I'd like to present her with the 2023 Agnes Purcell McGavin Award for Prevention. This is through the APA Foundation. So the McGavin Award for Prevention was established by the APA in 1964 and recognizes a child and adolescent psychiatrist who's made significant contributions to the prevention of mental disorders in children and adolescents and has influenced the general well-being of young people. If you don't already know about Dr. Fortuna and her work, she has been a leader in research that's organized around culturally sensitive, culturally humble interventions that include community-based feedback and active participation. And she has helped us to see and hear the voices of the community through every area of her research, and as we innovate in psychiatry, she has said, let's bring the voice of the community with us, let's engage the community, and let's have research to demonstrate the effectiveness of these interventions. So today, it's a real honor to present to Dr. Fortuna this award. A few years ago, I had the honor of working with her on a course where she was our honored guest speaker, and she chose to talk about resilience, right, and resilience of children and adolescents in the time and peripandemic. So this is her lifelong work, and it is such an honor to present this award to her. So I'm going to introduce her formally so you'll have a little bit more about her history and background. Dr. Lisa Fortuna is MD, MPH, and MDiv. She's actually Reverend Lisa Fortuna. She's a professor of psychiatry and executive vice chair in the Department of Psychiatry and Behavioral Sciences at the University of California, San Francisco, and she's chief of psychiatry at the Zuckerberg San Francisco General Hospital. She's been an investigator on several NIH and foundation-funded studies of Latinx and immigrant mental health integrated collaborative care models, family navigation, prevention of adolescent substance abuse disorders, and PTSD across the lifespan. Her areas of expertise are in health services and equity research, including the use of digital mental health interventions co-designed with youth, families, and their communities for improving access to care. So Dr. Fortuna, please come so I can present you your award. Thank you. Thank you so much, Dr. Gibbs, and to the APA for that award. It's a great honor, and thank you all for participating today in my reception of that award and even more importantly in the topic that we have today. That definitely is an extension of that idea of prevention and working with our youth and our families in a more comprehensive way, I think, and to sort of keep in mind as we're talking the importance of really having input from families about all of the interventions that we're talking about and the improvement of our care. So thank you to the APA for that award, and again, thank you, Dr. Gibbs, for presenting me with that. So we will start on our presentations. So we're here to talk about social determinants of health for youth and children, and really we're going to have an opportunity to engage later, so get prepared. So we really want to talk about how to practically approach this concept, right, of addressing social determinants of health for children. So these are our disclosures that you have here for all of us as presenters. So you can see that there. And I'm going to start us off on an introduction, some of it a review, because I'm sure most of you have a conceptualization of social determinants of health. I just want to start framing how we want to look at this throughout our presentations and our discussions today. So one is our learning objectives overall for today's session is really one, to gain a conceptual understanding of the social determinants of mental health, and in particular how we might think about that for children and youth, and I would say also for their families. Acquire tools at each level of intervention to protect and promote the mental health of children and youth, and then practice innovative thinking, and we'll have some opportunities to do that together of the ways that we can positively impact on social determinants of mental health for children and youth and their families. If we're going to talk about social determinants of mental health, it's very important to talk about structural determinants of health, and we know that these are often things that more and more, and rightfully so, we talk about together. And when we're talking about the structural determinants of mental health, we're really talking about policies, you know, those economic systems, those structural systems, those social hierarchies, that include issues of discrimination, racism, and disparities that relate to that, that have an impact on the perpetuation and the consequences of poverty and inequality, right? So those can be things that are housing, transportation, jobs, education, and those are the social determinants of health that are affected by these structural determinants. And then we know that these all can have very significant health outcomes, including maternal mortality, chronic conditions, delays in the treatment of mental health needs, where we're moving from prevention to actually needing to do secondary and tertiary prevention and treatment when we could have done things much sooner, right? And we know that there are structural and policy issues that have an impact on that, and when we're able to think about those things within this frame, that's what we're talking about when we're discussing the idea of structural competency, right, that have an impact on those social determinants of health. One of the things that I want to say here is that, you know, when we think about including community voice, there was a recent study that one of my colleagues did, for example, where they were really looking, working with black-identified mothers around different structural issues that impact on them in their health care. And one of the things that they came up with was just one example of many of this policy of when they can actually have their baby carriage on buses or not, right, and that that had a complete impact on when they could go out to go shopping or for food or to appointments. And so when we were thinking about let's think about, you know, what we're doing in the clinic, which is important as well, you know, she brought up, you know, a group of them brought up the idea that, you know, we need to even include policy issues around how we can even get around and when we can get around with our families to be able to get the things we need. So, you know, it can really be sort of thinking out of just our clinical settings, right, in terms of these structural determinants. So we have to widen our lens, right, and when we're thinking even about, you know, sort of our conventional understanding of diagnosis, right, and treatment planning, you know, a conventional way of looking at this is what DSM-5 criteria are met for diagnosis and treatment planning is one way that we can, you know, enter, right, into thinking about assessment. If we're looking at it from a health equity lens, we're asking more around the question of what types of social factors are influencing the child's development and mental health and can be addressed as prevention first, and then, of course, clinical services is needed secondarily. So it goes much more into the prevention realm first. In addition to widening our lens, in the conventional way, we might think about, you know, we might be thinking about these social contexts and asking what social programs and services are needed to address health disparities for children. That could be the question we ask. Moving it a little bit further into health equity in regards to social determinants, we can ask more about what types of institutional and social policy changes are necessary to tackle social determinants of health and equities for children and families. So going more upstream into those things that impact on those social determinants. One other conventional way of looking at this is we can say, how can individuals protect themselves against health disparities? In a health equity lens, we ask a different question, right? What kinds of community organizing, alliance building are necessary to amplify assets within communities that can support families? How can we engage the community in that regard as well? And this is one example from colleagues Spencer and Oblath. Rachel's here, so if we have further questions about this study. But this was really looking at social determinants and family well-being, right, on the health of ADHD symptoms through the pandemic. In a safety net hospital that serves primarily underserved and communities of color. And they looked at socioeconomic status, access to basic needs, and caregiver well-being and how that was associated with higher ADHD symptoms through the pandemic. And all of those things were independently associated with higher ADHD symptoms. However, once put in a multivariate model where you're sort of adjusting, controlling for different parts of these variables, only worse caregiver well-being was significantly associated with ADHD symptoms. So it really sort of speaks to how each of these things independently has an effect, but also if we really centralize ourselves also on the well-being of caregivers and how that impacts on their well-being. We're making a tremendous impact as well. Because caregiver well-being really fully mediated the relationship between social determinants of health and ADHD symptom severity. And we know that social determinants of health has real stress, sequence, and biological consequences. And it's at multiple levels. So if we really look at sort of long-term chronic stress from social determinants, including discrimination, lack of control over work and home life, social isolation, non-permanent work, coping that may result by substance use, early childhood not stimulating maximum brain development, all of these barriers to seeking mental health care, cultural, financial, class, gender, all of these things accumulate and really can have a significant impact on chronic disease, including mental health conditions in terms of depression and anxiety. So more and more we know that as a field we need to go to those sort of upper stream things and looking at it not only from a sort of social structural component, but also as a real stress model of illness that we need to be able to impact. And so, again, if we continue to think about sort of children and their own development, we can have a conventional approach, even knowing all this, of sort of continuing to ask how can we address individual child behaviors. And that is often the thing that we have. Even within different systems of care, we're always very concerned about how can we address a child's oppositional behavior or anxious behavior. And, again, from an equity lens, what we're looking at is what kind of community resources can be engaged to support child and family well-being. How do we support those families? And one of the things that I want to end is that we've known that there's these— we've had models for a very long time that look at this idea of how can we promote healthy child development, which includes mental health. And how do we do this within families, schools, neighborhoods, within our health care? How do we integrate primary care to be able to address those issues much more? And how do we really work with communities? And, you know, Cynthia Garcia-Cole, in the late 1990s, put together this model, which has been used in different versions of it for many, many years right now, is really that we have to look at the root of influences on minority children's— on minoritized children's development. And that it really—most of these things are structural and social, right? And social determinants. And that those include racism, prejudice, discrimination, oppression, as well as social position variables in terms of not just sort of race alone, but also how that relates to where youth and their families are positioned in society, right? Whether they're segregated, what social class, what kind of resources are in the community. What are the results of segregation, including residential, economic, social, and psychological stressors that are part of that segregation, that are based on policies and structural influences. But that we can also create promoting environments, as well as having these inhibiting environments good to healthy child development, which includes how do we address these issues in schools, neighborhoods, and in our health care. So I'm going to hand it off to Dr. Gibbs to go a little bit more on how we can do this clinically. Thank you so much, Dr. Fortuna. So my name is Tresha Gibbs. I'm a child and adolescent psychiatrist based in New York. I'm currently the clinical director at Rockland Children's Psychiatric Center. And in addition, I'm an assistant professor of child and adolescent psychiatry at New York University. I'm a former SAMHSA fellow, APA SAMHSA fellow. And over the years, I had the opportunity to sit on the council, the APA's Council on Children, Adolescents, and Their Families with Dr. Fortuna and Dr. Velez. And last year, a couple of us and several others were part of Dr. Vivian Pender's Presidential Task Force on Social Determinants of Mental Health. And so our contribution to the task force mission was to look at creating an educational resource document written by child and adolescent psychiatrists and trainees that really focused on how we conceptualize the social determinants of mental health, more specifically for children. So that resource document is located on the APA's website. And we're going to reference it somewhat and ask that you consider looking more into it for more detail about practical steps that you can incorporate in your daily practice. So on the right of the slide, on your left, is a triangle that we use to conceptualize what makes kids different. Much of the discussion about social determinants of health do tend to focus in on the basic needs and certainly access to care, et cetera. But from a child's perspective, we know that the social determinants also include factors related to their caregiver, mental health, caregiver's health, and mental health. Also the parenting structure that they're sort of embedded in. And additionally, it's affected one of the other domains that we conceptualized was their childhood experiences. So as we're building little children, you know, helping to support young people as they are getting older, we aim for them to develop resilience. And on the left, we tried to propose that it's a part of getting to resilience is looking at these areas and trying to promote optimal conditions in each of these areas. And on the left, we have preventing adverse conditions or mitigating adverse conditions. So we didn't want it to just be about what's negative or not right. We know that if we push into young people positive experiences and certainly many community-based experiences, relationships, supports, skills, sports, activities that build their self-esteem, et cetera, that in terms of their childhood experiences will help to promote optimal conditions and support their resilience. And so then in the face of, let's say, trauma or so, which is an adverse childhood experience, that we take steps to mitigate the impact of that. But we recognize that we can't always control what children experience. It would be nice if we could, but certainly in the event of adverse experiences, we hope that if we promote optimal conditions in each of these areas, then we will be able to support increased resilience in these young people. So in the document, we talked also a bit about how to systematize this, sort of the screening for these conditions in our work with young people and their families. And right now, I think it's fair to say that that doesn't really happen systematically. So we might, in a child psychiatry setting, have the psychosocial or the social history. We might separately screen for trauma, hopefully, Because every system should be doing that. But we may not be screening, frankly, for basic needs, right? Are you able parent, you know, is your family able to pay their bills? Do you have food insecurity? And we may or may not be screening for the caregiver's mental health, except if it sort of falls on an extreme, where we're saying, oh wait, something's going on with that mom or that that parent, that caregiver. They're under stress. So if we could arrive at a more systematic approach to these particular areas, we will be able to both identify code, provide the medical coding, and also intervene more systematically in supporting these young people in their development. So I'm going to use, we're going to, we decided to use a case. We do have cases in the resource document, just to highlight some of the content. So this is a case of a young child whose name is Michael, six-year-old, presented to the psychiatry clinic with mom for an evaluation for recent onset disruptive behaviors at school and at home. Mom reports that he has difficulty sitting still, following directions, focusing, keeping hands to self. She describes him as very energetic and off the walls, and this has become particularly troublesome as the family recently started being housed in a shelter, and mother fears that they'll be asked to leave if Michael can't calm down. So in the interview, when seen alone, Michael is easily engaged, observed to move quickly from toy to toy in the room, and he says he does not have a lot of toys at home and wants to play with everything. So he admits to getting into fights at school, but only when other kids make fun of him for being smelly or homeless. He says that before moving to the shelter, his family moved between hotels and friends' homes frequently. So when we look at Michael's story, if we're not obtaining a full comprehensive biopsychosocial history, we might be quick to say that, you know, you have a disruptive behavior, ADHD, and therefore should be treated in this way. But really, there are, while there are red flags for potential ADHD, there are other aspects of this presentation that are really important, and if we systematically reviewed these areas that I mentioned before, we could come to a close, a better understanding of what might be going on, and then potentially mitigate or decrease some of these symptoms. So, you know, we can look at, I mean, I'm sure things come to mind for some of you in thinking about this. I'm sure, you know, if you do child psychiatry, you might have patients like Michael, but there's significant familial stress. We haven't formally screened for maternal stress in this case yet, but that's something you would want to do. So, you know, not having enough toys at home, we wonder about maybe the stimulation in the home environment, the issue of housing or being housed or unhoused for this family. It's important to clarify, right, with the family about how stable things are, what are the plans, what are the supports in place, do they have what they need to work towards a more permanent housing. Another thing, you know, there's the complaint about fights at schools because kids were making fun of him, so there's this topic of, like, from an adverse childhood experiences perspective, bullying or potential bullying, so that could be something that's a bit of a flag. Those are some that come to mind. So, really, during evaluation, it's really important to identify any deficits and basic needs, family income benefits, food and security, transportation, health insurance coverage, educational concerns for the child, employment, housing concerns for the caregiver and family, and really to assess, integrate these as part of the treatment plan that you do work on with the parents and family. So, there are tools that we do talk about in the document, but just to highlight a little bit more some of the adverse childhood experiences or the childhood experiences that may or may not exist in your, you know, the individual patient's life, you want to look at screening for each of these domains for children, right? So, basic needs, the caregiver health and parenting, and then in terms of the childhood experiences, we spelled out, you know, abuse or neglect being sort of one related to trauma. Bullying, so being the victim of bullying or perpetrator of bullying is something we should be screening for routinely. The role of digital social media use, so what's the environment that the child is spending their time, how much time are they spending, but also what are they viewing, what are they learning? So, considering that as an extended venue for child development, not just the built environment, but the digital environment, okay? And then, you know, exposure to community violence, so we could be asking that question, are there factors related to fear or anxiety? Has my goal been exposed to any community violence? And then we included substance, substance use exposure in there as well. We also try to, we put for each of those items we have in the document particular screening tools that can be helpful, and what doesn't exist is sort of one generic or sort of overarching screening tool to address all of these aspects, but that's something we can talk about later in the innovation time. But we did also try to emphasize the potential benefit of using medical codes to capture some of these factors. So, the DSM-5 has updated Z codes for items or for descriptors that capture some of the social determinants of health and mental health as we've spelled them out. So, in the document, we also line up some of those with the item, with the domains that I have on the previous slide. So, for example, for Michael, that might include a code for Z59.0 or Z59.1 and, you know, Z60.4 for social exclusion or rejection. So, that's another tool. So, the medical record coding can be helpful for lots of reasons. CMS has been picking up and pushing for this and certainly in the medical arena with the idea that the hospital or the system can use the information gathered from the coding to identify trends, provide support for certain types of programming, and definitely as the Joint Commission has moved towards including health equity as a standard for accrediting hospitals now. So, measuring, monitoring, intervening in this area of health equity, being able to pull information from the charts that's coding, code-based, can be helpful for making decisions that help to support, you know, maximizing equity in the clinical space. So, I put this up just as a reference that the coding was something we emphasize as well. And then moving towards different levels of intervention, so the document goes through some of the things that Dr. Fortuna mentioned before, this idea that, you know, at the individual level, you know, a provider, a psychiatrist or therapist may not feel like they can change the whole system, right, and create the policy themselves, but that there are things that they could do. So, we differentiate levels of intervention. So, with the idea that upstream interventions seek to create a community level impact and improve the social conditions through policies, laws, regulations. So, an upstream, you know, potential intervention could be the idea that the Joint Commission has now decided that every hospital needs to have a plan for health equity. Like, it's huge. The results or the impact of that is not necessarily so clear yet, but it certainly allows for more discussions that can actually change people's lives and innovation that can change people's lives. So, again, we're going to get to a little bit to innovation and we're looking forward to getting your input as well and ideas that you have. So, midstream interventions, they might seek to create some impact by meeting the social needs at the level of services, resources, maybe at the state level or the organization level or the community level, and then downstream interventions kind of create an individual level impact during the clinical encounter. So, we think of screening as an individual level potential, you know, and mid-level, but certainly an individual level action that can be taken by providers, screening, coding, and then intervening. So, let's say that that's like, those are some individual levels. So, for Michael, what are some individual level items? So, we're thinking of his, in terms of, like, the, at the level of basic needs and education, does he have enough supports at school and does his family have, let's say, care coordination services or enough support with regard to the housing situation? Do they need more toys? Is that something that would be helpful? Does he, would he benefit from an after-school program to, or some service that would give him more of a connection to the community? With regard to his, the experience of being bullied, you know, are we feeding that back to the school? Can we refer to the family to speak to the school very strongly about the importance, if not, of having an anti-bullying policy, but also what are they doing about the, that situation? Can they facilitate some kind of reconciliation or teaching for the peers that are involved? You know, going up for him to, like, midstream, you might think about strategies that the school can take or the community can take to better help and support this family. And then, so, separate from Michael, there's the other examples of, like, midstream interventions might be, you know, Healthy Steps, early childhood, trauma-informed care, legal-medical partnerships in the clinical setting, the collaborative care, task-sharing models. They might need upstream funding, but in terms of the delivery can happen at the level midstream. Peer and family, peer services for the, for mom or other sort of, like, supports, peer supports, and explicit responsiveness to racialized stress and related inequities. So, there are lots of, you know, challenges that we would face, like, at the midstream level that require upstream intervention. This issue of not having, maybe, a common framework for understanding behavioral health between public systems and clinical care providers. The services are so fragmented and under-resourced that can be a challenge. You know, definition of medical necessity being outdated, that, and inconsistent trends regarding the impact of trauma and adversity on social-emotional health. So, there's some challenges to moving the field forward, but there are also lots of opportunities, and some, you know, organizations have tried to overcome those challenges through, you know, being able to offer dyadic care. So, this issue, you know, Michael came to us. Some, for a six-year-old, it'd be great if Michael could get dyadic work with mom. Mom's likely very stressed, and Michael's clearly having some stress, and their ability to, you know, partner and, you know, have mom best support this child could be accomplished with dyadic care, but even the structure isn't so well suited for that, because somebody has to have a diagnosis, right? So, then we end up having to give Michael the ADHD, or, you know, an adjustment, or mom a disorder, and who are you billing under? Those are some challenges. So, really redefining the service provision, and from a prevention perspective, imagine investing in this early, so that you don't, it doesn't require a diagnosis in order to access the care. So, that's, it's really important. Expanding peer supports and social models, ensuring access, and integrating non-traditional providers, that's another thing. Removing diagnosis as a prerequisite, and expanding provider designations, so you have more providers in the system, and really maximizing funding. So, those are just some ideas. It kind of gives you a little precursor to what we'll continue to discuss together as we move through the session. Good afternoon. My name is Herman Velez. I'm a third-year psychiatry resident at Boston Medical Center, and I will start Child Psychiatry in July at New York Presbyterian, Columbia and Cornell. I am the chair of the Public Psychiatry Fellowship with the APAF, and the resident fellow trustee in the board of the APA, and it's an honor for me to be with amazing mentors, Dr. Gibbs and Dr. Fortuna. One of the reasons why we brought this topic was, we are all here because we care about this, but how do you materialize it? What can you do, right? As a resident, most of the time, I see so many needs in my patients at Boston Medical Center, but sometimes I feel short. What resources do I have? I know clinically, I can screen for mental health disorders. I can maybe prescribe, but what can we do beyond that? So, I'm gonna show one of the tools that I found very, very helpful that was created at Boston Medical Center, and that might help us think about other ways in which we can have actions and start creating change around how we practice around social determinants of mental health. So, this is, we talked about equity, how do you promote equity? How, first, identify barriers, support and address needs through partnerships and networks, community, and our understanding of social determinants, it's fundamental. If you saw the triangle, we thought about resilience not only in the individual level, but also in the community level, in the family, but this has to be a, that has to be a way to document and measure the impact that this has on health and mental health, to improve the process. So, a way to do this was through the medical chart. How do we document this, and how do we find ways to improve or impact? And at the end, at the systems level, how do we promote taking social determinants as a priority, thinking about cost of care? So, at Boston Medical Center, the Thrive screening tool is a tool that screens for social determinants. It was based on a pediatric tool called WeCare, and it was developed by pediatricians, implemented at BMC and other pediatric urban clinics, and to create this, a more bigger, widespread project, an interdisciplinary committee was created. It had researchers, trainees, community engagement specialists, operation managers, health care providers, health literacy experts, IT analysts, and medical assistants, to kind of figure out how to make this a practical tool, and they included some social determinants that were aligned with the purpose of the institution and other national initiatives. That was evidence-based, that was able to collect the burden and be sensitive, asking about each of those domains during patient care, and what available resources they were to be able to provide, right? Because we need one to measure, but we also want to provide something, not only measure, but what actions can we take after we measure those social determinants. So, this is the general model. Initially, the patient is screened, someone, clinical staff documents on the medical record, and then the patient is provided resources. So, that, in theory, seems pretty simple, but we'll see how this has grown and what we found since it was implemented at Boston Medical Center. So, it started, it was implemented in 2017, and we continue to learn about our patients as we assess, and there are ongoing committees in each of the social determinants that are measured in the THRIVE screening. So, over a hundred thousand patients have been screened using the THRIVE program. Twenty- eight percent of the surveyed patients reported at least one social determinant of health need. Twenty-one percent requested support with at least one resource. Eighty-one percent adherence across all clinics, primary care mainly, and there is a directory of different resources. This is not an updated number, but then it was 1,182 resources, and these are the proportion of the social determinants that were more often identified with our patients, and two percent of patients needed food for that night. So, it was, it's such a big need, and it could be at any point. It could be proximal, distal, downstream, upstream, and in some of the cases, it was just immediate food for that night. At Boston Medical Center, we have a special population because we serve about 70 percent underserved minorities, about 60 percent black and 10 percent Hispanic, over 50 percent below the poverty line, and 30 percent don't speak English as their primary language. So with this patient population and their additional needs, how do we document what we're doing for them? If we saw Michael's case, we could, based on symptoms, say ADHD, prescribe a medication and move on. But Michael's case is different from a case that may be seen in another clinic that doesn't have the social complexities that that clinic has. But how do you document that in a way that the system wants to provide and can document the additional care that Michael would need in that case? So Mass Health decided to partner with the hospitals to bend the cost curve, transitioning to a value-based accountable care organization model. This is how much Mass Health was spending of the state budget and at some point it represented 40% of the state budget. So a big chunk of the state budget was going to Mass Health. So they started to find a way to change the model from fee-for-cost, fee-for-service, to this accountable care model, which is based on efficiency. How impactful are your interventions? And that's measured using the cost of the intervention versus the results. That works if our patients were all the same, right? But each patient's different and each client's different and their needs are different. So how can we find a way to measure what the actual care that the child is receiving based on its social needs? So this is what the Thrive screening tool was developed for, to kind of measure the services that were provided and the impact on the social determinants that were identified during the screening. So this is a screenshot of the screening. It's on EPIC, so you just ask question by question what the needs are and identify the language, identify each of the domains that I showed earlier, and it allows you to follow over time. So you can document every visit, how those social determinants have been impacted by each of the interventions. It can be accessed either through the director in EPIC or in the patient encounter specifically, and after the screening is done and the social determinants are identified, it provides the C codes for each of those. So we see in the C codes that are documented in this case, caregiver burden is one of the codes that it's documented, C63.6. That allowed us to measure what the needs are and how what we do can impact the outcomes. And the C codes get documented in the chart so that we're able to follow over time and document and then do more studies to figure out how those social determinants are impacting care. And now research grants are asking C codes to be documented. So it's also becoming a need to document these C codes for different purposes, including academic for research. This is what the layout looks like. It shows all the programs available. We're in Boston, so it's about 3,500 programs that are available for the different services, including food and nutrition, education, financial assistance, housing and shelter, employment, caregiving, health, legal aid, and transportation. It allows for immediate referrals through different tabs, and you can either give the information to the patient on-site, make referrals in the moment, or provide contact information. That also gets documented in the chart. It's also possible to select if the services are in a specific language. Spanish, English, we saw that at BMC. We have a diverse patient population, so we need resources in different languages. Cost, if it's free or not, if insurance covers those services or not. And there is also a consent process with the patient. So you can send information directly to the different organizations, and they can reach out to our patients. So this is one example in which Z codes and social determinants can be documented and have an impact on the system, on the cost, and it's something that's done in the clinical encounter that helps us feel like we're doing something else. A lot of the times, after I finish my intakes with my patients, just doing the screening and providing three to four of those resources that I print and provide it to them, that's already improving the patient relationship with the patient, and I feel that it's creating more engagement as humans, almost. Because it's like, I see what your needs are. Here are some resources that can help in other aspects of their life. Because another thing that we often see, now thinking about prevention, is mental health is everything. But how do we, in our clinical encounters, kind of focus on some of those social aspects that impact their well-being? This is the Thrive team at Boston Medical Center. Dr. Paolo Vitor Andradega is internal medicine. He's the lead investigator for Thrive. Now we're going to get to the interactive portion of the session. We are going to ask you to join in pairs and think about different social determinants that impact your community. Then we're going to see if there are any C codes that could play a role in those ideas and how they would impact the idea, and what tools or resources would be most helpful. Here are some ideas that we showed that we divided into different topics that we thought were important. It could be one of those that Dr. Gibbs talked about. So the first step is going to be to choose one of those domains. We'll put the slide at the end. Then think about interventions, either downstream, midstream, or upstream, and then have an idea to intervene or to impact that social determinant. As an example, for me, one of the things that has always been an interest of mine is working with migrant kids. So there is a C code for acculturation difficulty. Acculturation difficulty gets documented, but how can that impact what we do regarding cultural humility, cultural safety? Can cultural safety and humility be measured through using a Z code of acculturation difficulty in our encounters? That's one idea that maybe it's a way to put a complex abstract thought into a practical tool. So we'll have about 15 to 20 minutes to talk amongst yourselves about the different ideas that you have regarding your communities, and you can scan the code, and we'll show some of the responses and discuss. Feel free to come to the mic with any questions, observations, and the groups. Yeah, we'd love to hear what is happening at your facilities or your centers or your institutions so that we can share. It's a really important time for prevention. Hi, Brian Marcu. I'm with the Navy. I'm from Guam, so a lot of interesting situations I run into, military family members, austere environment. But between the Z codes and then some of the V codes, is there any way you distinguish or you just kind of prefer to use one category? I know there's a target of perceived adverse discrimination or persecution, I think, versus the bullying one versus child abuse. Any way you just decide or you're just kind of like, you know what, we're going to focus more on one area so that's consistent and we don't have to think about if there's any nuances or difference between that? So the DSM-5 has an abbreviated list of the Z codes compared to the ICDs. And so in some ways, I think to your question of how do you get to bullying, bullying is captured under perceived rejection. And so there are some that are very specific and that's a guide. But let's say for abuse or neglect, there are several choices. Is it current? Is it like, who's the perpetrator? It gets a little bit more detailed, but I would get to the closest one to what you're looking for. But I think to your point about, do you just prioritize and say, what are the main, what are we working on? And I think you should think about it. That's another way to just think about it is, what are we working on in this clinical encounter? What is standing out as a major issue? And highlighting those. I guess, is there any prioritization? Like if someone met a V code and a Z code and they were the same thing, would you prioritize like the V code over the Z or would you just pick one? So yeah, so these days for billing, the Z codes and you know are what we're pushing. That yeah, we focus on the Z codes. But there's some V codes that are like, they're clinical, but they're not, they don't meet the threshold for like getting a regular, like an F code, you know, for a diagnosis. So this is for like the purpose of pulling out those social determinants. So I think if you're hospital is accepting the Z codes already, or if your facility is accepting the Z codes, they're serving a slightly different purpose than the diagnostic piece like child-parent relational disorder. You know, there is a V code for that. But if you're collecting some of that, if the facility is collecting information about social determinants as it pertains to this, you might be using the Z codes. But I think they're, you can use either probably. But I'd push for the Z codes now. I'm just wondering operationally. Yes, thank you for telling me to come here. I'm wondering operationally how, like who does the questionnaire? And then I think it's really cool that it's tied to the Z code. Is that then pulled into like the medical decision-making for billing purposes, like automatically? Or I don't know how you're doing that within the computer. So for Thrive, depending on the setting, and anyone can use it, it's open. So every template has it. In primary care, because the visits are so quick, it's someone in the front desk that does the initial screening. So they do the screening and then do the referrals, but it gets documented in the chart and do the follow-up. In the case of mental health and psychiatry during our intakes, we have a little more time, and part of our intake is asking about a lot of these needs. So it's easy for us to kind of like just go through the Thrive questionnaire and fill it out. There are different work groups in the different departments to try to figure out what's the best way to implement it, because time is a limitation, a lot of the time to do a full assessment of social determinants. But in psychiatry, we kind of have the flexibility, especially if it's an initial intake, to kind of get into detail about some of these items that we ask. Second question was? About medical decision-making, are you using that to justify higher billing codes? Yes, since we do the ACO, the ACA model, so what the social determinants show is how much, how many more services that patient got, so that the hospital can bill more. That's kind of like the intention of it, for higher complexity. Yeah, great, thank you. And I think that's an advocacy area that's kind of upstream still, like having payers really see and use these codes to help understand the patient dynamics and the needs, the higher level of need that some clients have, and and that it would go to work, you know, it would improve billing. I don't think every system is there yet. Right, so it's really a very new phase. So this question is about the Thrive program and your resources guide. I followed that if the child and family, if they need resources, you can then share resources with them, you document that in the chart. Do you follow whether they actually connected to the resources? One question, do you follow that they may have connected but didn't get the resources and started closing that loop? And I was thinking about that in terms of working with some of those resource-based organizations, so that we could have that continuity. Do you, maybe you could speak to that? So in, at the end of, after the assessment, the patient can decide how they want the resource. You can print it out, print out the information, they can reach out, you can make the referral through EPIC. What I do sometimes is make the call while we're, do the intake while we're in the visit, and I think that's the best way to kind of keep track. So doing it on-site, since like phone numbers are there, emails are there, sit down with the patient, write the email together, send a message, leave a voicemail, and there is, you can reassess and it tracks each of those questions or each of those items that screened positive at the beginning over time. So you can see also how, for a higher complexity of care, how you are impacting not only kind of the specific diagnosis that you're treating, but all those other, other components. And the other thing I would add is, you know, there's an implementation question here, right? It's sort of who does the follow-up. So in, in San Francisco, we, you know, we have a similar system of being able to sort of identify and track. And, and one of the people that gets involved in that, one of the team members that gets involved in that, are the family navigators, right? Who actually sort of, you know, help with that follow-up as well. So there's implementation questions there too, about sort of who's your team and sort of, you know, making the connections and then also following up on the outcomes and what we're trying to use for that as well. There's a question that someone had posed to me yesterday about whether it's stigmatizing for families to have their social determinants sort of as part of their medical chart. So that once labeled, does the label kind of stay or follow or continue, you know, with them? But I really think that it's part of like a reframing of what we do, because usually this information, the information is in the notes somewhere, hopefully. And so it's really more about codifying it for the purpose of, you know, both like tracking and connecting, you know, that patient's specific needs to them. Versus we have, we serve this many patients and in this community, you know, 2% of people are homeless. Like at this hospital and, you know, in this day, we served like, you know, 50% of the patients we serve who are in-house. What are we doing? Does that mean that we look at a way to, you know, connect each of them to resources sort of in a group setting? Like how does it help inform what you do, but from an individual level, not necessarily just sort of community level and community stats? So I think it can be helpful in that way. The stigma piece is important, but I do think it's more like we've, it's a change that, you know, we, you know, we I think can be more beneficial than harmful, because the information is probably already in the chart. What I'm really curious about from the child perspective is how we get everybody doing the screenings for all of the child-related determinants. Not just the basic needs, but even that, because there is a limitation. Even I know that when we do our psychosocials, you'll still leave those conversations not realizing that person's hungry that day, right? So in OMH, we're moving towards like better screening for food insecurity in particular, but really all of it. So that folks don't just think it's about like, maybe just like trauma. You know, there are areas that we focus on over the years, but to really include all of it, including bullying, etc. And in the case of Thrive, there's always a consent process before. So it's really up to the patient how much they want us involved. But I think in general, it's only always welcomed, especially when things are done on-site as part of the visit. Any other questions before the activity to kind of go over any of the topics in the presentation? So we're going to think about different ideas that can impact any of the domains that we mentioned. So I'll put this slide at the end. It could be either on-site during the visit, at the community level, or maybe some advocacy efforts, or more structural ways that any of this could be impacted. And at the end, you can share a brief summary or what you identified was one of the needs in your own community and with your work. Yeah, we don't want to oversimplify too much, but has everyone picked one in your mind? All right. And then do you want to intervene at the level of like what you're doing with the patient individual? Or are you an administrator or a leader in either the inside the hospital or in the facility or in the institution or in the community? Do you have like a scope of influence? Or do you want to act as a legislator or policymaker or advocate? Right, what would you advocating for? So we'll give you a couple of minutes to discuss with each other and maybe we can circulate and try to hear what people are talking about. Yeah, do it in pairs. I think it'll be... Yeah, or threes, yeah. I love the conversations that are going on in the room. We have 10 to 15 minutes left, so we would love to hear some of your ideas and concerns and maybe brainstorm together. Every system is different, but I think there are opportunities to learn from things that are happening in different institutions and systems. So we're going to do it on the microphone, no need to share on the QR, but we would love to hear what your ideas are. Hey, yeah, I mean, one of the things that we were talking about is when you identify a lot of these problems, it's really hard as the clinician to, you know, you have your list of medications I use for treatment, my therapy referrals, other types of nutrition and other specialty referrals, but then all that other list of social referrals and having that all, having maybe someone like a navigator, someone who can then, I can refer them to this person who can then navigate those social supports or housing supports, transportation, things like that. Of course, you need more manpower and stuff for that, but it maybe filters it a little better and triages the level of severity and work that that's being done. Yeah, I would say that it's not necessarily maybe exclusive, right? So there's a role for the individual, like in that moment in the day to know what the resources are and be able to provide social referrals as needed. It's very gratifying because you're like, you're hungry? Oh my gosh, you know, to my 20-year-old patient, like, you know, here's a pantry. You can go there. You have access. Like, that's very empowering. And to your point that there are so many needs in, at least in New York State, there's funding for the Medicaid, for service coordinators who, care coordinators, I'm sorry, through the single point of access. So that's case management and that person does a full, more full assessment and is supposed to coordinate care and make sure, try to support the follow-up and all of that. So then that's like a midstream, upstream intervention that really impacts people. So you can give that referral and then you're opening up a whole world of support. So I agree with you, it can be a lot. Thank you. I was thinking more about the stigma question and I think the big difference between what you all are doing and the way that I was seeing the social determinants tool is that ours isn't tied to any action. So it's one thing if you're just putting a label on somebody else's chart and then being like, well, I've asked about it, as opposed to you guys are really hooking them up with other resources. And so I was thinking about, I was saying from my perspective, I am an Epic builder as part of like my clinical role and so I was thinking of how can I leverage what's already in Epic to be more useful? And one thing that I was just thinking of is that we, through the hospital, can provide lifts for people's appointments. But we're often told by management to not abuse it, even though I'm working with people who are street homeless. And using the social determinants would then allow you to really, I think, say, well, this person has a documented difficulty getting to appointments and so yeah, maybe we're using a larger proportion of the lift budget in community psychiatry, but we're also seeing a much larger proportion of people who need transportation problems. And so I think that's very cool. Hi, I'm a physician, psychiatrist, primary care, as well as a child of a pediatrician and a teacher. So I want to let you know that I've been working tirelessly to get content out and there's a wonderful CME that you guys need to take because one of the environmental things that's the elephant in the room is Wi-Fi, which my classmates at Stanford delay are tearing down of our library 20 years ago by 15 years. So please look at this conference I didn't put together. My husband's a Berkeley grad, EE comp sci, and I'm undergrad Stanford, did my primary care and I did, they said, why did you as a clinical person get accepted? All my friends who were academic chairs across the country, a lot of them have retired, but I want you to know that I only found out about this course a year ago and I don't have to photocopy papers and tell everybody one by one by it. It's Massachusetts for Safe Tech, Magda Havas, who's an amazing researcher with Golam down, who's a neurologist down at UC San Diego. They put together an EMF medical conference, it's an environmental stressor that has been known and the data's out there. So you have 20 and a half hours that you guys can take or give to your friends because you don't need CME when you're in residency but everyone else should get this. They've lowered the price to 20 and a half hours of CME and you'll learn about more than you want to know. I didn't take the course but I've been fighting this for 20 years with my husband and now this mom took it over and they're offering this, the doctors put their stuff on this platform under the events page. It's MA4SAFETECH.org and under the events page they have the EMF medical conference so they're doing CMEs for doctors, MD, DOs, nurses, nurse practitioners, physician assistants and EMTs. Thank you. Yes, but also for the parents in your communities, please let them know that they have the content for the parents to look at these factors because it's not being talked about in the research and it's an elephant in the room. And so the best one that she's done, I've only found out about it for a year, is February, it's called, it's free for anybody and it's the educational seminars that are one mom at a time and she actually did the best one in February to New Hampshire. So please look at that. So this is a social problem. Is it adjusting? I apologize. I just want to confirm everybody is following. So in terms of the no-sick problem, I've been working... Wait, see, I just want to make sure everyone is hearing you correctly and also that we're clear. So you're talking about exposure to digital media, social media use? No, this is actually about the things that they're bathing our students in saying it's smart tech. It is anything but. There was an MD PhD at Stanford. I had seen her assistant years ago, 2500N double blind to sleep control study of showing that these signals before 5G were inflammatory. Oh, I see what you're saying. Okay. Thank you so much. I'm going to need to move on. No, no. But they're saying that this stuff that they're bathing them in, my dad was a pediatrician. There was no, it was less than 1% of the psychotics. And I saw, I did most of what you would do for a child psych. This stuff of bathing our kids in this stuff and saying it's good for them, once you know about it and your doctors know about it, then they can put this back in. And you need to know that because it's an environmental, but it affects their behavior. It affects their attention span. It suppresses melatonin and it disrupts the voltage. Thank you. Yeah. We want to make sure there's time for other comments. They're doing the digital equity program and they're not, people know when you're getting broadband, you also have wifi signals that they're. Appreciate it. Yeah. Definitely. We appreciate your input. Oh, I just want to talk another level intervention is in the military. We have an interesting system. When we send people overseas, we do a pretty comprehensive screening for medical needs to make sure that if you're going to send them somewhere, they have that resource available. So I, we don't really incorporate, I don't think ACE is screening in that, that level. And it might be a good way to at least capture that because then you can triage, Oh, you know, maybe this isn't going to prevent you from going somewhere, but now we're a little more aware of what you need or even when people look at get access into the military. So just, I don't think we've incorporated this the way that it could be in a system that is pretty well-funded and everyone has access to care. So yeah, just something I was thinking. Thank you. Did anyone touch on a topic that hasn't been discussed yet? Or discuss a topic that was not presented over the mic? So I did hear a really interesting discussion about community violence over there and some of my colleagues were discussing that. And one thing that I thought was really helpful for us to take away and for all of us to share is this topic of our ability to be advocates. So even though I said, okay, you're with your patient, that's like downstream through the APA and AMA and large and ACAP, large organizations that have lobbying power, we actually have the ability to be at that, advocate at the upstream level through our district branches more so. Because we were talking about how it really, some of the solutions you're looking for are actually local level solutions, right? Local policies related to safe, promoting safe neighborhoods, for example, related to the community violence. And those are discussions that really can't necessarily be federally overseen. It's actually at the state level, but all of the district branches have legislative influence. So to really use that power as well. Yeah. So I don't know if anyone had any inclusion of that. I mean, maybe if you don't want to talk about it, but did that come up in any of your discussions about thinking about sort of some of the upstream interventions that you could do or advocacy? Did that come up at all? I think you eloquently stated that we were talking about Althea, who's from Atlanta at Morehouse. She's a medical student. And we were talking about violence in communities where children are walking, they could hear gunshots and all the stressors that are brought on by those episodes. So what we thought about is what can we do at the midstream, or even upstream? And as you stated, we certainly could look at policy. We can look at advocacy. And keeping in mind that with advocacy, so many people can be advocates, even the patients. And I hearken to an example of a recent national situation with gunshot violence. And when they went to the capitals to talk about it, there were nine and 10-year-olds stepping to the mic. But with these communities where there are gun violence and other types of violence, we need to engage at the local level as opposed to sort of jumping directly to the state. And at the local level, we can bring together many stakeholders. It's not just a child psychiatrist problem. You have pediatricians, you have the internists, therefore engaging your medical associations where you have all of the specialties represented. It's also a law enforcement issue. What's going on in those neighborhoods where you could constantly hear gun violence? Is it because the lawmakers are not patrolling? Have they just abandoned those areas? So bringing all of these people together, you have more collective power when you bring many of the advocates together. Thank you. And then I know in the back, there was a lot of conversation about not only sort of assessing and screening, but actually having programs or resources already in your clinics, right? I don't know if someone wants to briefly talk about that. Hi. I'm a medical student, and I guess I was, we were talking in our group about the idea that sometimes, like, I'm from Cleveland Clinic, Ohio, and like, we don't have a lot of infrastructure around having like connections to resources, or like, they're not a lot of allocated resources to have like navigators often in like psychiatry. And so we were talking about how like, there was a pilot program that was done in like, maternal minority health, where you had medical students actually serve as these navigators, where a physician could put in a referral for the social determinants of health, and then the medical student would do an intake and kind of help close the loop. And so we were talking about the potential of like, obviously, that's not scalable. But the idea of like, utilizing those things to then collect data, because then we would like put it into a red gap, and then be able to kind of look at the outcomes over time for those individuals, like, did they follow up with the resource? Did the resource accept them? Things like that. And so the idea of like, even if we don't have those resources, maybe if we can get people to like, use the Z codes often, we can look at, for example, like breaking up the population into people that had these Z code risk factors, and those that didn't, and then utilize that to then look at outcomes of like, how often they're being hospitalized and things like that. And then maybe if we can then allocate like a medical cost to that, then you can make an argument for why, like, having resources for these navigators or other things are actually going to long term save the health system like money, which in some ways is like an argument that's easier to make to like hospital administrators and things like that. And so that was one of the things we were discussing. Any additional comments or questions? If the resource document has screeners, has the Z codes, the DSM-TR also has the Z codes divided per topic. That's a good resource to access. And if you have any questions, feel free to come and talk to us, and happy to help in any way we can. And if you have any questions about Thrive, also happy to provide additional information and put you in contact with the research team at Boston Medical Center. Thank you everybody for coming.

Agnes Purcell McGavin Award

Dr. Lisa Fortuna

mental health prevention

culturally sensitive interventions

social determinants of health

Thrive program

Boston Medical Center

value-based care

community stakeholders

policy changes

equitable mental health care