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Box 802, Salt Lake City, UT 84110 Phone: (877) 744-1360 Website: 10 PERSPECTIVESVOLUME 47, NUMBER 2 Automated Breathalyzer Kiosk Technologies David Kreitzer General Manager 2855 Country Drive, Suite 100 Little Canada, MN 55117 Phone: (651) 383.1213 Performance-Based Standards Learning Institute Kim Godfrey Lovett Executive Director 350 Granite Street, Suite 1203 Braintree, MA 02184 associate members corporate members continued PROVIDING SOLUTIONS IN CORRECTIONS USING ADVANCED TECHNOLOGY11 AMERICAN PROBATION AND PAROLE ASSOCIATIONLESSONS LEARNED from the Design and Development of an Automated Appointment Reminder Tool for People on Probation Samuel J. A. Scaggs, Pamela K. Lattimore, Nicole Jasperson Justice Practice Area, RTI International13 AMERICAN PROBATION AND PAROLE ASSOCIATION TECHNOLOGY ADVANCES LESSONS LEARNED FROM THE DESIGN AND DEVELOPMENT OF AN AUTOMATED APPOINTMENT REMINDER TOOL FOR PEOPLE ON PROBATION In 2017, 45% of state prison admissions resulted from probation and parole technical violations (Council of State Governments, 2019). The incarcerations resulting from violations have led states to consider reforms to address technical violations; reforms have focused on incentivizing compliance and alternative responses to violations (Pew Charitable Trusts, 2019). A relatively recent advancement—most notably in the court system— has leveraged lessons learned from behavioral economics to improve compliance of justice-affected people (Fishbane et al., 2020). In the criminal legal system, “behavioral nudges” include postal mail, phone calls, and text messages that notify and remind justice-affected people to attend appointments that could lead to additional sanctions if missed (e.g., scheduled court dates, probation appointments). The messages usually provide recipients with the date, time, physical address of the appointment, and contact information of the agency or office scheduling the appointment. In the past decade, a small but growing body of research has investigated the use of automated appointment reminders in the criminal legal system. A subset of this research has assessed the impact of automated text appointment reminders on court and community supervision outcomes (Chivers & Barnes, 2018; Fishbane et al., 2020; Hastings et al., 2021; Lowenkamp et al., 2018). However, to our knowledge, none of these legal system studies have discussed the development of those automated systems. Given that deploying such tools requires an unknown amount of planning and troubleshooting with program and application developers, this dearth of information is a considerable limitation. This article describes efforts to implement the Interactive Computer-Assisted Recovery Enabler (ICARE) messaging system to provide appointment reminders to people on probation. This research involves a partnership between RTI International and Coastal Horizons, a nonprofit behavioral health organization providing nonclinical care management to people on probation in North Carolina. The brief summarizes the study’s formative assessment findings, lessons from preparing to launch this tool (e.g., working with HIPAA data, managing COVID-19 impacts), and the next steps for assessing this tool in the field. This study builds on a relatively new body of work around automated appointment reminders in the criminal legal system and shares lessons learned about developing and implementing the ICARE system. Prior Literature People choose to engage in treatment and comply with their probation conditions in an environment that contains observed and unobserved features that influence their decisions, a construct known as choice architecture (Pogarsky & Herman, 2019; for a more general description of choice architecture and nudges, see Thaler & Sunstein, 2021; Thaler et al., 2010). We focused on understanding the type of behavioral nudge that pertains to the transmission of informational content—specifically, appointment reminders for behavioral health care management—to people under community supervision and required by the state correctional agency to receive this care management as a condition of their probation. Individuals may miss these appointments for a variety of reasons, knowingly or unknowingly, due to forgetfulness, emergencies, lack of transportation, or child care needs, among others. These reminders are not meant to threaten punishment but rather to remind recipients about their appointment(s) with a care manager (CM), like reminders anyone might receive from a doctor or dentist. They are not meant to directly deter criminal behavior but to indirectly elevate the recipient’s assessment of the consequences of not attending their probation-mandated appointment. These nudges are meant to help people receive necessary care management and treatment and to reduce the likelihood of receiving a sanction. Technological tools accessed through mobile phones are increasingly being integrated into rehabilitation to improve justice-affected people’s outcomes (Michalek et al., 2015). By enhancing communication channels between CMs or service providers and clients, these tools could increase service receipt and retention. Lack of treatment compliance, a major issue in the criminal legal system, is attributed to system-level barriers to program receipt (Chandler et al., 2009; Taxman et al., 2007) and lack of client motivation and readiness to change (Walters et al., 2014). A growing body of research suggests that the short message service (SMS) function (texting), which delivers messages through mobile phones, is effective in reaching populations to affect health behaviors (Fjeldsoe et al., 2009). Also, texting can affect the most vulnerable people because mobile phone use is high among adolescents, younger adults, those of lower socioeconomic status, young adults with lower educational attainment, and those who rent or frequently move (Faulkner & Culwin, 2005; Franklin et al., 2003; Koivusilta et al., 2007). Mobile phone 14 PERSPECTIVESVOLUME 47, NUMBER 2 TECHNOLOGY ADVANCES technology enhances substance use treatment (Dahne & Lejuez, 2015; Litvin et al., 2013; Muench et al., 2013; Tofighi et al., 2015); HIV/AIDS testing, assessment, and prevention (Dowshen et al., 2013; Reback et al., 2012); and mental health treatment (Berrouiguet et al., 2016). Recent research suggests that appointment reminders via mobile phone may be effective for reducing negative criminal legal system outcomes among individuals from underserved communities (Fishbane et al., 2020) and among people of color (Ferri, 2022). Except for studies of court-based appointment reminders (Bent-Koerick et al., 2021; Bornstein et al., 2013; Chivers & Barnes, 2018; Ferri, 2022; Fishbane et al., 2020; Hastings et al., 2021; Kohler-Hausmann, 2020; Lowenkamp et al., 2018; Zottola et al., 2022), little empirical assessment has been done on informational content nudges in the criminal legal system. To our knowledge, Hastings and her colleagues conducted the only study of automated appointment reminders for community supervision populations. Overall, the results of this evaluation suggest automated appointment reminders increase attendance and reduce canceled and missed appointments for participants on community supervision (Hastings et al., 2021). A few studies with a design using a randomized controlled trial (RCT) of people assigned to a treatment group that received automated text message reminders or a control group that received reminders as usual (mail or phone reminders) found that these nudges significantly reduce failure-to-appear (FTA) rates (Bent-Koerick et al., 2021; Fishbane et al., 2020). Another study employing an RCT found no difference in FTA rates between the treatment group that received a text message the day before a court date and the control group that received standard postal notifications (Chivers & Barnes, 2018). However, Chivers and Barnes (2018) acknowledged an important limitation: 58% of their sample did not have a valid phone number, which limited the intervention’s efficacy. Separately, some studies have explored the optimal cadence of notifications. Although one study reports that time or frequency do not impact outcomes such as FTA rates (Ferri, 2022), others report that receiving a notification the day before an appointment is the most effective at reducing FTA rates (Bornstein et al., 2013). Some studies have also experimented with the content of text message reminders for court appointments (Bornstein et al., 2013; Fishbane et al., 2020; Thomas & Ahmed, 2021). Fishbane et al. (2020) explored the relative effects of three conditions: a consequences condition where assigned defendants were notified of the ramifications of missing their appointment, a plan-making condition where defendants were informed of the date and location of their court appointment and then prompted to make a plan, and a combination group who received a mix of messages from the first two groups. The participants in the treatment group that received consequences and combination messages had fewer failures to appear compared to the control group (Fishbane et al., 2020). In a study of postcard reminders, Borenstein and colleagues (2013) found that while a warning message was the most effective for improving court appearance, messages with a reminder-only or a combination of both a reminder and a warning were also effective at improving court appearance. Similarly, Thomas & Ahmed (2021) also found that using a combination of plan-making and warning message (about the consequences of non-attendance) was the most effective approach for improving court appointment attendance. Still, studies in this area have shown some promising findings that automated appointment reminders are effective at reducing missed appointments (Fishbane et al., 2020; Hastings et al., 2021; Thomas & Ahmed, 2021). None of the studies using a text message notification system describe its development and application. Current Study The ICARE study is the first to design, implement, and assess use of an automated appointment reminder tool to nudge people on probation to attend their behavioral health care management appointments. RTI’s partner Coastal Horizons operates Treatment Accountability for Safer Communities (TASC) in the eastern half of North Carolina. TASC provides nonclinical care management to people with substance use or mental health issues. As part of typical business practices, TASC CMs may notify clients about their care management appointments ahead of time via phone call. ICARE extends TASC CM reminder efforts by automating the process. The ICARE study includes two broad phases: (1) development of the ICARE tool, and (2) its deployment and assessment among TASC clients enrolled in the study. As the first step in using a user-centered design approach for creating the ICARE tool, RTI staff sought input from TASC clients and CMs via focus groups and interviews. The purpose of the focus groups and interviews was to learn about clients’ access to and use of cell phones and clients’ opinions and suggestions on potential tool content and features. One cognitive interviewer from RTI conducted three focus groups with TASC CMs, one focus group with TASC clients, and 11 15 AMERICAN PROBATION AND PAROLE ASSOCIATION TECHNOLOGY ADVANCES one-on-one interviews with TASC clients during November 2019 and January 2020. Findings TASC Care Management as Usual During focus groups with TASC CMs, we asked questions regarding the care management process at TASC to better understand its operations. The purpose of TASC care management is to track client progress and ensure clients attend appointments with treatment providers. From conversations during the project’s planning stage, we learned that TASC clients are typically required to meet with their CM once a month after their initial intake appointment. TASC meeting frequency is determined by CMs, who consider clients’ needs. If a client is failing drug screens or treatment programs, CMs may seek to meet with that individual more often (e.g., every two weeks). TASC CMs in the locations we visited typically manage caseloads of between 100 and 200 clients. TASC clients are mandated to comply with TASC care management for a minimum of 30 to 90 days (translating into one intake and one follow-up appointment), but they can continue to receive TASC services contingent on their needs. CMs reported that most TASC clients receive services for between three and nine months. Clients who receive short-term services may have been referred by the court and been determined to have no substance use history or to have achieved sustained remission. More serious cases require greater interventions, including inpatient treatment, which can prolong clients’ receipt of TASC services. The absence or “no-show” rate for intake and regular appointments varies across TASC offices. Statewide, 38% of TASC referrals did not attend their intake appointment (NCTOPPS TASC Initial Reports for Fiscal Year 2018/2019). CMs in one office reported that as many as 60% of clients miss appointments, whereas CMs in another office reported that no-shows were uncommon. Practices for handling no-shows differed significantly across TASC sites and even among CMs at the same site. In some cases, CMs reported that they honored a grace period after a scheduled appointment during which a client could reschedule the appointment without repercussions. Other CMs took a stricter approach, sending a missed appointment letter to the client’s probation officer 15 minutes after the missed appointment start time and directing the client to contact their probation officer to reschedule. The probation officer may use personal discretion in deciding whether to charge a technical probation violation once being notified that a client missed an appointment. Policies, practices, and consequences for attending TASC appointments appear to vary greatly depending on TASC site and individual CM, further underscoring the need for a reliable and consistent text appointment reminder system. ICARE Content The ICARE project’s main focus is to conduct an RCT to assess the effect of text appointment reminders for clients’ TASC care management appointments. During interviews, we asked CMs and clients what these appointment reminders should contain, when they should be sent, and whether they would be helpful. CMs and clients agreed, often enthusiastically, that text appointment reminders were a good idea. To avoid confusion, CMs observed that reminders should specify that the appointment is with TASC, because many clients are seeing other providers. They added that reminder messages should also include the name of the client’s CM and the TASC office address, but some of the clients felt differently. When provided examples of an appointment reminder text message, clients often preferred simpler, shorter reminder messages. One CM expressed concern that the messages might cause confusion for clients. What prompted this concern is that the TASC office is in the same building as the probation department in some counties. Because clients typically have appointments with their CM and probation officer on the same day, usually back-to-back, clients often associate their probation appointments with their TASC appointments. Thus, if a probation appointment is rescheduled, a client may miss a TASC appointment. Moreover, when a client’s probation officer reschedules a probation appointment, the TASC appointment does not change. A canceled probation appointment is not always conveyed to TASC, complicating efforts to reschedule a TASC appointment. Because scheduling practices and the degree of coordination between TASC staff and probation officers differ significantly across TASC offices, special considerations may need to be made for certain sites. In general, appointment reminder text messages often facilitate interactive communication with participants and ask them to reply “Yes” or “No” to determine whether an appointment should be canceled or remain scheduled. This feature allows for the business to be more efficient, as it both reschedules appointments without terminating someone’s care management and re-referring them and helps fill open appointment slots. For our study, we wanted to determine the extent to which study participants 16 PERSPECTIVESVOLUME 47, NUMBER 2 TECHNOLOGY ADVANCES responded to the reminders. Many clients said they would respond to the text appointment reminder message if it asked their plans to attend the appointment. Some said they would respond only if they were not planning on attending but would probably not respond if they were going to attend. Others noted that—depending on the time of day—they may respond but not immediately (e.g., if they received the text while at work). Other clients described entering appointment information into calendar or reminder applications on their cell phones that would trigger reminder alerts before the appointment and noted that although they may not respond to a reminder text, receiving one would prompt them to double-check that the appointment had been entered in this way. Even without a calendar, some clients stated that the appointment reminder would help them regardless of their willingness to respond. To clarify, answering “No” or “N” does not automatically cancel the TASC appointment. CMs suggested that if the client responds “No” or “N,” the automated response should clearly convey the message that the client needs to call the TASC CM promptly and that the appointment will not be canceled until that is done. Discussion and Conclusion Using input from clients and CMs provided by RTI during this formative assessment, ICARE was developed by Uptrust, a public interest company. Functionally, ICARE is simple and involves mobile phone SMS technology that includes (1) appointment reminders with the date and time of the TASC appointment and the address and phone number of the TASC office (transmitted by Uptrust on behalf of Coastal Horizons) and (2) a question about whether the client plans to attend the appointment. A client’s answer to this question activates a follow-up response of either a “Thank you” for responding or instructions to contact the TASC office. The system automatically sends reminders to clients both one week and one day before their intake and check-in appointments. ICARE is being deployed in all 53 counties where Coastal Horizons operates a TASC office. The message content is straightforward. To abide by HIPAA’s privacy rule and our Institutional Review Board’s guidance, and given that clients often share their phones with family members, we did not include any information about the purpose of the appointment in the text message body. REM. Hello. You have an appointment with the [location] TASC Office on [DAY], [DATE], at [TIME]. [Fill phone number if virtual] [Fill address and phone number if in-person] Do you plan to attend? Reply Y for Yes and N for No. If you do not want to receive these reminders, reply STOP. Y > GO TO CONFIRM N > GO TO CANCEL STOP > GO TO UNSUBSCRIBE WAIT FOR RESPONSE. CONFIRM. Thank you for your response. CANCEL. Please <call the office> as soon as possible to reschedule your appointment. Your appointment is NOT CANCELED until you call to reschedule it. UNSUBSCRIBE. You have successfully been unsubscribed. You will not receive any more messages from this number. Reply START to resubscribe. [STOP ALL TEXT MESSAGES TO THIS NUMBER UNTIL USER RESUBSCRIBES] START. You have successfully been re-subscribed to messages from this number. Reply HELP for help. Reply STOP to unsubscribe. Msg&Data Rates May Apply. HELP. Reply STOP to unsubscribe. Msg&Data Rates May Apply.17 AMERICAN PROBATION AND PAROLE ASSOCIATION TECHNOLOGY ADVANCES Other Lessons Learned Through Development During the ICARE project’s development stage, we learned several important lessons. The first pertains to the sensitivity of HIPAA-protected data and the difficulties in serving as the intermediary for information exchange between a covered entity and a vendor offering notification services. To meet the HIPAA security rule, we would have been required to transmit data through several secure storage systems, which would not have been practically possible to do each day. After consulting with Uptrust, they agreed to enroll people into the study and send us summary information weekly, so we could monitor enrollment on the back end. Because of the sensitivity of the data, RTI and Uptrust were required to execute a Business Associate Agreement with Coastal Horizons to access and receive any identifiable information on TASC clients. A second lesson is that coordinating the direct exchange of information daily between Coastal Horizons and Uptrust was a nontrivial effort. Importantly, Uptrust had to access information from Coastal Horizons’ record management system, Lauris Online, on a daily basis to ensure that it had the most recent appointment and contact information for participants. Because CMs meet with clients regularly, this information is updated in Lauris Online. The planning process for this exchange required months of planning to define Uptrust’s process of automatically extracting contact and appointment information from Coastal Horizons’ case management system, developing mock reports that Uptrust would use each day, enrolling people in the study based on eligibility criteria, randomly assigning people to the treatment or control group, and securely transmitting administrative records to RTI weekly. To administer retroactive quality checks on the process, we arranged for Uptrust to transmit summary information on ICARE enrollment and number of text messages transmitted to RTI each week. We also conducted a two-week soft launch of ICARE to confirm enrollment procedures were adhered to as instructed. We used this time to identify any inconsistencies in the tool as planned and modified the system accordingly. From start to finish, this process lasted about four months. A third lesson is that CM and client feedback in the process of refining the text message specification was important to ensure clients’ needs were met. Because of CM feedback during the focus group, we decided to forego allowing two-way messaging between CMs and clients. Separately, given social distancing policies, and because some TASC offices operated by Coastal Horizons did not operate out of an office in the counties where some clients lived, we had to tailor messages so as to not confuse clients who would just be checking in with their CM via phone or engaging in a telehealth appointment. Conclusion The ICARE study is a proof of concept that an automated text message system, providing appointment information, is a feasible approach to improving behavioral health uptake and probation compliance. To this end, we shared some findings from our user-centered formative assessment and lessons learned from working with a HIPAA-covered entity and technology vendor. In our case, the formative assessment allowed us to tailor message content and features to the needs of the end users of the automated messaging system (e.g., people on probation and receiving nonclinical behavioral health care management). We hope this research brief serves as a resource to others who are considering deploying a similar system. Since development of this brief, we started enrolling people in the ICARE study and conducting telephone interviews with ICARE participants to investigate their satisfaction with the tool and its usefulness for prompting them to attend their appointment. We are actively collecting administrative data from Coastal Horizons on ICARE study participants’ TASC appointment attendance and care management completion and will request administrative data on their probation outcomes in the coming months from the North Carolina Department of Adult Correction. The next steps in this study include analysis of differences in outcomes between the ICARE and TASC reminders as usual practices. References Bent-Koerick, K., Bergin, T., & Ferri, R. (2021). The court appearance pilot project: A randomized evaluation of an interactive intervention to encourage court date attendance. 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MAPIT: Development of a web-based intervention targeting substance abuse treatment in the criminal justice system. Journal of Substance Abuse Treatment, 46(1), 60-65. Author Biographies Samuel J. A. Scaggs, PhD, is a program manager in the Corrections and Reentry Research Program at RTI International. His research interests include corrections and court systems practice and program evaluation, use of technology in criminal legal systems, crime and victimization over the life course, and the role of community context in affecting reentry outcomes. Dr. Scaggs has published his research in Perspectives, American Journal of Criminal Justice, and Journal of Offender Rehabilitation. He has served as an evaluator and training and technical assistance provider to judicial, prosecutorial, correctional, reentry, and public health practitioners in several jurisdictions across the country. Pamela K. Lattimore is a Principal Scientist for RTI’s Justice Program Area. She has evaluated criminal justice interventions, investigated the causes and correlates of criminal behavior, and developed approaches to improve criminal justice operations for more than 35 years. She is currently the principal investigator for research studying pretrial policy, community supervision risk assessment, probation reform, prisoner reentry, and criminal record expungement. She is a Fellow of the Academy of Experimental Criminology, and a recipient of the ACA Peter P. Lejins Researcher Award, the ASC Division on Corrections and Sentencing Distinguished Scholar Award, and the AEC Joan McCord Award. Nicole Jasperson, MS, a research public health analyst in the Corrections and Reentry Research Program at RTI International, has specialized knowledge and practical experience in the areas of corrections and reentry policy and practice. Her research interests include barriers to reentry, recidivism, desistance, and leading quantitative and qualitative data collection and analysis tasks. Before joining RTI, Ms. Jasperson served as a research and data analyst for the Colorado Department of Corrections and the Minnesota Sentencing Guidelines Commission. TECHNOLOGY ADVANCESNext >