We received 85 responses of 219 requests (39% response rate), representing 34 unique provider organizations (
Location of survey respondent organizations (n=34; yellow marker).
Most respondents had access to smartphones (47/85, 90.4%), laptops (39/85, 75%), desktop computers (34/85, 65.3%), and high-speed internet (40/85, 76.9%) for providing D-RSS (
Technology access for digital recovery support service.
| Technology | Yes, n (%) | No, n (%) |
| Smartphones | 47 (90.4) | 5 (9.6) |
| Tablets | 14 (26.9) | 38 (73.1) |
| Desktop computers | 34 (65.3) | 18 (34.6) |
| Laptop computers | 39 (75) | 13 (25) |
| Routers and modems | 36 (69.2) | 16 (30.8) |
| High-speed internet | 40 (76.9) | 12 (23.1) |
| Printers | 43 (82.7) | 9 (17.3) |
| Microsoft Office 365 | 42 (80.8) | 10 (19.2) |
Outdated technology (n=85).
| Technology | Yes, n (%) | No, n (%) | N/A |
| Smartphones | 41 (48.2) | 35 (41.2) | 9 (10.6) |
| Tablets | 16 (18.8) | 12 (14.1) | 57 (67.1) |
| Desktop computers | 27 (31.8) | 24 (28.2) | 34 (40) |
| Laptop computers | 35 (41.2) | 32 (37.6) | 18 (21.2) |
| Routers and modems | 24 (28.2) | 36 (42.4) | 25 (29.4) |
| High-speed internet | 26 (30.6) | 41 (48.2) | 18 (21.2) |
| Printers | 25 (29.4) | 48 (56.5) | 12 (14.1) |
| Microsoft Office 365 | 25 (29.4) | 46 (54.1) | 14 (16.5) |
aN/A: not applicable due to not having access to the technology.
Respondents reported using a wide range of technologies for D-RSS delivery (
Digital recovery support service (D-RSS) technologies and platforms in use
| Technologies and tools | Type | Function | Values, n |
| Microsoft Excel or spreadsheet | Documentation | Data capture | 2 |
| Salesforce | Documentation | Data capture | 2 |
| DigiSigner | Documentation | Data capture | 1 |
| RecoveryLink | Documentation, engagement | D-RSS platform | 10 |
| Recovery Data Platform | Documentation | D-RSS platform | 6 |
| SoberGrid | Engagement | D-RSS platform | 2 |
| Clinical Management for Behavioral Health Services | Documentation | Electronic health record, claims payment system | 14 |
| Signify Health | Documentation, engagement | Telehealth platform, values-based payment programs | 1 |
| Doxy.me | Engagement | Videoconferencing | 4 |
| Zoom | Engagement | Videoconferencing | 30 |
| Google Duo or Meet | Engagement | Videoconferencing | 7 |
| Microsoft Teams | Engagement | Videoconferencing | 5 |
| GoTo Meeting | Engagement | Videoconferencing | 4 |
| Apple FaceTime | Engagement | Videoconferencing | 1 |
| Skype | Engagement | Videoconferencing | 1 |
| Smart Recovery | Engagement | Virtual recovery program, meeting locator | 1 |
aRespondents often provided more than 1 technology and/or platform in use. For example, one respondent said, “a number of various spreadsheets in Excel, RecoveryLink,” and another said, “REDCap, CMBHS, Zoom, Doxy.me”).
Respondents were asked to report barriers and facilitators of D-RSS (open responses).
The mobility allows for services to be provided anywhere. This technology is absolutely essential to providing accessible and flexible services that meet the needs of our participants.
Respondent-identified barriers and facilitators of digital recovery support service.
| Barriers and facilitators | Values, n |
| Barriers | |
| 17 | |
| 17 | |
| 9 | |
| 6 | |
| 5 | |
| Facilitators | |
| 39 | |
| 10 | |
| 9 | |
| 6 | |
The results of our thematic analysis identified four main themes: (1) impact of the COVID-19 pandemic on RSS, (2) barriers and facilitators to D-RSS use, (3) awareness and expectations of D-RSS, and (4) training needs. Within these 4 main themes are subthemes, all described below.
Interview respondent summary details (n=20).
| Organizations (n=16), n | Border | Interviews, n | Technologies and | Populations served |
| 1 | No | 1 | Zoom | Adults |
| 1 | No | 1 | Microsoft Teams | Adults and adolescents |
| 1 | No | 1 | Zoom, Microsoft Teams | Adults: house insecure and justice-involved |
| 1 | No | 1 | None | Adults: justice-involved, children |
| 1 | No | 1 | Zoom | Adults: with and without justice-involvement |
| 1 | No | 1 | Zoom | Adults: housing insecure, justice-involved |
| 3 | No | 3 | Zoom, Doxy.me | Adults and adolescents: justice-involved, adults: justice- or CPS |
| 2 | No | 4 | RDP | Adults: justice-involved |
| 1 | No | 2 | RL, Signify Community | Adults and adolescents: with and without justice- or CPS-involvement |
| 2 | Yes | 2 | Custom Salesforce app; Zoom | Adults: justice-involved, Indigenous community |
| 1 | Yes | 2 | Zoom | Adults: justice-involved |
| 1 | No | 1 | Zoom | Adults and adolescents with and without justice-involvement |
aD-RSS: digital recovery support service.
bCPS: child protective service.
cRDP: Recovery Data Platform.
dRL: RecoveryLink.
The COVID-19 pandemic prompted a rapid transition to D-RSS statewide due to stay-at-home mandates that forced providers to stop conducting services in person. Initially, respondents reported a successful transition to digital services:
We’ve been able to reach a lot more people a lot quicker, we’ve been able to maintain contact with them. Before the [pandemic], we’re knocking on doors, sending letters and things like that; suddenly, we get return ...
As the pandemic continued, some technological solutions became burdensome (eg, losing cell phone service), and some participants disengaged with their providers:
(...) actually, I don’t think there’s a big problem with being able to get reception for Internet or phone services here, but I think it’s more about, you know, either [the participants] are older and they ... All they have is like a small phone, and they can’t see that well on it, or they or they, you know, can’t afford the service for the phone or tablet, and it gets cut off ...
Increased access to laptops, tablets, and hotspots from schools and employers initially fostered a smooth transition to digital delivery. However, the shift simultaneously impacted the ability of many participants to discreetly access services:
We found out very quickly that clients didn’t have any privacy at home. So, they were sitting in their car with their phone doing behavioral health sessions. So, we set up two stations here, so clients could come in and use them ...
Despite these difficulties, the shift to D-RSS was viewed as having generated long-term benefits and remains integral to many organizations, allowing participants to overcome prepandemic barriers, such as long-distance travel, rurality, and lack of childcare:
I’ve seen more communication, I see more people attending meetings, because they didn’t have to try to make it down to the facility and they didn’t have to worry about catching the bus or gas money or getting off late [from work] to try to make a meeting. So, we’ve seen more people showing up for groups than at any time in the past, because it was just so easy for them to just get on their cell phone. Even if they are on the bus, a bus stop, they’re just getting off of work, and [virtual meetings] made it so much easier. I can see this being a big tool in recovery even after the pandemic, because we’re giving people the ability to be a part of something.
Interviewees identified both participant barriers to receiving services and organizational barriers to providing services, with subthemes identified in each. To address these challenges, several facilitators (and subthemes) emerged as well.
Providers reported that their participants often had issues accessing reliable internet, especially those located in or serving rural areas. Adequate cellular coverage in rural and border communities was also cited as an issue affecting both the RSS staff and their participants:
In addition, not only the participants have problems with reliable Wi-Fi and internet. I still have staff that don’t have internet. It’s a reality.
The rural communities have a greater barrier than urban areas because they do not have cell towers.
Many respondents stated that participants appeared to have access to smartphones:
But the technology is available. When we started on our harm reduction program about three years ago ... we were going to buy a bunch of phones and just hand them out. But there wasn’t that much of a desire for it, ‘cause they could actually get a free phone somewhere ...
However, 5 respondents from 2 organizations (including 2 border communities) mentioned that participants often use pay-as-you-go phone plans or phones with plans that include a limited number of minutes and/or data. Often, participants cannot afford a smartphone or cell phone with an appropriate data plan for accessing high-data consumption apps such as Zoom (
“... Keeping a smartphone and a computer current is expensive. You know, we have been buying low end phones, but broken phones can get expensive fast. I’m not sure tablets are the way to go. But we’re looking at it” [Quote from urban setting].
“One of the barriers the participants face is [that]changing phones and phone numbers constantly makes it difficult for organizations to reach them” [Quote from rural setting].
“I’m sure that a lot of people would love to have those type of resources—who wouldn’t want to have a tablet too. But some people are barely able to even obtain a cell phone” [Quote from rural setting].
Though participants may have smartphones, technology literacy for videoconferencing and app use appeared to be low. Several respondents indicated that some of their participants do not know how to effectively use their smartphones for apps such as Zoom and FaceTime.
A lot of people do have smartphones, but some people don’t know how to use [them] except for Facebook and social media, and they’re very sharp with things like that. But as far as other digital apps, they’re not very savvy with them. Computer savvy, yeah.
Low technological literacy appeared to be most prevalent among individuals older in age. More than half of the respondents from rural communities described generational differences; 3 of the 4 respondents representing border communities shared this perspective as well. Without assistance, older participants sometimes have difficulty downloading an online app or are unwilling to download an app or work with other technologies outside their comfort zone.
I think that [things] like installing apps on their phones, it’s just a little bit harder for the older clients, because we’ve had issues [with that].
When we do get back to face to face, we have to have a hybrid so that the physical presence [is there] but being also technologically connected so that everybody can participate. That was a great find for us during the pandemic because the younger people, they love it. They thrive in that environment and that’s what they want and they can feel as connected as an older generation that doesn’t feel connected electronically. They want face to face and you can meet both needs and that’s what’s important. Everybody has different needs and different barriers.
Literacy barriers were also identified for justice-involved RSS participants, specifically, for those experiencing extended periods of incarceration:
... I work a lot with people who come out of prison, and [maybe] they’ve been in prison for a while. All of a sudden, we have iPhones and they’re like “What do you do with this thing?” And I’m like, “well, it’s just like a computer” and they’re like “well, I haven’t been around a computer. I don’t know how to work at computers.” So, it’s really difficult for them to be able to say, “Hey, I need to download this app. And how do I work it?” It’s pretty simple for me ... but for somebody who’s fresh out of prison and hasn’t seen a phone in 10 years, then they’re really shocked about it.
In total, 16 respondents served participants experiencing housing insecurity, most reported in urban areas. One respondent estimated that up to 90% of their participants had recently, or were currently, not residing in a permanent living space, which creates difficulty in communicating with participants.
... if they can’t get [to] a program, what we do to try to alleviate that is ... we ask them, “where do they hang out? What store? What streets?” So that if we can’t get a hold of family members, we can at least go out and look for them ...
Respondents reported that most participants they have served were fluent in English, though 3 organizations also worked with Spanish-speaking individuals, comprising up to 75% of their participant population, and were unable to provide services in both English and Spanish to meet this demand:
We don’t have Spanish language or Spanish-English bilingual coaches on staff and we have several volunteers. One volunteer is not bilingual, she’s Spanish only. And so, we are working at expanding that out and are looking at that increasing over the next year.
It could take you an hour to enroll somebody do the recovery capital, do the assessment, do the recovery plan. And if it takes an hour doing it in English, it takes that much longer to do it in Spanish and translate and sometimes you’re having to toggle between “Google translate” a lot.
Furthermore, respondents from 4 organizations stated that approximately 50% of the individuals they serve have reading literacy challenges—their participants often had difficulty understanding documents related to their care and the services they are receiving. For example, one respondent mentioned:
They accept anything that’s told to them, they sign anything that’s put before them without understanding, without questioning. Now, even if they were not to agree, they would look at it as detrimental to them. Because somebody would then ... look at him in a different way that makes it harder to get through their probationary period.
Despite the frequent use of D-RSS in this study, several respondents (n=8) from organizations serving primarily urban communities mentioned the importance of delivering RSS to participants in person. They described how efforts to engage with individuals in the field often center on building trust and engagement with the services:
We don’t just have them [participants] come to us and sit in our office. We go to them a lot and that’s I think one of the reasons (...) we had a lot more connection with our people long term than a lot of the other programs.
We’re talking to people out in the streets, and so they know our face and they know our numbers. So they call us and tell us when there’s a relapse ... I wanna say 80% of the time they’re calling up peer recovery before they call the cops.
Respondents noted that for some participants, the sense of trust developed by being embedded in the community may not happen as organically in a digital relationship:
... A lot of people are really buying into more digital ways of communicating and more ways to access services remotely. I think that it, of course, will present challenges because you have people in their own way of thinking like “no this this can’t be right: how could I possibly like really connect with this person via this online platform?”
Finally, while videoconferencing has allowed organizations to expand services, especially into rural areas by removing barriers such as transportation and childcare, one respondent acknowledged that D-RSS, even with video interactions, will not always allow them to thoroughly assess a participant’s well-being:
You can’t really use all your senses to see how your client is doing through Zoom. It’s just their smile, their face and that’s it. But when you see somebody face to face, you could see different stuff. Like the clothes they are wearing, if they’re tattered, if they haven’t taken care of themselves, if they smell], stuff like that.
Many organizations are providing D-RSS via phone calls and text messages. Respondents representing organizations serving urban communities shared this preference significantly more than their rural counterparts. Texting appears to permit respondents to quickly engage with participants with a higher response rate:
I have one recovery coach who every morning sends an individual text of encouragement to every one of his clients. Even after they drop off, he continues, and then that sometimes brings them back because they know somebody is thinking about them and cares about them ... but if they had to open a special app to see it, I don’t know if they would.
It’s amazing how [much] quicker of a response you get via text message, than a phone call or anything else.
At times, staff members take on multiple roles for their organization to be able to meet the existing demand for services. In total, 5 respondents mentioned low staffing as a barrier to providing services to individuals in general. One respondent said:
We need more workers, plain and simple. We need more, the need is so big, so great. We think we are doing a great job ... but even in that we’re still missing.
Although the inclusion of D-RSS could address some of these bandwidth issues, multiple organizations still mentioned staffing as an issue to optimally using D-RSS platforms:
... Even if we had the transportation and we had all these tools, I lack manpower to be able to do what we can—like more education groups, wellness groups, social activities, all of that could happen. If I had more people, for example, when we had those large groups on Zoom, I could have split those up and not have so many people where you can’t really participate. If I have more coaches, we split up different groups. Everybody takes 10 to 15 [participants] and then you have a more manageable group.
In total, 7 respondents, all from urban settings representing distinct organizations, including 2 border community organizations, described employees who went above and beyond to ensure that their participants remain engaged in D-RSS. Employees might arrive at work early to set up Zoom meetings, remain attentive to attendees who get disconnected, and thoroughly follow up with them if participation decreases. One organization even conducted an online survey with its participants to ensure that Zoom would work for them. The commitment is best captured by this interviewee:
Everybody is in recovery from alcoholism or drug addiction and we’re just on fire to serve that new person that seeking recovery.
Both rural- and urban-serving respondents reported a high level of comfort with features such as texting, phone calls, navigating to websites, and smartphone use in general:
All of our coaches ... have extremely high aptitude in technology, it’s one of the things we screen for during the interview process.
All of our recovery peer support specialists are very familiar with all the platforms, and they are very comfortable with using them.
In total, 13 of the 16 organizations represented by respondents indicated that they would be open to using D-RSS, one highlighting:
... Our organization, and I could probably speak for most organizations from El Paso ... [we] are waiting for somebody to come and show us ... what’s available. I talk to a lot of recovery coaches throughout the city and a lot of them are on the same boat as we are. We started off big with Zoom, but then it ... teetered off. It would be great [if] somebody comes along and tells us “Pick what best works for your organization.” That would be awesome.
Yet, the need remains to “... provide equipment for both the participants and the RSS specialists” to ensure access for the successful use of these tools. A respondent from the same organization spoke about a hybrid RSS set-up where participants could opt for D-RSS or in-person RSS:
[We] would like to have a drop-in center where [the participants] can come and have access to the services and it does not mean they have to come in person, but they can just come and access the services they need.
Ease of use for D-RSS platforms was also an essential facilitator for RSS organizations, at times made possible by having the right equipment:
... We’re given laptops that we can take to and from home and we’re given portable Wi-Fi. So we pretty much can get in contact with any of our participants or clients at any given time whenever needed.
Awareness and use of unified D-RSS platforms for engagement and documentation varied widely across organizations. Only 6 respondents representing 3 organizations (all in urban settings) reported using a dedicated D-RSS platform. Most organizations instead relied on multiple disconnected technologies and software, such as smartphones, videoconferencing platforms, state electronic health records, and spreadsheets, to meet service and documentation needs.
Of the organizations using a D-RSS platform, one in an urban border community was using a version of the Salesforce platform that they had customized specifically for D-RSS delivery. In total, 4 respondents from 2 organizations described participant-centered customizability and availability of options for delivering and recording delivery of RSS as key features. Other features were described that would improve a D-RSS platform:
... [to]generate little graphs every time you meet with a peer; you could ask five questions about different points, different pieces of recovery capital [recovery capital is a measurement of a participant’s resources that can be used to initiate or maintain recovery], or different parts of recovery, or quality of life, and then how they feel about the service that they received from the individual that is providing coaching ... Recovery Link [the platform used] doesn’t have that.
Respondents from both rural and urban settings indicated that an RSS platform that could be used for hybrid services (digital and in-person) would be beneficial for their organizations.
The key is to serve people where they are at, if they need face-to-face then we do face-to-face or virtually.
Respondents highly valued the ability of D-RSS platforms to document interactions with participants, including the ability to generate reports. Respondents from 14 organizations (5 rural and 9 urban, including 2 border communities) mentioned double documentation of services as an issue stemming from different grants or contracts requirements. Therefore, the ability to upload all required documentation to one platform was highly desirable. One respondent saw the potential benefit of D-RSS platforms to:
... cut down on some of that documentation to where we could better serve the person’s needs, instead of tracking them down and sticking a stack of paper in front of them or having to get hold, to try to get them to sign something.
Furthermore, one respondent emphasized that documentation can also facilitate building rapport between the providers and the participants:
Our coaches use RecoveryLink more for data input than anything else ... because we really lean into personal rapport building, RecoveryLink is generally not even something that’s open during a session ... our peers are encouraged to document after a session.
In total, 7 respondents indicated that data capture and reporting are beneficial in a D-RSS setting due to the current options. A total of 3 respondents mentioned challenges using the state data platform for generating reports, citing double documentation and limited training availability as specific challenges. A total of 4 other respondents indicated that their organizations use multiple programs for reporting, which can become cumbersome and vulnerable to error.
Respondents from 12 organizations (5 rural, 7 urban; including 3 border community settings) stated that they need external funding to support a transition to a D-RSS platform. In total, 5 respondents (including 5 from border communities) spoke about needing additional funding to hire a staff member to conduct training sessions for their peers and participants and uncertainty about how they can afford to do so. A total of 3 respondents mentioned that access to appropriate technology (ie, smartphones, tablets, and computers) for both participants and peers is one of the biggest barriers to providing D-RSS:
The company doesn’t give them ... like laptops or tablets or cell phones, so they’re having to work from their own [devices].
One respondent mentioned that current funding restricts them from purchasing equipment for their peer support specialists and participants.
... more funding opportunities that designate purchasing telephonic equipment or telecommunications equipment for individual participants specifically like the Be Well VBH program that’s accepting applications. If there were more opportunities like that, it would change the landscape.
... I can see that being a definite challenge if we’re gonna need to ... supply devices to individuals we serve. Funding might be the only thing [preventing us from providing] devices to our clients ... I don’t see any other real barriers.
All except 3 respondents (including 6 rural and all 4 border community settings) mentioned training as a major barrier to D-RSS uptake:
If we could train them [participants] on how to use it. And ... if we provide them with the equipment they need ... I think if they have the equipment ready, and the training, then I don’t see why it would be a barrier. But the biggest thing would have to be the training.
Concern for adequate training was mentioned considerably more in respondents serving rural and border communities compared to urban communities:
Realistically, I definitely think you need to do a training component to build that confidence for it to be successful. But I think in order for it to be successful, you’d have to have a checklist of making sure all the equipment is in place, the training is in place, the comfort level is in place.
An additional desire was the availability of technical assistance since not everyone learns at the same rate:
With any new thing, what we hear from our staff the most, is “don’t just throw me some new software, give me a little bit of training on it.”
While many respondents mentioned working with participants who had high technology acceptance and technological literacy, others described challenges in helping participants to learn the virtual platform and their subsequent decision to offer hybrid training meetings to meet the needs of different generations:
Typically, if they didn’t know how to use it, we would give them a YouTube link to show them how to maneuver through Zoom and what they had to do. It was more difficult with the older population ‘cause they still have flip phones, and they didn’t have smartphones. That made it a little more difficult. But if they still needed help, they could even come in in person and we could show them what they needed to do, and help them set up their phones.
Conversely, respondents serving urban communities, including one border community, described having a 1-week-long training course and other training throughout the year, including onboarding training for new staff and ongoing training as part of contract requirements. For one organization, training included sessions to understand how to document the delivery of services and export data for reporting.