation sessions, particularly early in study involvement.
They also noted that financial incentives had a positive effect on targeted HIV health-related behaviors, like attending medical appointments, which provided a rapid pay-off with an escalating sum. The incentives also helped participants purchase goods and services that facilitated their access to improved health and overall care, like food, medicine, bus tickets, etc.
The contingency management programming was more challenging for patient navigators when it came to applying it to substance use-related behaviors, especially when the incentives were tied to negative urine screenings that were delivered with low frequency.
Navigators also noted that not all participants responded in the same way to the CM programming and that the incentives were especially helpful when participants were financially strained with limited resources or low in internal motivation.
Conclusions: Overall, patient navigators found the use of contingency management to be helpful and effective at influencing participant behaviors, especially navigation session attendance and HIV healthcare-related participation. On the negative side, navigators noted deficits in the ability of the CM programming as structured in Project HOPE to impact substance use behavior. These perspectives provide valuable insights that will be useful for program planning in the future, including improvements in specific parameters of the intervention and improved training of navigators to help them better anticipate and deal with individual client reactions.
Citation: Mitchell SG, et al. How patient navigators view the use of financial incentives to influence study involvement, substance use, and HIV treatment. Journal of Substance Abuse Treatment 2018;94:18-23.