Hi everyone. We'll go ahead and get started. Thanks so much for being with us here today. We're here today to talk about the future of virtual care for people with serious mental illness. My name is Nicole Kozloff. I am a child and adolescent psychiatrist in Toronto at the Centre for Addiction and Mental Health, where I work primarily in an early psychosis intervention program. And the background to this talk is that I think many of you will have similar experiences, that in the context of the COVID-19 pandemic, we were forced to transition to deliver a lot of our care virtually. In the context of early psychosis intervention, it wasn't all of our care but most. And we found that there was actually not a whole lot of research or resources to guide the delivery of virtual care to people with serious mental illness. As many of you know, there was substantial literature focusing mostly on depression, anxiety, and in general, psychiatry. And not all that much in the way of delivering care for people with serious mental illness virtually. And so we've learned something over these last few years. We've taken the opportunity to apply an evaluation framework that we had used in an implementation study to look at the transition to delivering care virtually and evaluate it. And while we've done that through a formal evaluation, I think all of us have picked up some skills along the way. And so today we're going to hear from people working in a few different settings for people with serious mental illness. And they'll present research as well as their experiences delivering care virtually. And then we'd like to turn it over to you and to hear from the work you've done in your settings and what you've learned along the way. And hopefully by the end of today's talk, we'll bring together some ideas and chart a path forward. Because at least in the setting we work in, I think what we found is virtual care is here to stay. As much as we try to to get people to come in in person for much of their care, many people are still asking for their care delivered virtually. So I have no relevant financial disclosures. So as I mentioned, after the presentations we'll do a small group activity. We'll ask for participants to share back what they've discussed and hear further from the panel. And then we'll have some concluding comments and question and answer period. So first I would like to call up Alexia Polillo. She is a project scientist at the Slate Family Center for Youth in Transition at the Center for Addiction and Mental Health in Toronto. She received her PhD in experimental psychology from the University of Ottawa and has extensive experience with community and mental health services research program evaluation and patient and family engagement. Her work is focused on improving early psychosis intervention services and engaging patients with lived experience and family members in the evaluation process. Alexia. Hello everyone. I won't introduce myself again. So yeah, today we're going to talk a little bit about a study that we did in implementation and effectiveness evaluation and kind of our journey to virtual care and what we learned about what worked and what didn't work. The study was funded by the Canadian Institutes of Health Research and the University of Toronto. So early psychosis intervention is an evidence-based treatment that has become standard of care for youth with psychosis and in our EPI program we deliver the navigate model of coordinated specialty care and it really was designed to be delivered in person emphasizing frequent contacts as well as community outreach. But when the COVID pandemic happened we really had to shift to virtual care without any guidance to you know the adaptations that would be required for virtual care as well as planning and training that would be required. So the Slate Center for Early Intervention Services is CAMH's EPI program and it provides assessment to young people aged 14 to 29 with provisional psychosis and treatment is offered for up to three years. The navigate model of coordinated specialty care is a manualized package of EPI services and it delivers four main components which you can see here. So individual psychotherapy which is most commonly CBT, family education, medication management and supported employment and education. And for us the shift to virtual care happened in March 2020. And I'm not going to go over these in detail but we looked at five we had five main study aims. The first being what adaptations would be required for virtual care, what facilitators and barriers we encounter for virtual delivery, satisfaction from the patient family and provider perspective, fidelity to the EPI model which is set by the province as well as the navigate model and then looking at service engagement and any health equity considerations. There were four main areas that required adaptations to deliver virtual care. The first being in the area of technology, making sure that we provided hardware and software to clinicians and the organization-wide rollout of Webex which is the digital platform that we used. And it's important to note here that CAMH really is a well-resourced setting. We have a virtual kind of mental health program or department that trained over 400 clinicians during the shift to virtual care and these kind of adaptations were already in the works prior to the pandemic. The next is procedures. We had the rollout of CAMH's virtual care policy, changes to the privacy, safety and confidentiality standards to be delivered in person or virtually, sorry, and the changes to physician billing by the province as well. Clinical practice was another area. This really was the training component so orienting clinicians to new software, how to do risk assessments and crisis management virtually as well as how to build engagement with patients virtually and deliver trauma-informed care. And then also taking into account any health equity considerations that may have come up. And we also created web-based resources to deliver the Navigate components and just help with the virtual context for patients and clinicians as well. And then we sent out weekly tips and tricks to clinicians that I'll show you in the next slide. So these were kind of some of the areas where we had these tips and tricks. So technology, clinical practice, engagement and wellness. For the facilitators and barriers to care, most of the components were generally facilitative with 27% being mixed and no barriers. These really were in the area of the shift being in the context of the pandemic. So many of the kind of barriers that came up were really related to the shift being unplanned, quick, you know, overwhelming at times. But clinicians did recommend continuing virtual care, ideally with patients having the choice to choose how they want to receive their care. When we look at the family member and patient perspective, we can see here that for the items whether or not virtual care was safe, timely, efficient, effective and patient-centered, they all were past the threshold for agreeing. 78.5% of EPI patients and family members believe that virtual care was just as effective as in-person care. And we can see a little bit of kind of mixed perceptions here when we look at providers, specifically in effectiveness. 62.5% of EPI providers believe that virtual care is just as effective as in-person care. And you can see that the effectiveness rating was slightly lower than the threshold for agreeing. And when we, you know, spoke to providers and, you know, we did some qualitative work with this study as well, you know, they said that there were times when virtual care was not as effective in the areas of, you know, being able to assess like nonverbal cues. If patients were in distress or crisis, virtual care was difficult, as well as monitoring medication side effects and physical assessments like metabolic monitoring. But still, you know, 94% of EPI providers believe that they are able to provide high-quality virtual care, and EPI providers believe that they received proper training to provide virtual care. We also looked at fidelity to the EPI standards and model. And pre is pre-virtual care, and the post group is post-virtual care. We can see that they're, you know, they're largely unchanged when we look at the ratings or the fidelity scores. In the access and continuity area, there is a slight decrease in post-virtual care. Really that, you know, we attributed that to the increase in hospitalizations prior to getting in contact with the EPI program. And then assessments and care planning also was slightly decreased, and that was the psychosocial assessment that's done and documented in the consultation note, that was also less documented. And looking at service engagement, we haven't done a formal statistical comparison here, but when we look at 2018 to 2020, we see that 17.8% disengaged at nine months, compared to the 15.5% that disengaged at nine months in the virtual care years. And when you look to the qualitative interviews, we did qualitative interviews with patients and family members, and we also did a focus group with providers. So I just pulled out some kind of key words and themes that came out of the findings, and one of the main kind of takeaways of those qualitative interviews was, we kind of have two groups. We have the group where, you know, virtual care was convenient and accessible, and it gave their life balance. They felt like they were able to actually, you know, still connect with their clinicians and want to see it continue. And then we also have a group which kind of has a different perspective, where, you know, they felt like it was distant and impersonal, and really kind of struggled to build that therapeutic connection. Also, you know, if they were isolated, coming in person to appointments was something that gave them structure to their life. They were able to get out of the house and kind of have that social connection by meeting with their clinician. And lastly, looking at health equity factors, these are some factors that came up during our qualitative interviews. So access to technology and space, particularly for people experiencing homelessness, living in poverty, they may not have access to computers, phones, and digital literacy as well. That was something that came up with family members. Having difficulty using technology in general, so making sure that there's capacity to help with training. Privacy and stigma, this came up in our qualitative interviews. Some people felt they experienced more stigma coming to a hospital and just felt more comfortable doing virtual care. And then lastly, virtual care reduces geographical barriers. We offer family groups and since they went virtual, we've had a big increase in attendance for family members. So yeah, generally positive experiences with virtual care. There were some mixed impressions, especially from the provider perspective. So that tension between balancing quality and convenience and the importance of making sure that patients have a choice on how they want to receive their care. And that's also something that came up in the qualitative interviews. There was no significant measurable drop in fidelity and disengagement from services was likely unchanged or improved. So we'll find more about that when we do the analysis. And then lastly, always taking into account equity considerations. And yeah, thank you to the study team and the patients and funders as well as CAMH Virtual Mental Health. And now, Carrie. I think if there are questions specific to each of the presentations, we could maybe take one or two after each presenter. Does anyone have any questions specific to Dr. Polillo about the experience in early psychosis intervention? Okay, so I will call up Carrie Cunningham. Carrie Cunningham is a board-certified psychiatrist and family physician and assistant clinical professor in the UCSF Department of Psychiatry and Behavioral Sciences. She serves as the medical director of the UCSF ZSFG, that's a lot of letters, Division of Citywide Case Management Programs, the substance use medical director of the Citywide STOP Program and engages in direct patient care, teaching and program development. Dr. Cunningham received an MPH from UC Berkeley, attended medical school at UCSF, completed a family medicine residency at UCSF San Francisco General Hospital, a psychiatry residency at Cambridge Health Alliance and trained at the UCSF SFGH Public Psychiatry Fellowship. Dr. Cunningham. Thank you very much, Dr. Kozloff. Thank you. So as I'm putting my slides up, so I'll be presenting about a clinic that's just a few blocks away from here, actually in San Francisco and it's nice to be able to think about the similar challenges and lessons that we learned in both of our programs. All right. So this is our clinic's motto, bridging help, hope and health. Technology's role in improving access, staying connected and innovating care for people with serious mental illness. I have no financial disclosures. And so I'm just gonna talk briefly about our clinic, the UCSF CSFG, which is a clinic in San Francisco, to talk briefly about our clinic, the UCSF CSFG Division of Citywide Case Management that is really close by at Sixth and Mission downtown here. We serve over 1,500 clients with serious mental illness. 40% of our clients identify as black or Latinx, at least 70% use substances, many stimulants and 100% experience serious mental illness. We are the largest provider of intensive case management services in San Francisco, the only ICM in San Francisco that serves Cantonese speaking clients, the first ICM to have a black or African-American culturally focused team and the only ICM with a justice involved focus. So I'm gonna talk about three strategies we've used and implemented in the face of the COVID-19 pandemic, where we adapted, innovated and implemented a tele-ICM program, para-telehealth, we sort of made up the name, so I'll discuss that and hybrid care. So for tele-ICM, so this really started with the pandemic. We had talked about, you know, what are best practices with using phone with our clients? How do we text safely with our clients? But really hadn't gotten very far in the conversation when COVID really pushed the agenda forward. And so this is an article and you're welcome to scan the QR code and read about our experience with telehealth. When telehealth came to the tenderloin in the UCSF magazine and I'll be talking a little bit about the findings from that article. So this is from Alison Murphy, the director of our citywide supported housing programs. And this is at the beginning of the pandemic. We were literally creating barriers between us and the client, while the whole point is to break down barriers. So our intensive case management services, the goal is really to meet clients where they're at, to outreach people who are really often difficult to engage in the community. And we were learning how to use telehealth to continue our work in the community. So a crisis creates an opportunity. The COVID-19 pandemic really advanced our timeline on telehealth through necessity. So we had this need to maintain connection with our clients. We had a resource in the Bay Area with philanthropic investment in technology. And this allowed us to create a telehealth, tele-ICM program. So preparing for tele-ICM. So this is from, and I'll reference it later, a SAMHSA resource guide that's very helpful in thinking through this. And I wish this guide had existed when we started and that we could have thought through all of these things. But I think the system just naturally changed in the setting of the pandemic. We were all of a sudden able to bill for telehealth visits. We were doing a rapid assessment of our organization and our organization's readiness. We were in real time as clients and providers learning how to do telehealth and thinking about how do we talk to our clients about this and how do we get their buy-in and staff and providers. So really, our assessment in the very early stages was asking a lot of questions. Will clients be able to use phones? Will they answer them? Will they lose them? Can they keep them charged? Will the phones get stolen? Who already has a phone? And what kind of telehealth do we want to try to provide? Whether these are therapy sessions, check-ins, or Zoom groups. So this was a phased implementation approach where we started with initial tele-tool investment. This was through philanthropic funding. We were able to get 220 flip phones and a few smartphones out to the community to clients and some iPads for staff. And we learned some lessons early on that flip phones are easily lost. And we actually had to do things through a monthly voucher program that had to be re-upped by talking to the client, having them bring in their phone or going out to use their phone. And that created unnecessary barriers to being able to do the telehealth. So we gathered some data after this initial step and were able to look at things like what type of device do clients normally have? 34% of our clients after the initial telehealth investment had smartphones, 21% had flip phones, and only 8% had no access to telehealth, no iPads, no computers at home, no flip phones or smartphones. We also looked at device retention. And this is from polling case managers and our employment specialists. So we looked at actually most of the time or all of the time clients were able to hold onto their devices. So when we looked at device retention, again, 24% most of the time and 48% all of the time. So people were holding onto their devices and we were able to get in touch with them. We also looked at internet access and either most of the time or all of the time the majority of clients did have internet access. We looked at Zoom and we were learning alongside our clients how to use Zoom for our own meetings, for client interactions and helping to train clients on how to use this modality as well. And luckily had this available to us for free through UCSF. So again, for internet access, most of the time 27% of clients had access and 38% had internet access all of the time. So then we did another survey looking at the kinds of telehealth interventions that our staff used with clients. And we saw that most were phone visits, most were about half and half were scheduled or unscheduled and most were rated as being moderately or very well or going moderately or very well with telehealth. So in research, they actually found that telephone was the most common telehealth modality used among mental health professionals during the COVID-19 pandemic. And as you see from our numbers, most sessions were conducted over the phone and not using video. There were nearly as many scheduled as unscheduled sessions. Only a quarter of our clients required technical assistance and only 10% had attrition of the donor provided phone. So again, most people were able to hold on to the technology. And more importantly, what was happening with clients with this telehealth technology? Well, in one situation, a client had been exposed to COVID-19 while in our psychiatric emergency services, but wasn't informed of the exposure. A contact tracing team was able to reach out to his social worker at Citywide, who was able to then alert him and immediately help himself quarantine. Another client, a social worker was able to reach a client who had overdosed on fentanyl and persuade him to enroll in a recovery program. And there were countless other calls, right? Emotional support, help with getting food, social security benefits, other essential resources, all the things that we do on a day-to-day basis and now we were using telehealth to help us do this during a pandemic. So when we looked at all of the data together, we were really looking at how well are clients connected to technology. And our overall findings is most clients are able to maintain their devices, most have access to internet, only a quarter need technical assistance, so most are able to use things on their own. And actually the program increased the cell phone access to clients by nearly 40%. And what we really learned are our clients are more connected to technology and more capable of using technology than we had previously assumed. So now we're in the second phase of this implementation and looking at a tele-ICM program with foundation funding, enhancing our telehealth curriculum, looking into using telehealth navigators and creating more infrastructure for this program. And also giving cell phones to our staff who also need to have the right infrastructure to be able to communicate effectively with clients. So our future in tele-ICM is gonna be in a new building sometime this year or next, and it's gonna provide a new opportunity to improve our telehealth infrastructure. We're gonna be creating a digital literacy cafe with computer kiosks where clients can have telehealth literacy assessments, groups, hybrid spaces, so all of our meeting and group rooms will have hybrid technology with the right speaker and camera and other technology needed to really make it a good experience for the people on the other side of the screen. Mobile workspaces, so we'll have more laptops in our new clinic. Our phones have all gone to a system called Jabber, so that's a remote voicemail and landline, no more landline, and then Faxes as well has gone to a program called RightFax. And then we're also gonna have Wi-Fi. So a lot of people take for granted having Wi-Fi in their building. Our current clinic does not, but our new building will have Wi-Fi, which will open up a lot of new opportunities. I'll just talk very briefly about a couple of other interventions. So I mentioned earlier on paratelehealth, and I'm gonna show a brief film by one of our own supervisors. So let me toggle to that. Can you see my mouse, is that, okay, oh, there we go, thank you, okay, I think I have to pull this over, okay, and back, okay. This is the story of one division, citywide, resilient in the face of adversity. The year was 2020. The great pandemic had brought San Francisco to a grinding halt. Clinics around the city were forced to close their doors, leaving many uncertain as to what the future might hold. Fortunately, one amazing division came up with an idea that would set humanity back on its course. We now have archival footage depicting this grand idea in effect. Friday, October 2nd, 2020, a clinician receives a call from their client. They're on their way to the clinic to pick up their meds. They're 15 minutes away. The clinician springs into action. The air quality is bad, and they do not want to meet at Mint Plaza again. They check the shared calendar. As fate would have it, a slot is open. The clinician makes their way to the milieu, an area that once bustled with life. It calls to them, yearning for the sounds of activity running through its walls once again. Unbeknownst to all, this would be the first step towards that dream. The clinician checks that 30 minutes has elapsed since the last meeting has completed before cleaning anew. They know this step is pivotal to their safety. They commence the all-too-familiar ritual of cleaning their surroundings. The smell of bleach assaults their nostrils, but is almost comforting in that they know the virus is at bay. The moment they dread most is fast approaching. They must log into the computer and launch Zoom. They hope that they'll remember their password. Success. They take note of the meeting ID and password and enter this crucial information into the client's computer. They turn both door cards to make sure nobody will undo their work. The client is almost here. Citywide's valiant nursing and safety team are ready on the front line, armed with infrared thermometers and shielded in protective gear. The client approaches the front gate. They make it through and enter the clinic for the first time in months. The AC hits their skin and they can breathe again, a respite from the harmful outside world. A familiar face, the clinician greets their client and leads them to the interview room where they will finally be able to remove their mask. They talk, uninterrupted by the sounds of the outside world, unconcerned about the virus for at least an hour. They laugh. Alas, the meeting must come to an end. However, they both walk away with a renewed sense of hope. Maybe things aren't as grim as they seem. After all, community always finds a way. They part, but both know it won't be for long. Citywide Paratelehealth has restored their connection, and for that, they are grateful. Go for it, Evante. I am endlessly in awe of the creativity of people at our clinic, and this is a very creative staff training video, but also evokes, obviously, the fear in the early part of the pandemic, and I also should mention there were wildfires happening at the time, so the orange sky was real, and that was part of the lack of safety and being outside. So now I need to bring this back over here. Okay. So Paratelehealth allowed us to extend on-site visits at a time where most people were meeting off-site, right? We never wanted to close our doors to clients, so for clients who couldn't, you know, wanted privacy, couldn't connect from their homes, we wanted them to be able to come on-site and have extended visits with us. We were also able to do groups via Paratelehealth, so people would be in various of our interview rooms and meeting as a group, but over telehealth, and it ensured access to other care providers that's still ongoing today. So people are meeting with their primary care via telehealth from our clinic, their specialists, they're attending court, speaking with their lawyers or their probation providers, and also talking to their conservators. And then lastly, just a little bit about our hybrid care model. So this, again, is an attempt to really meet clients where they're at and what clients stated preference at this point in the pandemic. So we, you know, innovating to increase access and acceptance and learning lessons that some clients like being able to attend groups from home. People like being able to be at home part-time and meet with their case managers in person some of the time. So we're continuing hybrid group therapy. We started some apps for contingency management, and my colleague Dr. Mitsuhishi will be talking about the GAIN project. We also used an app from Paratherapeutics, but it has since lost its funding, so it's no longer available, but we were using a contingency management app through the pandemic. And continuing individual visits, both by phone check-ins and video visits, according to client preference. Of course, there are lessons that we've learned throughout this, right? It takes significant research, as I'm sure all of you know, to implement and sustain innovation. That includes staff time, ongoing funding, and program administration. There are often competing priorities in an under-resourced setting. Obviously the COVID pandemic really advanced our telehealth infrastructure, but we need to continue to make this a priority. And the limitations of telehealth. We're an intensive case management program, so sometimes it's not possible for our providers to do an accurate and thorough assessment, particularly for crisis assessment via telehealth. And rapport building does take in-person meetings for many of our clients. There are also some client-related factors. Mental health symptoms can be a barrier. For instance, some clients have paranoia and so aren't able to use, or don't want to use telehealth to speak with their providers. Some cognitive limitations, so really tailoring the kinds of telehealth tools to the client. Some clients are hard of hearing, so again, using technologic tools to help there. And client preference. We really want to honor what clients are telling us. So this is the SAMHSA resource guide that I referenced earlier, and we are highlighted. Dr. Mitsubishi has written a part for Part 4, Examples of Telehealth Implementation and Treatment Programs. So I highly recommend this resource. It does give this broader overview, some of the successes in telehealth with people with serious mental illness, and how to think about implementation steps in your setting. So thank you very much. And let's go back there for a second if you want to scan the QR code. So thank you. Are there one or two brief questions for Dr. Cunningham before we continue? Okay. Sorry, I'm just going to pull these back up. Okay. Okay. So next we will hear from Dr. Fumi Mitsubishi, who's an Associate Professor of Psychiatry at the University of California, San Francisco, and directs UCSF's Citywide Case Management, the largest intensive case management program in San Francisco. Annually, Citywide serves nearly 2,000 patients with serious mental illness, unstable housing, and institutionalization, including justice involvement. Citywide is proud to be at the forefront of innovations that support the recovery of its patients, including technology-supported treatments that aim to shrink the digital divide. Dr. Mitsubishi? I should pull up my slides. Okay. Okay. Hi, everybody. Are we post-prandial? Yes, we are. Okay, so I'm going to try to get our energies up a little bit, and I'll tell you a little bit about the GAIN project, which I have a colleague in the audience who is intimately involved. She's our evaluator, so if you have questions, ask her questions. She will answer you. Okay, so let me, how do I get this thing up? Oh, look at that. Okay, so let me tell you, so first of all, Carrie's presentation just now, Dr. Cunningham's presentation just now, brought up a lot of memories. I don't know how it is for you, but COVID-19 was a big deal, right? And still is, and we went through a lot. We went through a lot of adaptation, like trying to make this work somehow, and it's a little, I've always thought, like, why do we care about technology for folks with serious mental illness? And we didn't used to. But when the necessity came, we did. And then we found out, wow, there's a lot of potential here, and we really need to figure it out. And yet, we're going to find that there are limitations, right? And that's kind of where we are. We're trying to figure out what we can do and what is difficult to still do, given the fact that we're talking about folks with schizophrenia or psychosis, and also people who experience homelessness, and a lot of social instability. And sort of knowing, like, what are the tools that are needed, and how do we move forward in this field and not forget that this is so important for the future of care, but also for the future of recovery for our clients. That's really where we're at, right? Okay. So I'm going to tell you about GAIN, which is a project that is philanthropy funded, and really started when a couple months into the pandemic, my patient, who I had treated for the previous eight years as a psychiatrist, died on the streets of San Francisco. And this was a big deal, right? And it turns out that he was not the only one. So in 2020, 2021, San Francisco, lots of urban centers across the country. This is what we saw. 170 people in citywide case management died. Out of 2,000, this is one in 12. This is unacceptable. And in really all of San Francisco, 1,340 accidental overdose deaths, right? And so that's twice as many people as folks who died of COVID. So we did a great job of COVID. We didn't do a great job in terms of helping our people. And so, you know, I basically wanted to commemorate my client. I told a story, which became a video and was shown at a fundraiser at UCSF. And my leadership from my department and UCSF essentially helped to identify a funder who gave us some money to do a project. So we pitched something, right? And it was a project that I think is a really low-hanging fruit. This is the graph from the medical examiner's office in San Francisco. 2020 overdose deaths. The black line is overall deaths, right? But the blue line, we all know the blue line, it's fentanyl, right? Three-quarters of folks who died of an overdose in San Francisco, fentanyl was found. Most likely the proximal cause of death. Now, focus on the yellow line, because what is the yellow line? It's methamphetamine. And so I do not like to use gun analogies. But if you imagine that fentanyl is your bullet, the gun, I think, is methamphetamine. And so if you don't address the methamphetamine crisis, you're not addressing the overdose crisis. So, sorry, you were not supposed to see that. But you all know this, right? You all know that we don't know how to treat methamphetamine addictions very well. There are no medications that immediately address methamphetamine. Although, reading The Atlantic recently, I thought maybe Ozempic might be the solution. But we're not there yet. So, we don't have a real solution. However, there is a true and tested solution that's been proven to work over the last 20 years, over multiple trials. And that's called contingency management. I think you all know this. I don't need to explain this. Very, very simple psychological principle at use here, right? You provide rewards, and it can change behavior, especially escalating rewards. So here we are. I do this at home, right? When my six-year-old refuses to put his shoes on before school, I give him a star for one shoe. Second shoe, another star, maybe. And then it's on the right foot, then another star. And then he does that for five weeks. I'm like, oh wow, maybe you can get a pet, right? We do this. And I do not want to infantilize my clients, but this is a basic thing that we do that helps change behavior. We do this with our apps. I close my circles every day. I'm addicted to this thing. That's the only way I get my steps in. So this is how we do it, right? Escalating rewards. Two negative urine tox screens, 10 points each. Third one, 20 points. You don't show up. You have a positive drug screen. Less points or no points. And then the next time, you go back up. From 10 points, you start, right? And then you accumulate the points, and you can exchange those for some dollars. Now, what's so exciting about this in California right now? It's the fact that as we were pitching this, California has started through the process of reforming Medicaid. This is called CalAIM, right? For those of us who are in California, we know about this. And there's a federal waiver that was applied for and was obtained such that we could do contingency management as a pilot actually starting this year in California. Super exciting. And they decided to use a digital app to do this. So when we were pitching this, we were like, okay, we got to do digital app. And besides, you know, you're in San Francisco. You got to create an app. This is what we do here. So we did that. And we found a technology company that employs folks who are formerly incarcerated and then created this app. And then I discovered something called the MVP. Do you all know what an MVP is? Minimally viable product. It's a very exciting name. But it's called SprocketCM, and you can find it in your app store. So this is the flow for GAIN, and we're going to focus on mission A. Mission A is tech training. Because, you know, you can do all the apps you want, but if your patients, your clients are not able to use the app, if they don't have access to it, then it's useless. So we got to have that. And then the first thing we did was actually provide them points, right, to be able to do this. And then, of course, mission B, which is, I'm not going to go over this in a lot of detail, is really helping folks stopping to use their substances or at least reducing their use. And for each of these things, we're providing points. In addition, and this is kind of an innovation for GAIN, we're actually going to provide points for folks to be able to complete wellness tasks. So these are tasks such as going to your appointments, going to fill out your SSI, making your housing appointments. All of these things are being rewarded. And just so you know, you know, in ICM or, you know, in assertive community treatment, we often provide small rewards to help people move forward in their treatment goals. And so instead of doing it ad hoc, we decided to do this in a more systematic way to really change those behaviors. All right. So you heard from Dr. Cunningham about what we did at Citywide to really bring in technology. But in the end, what you need, I think, what I think we discovered is that we need to really work on access and access in a broad way, right? And how do we do that? We do that with people. And so the first ingredient to this is a digital peer navigator. And you'll hear more about that. The second ingredient is a digital literacy assessment. Talk more about that in a bit. And then a digital learning curriculum. And lastly, you need to be able to provide actual tools, sort of a smartphone, you know, that's capable of running these apps. And also a data plan, right? So you need to have all of the materials in place. So we were really lucky. Our first digital peer navigator was somebody who used to be employed at Google and had some lived experience. And she joined our team and was integral in helping us develop a digital literacy assessment and a training curriculum. And then really the intention was to have her hold individual and group digital training sessions with clients and help them learn those skills, right? And also we intended to have a home digital needs assessment. And so this is an outreach-based way of seeing, hey, maybe an ecodot is better than a computer or whatever, you know? Like really help them set up their home in a way. So what were the components of the digital literacy assessment? I think there are lots of literature out there that specifies this, usually coming from disparate sources. But digital access kind of resource websites. But also like, you know, during the pandemic, we talked a lot about the education field was really rife in like trying to figure out how literacy, how to do literacy. So we reached out to those pockets, but also ultimately wanted to adjust our literacy assessment so that it really would be appropriate for our clients. So there were questions like, are you able to charge your phone? You know, those are the things that we really struggled with for some of our clients. So first of all, do you have access? Do you have the device and connectivity? Are there any specific barriers that you're encountering frequently to access technology or use technology? How familiar are you with technology and of course the Internet? And what are you currently using it for and what would you like to use it, right? Are there things like social connections, communication? Do you access information, right? Or do you access actual healthcare and services and any other resources? Are there any assistive or adaptive technology that you're currently using or would like to use? And our training curriculum sort of like reaches all of the different spaces that we feel were really, really important. I really want to highlight the online safety. We have found that some of our clients who have joined the GAIN team have been, you know, essentially victimized, right, through the Internet. Responded to a text message saying, hey, click on this and whatever and then they gave away their personal information. And this is something that we really need to look out for because in as much as we want to help our clients kind of move to the other side of the digital divide, we still want to make sure that they remain safe and that, you know, this is not a source of victimization. But, you know, like completing online forms. That's a big one, right? And this is something that I really feel like if we don't help our clients do this, they won't be able to fill out SSI form, right? Like what kind of recovery are we talking about? And so ultimately we decided to call this digital belonging. So I'm really borrowing this term from D-I-J-B, right? Diversity, equity, inclusion, justice and belonging. So digital inclusivity is going to lead us to digital justice and it's going to be supported by something called digital belonging. So I know it sounds a little like, you know, I'm waving my hands over here because I am. This doesn't really exist, but we have to dream it, right? Because technology use and access is ultimately a determinant of health, right? It's a determinant of how somebody is successful in society. And if our proposition to our clients is recovery, we need to be able to support that. Oh, this is not the slide that I wanted to show you guys. Okay. So, that was weird. Okay, so literacy, knowledge, ease, right? You also need to know how to troubleshoot. How many of you have used something and it doesn't work? Technology oftentimes doesn't work and we need to figure out how people get their right supports, how the TA, right, that needs to be embedded, the supports that you need to develop in your community in order to be able to do that. And we wanna make sure that people are using technology in ways that they want. And that should be based on, you know, not just the basic needs and communication. Those are the simple things, right? What about entertainment? What about joy? What about the things that support you psychologically, spiritually? Those are the things that people need to reach out to to make this be meaningful. And then we need to know that technology always changes. You gotta like download the new iOS, right? And you gotta do that without fear. I don't know, right? And so I think that we need to be able to figure out how to provide or teach the capacity to adapt. And then the goal is to become a native user, whatever that means. I think this is gonna get easier as generations change, but, you know, how do we create the feeling of being a native user? And as Carrie was telling you earlier, what we discovered at Citywide is that public mental health systems are not in the 21st century. We don't have Wi-Fi, you know? We don't have computers in our interview rooms, didn't a couple of years back. We don't even have workers who really are invested in and feel comfortable using technology. So how do we get up to that, speed to that? So those are the things that I think about when it comes to digital belonging. And I'm really hoping that you, all of you, are here to think about that with me. So, oh, and then ultimately we need to really shape technology by really involving consumer voices in the act of shaping it. All right, this is the team. I just wanna say big thanks to the, first of all, the game team, but also our department and our development and alumni relations folks. So I do think about my client. I think about how he would have probably laughed at me. He would have said, what are you doing, Fumi? Thinking about technology and so on. But, you know, I often think that maybe he would still be alive. And so I know we're talking about technology, but we really are talking about lives here. Thank you. Any questions for Dr. Mitsuhishi? Okay. Well, we'd like to hear from you about your experiences with virtual care. As I've said, oh, sorry. Let's go back here. As I've said, I think we've all had experiences trying to implement virtual care in our various settings. And so now we'd like you to take, let's say, five minutes to reflect and maybe stand up, have a stretch, move next to somebody, and ideally somebody you don't know, and tell them about how virtual care was implemented in your setting. And think about a few things. Think about the ways that you might have been prepared to deliver virtual care and the ways you weren't prepared. What did you need to start delivering virtual care in your settings? So think about the technology, the training, policies and procedures, additional supports. And what's the current state? Because I think we've made the assumption that people are still using virtual care in their settings with people with serious mental illness. That might not be the case. Has it been totally abandoned? Is it like my setting in early psychosis where I'm trying to drag people back into the clinic? And think about how decisions are made now about delivering care virtually versus in person. What works well about it? What needs to improve? So we'll take the next five minutes. Talk to somebody you've never met before and talk to them about virtual care in your setting. Okay. I think we will get started back again. And we hope you will be brave enough to come up to the mic and tell us where you're from, what kind of setting you work in, and what you chatted about with your partner today. And sorry, I should have mentioned at the beginning, the session is being recorded. Hi, everyone. My name is Brian Furlong, and I'm a psychiatrist that works just down the road from a couple of my colleagues at CAMH in a place called Guelph, which would be about an hour southwest of Toronto. And I work half-time emergency department psychiatry and half-time with an assertive community treatment team that covers both an urban area and a rural area. I had the privilege of conversing with a third-year trainee from Texas and it's as if, in fact, we shared the same world because the issues we had are totally sort of not different. I was delighted to hear about some of the wonderful practices and developments from the presentations, and I don't doubt anything that was said sort of for a moment. And I think I was saying to my colleague there that sometimes in the world I found that how you view the world sometimes depends on where you sit. And sitting where I do in the community where I practice, I think there were a number of issues that stood out for me that perhaps I see somewhat differently. One was that during the pandemic, when it came to the ACT team, the urban area was no big issue in terms of being able to access both resources and technology. But once I entered out into the rural area, I'm talking about communities that we had one patient in with a population of 75 people living in the community. The available technology was, if you were lucky, a landline. There was no cell phone access. There was no internet access. And that's the reality of life. And in a way, it's sad to be saying that in 2023, but that was the reality we were dealing with. That created some real limitations for us. Some of you will know that, you know, in terms of at least in Ontario, the standards for ACT teams pre-pandemic were that about 75% of your care had to be delivered outside the office. And so, of course, there was a large community focus. And for those in the urban area, we were able to do versions of what I've heard here, perhaps doing it somewhat differently. But the rural area was a totally different world altogether. And sort of that was one part of what I would say. I won't take up too much time. I'll say on the other side, when I sat in the emergency department doing my other part of my job, I saw something quite different that also, however, stemmed from both more so the urban area and less the rural area. I think the experience I had with the pandemic is that for many community agencies, they move to either virtual staff, and more often virtual staff with the clinicians from home. And I think an untold part of it, at least in our community, was that, boy, that had very significant negative impacts on the emergency department. And we moved from having ER wait times of 8 to 12 hours to two days and having 20-odd patients waiting for admissions and or waiting for assessments. In part because some of those patients that would have normally been seen and evaluated by clinicians in person were now, and still could have and perhaps should have been seen, instead they were redirected to the emergency departments. And that had, on some days, just disastrous impact in terms of just the overcrowding, the impact on families, the impact on staff, and the like. So I just wanted to add that piece from our end. Thank you so much for that. I really appreciate, first of all, we all work in urban programs, and you highlight a real issue, which is access to technology, connectivity in rural areas, which is a major limitation of virtual care. So thank you so much for raising that. And then second of all, the unintended consequences of this shift to virtual care can sometimes be the inaccessibility of in-person care, which is necessary in our research we found, especially in crises. And so the impact that that can have on emergency services. So thank you so much for raising those issues. Anybody else willing to share? I dropped my chapstick. I didn't pick it up. I think I earned myself this privilege. I work at Fountain House in New York, one of the 300 clubhouses worldwide made for and by people with serious mental illness. And before that, I worked for a large not-for-profit in New York City, the Institute for Community Living. And during the pandemic, we did a study of telehealth satisfaction and outcomes among the people in case management, housing, ACT teams, clinic, and day programs that we served. And about 20% of people actually said that even after the pandemic, about 80% were satisfied with telehealth, and 20% of those said they would really prefer to stay with telehealth only. And when I moved to Fountain House, my folks from ICL actually only wanted to come with me, and they would not have been able to do that if they had to travel to the clinic. So I keep them by telehealth only. And now, as New York State is driving ACT team folks back into in-person visits, I have a lot of unhappy customers, which always brings up the element of coercion, right? No, we have to see you in person now. They were perfectly happy getting lots of phone calls with us and chatting at all hours at their convenience. And now, once again, we're going back to, you know, you have to be at this certain place at a certain time. So that's uncomfortable. At Fountain House, people had a hard time with being virtual during the pandemic. They're very in-person folks that like to engage in Clubhouse, but we do have a growing virtual Clubhouse setting where I think people feel that B and D, I, J, B, you know, they really feel like we can address this issue of belonging by joining morning meditation, lunch cooking class, you know, virtual karaoke at their own leisure. So, you know, flip sides. I don't know if I should represent my colleagues too, but we all ended up being from New York. We never see each other. So we chatted, and I think it's a lot of similar experiences. Hi, yeah, and thank you for the presentation. Just so much stuff you guys were saying. It was resonating. So I'm a medical director for our health home care management program. We're at Northwell Health. We have close to 7,000 to 8,000 members at this point. Very similar proportion of SMI. And with technology, I feel like we have a certain population where they're engaging with us and our care managers, but still really difficult to get them to the clinic, despite our best efforts for in-person. And I've even been able to step in as a clinician and do some of the work virtually. With someone, they had a really not able to leave the house. So we set up the virtual visit. And coupling that with the care manager was really helpful. Because if it was a clinic that didn't know them or didn't have the same investment, if you're 15 minutes late, your name gets crossed off. No one follows up with you. And then the whole cycle starts again. But because I knew the care manager, we were working together. We were troubleshooting for about 15, 20 minutes. But then we got it to connect. And then we got it to work. So I feel like that's another kind of opportunity. I also had a question for you guys, because again, coming from New York, and sort of post-pandemic, a lot of services not recovering and people feeling disjointed and kind of doing worse. We have a lot of challenges. San Francisco having a lot of challenges. What are you seeing kind of on the other side and what kind of path forward to getting folks better? I'll say we just opened our mil-use space up again about three months ago. And people trickled in slowly. And I think I felt, as the medical director who had sort of shut down our clinic early in the pandemic, pretty guilty about, oh no, are we not recovering in this post-pandemic era? But now it's bustling. And it's nice to see familiar faces. Unfortunately, we've lost a lot of people in the pandemic, as Dr. Mitsubishi was saying, but we are seeing people back on site now and re-engaging more. So I'm hopeful. I'm hopeful that we'll get some of that in-person back again and some of our connections back again. And using the technology thoughtfully, but not replacing our in-person interactions. Any additional thoughts from the panel? Got to share the microphones. I think the question is always, for whom and in what ways is technology useful? And also knowing that each person may be on a journey shifting on that, right? For many, I mean, 80, 20, right? Like there's that breakdown of, it sounds like 80% were happy with technology and 20 wanted to still remain using it. And I think maybe it's one about clearly assessing that and understanding why somebody may be more interested in technology. Is that a good idea? Maybe it's actually good to be in-person for some folks at some cadence. I just feel like we're trying to figure this out. And this is a rich moment in that way. And there isn't a single solution for every person and we have to be really open. Unfortunately, systems tend to work in a way that's a lot more blunt. But those of us who are in this field who are ultimately looking at each individual, I feel like actually the care of people with serious mental illness is personalized care. It has to be personalized. And we have to be thoughtful about that. So yeah, that's my thought on what recovery looks like. It's not coursed out. But I do think that some technology is important. And I really, really, really think that our clinics need to be more technologized and to really be able to gain that without necessarily meaning that all care is to be based on, has to be telehealth by any means. And I mean, there's a whole story here of all the challenges that we encountered in creating an app and doing all those things, which maybe some of you kind of are familiar with. And then there's also this question of, are we doing this, you know, like, basing care on an app is not, is not gonna be the one way to do this. That's the bottom line. Because I feel like we need to have multiple pathways, right? There are so many people that we're trying to serve who will not be able to use an app. It's just not possible. And we have to be clear on that. But there are some people who will. And that's kind of interesting. Do we have one more person who's willing to share what they spoke about? Or we could move to questions for the panel. Any other reflections from the group? I don't want to monopolise the room, but given that there's a short list behind me, I will say that one of the issues that struck me from our end is a lost opportunity, and this is just one that occurred to me on reflection of this last sort of several years. So people in the audience won't know that the small city that I live in is immediately adjacent to a city that is probably the chief technology development city in Ontario, if not Canada. And at the end of the pandemic, one day I had joined a health fair to see what new was happening in the region, only to discover that there was a project that would have been near and dear and very beneficial to us that had got installed at the technology end of things, because the developer could not and didn't know how to access healthcare providers to see if this piece of the technology would have been helpful. What it was is a method for administering medications at home, where in essence a piece of equipment would go into the home and you could get one, two or three days' supply of medications at the home, and then depending on the timing of the medications, there would be a message that would come back to the clinician about if the patient had taken their medication or not. Now, you may say, well, wait, in my previous comments I was talking about lack of cell phone reception in the rural areas, but we also service an urban area. Had we been able to work on that project and use that technology in the urban area, it would have freed up manpower and resources that we could have done more work in the rural area. So, we were at a disadvantage. The technology developer was at a disadvantage. It was like never to twain should meet, only to find it was stalled, and yet had we been able to come together earlier, what a great opportunity it would have been. Thank you for that. I think you raise one of the really kind of critical ingredients in creating virtual technologies, digital technologies for people with serious mental illness, which is engaging people with lived experience either of having mental illness, their family members and providers, and that those collaborations are really essential. I'm just going to, as we close, highlight some of the themes that we heard in the presentations. So, first of all, the theme of not reinforcing barriers, and that was so critical in the pandemic. The quote from the social worker who directs the program about that kind of feeling of desperation early on in the pandemic, that these services need to be low barrier. I heard a few examples of physical resources coming from philanthropic funding, and so I think that's really interesting, and suggests the need for, and then I also heard about a program that was funded, lost its funding. So funding is obviously crucial in terms of continuing to deliver effective virtual care. So we just had a question from the audience about how our various programs went about securing devices for for patients to use. Could you speak to that? So this was just at the beginning of the pandemic when we knew this was a gonna be a big crisis and being a part of University of California San Francisco is hugely privileged position. We have some fairly well-established donors who are willing to really just just spread their resources and so just got a big grant and got a think a bunch about 200 flip phones that was the first donation and an additional bunch of tablets and you know like hot spotting equipment and those kinds of things. And then we and then as the crisis kind of continued there was another foundation that came forward and was willing to help us and it was like a one-time grant to really actually initially help us with the situation that that was going on in San Francisco where there were these hotels commercial hotels that were being converted into residences for folks who are homeless and were considered to be COVID vulnerable and we got this grant essentially to help settle these clients were in these residents and then over time it became apparent that this was a really short term fix and we needed to think about how to suffuse technology into ICM that became our new project and so we use those funds to like purchase new equipment and in the end what we ended up purchasing was cell phones for our staff. Ourself our staff who are you know assertive community treatment providers did not have cell phones because you know we were you know funded by contracts from the city and we didn't we just hadn't had that resource so it's a huge influx of resources there that's really helped us because you know like what we realized is like giving equipment to clients is great but first doing that for our staffing was like even more critical. Our staff will go into the community and actually do kind of do a session with the clients in the community with their primary care provider or their court appointments and those kinds of things and so it you know that's so we decided that that's where the resources ought to go. I think if you're asking about specifically which kind of equipment we chose for each thing it was more like what does the client need and for what use is it and then and selecting the equipment. We did try to develop a tool matching algorithm so what we realized is that some of our clients suffer from tremors for example and so a touch you know like touch a touchscreen is not really the best equipment so maybe a voice activated item. They are you know assistive devices out there that are better suited for some of our clients maybe with cognitive disorders can't remember passwords right and so it's like what we're developing and we've thought about was like how do we get the right tool to the right hands and write the right sort of training to the right people. So that's a that's a separate project that we're working on right now. That's a great theme also the importance of personalizing the tool, the resources, the training. We had similar experience at our hospital at the Center for Addiction Mental Health. We had a donor fund purchasing of tablets for the inpatient units. We had cell phones and SIM cards donated by some of the big telecom companies and we also purchased cell phones for our case managers who didn't have cell phones until that point and now text message with clients all the time. So a couple resources just to highlight and so the SAMHSA resource guide that was shared, the digital health equity framework which I think captures a lot of the themes we talked about. What was really interesting is that our clinic in a different country also uses Jabber, also uses Rightfax. So I do not work for these companies but I think that what's important to highlight is having options for voice over IP and digital fax because for some reason we still use fax in health care and that's not going to change anytime soon at least in Canada. And from the comments again we heard the issues around connectivity in rural areas, some of the unintended consequences of the shift to virtual care, the risk of reinforcing coercion. I think that was a really important point when you bring people back in person and say like well we're really going to have to see you in person after saying we can only see you virtually for three years. You know that messaging really needs to be thought considered carefully. And lastly of course the personalization of care being so important. So and then just wanted to highlight for people that SMI Advisor has a number of resources that deal with both high quality provision of virtual care but also some of the funding issues that we did not capture today. Okay so I think what we can say is that virtual care can be adapted for effective delivery for people with serious mental illness. We heard about some of the relevant considerations particularly digital health equity considerations, importance of digital literacy, assessing literacy and access to technology and digital belonging, the organizational infrastructure, assessment and training. So just want to thank our panelists today. Thank all of you for your attendance and your active participation. I know we're at three o'clock but we can hang around for questions for a few minutes after and and thanks everyone.

virtual mental health care

serious mental illnesses

post-COVID-19

Nicole Kozloff

technology training

nonverbal cues

telehealth

financial resources

GAIN project

rural connectivity

digital literacy