Yeah. All right. Good morning, everyone, and thank you for joining us this morning. My name is George Alvarado. I am medical director for behavioral health at Northwell Health Solutions. That's our behavioral health population health arm at Northwell. I'm going to describe a little bit where that is, what that is for folks that aren't familiar. And I'm also joined today by Dr. Mayer Bellison and also Dr. Manish Sapra. And when they come up, they're going to tell you more about their roles in our health system. But today, focus of this topic, this meeting, is going to be supporting the mental health of health care workers. Really couldn't think of a more timely topic right now. And I think everyone is probably familiar with this experience sitting in the audience, right? So you get a call, and it could be from a colleague. And there is someone in their department, or they have a family member, or they have a child, or they have someone that needs help. They need to get linked. They need to see a psychiatrist, therapist. And what typically happens, or how I usually would experience these things, is you kind of scramble, right? So can our clinic squeeze this person in? Do we have a list of private practitioners, a colleague? Is there someone I could call which might be able to accommodate this person? But it's very piecemeal, right? But especially if you think about it, lately, we've all probably been getting a lot more of these calls, and very difficult to do it. And so what this presentation is about is, how can we start to think about this more comprehensively? Because there are solutions out there. But a lot of times, those solutions, they don't really fit the bill. They're not enough. They leave a lot to be desired. And very often, these solutions don't involve the division of psychiatry, or psychology, or the clinical resources. A lot of times, it's EAP doing this work, or it could be outsourced to different groups. So what we did, and what we're going to be presenting here, is how we start to actually create this within our own health system, using our clinical leaders, and leveraging our clinical resources. And so going forward, nothing to disclose. Probably should have started with that. But overview of the problem, and I think this is going to resonate with everyone in the audience. So extremely challenging work conditions. This is even before the pandemic, working on the front lines, inpatient, ICU, ambulatory docs, psychiatric docs, inpatient units. And so long work hours, irregular shifts, intense physical and emotional labor that goes along with this, just exposure to folks at their lowest. And so really being able to think about, how do people keep going? How do we build a resilient workforce that's able to keep on showing up and doing this work? And not even just showing up, but showing up and doing their best. And so the COVID pandemic, that showed just throughout society at large, but also within the health care workforce, really extreme stress and difficulties that folks were exposed to. So these are just a series of different statistics. 93% of health care workers reported being stressed out and stretched too thin. 82% shared being emotionally and physically exhausted. 32% of nurses reported they might leave their job within the next year. And 22% of health care workers report experiencing moderate depression, anxiety, or PTSD. And so really staggering, and it just speaks to the need. And this is the need within the caregivers, not to mention the need that we're already aware of in the larger population. And when we think about it, too, there are already prevalent access issues, which were going on before the pandemic. Now, systems are stretched even more thin. But what I would kind of posit to this group is really thinking about health care workers as a specific population, because we're all familiar with it. And when I was in training, I had folks who were physicians or who were nurses or who otherwise worked in health care, but really thinking about, what are the specific needs of this group? And what are different ways that we could engage them? Because even if we think about access, it's not just, well, all right, here's a list of clinics that you could go to. If they get to that clinic, will they really understand what they're going to? Will they be able to meaningfully address it? And that's what we're talking about. Could we build interventions, really a continuum of interventions, that are tailored to the specific needs of this group? And so employee assistance, very often this is offered up. This is the solution. This is where employees go to get help for this issue. But there's a lot of barriers. There's stigma around it. Is this going to affect my performance, my job, my advancement? I don't want the hospital to know that I'm having these issues. Confidentiality, limited breadth of resources, there could be counseling. Sometimes there's apps. Sometimes there's wellness programs. But are they really enough? Number one, do people know about them? Are they willing to use them? And do they really fully address what the needs are? And again, thinking about frontline workers, a nurse that's working in the ICU, that's getting off a shift that has seen several patients die. That's what we're talking about. Do we have offerings that could actually address that? And again, a lot of times these solutions could be siloed. So there's outpatient referral. There's some type of wellness programs. There's resilience offerings. But do they talk to each other? Are they really part of a system, or are they just a bunch of disjointed solutions? So I'm going to go. Most people probably recognize who this is. So I'm just going to quickly play this video. Bill, this patient needs their dialysis machine started. Can you go find their nurse? Yeah, I tried, boss. I can't find the nurse. OK, can you go find a different nurse? Yeah, there are no other nurses. What? Why? Well, we've lost a lot of nurses to burnout. OK, can you find a nursing assistant or a nursing student? We don't have any. Well, what about that guy? Me? Yeah, what do you do? I'm the Surgeon General of the United States. Oh, do you know how to start a dialysis machine? Unfortunately, no. Yeah, me neither. I can try to help you find a nurse. Yeah, we don't have any. I guess burnout's hit them pretty hard. Well, health care workers have been pushed to their limits during this pandemic. You've all worked so hard caring for others. Now it's our turn to look out for you and to figure out how to take better care of you. Well, we are getting pizza for lunch. Free food sounds great, but burnout is a complex issue that requires us to think more broadly about how we create a healing health care system for both patients and health care workers. That means creating more time for connection with our patients and each other and less time clicking on boxes in an EHR. There are so many clicks, Dr. Murthy. We also need to shift to more collaborative models of care because we truly are stronger and better together. So to everyone who's been on the front lines of this pandemic, I want you to know that we see you, we appreciate you, and we have your back. Thanks, Dr. Murthy. Hey, do you want to do some surgery while you're here? Oh, I'm the surgeon general, but I'm not actually a surgeon. I'm an internist. Oh. Do you want to stand around and talk about hypodermia for a couple hours? I would love that. So actually, my favorite line in there is when he mentions we're getting pizza for lunch. Because again, necessary but not sufficient. To actually build resilience and to keep folks going. I just want to advance my slides. Okay, and this actually, good segue. So this is a framework that was put out by the U.S. Surgeon General. And really talking about how do we build workplaces? Because it's not even just being able to patch folks up or get them back on the front lines. How do we actually build systems that decrease the amount of burnout? And to some degree, moral injury that can occur when faced with incredible amounts of stress. And so I really like this framework. So protection from harm, connection and community, work-life balance, mattering and meaning at work, opportunities for growth. And so really kind of thinking about the well-being. And so this isn't just a mental health initiative. This is talking with administration, talking with employees, bringing lots of different stakeholders to the table to make this happen. But that mental health is really a key and essential piece for this. And if we think about it this way, and a lot of the solutions that have been offered up so far are really not up to the task. So talking about Northwell Health, where we're coming from, large health system, we're based in the Northeast, largely in New York City, Long Island, going East, 83,000 employees. So one of the largest employers in New York State. And so again, just thinking about kind of the scale of this and being able to find solutions for these types of problems. Especially if you take 83,000 and put it up against those statistics we were saying earlier, with a very high incidence of depression, anxiety and other comorbidities. This just gives a little bit of a sense of our math. But this is a message from our CEO. And this is again, speaking to the idea that it's not just a single stakeholder. Really from all levels of leadership and all levels of the health system working on this together. And I like this quote. So health systems and healthcare leaders have a significant role to play in creating cultures that address mental health challenges. And it's imperative to consistently tune into how employees feel. And so starting to build this, starting to create this continuum. And this is just kind of a sample of what we're gonna be talking about today. And I'm gonna hand off to Dr. Bellison. But really it's not just one thing. It's not an app. It's not a clinic. It's not a pizza lunch. It's really lots of different kind of modalities that could meet folks in different levels. Are they just having a very stressful day? Coming off a different shift? Is it a persistent pattern? Is it something that actually requires referral to specialty services or to an ambulatory center? But really being able to have that and have a comprehensive integrated approach. And that's more what we'll be talking about today. Dr. Bellison, thank you. Thank you, George. Thank you all for being here. My name is Mayor Bellison. I'm an AVP in the Behavioral Health Service line. And my background within Northwell Health, my background as a clinical psychologist has been primarily around focus with trauma. And actually prior to COVID, a lot of the work that I had been doing was around veterans and their families. And I think in many ways that became very useful and helpful as we began to support our healthcare workers during the unfolding of the crisis of COVID. So I think George really painted an excellent picture and context as to why we need to be doing this work. And I'd like to just share a little bit more about the emotional context and tone within which our center began. I share with you a picture of a young boy playing Uno. This actually reminds me of my son who loves the game. You may be familiar playing with your children and you might know that experience of getting down to that last card you're about to win. And then your opponent gives you these draw fours, these jokers, next thing you know, you're back in the hole. So if you're my son, you throw a temper tantrum, but mine too, yours too. And essentially that's been the experience of what it's felt like, right? We've had the COVID related stress, the staffing challenges, the balancing, caring for our kids and work, the patient acuity, the administrative regulatory difficulties, and also of course, the financial strains. And so not surprisingly in this context, our center that I'm going to talk about, the Center for Traumatic Stress Resilience and Recovery has conducted research with a focus particularly around the impact on our workforce and including with physicians and nurses. And not surprisingly, we found, of course, as George indicated, higher incidence of depression, anxiety, and PTSD among those with greater exposure to COVID. And in this context also, we've just seen an accelerating rate of burnout. But most poignantly, of course, is the experiences that we know of adverse events like suicide, which have been greater for our nurses and possibly for our physicians as well. And so I share with you a picture of Dr. Lorna Breen, who many of you may be familiar with, a physician. She actually trained in one of our sites in LIJ. And she was working in the New York City area in Columbia. And she died by suicide early in the pandemic as a result of both the strain of everything that she was witnessing and seeing, but also in part because of some stigma around her fears over how seeking help may impact her license and her privileging applications, which as it turned out was unfounded in New York, but at the same time is true in other states and also speaks to the importance of one of the areas that we need to be thinking about with supporting our healthcare workers, which is, of course, the stigma as a barrier. But critically, her family has started the Lorna Breen Foundation, which has really catalyzed a lot of tremendous movement towards supporting the wellbeing of our healthcare workers. And speaking a little bit more to the poignancy of those moments, and I recognize this quote is a little bit jarring, so if you need a moment, but we've had colleagues sharing with us during the immediate moments of COVID comments such as not being able to do anything for my patients as they screamed out and begged for their lives, not even being able to hold their hands while they pass on, feeling worthless and useless as there was nothing we could do for these patients, really speaks to the traumatic stress that they were under. In addition, even with regards to the ongoing practice, we've had colleagues sharing when there are bad patient outcomes, if you practice and or operate long enough, it will happen. We need to create a more supportive environment. The trauma of the event does not go away after a 30-minute meeting. And so to this end, in our center, and actually just more broadly in Northwell, early in the pandemic, we convened an emergency operations center to focus on providing the emotional support that was needed for our staff. And we were driven in part by our understanding of the literature and the research around recovery from traumatic stress events. And so as we know from the work done post 9-11, Hurricane Sandy, other events, there are typically four trajectories of recovery over time. So hopefully you can differentiate these a bit. We'll see with this laser pointer. We have those who have the green down there, the sort of steady resilience. It doesn't mean that there isn't any impact. Of course they wobble as well, but on the whole, they stay within a smaller range of distress. We then have those that will have what we could call a delayed resilience. So initially they will go up in terms of their experience with distress, but then over time, we'll come back down towards that green level. Sorry about the microphone. Then we have the experience of those with delayed distress, folks who may be months down the road, a year or two years down the road may come forward having experienced the events that they have and coming forward with presenting problems at that time. And again, as I mentioned, my work with the military, we've seen folks that have come forward for PTSD connected to Vietnam 50 years later. I also work with World Trade Center responders. 20 years later, people coming forward, maybe at a point in their life where there's a transition, retirement, et cetera. So these events can continue to have an effect. And lastly, we have those with the chronic distress, those who may be prior to the events, they were experiencing some distress, or as a result of the events, they experience impairment that continues over the long run. And so of course, in thinking about our efforts and targeting our activities, we need to be able to think about all of these trajectories. How can we foster and enhance the resilience of the individuals that maybe will have that delayed resilience or just enhance it for those with the steady resilience? And how can we bring down the impairment and the distress for those in the red zone? And to this end, one of the solutions that Northwell helped to put forward is the Center for Traumatic Stress, Resilience and Recovery whose focus is around initially stress and trauma related activities, including services such as evaluation and monitoring, but also preventative and resilience building services and clinical services as well. And as you can see, it's meant to have a system footprint, supporting our team members across the downstate New York City area, and closely collaborating with our system partners. So that includes occupational medicine, HR, and our other employee support programs that George had mentioned earlier. And lastly, a program that we run called Stress First Aid, our peer support framework, which I'll talk about a little bit more towards the end, is one of the principal efforts that we engage in. And as you can see here, going through our preventative to resilience building to clinical services, over a couple of years, we've touched about 20,000 individuals across the system. And we've been working to really embed some of the principles that I'll talk to you about in a moment within the training of our workforce through various mechanisms, and as was featured here by AHA in their disaster preparedness guide, really can serve as a model for what we can think about in supporting our employees. So I'm going to share with you a little bit more about our services, but before I do that, I want to share with you about some of the animating themes behind our work. And so the first theme is that of providing trauma-informed care. So some of you may be aware and familiar with trauma-informed care. This is a guideline as put forward by SAMHSA. There are other guidelines out as well. The main focus, of course, of trauma-informed care is shifting from a problem-focused model to appreciating that it's about the context and the experience of the individual. It's not what's wrong with you, but what happened to you. And so there are a number of principles to be embedded in the care, including the idea of realizing the widespread impact of trauma, and then I'll put in stress as well, and the pathways to recovery. Recognizing the signs and clients, but also good trauma-informed care is not just about what we're doing for our clients, but how we're recognizing the signs in our staff and in our colleagues, making sure that we have good self-care. Responding by integrating the knowledge around trauma into our policies and practices, and of course, resisting any activities that may re-traumatize. The next concept is around resilience. And so this is one definition put forward by Ann Mastin, one of the gurus of resilience research, and she highlights, it's the capacity of a system to adapt successfully. That system could be the individual, or it could be an organization. And what I wanna highlight are a few points, because resilience work has actually also received at times a bad name, and particularly, I saw this both in the military as well as in healthcare, where individuals have used it in maybe a blaming or a pejorative way, saying that you need to be more resilient, you need to suck it up and get through it. But that's not how we think about resilience, of course. In fact, resilience is a process. It's a process of moving forward, not necessarily bouncing back, but finding a way to go forward. And it's built on a number of resources, both the individuals coping, of course, and skills that can support them, but also really the organizational supports that need to be there. So it's not that it's immunity to stress. Individuals will continue to experience stress when that arises, but it's making sure that we have the right supports in place. And so another theme that, or I would say, framework that really guides our activities as well is the systems approach to burnout put forward by the National Academies for thinking about how we can influence burnout. And our center is a traumatic stress center, but burnout as an occupational injury really does carry a lot of similarities with stress and trauma. And in our role, we can really play a pivotal role in supporting the system as it addresses the complex issues of burnout. And I think there are a couple of points that I would highlight from here. One is that it is about the interaction, just like we were talking about with resilience, between the nested levels that the healthcare worker is embedded in. So the larger health system, the demands that are on the individual, the resources available to them, and then, of course, their individual coping as well. And so we need to think about the interaction between these components. And in terms of some of the work that we can do from a behavioral health perspective, it's include, as you could see emboldened in italics, the meaning and purpose in work, supporting that, supporting the social support environment within which the individual is operating, and then also coping strategies, resilience skills, and social support as well. And lastly, I want to highlight this tool called the Stress Continuum. So this is built off of something called the Operational Stress Continuum that was developed originally for the Marines. And it serves as a really great communications tool for characterizing what we know about stress and trauma. Essentially, rather than looking at stress as an experience that is binary, you're stressed or you're not stressed, you're okay or not okay, it says, let's appreciate that there are gradations, there's a continuum. We could be in the green, where we're feeling relaxed and ready to support others, feeling good, maybe we focus on enhancing our wellness. We could be in the yellow, where we're having that normal stress. And again, stress is something that we normalize and acknowledge is important for us, in fact. But sometimes we can get into that orange or that injured zone where we're having what we would call traumatic stress injuries, such as burnout or wear and tear, losses, moral injury or moral distress, and then traumatic stress as well. And when we're in the orange, we try to do things to try to support ourselves so that we don't go into what's called the red, where we're feeling impaired, where we're having more symptoms, functional impairment, maybe conditions like PTSD, depression, substance use. So what I hope you can gather, though, from this tool is that, one, it gives us a simple way to be able to talk about our stress and to share where we're at. And two, it also uses language that is non-stigmatizing. It's focused on just function and functional impairment and using colors rather than actually using labels, like saying I'm depressed or have PTSD. So with this in mind, I'll share with you a little bit about some of the services we've offered and built to support our team members. The first one being monitoring and evaluation. So at Northwell, we were able, over the past couple of years, to implement a well-being survey. And this has been one of those products that really represent the partnership, a partnership between our center and behavioral health as well as HR. The goals of the well-being survey are to help understand how team members are feeling at this time with a focus on stress and burnout, to be able to assess well-being resource program awareness, as well as obstacles to utilization of resources, as well as opportunities for additional support. So this survey, we've been able to influence it by making sure that we're incorporating standardized scales, PHQ-4, for instance, a modified Maslach, Connor-Davidson resilience scales, the Mini-Z for burnout, and then also items from our vendor, Perceptix, which we use for our larger surveys, including our engagement survey, that speak to some of the elements around resilience and organizational support that I was talking about earlier. And meaningfully, we provide this survey just like we do the employee engagement or experience survey that I'm sure many of you have seen if you're working in healthcare systems as well. So it's really a system-wide effort. And this, the data I'll present now, comes from our 22 survey as we're about to launch our 2023 survey. The last point that I'd highlight is that some of our responses, it just so happened to work out. As you can see, it maps onto that stress continuum as well. It's a five-point Likert scale, but the unfavorability being there in the red. And so we see that, you know, using this kind of survey and monitoring, we were able to identify that 33%, 33.5% of the population was endorsing burnout, 35% endorsing stress. Arguably, it could be a little bit higher. These are the unfavorable numbers, but being in the neutral on this may not be so positive either. So, you know, if you look at it inversely, you can say that only 39% are not feeling burned out. We also see sentiments of anxiety and depression. Of course, it's not diagnostic. Symptoms of anxiety and depression being between 11 to 21%. We then also use some thematic analyses in open text to identify stressors, both work-related stressors and personal stressors. So we see examples such as work-life balance, management, efficiency of practice, and personal stressors including caregiving, finances, and loneliness as well. This gives you a little bit of a snapshot of some of the other kinds of domains that we assess, including psych safety, feeling comfortable and safe to come forward with, you know, errors or when issues are arising. Resilience drivers, which are essentially organizational supports, as you see, such as my manager cares about me. And then a sense of awareness of resources and knowing where to go to get support for well-being overall. And so as you can see here, in utilizing this scale, we were able to identify with our workforce that close to 40% indicated a desire for resources that support their emotional well-being followed by a little less identifying a need for financial well-being resources. Moreover, we identified a barrier to utilization of these resources being principally not having enough time. And, you know, this is, I'm sure, an issue facing all of us and in your organizations as well that we continue to be working on. So how does this survey then get used? Essentially we take the results and just like you would with an engagement survey, we share it with our managers, with our leaders. We encourage them to continue to do the things that are positive, reinforce the progress that they've been making. For instance, we saw in 2021 awareness of resources was more of an issue, but by 22 we had seen increases in awareness of resources. So promoting the well-being resources, highlighting success stories, people coming forward, talking about their experiences. And then we identify opportunities to improve further with resource utilization, thinking about burnout at least at the local level and whatever we can do at the team level to try to manage the stressors and the stress experiences. And then lastly, we highlighted last year the need to also do more around financial well-being given that that was a top priority identified. So now I'll talk to you a little bit more about the clinical kinds of services we offer. And again, using our tool when individuals are in the red, it's helping to make sure to connect them to behavioral health. And to this end, our clinical services are traditional as you would expect in any kind of trauma center, evidence-based therapies for trauma-related and stress-related conditions such as PTSD or adjustment disorders. So therapies such as unified protocol, cognitive processing therapy, prolonged exposure, as well as of course medication management. And as you can see, we have our services located throughout the system to be able to meet team members where they are, including of course through virtual. And I'll share a vignette of a case that kind of represents some of what we had seen specifically in relation to COVID. So Laura, of course her identification is being protected, but Laura is a 40-year-old single female physician who saw treatment connected to the loss of many patients, but also a family member, specifically her mom. And when she presented, it was about six months post-initiating treatments with medication. She was still experiencing intrusive thoughts around COVID, avoidant behaviors, not really wanting to go back to the units, low irritable anxious mood with anhedonia, and difficulties with sleeping and concentration as well. Most critically though, she also was experiencing a lot of feelings of shame and guilt, feeling like she was responsible, for instance, for not saving her mother who died by COVID. So we saw changes in her performance at work, and a trial with SSRIs showed no improvements. So she engaged in a course of treatment with cognitive processing therapy where the focus was specifically on the kinds of beliefs that she had, such as she should have done more, she should have been able to save her mother, to help her to see really that in fact the illness was its own enemy, its own animal, and it was doing its thing, and that there's only so much that anyone could do. There were lots of healthy people that were lost, of course, and to begin to let go of some of that feelings of blame and shame that she was carrying so that she could begin to feel differently. Over time, we saw a reduction in her PTSD symptoms, as well as her depressive symptoms, and she actually didn't need any more medications and discontinued her medication by the end. I'll also just give a note that our clinical services also become, we develop them to also be available to the community. So we have a program focused on what's called Finest Care to serve the NYPD, where basically providing some of the same kinds of tools and resources. We offer five free sessions to the 35,000 uniformed members of service when they call in, of course, with a 24-7 telephone access line. And we've seen over 180 calls in the year that we're running, 80 officers served for over 300 visits. So now I want to talk a little bit more about our resilience services, what we could think of as our preventative services, both universal and indicated prevention. And there's a number of programs that we've built. And these interventions in general are focused on helping to educate, as well as build the resilience of our team members and the teams. Some of these services include concepts like well checks, 15 to 20-minute visit to be able to talk about one's well-being, perhaps do some brief assessment like a PHQ-4, and then connect on to services as needed. We have resilience coaching, which is a term we describe to capture about a three-session approach to talking about specific stressors and developing coping skills with one of our therapists and then being evaluated if further care is needed, or oftentimes that's enough. Presentations, educational sessions around stress, trauma, building resilience, and then stress first aid, which I'm going to talk about in a moment. So in terms of stress first aid, this is essentially a peer support framework. And as we heard earlier from Dr. Alvarado and Dr. Murthy, the concept of creating support and social support is really critical. It's one of the most robust protective factors against PTSD and also for enhancing recovery from PTSD, as well as minimizing the likelihood of suicide. And it's something that our team members really have a hunger for. And so this data here just comes from one study from Dr. Jo Shapiro's group. She's a surgeon in Brigham and Women's that oversees the Center for Professionalism and Peer Support. And in surveying physicians, she identified that 79% of physicians reported a professional or personal event in the past year, such as legal issues, medical errors, adverse patient events, illnesses, and that 88% of physicians reported that a colleague was the preferred source of support. And you know, this is for physicians, but the truth is this is the same could be said for our nurses and for other health care workers as well. And what we know is that peer support in general has been demonstrating efficacy to enhance recovery. It's a major part of programming that we build in for mental health of our community members as well, because peer support really fosters a sense of connection that allows our colleagues to normalize their stress reactions in the community, support each other, and over time even shift culture by basically being able to say it's okay to not be okay. Coworkers, colleagues can give that informal source of support to each other as the first level and then be a bridge into higher care if needed as well. And I think that this also really underscores some of the recent work released by the Surgeon General, his advisory on our epidemic of loneliness and isolation, which highlights of course that that epidemic is as devastating as smoking and obesity for our overall health and really speaks to the point of building community in order to manage stress. So at the heart of stress first aid are really three foundational components to help our colleagues to better recognize when they or a colleague has a stress injury, to be able to act in an evidence-informed way to support each other or to support oneself, and to know at least two resources you can access or offer someone in distress. So coming back to our stress continuum, we basically use this tool to educate all of our workforce around the sense of stress and levels of stress that they may be having or trauma exposure. And then as you see on the bottom, we also anchor the kinds of activities that they can do, what their role is, both for themselves as well as for others. And then we emphasize a focus on what are essentially the five pillars of recovery from stress. So in stress first aid, this is actually captured as what's called the seven C's, but it's built on these foundational elements that was identified in the aftermath of 9-11 as the critical ingredients for recovery from stress. These include establishing a sense of safety, both physical and emotional safety, calming interventions to relax and reduce our arousal, connection for that social support once again, self-efficacy to have the skills to manage specific stressors, whether it's how to work remotely or how to do a new intervention or take on a new role. And then hope, which is about faith, optimism, it could be meaning making as well, and thinking about how we can reinforce those activities. Lastly, we emphasize the knowing the resources. So as Dr. Alvarado indicated earlier, we have a range of services. We're fortunate in Northwell to have such a range. But one of the issues becomes also people not knowing where to turn. So you may have seen that in some of the data that I presented from the well-being survey, not being sure which program to utilize. So we approach this in a number of ways. Firstly, you see that little icon there, the yoga icon, that's put on everyone's desktop as a way to easily access the emotional support resources. We have that flyer, which is part of our messaging to highlight that there's no wrong door. Wherever you turn, there is connectivity between the programs so that if it's not the right resource, we'll connect you to the right resource. And then we talk at length about the different services, from B Health, which you're going to hear about in a moment, from Dr. Sapra to our center, to the chaplaincy services, our EAP wellness programs, a resident mental health program we've stood up, and Team Lavender, which is an immediate crisis response. So we've been engaged in a train-the-trainer approach, where we've implemented now in 19 hospitals. And we've recently started moving into the ambulatory space and with our physician partners as well. And at this point, we've trained about 13,000 team members on some of these tools. And we've gotten great reviews, about 4.51 out of 5 average, and this is for potentially at times a one-and-a-half hour to two-hour class that people have been sitting through. But it's not just a class, it's interactive opportunities for discussion as well. People saying the best class I took so far this year, learned so much that can be used at work for sure, but as well as at home. That was one of the very rewarding experiences with this program, is people sharing with me that they've used it with their children, they've used it with their families, their partners, they were able to open up conversations, connect their kids into resources as well. This gives you a little flavor of what the program looks like at times. We have this concept, the stress buster. Actually, I don't have a slide here I should mention that among the things that we focus on is integration of the activities into the workflow. So we highlight raising awareness with signage. We talk about growing the green by talking about skills like the stress buster you see here, and then also having a huddle where people check in on their colors. And then we talk about stop the burn, about how to intervene when stress levels are high. And I think you could see here a good example of some of the activities around stress first aid. We also have been evaluating the program, so I'll share with you some of our pilot data. But basically off of that National Academies model, we see here that our hope is SFA will impact coping, perceptions of support, resilience, which may have more distal impacts on stress burnout and unplanned absences. So at our pilot site where we have 12 months of data, we saw SFA self-efficacy, so competency change significantly, resilience, and also awareness of resources. We also saw positive changes in organizational support, burnout, stress, though not statistically significant. And of course, this isn't a research study, so it's kind of hard to say much about causality, but still really compelling data. But most compelling are the anecdotes. A colleague who shared just the other week, we had an employee show up to work with puffy eyes as she looked like she had been crying. Her manager would have typically offered her to go home, but having just attended the SFA meeting, she started a conversation over how she was feeling. The employee opened up about all her stressors, and the manager was able to help connect her with the AP to get additional support. The manager shared with me that she was grateful for the class and helping her feel more comfortable to take these steps, really equipping her to be able to open the conversation and know where to turn next. So before I end, I just want to make a note as well on this point of partnership and collaboration. Our survey being a partnership with HR, but in general, it's about the connectivity with the other programs. And so as represented by that No Wrong Door flyer and what I was highlighting earlier, it really is about coming together to coordinate. And so we implemented what we call the CARE Collaborative, which is our monthly space for the leads of the different programs to come together to think about the resources and the supports that we need. So really creating the structure to allow for that to happen. And this has been indispensable in terms of responding to crises and to events and also proactively planning. So you see on the right a flyer, it's not really a flyer, it's a guide leading through traumatic stress from a critical event leader guide, which was developed in the aftermath of and really concurrent to the response to a shooting in one of our ambulatory spaces that resulted in the killing of one of our employees. And as you can imagine, team was very distressed and the leaders were at a loss as to how to respond. So taking the tools that we've been talking about, stress first aid, baking them into this guidance for leaders and then also the structure of the collaboration allowed us to really organize our response. And for 23, our goals include suicide prevention activities with collaboration with AHA, enhance our listening data infrastructure and recognize the efforts of our caregivers through a retreat as many of the, you know, specifically the CARE Collaborative caregivers, because many of them, such as our team Lavender, the people doing the work with stress first aid are all budget neutral, it's all volunteers. So I appreciate it, your time, and I'll turn it over to Dr. Sopra. Thank you, Mayor. Thank you. That was, so my name is Manish Sopra, I'm a psychiatrist, I oversee the behavioral health service line at Northville, I'm executive director for our service line there. And you know, since the pandemic came upon us, I, you know, we just raised our hand and we said, we want to work with the system, if the system would want to work with us, to meet the mental health needs for our, you know, colleagues, our employees. And I have to commend Mayor for the work that he did and his team that we built, you know. And it was all done at the peak of the pandemic, you know, with the business plans, the recruitment, recruiting several psychologists from all over the country to come and work for us. And, you know, it's been so well received and, you know, and you mentioned AHA, the American Hospital Association, which has really highlighted our program and we continue to collaborate with them to take this further and hopefully to other hospitals and health systems. So I'm going to focus on talking about the mental health needs of the employees. This will be more on the clinical side. And it is sort of a New York problem, I think, but it is in every geography to some extent. We work a lot for our, you know, underserved communities and I know we struggle in bringing all the resources to everyone, especially the uninsured or people on Medicaid and Medicare. But New York has a strange problem. The commercially insured people are so underserved because nobody is accepting insurance. And the health systems behave like as the 80s and 90s never left, like, you know, so there are five, six health systems, there's no monopoly from one place, there's no population health, value-based care, they're just fighting for commercially insured patients, but not for behavioral health, for every other situation. So there are narrower networks. And so our insurance actually at Northwell now is called Northwell Direct, which basically means you can come and see other, for your clinical services, you can come to our own hospitals. We have plenty. We're the largest health system in New York. But it's really costly to go outside the health system and get care, because you're paying copays and deductibles and things like that. So how do you provide care for 83,000 employees, especially mental health, when you have such narrower networks and also ghost networks, right? So many doctors and psychologists who say that they will accept your insurance, but actually have waiting lists, and they're really not going to be able to do that. So that was the problem we were facing. And I'm gonna just talk about a few things that we did to help with that. So one was this issue of care navigation, that just creating a phone line where we staff it with licensed mental health counselors. And I talked about this access primary. So it's very hard to really navigate our health system, right, especially the mental health system. As I talked about, there are waiting lists, there's no clear information as to who's accepting patients. People don't know which door to knock, right? What kind of services they're looking for. Are they looking for a therapist? Are they looking for a psychiatrist? A specialty clinic? So, and they don't know how much it's gonna cost. So I think what we did was we basically set up a concierge behavioral health line for our employees, where anybody can call 9 a.m. to 5 p.m., Monday to Friday, we don't call it a suicide line, it's not a crisis line, it's not a hotline, it's a warm line. And you can call about anything that's on your mind. You'll be, the phones are answered by a licensed mental health counselor. You can call about yourself, you can call about a family member, a neighbor, whoever, whatever's on your mind, and you just get expert advice on how to navigate behavioral health system and what's the next step. So we've seen a significant increase in the volume. In 2001, we saw 1,007 calls from our employees. In 2022, we've seen more than 2,000 calls. So as we were doing this, we thought about, this is, I'm gonna talk a little bit about what kind of concerns people call about. So it's mainly anxiety, depression, treatment for ADHD, trauma, we talked about that. And folks are connected then to individual therapy, individual psychiatry or therapy in psychiatry. And the counselors who are taking these calls have all the information about where our employees can get access with their coverage, and in which geographies. And we actually built some more services so that we can meet the needs. And this gives us a good sense of what the need is. So we keep building more. So Northwell Direct, I talked to you about this. So we reached out to them and we developed a relationship with them, which we call a tier one. So we have a select clinics that the service line operates, where they agreed to actually, you know, work out a financial arrangement that those clinics are paid well, so that I do not have to go in and ask for, when I'm expanding services, behavioral health services, I'm not showing more and more red to my chief operating officer at the health system. We are able to write business plans that sort of tend to break even. And we did some benefit design adjustments too, like removing copays for mental health treatment, especially when they call the care navigation line. Okay, and then we, I'm really excited to talk to you about BHELT, which we launched recently. This is our digital platform. So we were running this navigation line, which is over the phone. A lot of people are accessing services now digitally. They wanna text and chat, they wanna call. So BHELT allows you to do that. It's not an app, it's actually a website, which you will hear about the web address later, but it's only available to Northwell employees. If you Google it, you'll not find it. Because the services are only available to that select population. I talked about this. So, sorry. This is what BHELT does. We do self-screening and personalized feedback. So if you go on the website, employees can work through a screener and get some feedback. I talked to you about care navigations. There's video and text chat with the therapist that's available. There's symptom tracking through measurement-based care, and there are some self-help tools that are available to the employees there. You can sign up for online therapy. That's the other two. So I have a short two-minute video that I'd like to show you about it. Make sure we're starting right from the beginning. A mental illness can be devastating and isolating and more common than most people realize. According to the National Institute of Mental Health, over 20% of adults have some form of mental illness, and less than half of these individuals access treatment. Unfortunately, navigating the landscape of treatment options within the behavioral healthcare system can be overwhelming. For instance, how do you choose For instance, how do you choose between a private practice or a hospital outpatient program? And what type of treatment do you need? Medication, talk therapy, or a combination of both? Care for treating common mental illnesses varies tremendously, making it challenging for an individual to find high-quality, affordable treatment. When seeking help for common issues like stress, anxiety, depression, or sleep problems, it's hard to find good quality evidence-based treatment. Even if there are options available, you may not be sure where to start. That's why we built an online platform to guide you in seeking help. Bee Health provides easy access to timely, targeted treatment in the privacy of your own home. We offer behavioral healthcare navigation and online therapy. And if you're not ready to seek support, we offer an anonymous screening when you visit our site. You'll get personal feedback about your concerns and strategies to approach change. Bee Healthcare navigation support will help you identify the right healthcare. You will start by chatting or talking by phone to a care navigator who will answer your questions, provide a personal assessment, and then assist with scheduling your therapy appointments. All of your information will always be kept completely private. Our online therapy will include weekly video sessions with a personal licensed therapist, along with support provided via chat and text messaging. Our therapists are trained experts in cognitive behavioral therapy, or CBT, an evidence-based treatment modality that has proven efficacy in overcoming common mental illnesses and improving quality of life for our patients. The team of care navigators and therapists are here to support you. If you're looking for help for yourself or a family member, visit us at gobehealth.org. ♪ So that's like a message that goes to exactly what this application does and how our patients can benefit from, I mean, our employees can benefit from it. So we did it all in-house. We contracted with a dev team, programmers who actually are here are California-based, but we had psychologists. We have so much talent in the health system. That's the one thing that large health systems can do. And then, you know, work with our marketing team and also have a research arm connected to Be Health, which is, again, a thing that a health system could do. I do not know if, you know, with so many of these digital so-called disruptors are working with, like, how good is the research that they're doing along with that. That's a picture of all our team members there. Dr. Bancroft there, this works. Sorry. Does it have a pointer here? Anyways, I can do this. Dr. Bancroft is a lead psychologist, and she developed this, you know, this manualized therapy based on the unified protocol using CBT to treat anxiety, depression, and other conditions that people were accessing the services for. And then we, you know, hired several psychologists from the area. Most of them are private practice individuals working, you know, part-time with us and part-time in their private practice. It's, you know, one place that I can truly say that we are doing evidence-based treatment, you know, evidence-based psychology. So while it's a digital tool, I just want to say that it's really about the workforce and getting the, you know, intervention right. So we launched it in the summer. We got funding from the Total Rewards, which is our HR department who's actually built it. We did it in less than, I want to say about, you know, I don't want to tell them because it's recorded. We do get good money from the HR, but we did it. We saved money on what money they gave us, which we are continuing to use to, you know, develop the, this platform. And so we launched it in summer of 2022, and we've seen a significant enrollment. We have more than 800 people have signed up so far within this, and about 450 have started therapy. So right now we're working on screening, care navigation, and online therapy, and like building some self-care modules, some health self-care and coaching, and then medication management. This is some outcome data. This is just actually really, really early outcome data that we have seen. So our average length of treatment sessions, I'm giving a talk later today about digital mental health services and all, but one of the things I'm going to talk about there is that so many digital tools that are available do not have a high retention rate. People do not really stay, you know, the stickiness or staying with the interventions is a tough thing. Even with our own, like traditional outpatient therapy, the real data in the community is that most patients only have two or three psychotherapy sessions. And I'm really glad to see that, you know, the average session length is about 10.8 weeks using this intervention. And we have seen decrease in both PHQ-9 and GAT-7, and I'm able to now take this to our HR and also show them the comparative benchmarks from some of these companies, which I'm not gonna name, but, you know, these studies that are listed here are by some of the digital EAP-style companies that are working in the market right now. And it's great that if you can develop your in-house tool, which is cheaper, but also works better. And that's some more data on improvement and recovered. So improved, as in like, you know, they have this percentage of patients whose scores decreased five or more on the PHQ-9 or four or more on the GAT-7. And recovered, we're defining as percentage of patients who improved and had a final score of below the clinical threshold. And then asymptomatic, whose PHQ-9 and GAT-7 scores were less than five. And I think that's my last slide. Okay, we're gonna end here and we'll take any questions people may have. Hi. Linda Bresnahan, I'm with the Federation of State Physician Health Programs. Love what you presented, and a great model. So I wanted to ask your health system is based out of New York? Yes. So your state physician health program, is that a thought in terms of an option? Do you think about that in terms of utilization within your list of resources? And the second comment was just about the American Foundation of Suicide Prevention. I was at a session this morning, Christine Mordier's here. They have an interactive screening program for suicide. And you mentioned working with the AHA. So it's just an additional option for you to think about because it's a ready-made tool that you can implement in any healthcare system. We're working, many of our state physician health programs are implementing that with their state medical societies on their websites. So it's, I think, a low-hanging fruit tool that's ready to go and implement and connects individuals that, confidentially, that get screened at risk with resources. Yeah, I don't know, Mayor, if you wanna talk anything more about it, but we are in the suicide collaborative. We are working with AHA and exchanging the best practices with them. I don't know if we have already worked on this. We haven't worked yet on that tool. We are aware of it, but it is something to consider how we can integrate that as well. I think, as part of the collaborative, our focus for now, each group is taking a priority focus. And our focus right now is on our crisis response because of some of the disarray that we've seen at times in response to that, but I agree. I mean, I think that's a very useful tool and could potentially go in with B-Health and other resources. Yeah, AHA also has developed a stress-o-meter, which is quite similar to the color scheme that, we don't call it anything, right? Do we call it a stress meter, or? Stress continuum. Stress continuum. So they're calling it a stress-o-meter, and I think they've trademarked it, but it's, and this was done, you know, we already have the stress continuum, and AHA just released it a few months ago. So it's quite similar work, and I think that came out also from working collaborative. So the physician health program that you mentioned, that's, you mentioned the program that's supported by the state, right? In New York, at least? The state medical board? Right, yeah, so every state has a physician health program. So I'm the executive director for the National Association of those programs. So right, New York has a physician health program that's a member of my association. So these programs in New York, at least it's run out of the state medical society. So they were designed with additional confidentiality protections for physicians to come forward and get assessed when they're at risk of impairment for mental health, substance use disorders. So they can get connected to resources for therapy. It's just another door, and obviously I'm biased. I'm the association, the executive director of these associations, but they do have, for those that don't wanna go within their institution to get help, for those that feel comfortable, they do have added layers of confidentiality protections, immunities against their records that protect physicians' privacy of information when it comes to getting help. Most physician health programs have statutes that prevent the records from being subpoenaed for malpractice, for example. And they have a network of providers that are used to providing treatment to healthcare professionals. Yeah, actually, I believe the medical director of New York actually works for the PhD program, Dr. Seltzer. He works with us in the Northwell Health System, and he's part of our EAP. And his effort is called PRN, Physician Resource Network. So PRN is connected with the state PhD program. As you can imagine, there is still the stigma that doctors have, right? Are you connecting me with the state PhD program? As much as Dr. Seltzer will explain them, like, you know, the differences and that. One of the main issues that we feel from our GME, the Graduate Medical Education Department within the system, they came to us about access to care for the physicians in training. So Mayor briefly mentioned this. We also, post-COVID, built a resident and mental health program. So Northwell, as a large health system, we have about 1% of all residents and fellows in the country, about 2,000 or so. So we built actually a special program just for them so that we can treat them in-house. But it is connected to the PhD. So we have escalations, and there are times that we have to, you know, provide services in a more confidential way or in a state-connected way. We certainly do that. Sorry. Hi, I was just curious. A lot of what you spoke about had to do with those who were Northwell-insured. What services did you offer for those that didn't have Northwell insurance? So people who do not have, they get the Care Navigation. The Care Navigation services are available to everybody, but they don't have to be. So there are employees who do not take our insurance because they have it through their spouse or through other means. We still give them Care Navigation services. Even as sometimes, you know, like, for example, we have a call center in Florida where 300 people work. So we had to figure out, like, you know, in their area, their geography, what is the network that's available? And we trained our mental health counselors for that. Thank you. Sure. Hi. I... Great presentations. Thank you. I'm really interested in the issue of physician and nursing personnel buy-in to systems that offer help. I work in the Bahamas, and there's a lot of cynicism within the medical and the nursing fraternity towards mental health services that offer help. And I'm just wondering if you could talk a little bit about that. Yeah. So I work in the Bahamas, and there's a lot of cynicism around mental health services that offer help, stuff to do with confidentiality, issues to do with labeling, job security. How did you address some of those concerns? So I think there are a few ways on that. One is, you know, the stigma, right? The stigma is...which exists just in our society on accessing mental health treatment and letting people know that I am accessing mental health treatment, letting your team members know it. So for that, I have to credit, like, you know, our senior leadership, as George had highlighted, too. There has just been such an awareness campaign from our top leadership on that and accepting. And there have been actually many leaders within the organization who have... You know, when we do these vast town halls, they're virtual, like 4,000 or 5,000 people will join in. They'll talk about their own struggles or their family members' struggles. So that, I think, you know, work has been really helpful, especially in substance use. We have done a lot of work as an organization in reducing that stigma. Then there is something linked to that, I think, is institutional stigma, right? Which is, how do you get privilege from your medical staff office? Do you have any mental illness that you are under treatment for? These are questions that we ask, right? So we've taken care of that. We made changes in when we are... We just ask a general health question. Are you suffering from any illness or do you have any health-wide duties as a physician or as a psychologist? And we've publicized these changes so that we're trying to get rid of institutional stigma, which may exist. So that helps. Accessing treatment doesn't still help the confidentiality situation, right? So some of these programs that we have built, which is primarily for employees, they do not... They're not in our EMR for the systems. We use an all-scripts product. We're going to be going to Epic soon. Be Health does its documentation in its own platform. The Resident Mental Health Program that I described is on Microsoft Word and paper charts. We sort of try to keep those things confidential as much as we can. There is a lot of employees who still go to our traditional clinics, and those clinical notes are actually in our charts. So, you know, I think those campaigns and just having some availability of treatment that is available in confidential settings. I would like to have more of the broader network, you know? So we have done some work with building the Northwell Direct network so that there are some individuals who still do not want to come to your own health system, right? So we try to find services for them outside in the community through the help of our care navigators. I don't know, George, if you want to add anything. I would just add one thing. So, Mayor, Dr. Belson mentioned that we also do work with the police department, and also a lot of suspicion and sort of cynicism sometimes about the services that are being offered through the department. And so this was set up as sort of something outside of the department. But in order to even be able to get buy-in, you know, talking to some of their leaders. So, you know, they have groups that promote, you know, officer wellness. Similarly, you know, if there are leaders there of the physicians, even bringing them to the table and sometimes acting as mediators, or if there's other folks that could be really kind of advocates for this type of program to try to partner with them, that might also help move it forward. Any other questions, thoughts, comments? Yes, this is my fault. I did not get the deadline. I can actually put my e-mail up there, and folks can e-mail me, and, you know, that might be the best way. The slides will be available, but not the links to the video. But everything else will be, yeah. Okay. Thank you for coming. Thank you.

mental health

healthcare workers

COVID-19 pandemic

resilience

trauma-informed care

stress first aid

burnout

Bee Health

digital platform

Northwell Health

workforce well-being