Hello, I'm Dr. Jacqueline Moss Feldman, MD, a member of the Scientific Program Committee for the APA Mental Health Services Conference. It's my honor today to facilitate this session, Community Leadership and Frontline Care. How do coalitions between different disciplines work together to effectively advance patient care and address social determinants of care? Given the prevalence of intersectionality within social determinants, leaders in multiple disciplines, not just psychiatry, who are engaged in frontline care must work together more effectively than in the past. Our expert panel of speakers today will offer their thoughts. Let me briefly introduce them. Our first speaker is Ken Thompson, MD, who lives in Pittsburgh. He graduated from Kenyon College and Boston University School of Medicine, where he was a National Health Service Corps scholar. He was a resident in psychiatry at Albert Einstein College of Medicine and did a postdoc in mental health services research at Yale. He's been faculty at Yale and at the University of Pittsburgh. He was the director for medical affairs at the Center for Mental Health Services in SAMHSA. He's the chief medical officer of the Pennsylvania Psychiatric Leadership Council and a policy and advocate organization. Hello. My name is Ken Thompson. I'm a psychiatrist in Pittsburgh, Pennsylvania, and I'm very, very pleased to be part of this panel on community leadership and the frontline. In particular, I'm pleased to be doing this with Jackie Feldman, who I've known a long time, and with my fellow colleagues on the panel. I look forward to the conversation that comes out of this. Community leadership and frontline care. I'm going to talk about primary health services and public health. I'm going to try to talk, actually, probably from a relatively high latitude, or not latitude, about these topics, because I think the opportunity for leadership and development is quite high, but we have to figure out where we're trying to steer ourselves to go to. First I'll talk about primary health services and then public health as two issues. As you notice, my title was called Becoming Primary Health Services and Becoming Public Health. The long and short of this is that I'm going to suggest that psychiatry needs to stop seeing primary health services as something that is other than what we do in psychiatry. That's going to mean some changes in what primary health services do, but also how psychiatry thinks about itself. The same thing is true for public health. These are, in fact, disciplines in which I'm suggesting psychiatry needs to become part and parcel, so we don't actually see a differentiation when we talk about these ideas. Talk about primary health services first, and I'm going to give you a little bit of background to myself, may help understand some of my perspective. My father was an internist. My mother taught history, and I was interested in becoming a physician, and really for a long time struggled between primary health care, primary medicine, and psychiatry. Obviously, I ultimately decided on psychiatry, but it was with some duress. At the time I went to medical school, Alma Alta, the Declaration of Alma Alta had come out and it was pretty clear that the move towards developing health services that actually helped people be healthy and helped people be less ill required primary health services. I had the opportunity while I was in medical school to spend some time at the University of Edinburgh looking and trying to understand the National Health Service in Scotland, and had the opportunity there to go with a psychiatrist from GP practice to GP practice in her course of work, and saw the possibility for psychiatry and primary medicine to really become part and parcel of an overall public primary health service. I then did my residency in the Bronx and was exposed to the social medicine program at Einstein and its vision of whole person primary health services and what was then called community oriented primary care. So I've come at this with a real background in primary health services. My wife is an internist and runs a federally qualified health center, which will come up in the story a little bit later on. Throughout my career, I've worked in primary health settings as a psychiatrist and as a primary health provider. Things moved along, particularly in this area with the new Freedom Commission in the early 2000s, and subsequently after that, SAMHSA, which I at that point was the medical director for the Center for Mental Health Services, became very involved in the federal work group on behavioral health integration into primary care. So at that time, this movement to, quote, integrate care was really just in its beginnings. And we organized a number of conferences and started to work on a variety of approaches to both address reverse integration, meaning bringing primary health services into mental health services, as well as to continue to work with the Health Resource Service Administration, HRSA, to build mental health capacity in primary medical settings. This continued, and as you've just heard or will hear from Amir, the rise of behavioral health integration into primary medical care has really become quite substantial, particularly after the ACA, the Accountable Care Act, and the recent Recovery Act. So there is funding to do this. Money is going into this in FQHCs, and I'll talk about that in just a second. But I want to say that for the most part, while psychiatry has been involved, and we've actually, the APA has gotten funding to do trainings in the collaborative care model, psychiatry has had a significant problem identifying itself as a primary health service provider. There's a little history here. Initially, the federal government considered primary care to include five different medical branches. One of them was internal medicine, pediatrics, family medicine, no surprises there, OB-GYN, and psychiatry. Unfortunately, at some point, I'm not exactly sure of the dates of this, sometime in either the 1990s or 2000s, psychiatry decided that it would be better for its identity to be considered that of specialty alone, and actually decided to no longer consider itself a primary health specialty. I personally think this is a colossal mistake, and I'll say some more about that in a bit, but we continue to have a kind of an odd relationship with primary health services as a result. Now, where has this come to for me right now? I actually work in an FQHC, and as you'll hear from LA, or if you've already heard from LA, depending how we play these out, I'm engaged in what I would call the fusion model. This is not about integrating behavioral health into primary medicine as though primary medicine was the host and we were sort of a guest. Actually, the way we practice in our federally qualified health center is that we are taking care of a whole person. Whole persons present with medical and psychiatric challenges. Both of those need to be addressed. We address it in whatever way we can. If the primary medical person can address it, they will. If the primary psychiatric person needs to address it, they will. And we work very closely in teams with support, particularly around basic needs, making sure that people are housed. A term I prefer rather than social determinants of mental health when you're talking at the clinical level, basic needs is a key element of the fusion model. But the important aspect I want to get across is that psychiatry can be and should be in the primary health space as not a guest or not as an add-on, but as an integral part of primary health services. I think the epidemiology of psychiatric challenges in our society supports this. And I think the fact that there is a clear utility in having folks have their care coordinated and linked together is at this point, I think, is pretty obvious. So with that fusion model in mind, I'm working with something called the Pennsylvania Psychiatric Leadership Council, which I'm the medical director of. This is an organization that came together in the state of Pennsylvania about almost 20 years ago to ensure that we had really good public service psychiatry in the state and to support our... At that time, we had three. Now we're working on possibly having five centers of excellence and fellowships in public service psychiatry. So that PPLC has become really involved in advocating for primary health services in which psychiatry is a key building block and foundation. And we've partnered with other organizations to create something called the Coalition for the Common Health, which is an overall state initiative to support whole person primary health services being developed across the state. This is being modeled... We're doing this at a state level. At the federal level, the Primary Care Collaborative and Primary Care for America are organizations which are pushing for primary health services as a key foundation of the building of a renewed American medical care system. And I want to go from there to talk about where we are right at this moment. In May, this report came out, Implementing High-Quality Primary Care, Rebuilding the Foundation of Healthcare. This is from the National Academies of Science, Engineering, and Medicine, the old Institute of Medicine. I highly recommend that folks look at this document and consider it very in detail. It is really important that I think psychiatry begin to think a little bit more deeply about its relationship with health services and primary health services in particular. We have made a lot of hay saying that there is no health without mental health. I think that's very true. However, there is no mental health without health. And the idea that we would have really, really good mental health services, and particularly community mental health services, without having extraordinary primary health services is, I think, highly unlikely. In fact, what I would suggest is that psychiatry and psychiatric care is a foundation of primary health services. And we need to see ourselves as that, and that psychiatry must come to see primary health services and our engagement in them as the key to our serving the nation. In the future, I envision that there will be primary health services that are available to folks, whole person, based on meeting both medical and other social needs in a way that is timely, expeditious, effective, and useful, that promotes health and well-being, and helps people recover from illness. And I think that's going to be a critical part of our work and our connection and participation in primary health services. So that's primary health services. Now I want to talk a little bit about public health, a whole other realm, maybe, but related. Again, I've talked a little bit about my background, but I want to talk about it in a little more detail around public health. As I said, in medical school, I had the opportunity to go to look at the National Health Service in the UK. And at that time, I spent time at the Usher Institute at the University of Edinburgh, where I was there when something called the Black Report came out. This was a report that documented some of Michael Marmot's first work looking at how illnesses were distributed in the population in the UK, particularly using data from the Civil Service and categorizing people by their social class. And what he found was the key finding, the most important finding, the continuing finding that we have with regards to health equity. Folks who have the least resources have the highest level of health challenges, and folks who have the most resources for life and their endeavors have the least troubles with health concerns, and that's a stepwise function. So it's not like it's just people who are poor and then everybody else is the same. It's actually a step ladder. And that report came out. It was immediately sequestered by Maggie Thatcher. It had been commissioned by Labour, but Maggie Thatcher had come into power. So I saw a bootleg copy of it, and it has forever changed how I understand how health is distributed. Because remember, in Britain, everybody has access to primary health services and to the National Health Service. So health services themselves are not the thing that drive the health status of populations. They contribute somewhat, but not all that much. I also had the opportunity to go to Einstein in the Bronx for my residency, and I was exposed there to lots of people who were engaged in the original community mental health movement, which was a public health initiative in large part. Folks like Len Dool, who moved on to conceive of the Healthy Cities movement. Steve Goldston, who really built the community mental health centers. Gerald Kaplan, folks may know as sort of the father of community psychiatry. And Seymour Saracen, who was a psychologist at Yale, who really kind of conceived of populations of communities and the role that psychology and psychiatry can play in that. So I'm steeped in health inequities. I got a foundation grant from the Soros Foundation to look at health inequities. And at the time, well, I'll come to that in a second. I then was able to go on to SAMHSA, where we were able to start a conversation about the inequities in mental health, which weren't entirely tied to access to mental health services. Again, remember, what drives inequities in health status and mental health status is largely not related to health services or access to health services. It's related to the conditions and circumstances in which people live. And over time, I've had the capacity to work in old industrial cities, which have really been challenged with inequities in health. Pittsburgh and Glasgow with support from the Robert Wood Johnson Foundation. And in all this, what I've come to understand is that, you know, the United States, we really struggled with this. For many years, I would try to talk about health inequities. And what I got back from most folks was, well, of course, we have health inequities because people don't have access to health care. And that was particularly true. It was particularly true before the ACA. It's still not completely untrue. But it's only been recently, maybe in the last five to 10 years, that people have begun to understand that it isn't health services and health care per se alone that makes people healthy. It's the circumstances that they live in that really drives this. So we've moved, I think, to health inequities as a concept from health care disparities. That's a good thing. And I think it allows us to start to think a little bit more about the circumstances that people live in. And that then drives a more public health approach, not purely a clinical approach. In addition to that, in the UK, I was exposed to this concept, particularly when I spent time there during my Soros funding, to the idea of social exclusion and inclusion, which is another angle. We usually think about race, class, gender, all those things in a sort of intersectorial approach. A larger element within society is the way in which we exclude populations in various ways and in different kinds of ways, and in ways in which we include them as a driver of what kind of resources they have access to and to what kind of opportunities they can take advantage of, and what kind of toxins and negligence and potentially even straight out oppression they get exposed to. Those have been really kind of key concepts to begin to think about what you do to address that. How can you move a society to be more inclusive? This has been fueled by the deaths of despair. This is a topic, you know, in psychiatry, I think we've only just begun to start thinking about this, although it's been publicly sort of talked about for almost six years now. It's been six years since Angus Deaton and Anne Case came out with their initial report. This was a report which demonstrated that we were seeing a historic event in the fact that the longstanding decrease in premature mortality and the longstanding increase in life expectancy had been reversed. Particularly for white Americans, at the time the study first came out, white Americans who did not have a high school education, a reversal in the decline of premature mortality and a reversal in the increase in life expectancy had never happened in recorded history in the United States, except potentially during the flu, the Spanish flu. It may have happened again in addition with COVID, but it was happening even before COVID because of a triad of illnesses or deaths related to opiate ODs, alcohol and alcohol use and suicide. And these are all, by the way, psychiatric challenges and call us not only to be concerned about the high level of disability, which is the general problem that psychiatric illnesses present, to actually being concerned about mortality and morbidity in a kind of very profound way. So the deaths of despair as a social issue and as a public health issue really defies a very psychiatric clinical approach. And I began to work and have been working with the Brookings Institute with some folks there around thinking about what kind of initiatives could be designed to go to the communities that are in despair to help people move out of despair or not get into it in the first place. That goes beyond simply doing the provision of clinical services, which we believe are the provision of clinical services, which we both don't have the resources to do and are not always as effective as we need them to be. So what are the things that can be done at a larger level? Part of that work has led me to be engaged in a recent effort to bring something called integrated community therapy, which is a large group dialogic method coming out of Brazil that takes anywhere from 10 to 50 people in a room and helps them develop emotional literacy and social solidarity and emotional solidarity and actually uses community to become a form of therapy and social support. And in a society in which we are fragmented and particularly during COVID time, this particular mechanism is something that can be done on Zoom. So this and I think other approaches that help reweave a social network and a web of social support are the kinds of tools that psychiatry, if it was thinking from a public health perspective, might begin to think about investigating and developing. All of this has come to a head with President Pender's special task force on the social determinants of mental health. And psychiatry is now being called to really think hard about how we are going to relate to the living conditions and the circumstances that people that we are caring for and who are not yet our patients and if they did not have things in their lives happen to them or if they were not exposed to toxins or social challenges might never happen to them. So how do we think about moving to prevention, to the promotion of health and mental health and well-being, the concept of salutogenesis, what makes people healthy? By the way, this is very much tied to the concept of recovery. What helps people recover is not merely the treatment of their disease. That, I think, is a very old-fashioned psychiatric perspective. What helps them recover is as much a discovery of what makes them healthy, not exactly the same thing as treating disease. Further, what kind of healthy public policy or health in all policy can we as psychiatrists begin to help society imagine and pursue? And I'll give an example of this. Last spring, Congress passed a child tax credit, which is an affirmative tax credit. You don't have to claim it. It comes to you. And it is a significant amount of money for each child. We had a poverty rate among children of somewhere around 20 percent. Probably, that is the best indicator of the likelihood of further psychiatric and other health challenges of any social indices that we could imagine. And anything that reduces child poverty is actually practicing good health and psychiatry good health and psychiatry long before people are ill. So in some ways, reducing child poverty is like practicing geriatric psychiatry in the 22nd century. We're reducing the number of people who'd be showing up ill 100 years from now, among the kids who are presumably going to be able to live that long because they're no longer living in poverty. This particular tax credit was passed for one year. I don't know what psychiatry and organized psychiatry has said about this as of yet, but I can't imagine a more important public health initiative for us to support and for us to be very vocal about it. Similarly, there are initiatives now to promote healthy communities and place-based initiatives in which I think psychiatry, and in a public health sense, a psychiatry that imagines what it is that helps people be healthy, a psychiatry that helps people build and connect social resources and social networks, are really critically important parts of how we begin to move our society out of its extraordinary inequities based on social class and race and that we begin to imagine a society in which the kind of psychiatry we all want to practice is a psychiatry that supports and promotes health and well-being for everybody. As with primary health services, psychiatry must grasp its future in public health. What we need is vision, leadership, partnership, and everybody to do what you can. Thanks. That's my email if anybody has any queries that they can't get answered in the course of the questions during this session. Thank you. Our second speaker is Dr. Rochelle Head Dunham, MD. She's an addiction psychiatrist who currently serves as executive and medical director for Metropolitan Human Services District. Dr. Head Dunham is assistant and associate professor at Tulane and LSU, respectively, and was formerly Louisiana OBH assistant secretary, state commissioner for mental health and SSA, director for addictive disorders. Named a physician champion for the state of Louisiana, she is a thought leader and strategist on systems level change. Her visionary impact to our communities is progressive, transformative, and health justice informed. She will speak on community leadership and cultural anchoring of frontline care. Hello. I'm Dr. Rochelle Head Dunham, and it is my pleasure to share with you thoughts around community leadership and cultural anchoring of frontline care. This is a very important topic that we are speaking to this morning because it speaks directly to the importance of putting in place in community-based service delivery, services and programs that address social determinants of health that serve as a complement to our traditional primary behavioral health services for the people that we care for. And so who are we? Metropolitan Human Services District is actually one of 10 local governing entities created in 2003 by the Louisiana State Legislature for the provision of behavioral health and intellectual and developmental disability services to our local designated parishes. Behavioral health individuals are served in our parish who are underinsured or uninsured, predominantly Medicaid-eligible individuals who meet the criteria for a mental illness and addictive disorder or an intellectual developmental disability. Our staff represents the largest complement of licensed and certified behavioral health and IDD professionals, and contractors also work with us to serve our geographic areas. Our mission and our vision is listed on the screen, but we pride ourselves in ensuring person-centered supports and services to our designated eligible population. And our vision is always, always and forever expanding the core of our agency and enhancing our partnerships. So how do we do this? Our methodology really is trifold. We center ourselves around person-centered care because we recognize that the people we serve are truly partners in serving our communities. We practice person-centered care by working with individuals to ensure that they are making informed decisions. Decisions aren't being thrust upon them, but they are very active in choice and decision-making about how we can provide our customized services to meet their needs. So we employ choice to empower them. We share decision-making processes. We also collaborate and reciprocate, and we also adapt needs, interests, and preferences to the individual. The second prong of that approach is culturally relevant services. At the end of the day, it is important to acknowledge that we have multiple cultures within our world, and all of them are beautiful and perfect. However, if we dismiss the cultural differences for our groups of people, then we miss our capability to get great outcomes in the service and delivery system. And so diversity, equity, and inclusion within our agency is uttermost. And then finally, we like to use data to drive our decision-making in order that we can achieve the best in the delivery of the best practices for our population. So that's who we are, but who do we serve? We serve adults and children ages 0 to 65, as well as their families. And our designated parishes are New Orleans, Plaquemines, and St. Bernard. And I'll tell you more about that in a minute. But no one is denied access to services due to inability to pay. Again, Medicaid is, and Medicare are the primary insurers of individuals who seek services. So you can come uninsured, indigent, and we will sign you up. Most of those people meet criteria anyway. For IDD, your insurability is not, or your income is not important. It is that you meet the state criteria for those services and supports. And we have a crisis line that's in place 24-7 because crisis really is the name of the game at this point, I think, in the world. And certainly with our populations vulnerable, crisis care is important. But our single point of entry allows for ease of access because people only have to remember one number to gain entry into the world of services at Metropolitan Human Services District. Demographically, just to give you an idea of how we look. Now, this is a composite demographic, but we have six different sites that we operate services out of. And there's a little variability in the other areas that are not in New Orleans. But overall, 69.1% of the people we serve are black or African-American, 21.7% are white. And then the other demographics are listed as such without as much specificity, which is something I think we need to correct. But there we are. And so that's also represented by the pie graph, which shows the number of people who are in those categorical areas with 5,600 people being African-American. And then by gender, almost a 50-50 split in terms of gender. We have made some adjustments to how people can respond to their gender so that it can open up the door more to LGBTQ communities or communities that don't identify as male or female. Another demographic representation is by age. 065 is our age-inclusive group, but the largest percentage are between 21 and 64. So about 80% of our people are adults, 20% are child and youth. Our parishes are represented. And as I indicated, 86% of the people we see are in the New Orleans area, which is a pretty large, complex, complicated metropolis. And then in terms of the person served by count, these are the various locations of our clinics. And we have roughly 6,000 or so adults in our care, unduplicated, and 1,400 child and youths. So how do our providers look? We're talking about culturally relevant services. Then we have to recognize the impact, and we do, of intellectual-cultural mirroring of those served and those who serve them. And I think that this is very important that our providers look like the people we serve because there is some natural ability to connect to the more complicated, non-diagnosable conditions that people represent with that have to do with living and negotiating life on a daily basis. And by having the cultural balance there, it assures that we're able to understand because much of what people are talking about is relatable on some level with the people who are in our own lives. And so this is what we look like demographically in terms of that mirroring reference where 66% of our providers are African-Americans serving a 69% African-American population of individuals. And the other numbers look similar as well. 11% providers are white, and 22% of our persons we serve are white. And then 19% chose to not identify themselves ethnically. And within our population, we have about 6% of that percentage as well. So selecting the right people to work for our agency, given its own culture and the emphasis that we place on very specific things that have to do with the disenfranchised. We require strengths and competencies for the position that are specifically oriented in that direction. We do look at people's prior employment to see whether or not they've been acculturated in this way. And these are questions that we ask to make sure that they're a good fit. We do prefer career-oriented employees, even though we are a state civil service agency, our idea is that you should never leave any place the same way you came. And so our intent is to make people better at who they are. And this is what our numbers look like. We average seven years and three months on the 10-year line. And for retention, we're at 90%. Our benchmark is 90%. We've been meeting that for years. And we actually have had, we have a very low turnover rate with the benchmark being 12% and we're at 10%. So staff training is clearly a priority in order to maintain this type of environment. And what we've done is we have included within our training series, which runs throughout the year, is provided by various members of our team, the psychiatrists, psychologists, as well as our attorney and our director of quality and data. They all are part of our training or staff team and our staff are able to get CEUs, but there it's an annual requirement of six hours of training on subject matter that speaks specifically to frontline care, which is the complex mix of social factors as well as diversity and equity challenges. And so the list is there. It's not an exhaustive list, but things like trauma-informed care, being able to work in a multicultural environment. Suicide is a big, big deal. It's a growing problem in black and brown communities. And of course, trauma is a big deal, but we've also spent a lot of time working on how to effectively work with the LGBTQ community, particularly since we want to make sure that our agency is available to everyone who meet our basic criteria for those three disability populations and that they feel comfortable that our staff is capable of delivering unbiased, equitable services. But the clinical services are only a component But the clinical services are only a component of what we prioritize. There are a number of services and supports that equate to really addressing the needs that are not necessarily amenable to medication and psychotherapy, but are amenable to connecting people with the right supports that are addressing major components of their quality of life. And that's where those social determinants become really, really important and many times are allowed to progress because we don't see them, we don't plan for them, we don't prioritize them. There are a number of ways in which we demonstrate priority in this area in order to address those needs. So the first is very early when I came to the organization, I created what's called a Resource Coordination Unit, and that is two to four staff whose only job is to route and traffic calls and requests that come in through our central line specific to needs that are not pharmacologic, not core clinical needs, because every need is not met with a prescription, right? So we make sure that the people we are serving and their families, our clinic managers and staff, our treatment teams at all of our clinics can rely on current and informed knowledge from our non-MHSD specialized services and external supports that enhance the holistic care the person served and better addresses their social determinants. And so things like housing, things like I am not able to pay my rent this month because I lost my job. We have funding that's available to support things like that. I can't purchase school uniforms for my kids. I just don't have the money. We can provide those types of services. Where do I go to find out about how to get another driver's license? That kind of information is critical. What can I do about being homeless? It's important to take the medication and to come to the psychotherapy sessions, but it is more important to have a roof over your head. And so we recognize that, and we spend time through this unit making sure that we can assist people in any way we can, and we keep a current list of resources available so that our staff can access it. The second thing that we do in our programming that I want to highlight is that we provide flexible scheduling. You know, the pandemic really did activate everybody to an appreciation of telemedicine. It has always been a very valuable way of delivering services, and the year prior, we had begun to transform our system such that we'd be able to meet the needs of that population. And that was really driven by the fact that there are so many people who are uninsured, who are having jobs that are minimum-wage jobs, and they just cannot take off to come to a clinic that is open from 8 to 430. It's just not reasonable. And so it is our responsibility to make ourselves available to them so that they can communicate, inform us, provide the information we need in order for us to help them. Telemedicine is one of the ways that you can do that very, very easily. But we also have a walk-in policy wherein you can come at any time to receive services. And now that we have that paired with tele, it really does mean you can get services at any time. But some people want to be face-to-face so they can elect to come in clinic for services. And the whole purpose of this is empowering them with choice. Too often in behavioral health, decisions are made by the professionals, including when you come for your next appointment. What we try to do is undo that and ask people more. When do you want to come? And how do you want us to serve you? And then we create our system of operations that allows for that kind of flexibility in support of a population who doesn't live on a clock that we live on on a regular basis, whose predictability in life is often not very predictable, nor do they often feel in control of much of what's happening to them. The other thing we've done is appointment reminder system because we really do want to meet them how they are. And how they are means that they don't always have a phone. They definitely don't always have, our population doesn't always have access to the Internet. And so this system allows for communicating up to 10 days prior to the appointment and then periodically leading up to the appointment in multiple different ways. The system also, however, allows for those persons serve, the benefit of having the opportunity to express their opinion so they can give us feedback. I can't make that time. Could you schedule me another time, et cetera, et cetera. They also use the system to evaluate us because it really is a dyadic situation in a clinical scenario. And so the opinion should be dyadic as well. And so we really appreciate their feedback and we incorporate that feedback into our provider data monitoring reports. Another specific feature that we have in our system being mindful of the population we serve is valuing tremendously the role and the power of peer support. And so we have a peer support specialist who are frontline public health workers who have lived experience. And those experiences are used to support others in their journey to recovery. They are one of the first faces that people come into our service delivery system meet. Many people are much more comfortable with somebody who has walked in their shoes, if you will, as opposed to somebody like myself. With all my credentials, it means nothing if you cannot develop a rapport and you don't trust that I understand. And so recognizing that, we absolutely have the value of a peer on board in everybody's case, especially if they want it and desire it. And so it centers around recovery-oriented, person-centered care. And all of these things listed are the ways in which they are impactful in people's lives over the course of their care. And another way that we use peers and recognize the complexity of our population is through putting in place targeted efforts to help people transition from one level of care to another. We know in behavioral health that the greatest opportunity to lose someone to care is when they transition from one level to the next. It could be a higher level, like hospital care to outpatient care, or it could be from outpatient to hospital care. And so because of that, we have incorporated with person-centeredness at the core an opportunity to have a peer support specialist at our number one site for admissions for behavioral health to shepherd that person warmly into service in our care centers. We also have someone in the emergency room and on the admission floors working with the hospital consultation liaison staff to identify people who have opioid use disorders and or other substances to help shepherd and route them into outpatient care with us. That's a critical, critical component of taking care of a population such as ours because that level of connectivity is often not available to them. And so we personalize it in such a way that the peers are constantly in contact with them and making sure that their needs are met as they leave from one level of care and attempt to regain or initiate care at the community level. So that's some of the unique features of our services, but what about our partners? Because we really could not do this without them. And so there are a couple of partnering opportunities that we have created over the course of the recent years, but we have done quite a bit of partnering over time. That's core to our vision, building those partnerships. And so I want to share with you a very nice partnership that is specifically targeted to social determinants of health, and that is with the Healthy Blue Medicaid plan. There are five plans that are contracted within the state of Louisiana. All of them are required to look at performance projects with the various entities across the state. This is one that is specific to the Healthy Blue plan, and it is targeted around, as I said, SDOH and integrated collaborative care. And this is their data sheet, which serves as the basis for the six pilots that they have engaged around Medicaid, patient population, and Louisiana is particularly targeted because of the data that's represented here. Relative to other states, Louisiana is likely to have behaved differently than other states with regards to Medicaid populations as well as the chronic care conditions. For Medicaid eligibility, one in three Louisianans are eligible, which is a huge statement about the income status of Louisiana. And then one in six Louisianans have a chronic care condition. So those numbers compare in the shaded blue in the table for Louisiana to the other six states that are involved in this pilot project, with us clearly leading the pack in terms of Medicaid percentage of population and population with chronic gaps. So when you have that data, it is important to put in place efforts that target and select out that population and wrap around it supports that make sense in terms of increasing their chance of good outcomes in care. And so we have created a workflow and navigation incentive project that looks something like this. And without going into any detail, what I want you to just pay attention to is that we've got multiple components of our care engaged in this effort with the Medicaid plan, social workers or licensed clinical staff. That resource coordination unit I mentioned is a part of this, key, key part of this. Those peers are very, very much a part of it. Our care center, which is our single point of entry, is the intake zone for this. And our navigators involving that particular navigator who's at the hospital is involved as well because there's a special reimbursement rate for those navigator services. And then, of course, we have referrals through our service delivery system as well as in non-metropolitan sites for services. And then, of course, data reporting is key because at the end of the day, it's going to help measure the success of the project and also hopefully inform changes that we can implement into our service delivery. And this is what their integrated collaborative care model looks like in terms of the codes and the professional services, the time units, and the rates. And as you can see, these professional services are services that are specific to people who meet criteria for social determinants of health. And this is an enhanced rate that they allow for us to bill for some services that are not traditionally available to us for billing. And so this project is newly initiated. We're about eight months in, no, about six months in, and so we're very excited about this collaborative effort. The next collaborative effort I want to mention to you is the New Orleans Behavioral Health Council. We've been members of the council since 2015, but it is a collaboration aimed to bring together providers and advocates from across the entire spectrum of behavioral health community in our area to facilitate coordination of behavioral care, to advocate for policy change in behavioral health care, to influence funding in behavioral health care, and to also engage with the community. And seated as chairs are myself and the New Orleans Health Department Director representing our agencies, but representing the mission and focus of this particular collaborative effort. And these are the priorities of the council and the goals. And without reading them to you, I just want you to note that we are interested in long-term strategies to plan for behavioral health improvement across and within agencies. We also are very much interested in sustainability with that change across those systems. We recognize through this collaborative that data is important. And so data sharing is difficult within behavioral health because of some of the limitations of 42 CFR on the addiction side and also HIPAA in general, but we are working around it through that. And it also serves to improve the community health of people with mental and behavioral challenges. It's a sector-based organization wherein the core is led by, I think there's a team of eight at the core, all of whom are from one of these four surrounding disciplines or sectors. And so the sectors are based upon needs that people present with. We all know that there is the medical component and the psychiatric component to behavioral health care. So health and hospitals is represented, but we also sometimes miss that housing is a huge factor in behavioral health stability. And so there's that component and people who are involved in that sector. Education and the education system, the impact of behavioral health needs on families and children at the educational levels is very important. And so we do have a component there that works collaboratively with the school system. And then of course the criminal justice system, I can't speak enough about the high percentage of people with behavioral health issues that are actually involved in the criminal justice system and why it's so important that we be actively involved with that sector in making sure that those needs are being addressed and that people are being diverted, more importantly, away from the criminal justice system into direct behavioral health care. And this is just an at-a-glance snapshot of some of our partners, just to give you the depth and breadth of involvement in this behavioral health council and these various groups are represented in those various different sectors on the previous slide. And then the last collaborative initiative that I wanted to just shed light on is our newest one, which is our Train the Community Mental Health First Aid Collaborative. This collaborative is comprised of a group of mission-aligned stakeholders from public health, our agency, which is behavioral health, and also our local national mental illness agency to train all local families, businesses, agencies, and organizations on mental health first aid. The goal here is to enhance the well-being of our community, independent of race, ethnicity, or socioeconomic status. The importance of mental health first aid is that we are living very much in a crisis-driven society, unfortunately, and the behavioral health world of professionals, as we all know, will never ever be able to wrap its arm fully around the need. And so we really do need the community to be able to step up as a result of being trained on what to say, what to look for, how to intervene with their own family members, as well as with others in order to help us get in front of the mental health crisis that we are living in today. And so that is the third of the three collaborative initiatives I wanted to mention. And having said that, I appreciate you for listening and for your time, and I'm looking forward to the Q&A section of this discussion. Thank you so much. Dr. Amir Ahuja, MD, is a director of psychiatry at the Los Angeles LGBT Center. He is also president of the APA allied group, AGLP, the Association of LGBTQ Psychiatrists. He has a private practice in Beverly Hills, California, and Little Silver, New Jersey. His book about LGBTQ intimate partner violence will be out in late 2021 or early 2022. He will speak on integrated care challenges and successes in an LGBTQ clinic. Hello, everyone. This is Dr. Amir Ahuja. I, as Dr. Feldman mentioned, I am the director of psychiatry at the Los Angeles LGBT Center. I want to thank Dr. Feldman and Dr. Head Dunham and Dr. Thompson for being with me on this presentation. I'm going to be talking about integrated care challenges and successes in an LGBTQ clinic. I want to make sure that we cover some aspects of integrated care here, and the other presenters have been generous in giving examples of this. What I'll be doing is talking a little bit about the mechanics of integrated care and also how we implement it at the LGBT Center. The Los Angeles LGBT Center was started in 1969. It provides services for more LGBT people than any other organization in the world. We have over 700 and now really 800 employees, and we count about over half a million client visits a year. It's a lot of people of contact with our clients. What we'll be talking about in this presentation is mostly the services that we provide in terms of health and mental health care. However, we also do social services and housing, leadership and advocacy, and culture and education, which are more outward-facing services. As we can see, the social services and housing relate to our integrated care. The rest of it is more advocacy and fundraising and other things like that. One way I think about integrated care and what I wanted to structure this presentation in is that there's really four steps to implement integrated care. Anyone interested in trying to get more integrated care in their facility would probably have to follow these steps. I thought it would be helpful to see this in terms of those four steps. There's really the vision of what integrated care is and why do we want to do it in the first place with behavioral health and primary care in particular. We need a needs assessment after that of why is there a need for it and what gaps are we trying to fill with integrated care. Then the implementation, of course, and then the quality control. Again, we've already had mentioned some talk about the quality control or all of these steps, really, but the quality control, too, in terms of data that we use to determine whether it's working. We'll get to that at the end. In terms of what we're talking, and of course, there's lots of ways to integrate care, but in terms of what we're referring to or I'm referring to in this presentation is really substance abuse treatment and mental health care being integrated with primary care. That's the model that I'm talking about. What I'll start with is why integrate. The statistics are pretty overwhelming in this area, which is why we're so concerned about integrated care. It's an overwhelming 50% prevalence of mental illness and substance abuse with many healthcare clients. Because that's such a large part of what any doctor is going to see or any facility is going to see, it's important to integrate because we don't want to ignore something that's in half the population. Medical and behavioral health problems have a bidirectional negative effect. That means that, as we all have seen, I'm sure, with our patients, that chronic pain makes depression worse, for example. Depression makes cardiac health worse in studies. Really, both ways, there's a negative impact of having one condition on the other. Also, only 50% of behavioral health issues are treated by specialists. Largely, primary care doctors are treating this. We need to know first when they need to refer to a specialist, how can they be supported in caring for mental health, especially when there's just a shortage of mental health providers. We know in the pandemic, mental health has been a huge issue. It's gotten worse for many patients. More and more people are showing up to their primary care with mental health issues. The other thing is that serious and persistent mental illness causes lifespan to decrease by 25 years overall. I think, really, this is a huge concern in terms of, just in general, the fact that anything that can decrease your lifespan by 25 years is huge. I think it's a multifactorial issue, but that doesn't mean that it's a medical problem for primary care, for specialists, because these people with SPMI, we call it, are really disproportionately engaged in medical care and need medical care and for a variety of reasons are not living as long. That's really important. That goes to the next point, that the rates of medical illness in those with SPMI are higher than the general population for all categories of illness. That means heart disease, cancer, diabetes. There's disparities in almost every condition. That's why it's really important because all specialists and primary care doctors are going to see these patients. They're going to see them worse than their counterparts who don't have SPMI. In terms of the aims of integrated care, why integrate, again, is the question. There's a quadruple aim, really. You want to have an improved patient experience. You want to have better health outcomes, as we're talking about. You want to have an improved staff experience, which we already heard talk of, that retention is better, satisfaction is better. You also want a lower cost of care. You don't want to duplicate all the things that you're doing because multiple people not communicating means you're going to be repeating studies. You're going to be repeating labs. You're going to be doing the same investigations over and over. That does cost more money. That's just one example of the cost savings. One thing I wanted to mention, again, is to expand on what I've said about the health issues. There's particularly this four modifiable risk factors with a higher prevalence in behavioral health issues. There's tobacco use, substance use, as we know from our patients, poor diet, and a lack of physical activity. All things that are a huge issue in our populations. There's poor health care, too, for many people with serious and persistent mental illness. That could be from stigma. People don't necessarily do all the tests that they need to do because these patients are not reality-based or they don't trust what they're reporting or those kinds of things. Behavioral health symptoms also reduce compliance and patients' ability to self-advocate. There's a lack of specialists in general. There's a chronic stress and economic hardship, which is very key among SPMI patients. Independently, we've seen that those things cause disparities in health outcomes anyway and mental health outcomes. Even if you didn't have SPMI, just that alone would cause those disparities. You have this multiple compounded reasons to have disparities. In order to combat this, there's been legislation that has been passed to encourage people to have integrated care. As we heard mentioned, some of the insurances are now trying to create codes and pay better for integrated care. It's another incentive. It's trying to incentivize these things. There was the 2008 Mental Health Parity and Addiction Equity Act, which required many insurers to make sure that they cover mental health on an equal footing with physical health. Also, in the 2010 Affordable Care Act, there was Section 2703, which supports the creation of medical homes. In 2016, the 21st Century Cures Act, Section 9003, is encouraging integrated care and gave up to $2 million in grants for organizations that were willing to pursue integrated care. Some of the other stipulations in that bill are in this graphic. Mainly, it was... There's multiple things in the bill. It strengthens the suicide prevention hotline, crisis intervention, and we've talked about crisis. Those kinds of things. Also, funding to fight the opioid epidemic, streamline the process to approve medications that are life-saving for people. There were some other aspects to it and some directly related to mental health, but this was the one that for this presentation in particular is important. Once you do the vision part, we have these... Why has been answered in some ways. The needs assessment is, what is the current structure? Is it disjointed? Does it take too long? Is it inefficient? Is it not enough, inadequate? What are the really needs that we're talking about? Then the who of it is, who are we trying to reach? That goes to the where as well. Where are we? Are we in the South? Are we in an urban area? Are we in the West? Are we in rural areas? Is our population high socioeconomic status, low socioeconomic status? Do we have a lot of undocumented people? What are we trying to... Is it racially diverse? Which minorities are we talking about? Of course, LGBTQ people, what's the population like there, where we are? That's important in terms of identifying which populations we're trying to work with and what are the needs of that community, which could be very different depending on where you go. What expertise do you have at your disposal is important to know what can you offer. First, to know what you're trying to recruit for as the administrator of a facility, but also for a center like ours, but also what do you have right now that you can offer? At our facility, we'll go into how it works at our facility, but we have certain expertise that that we can give and some that we don't. We have to know your limits too, and again, try to improve on those. In terms of implementation, what are the parameters of integration? We talk about each of these areas, what are the traditional models and then what is the integrated model version of that? In terms of the mission, is a case based as a mission or is a population based? Is a financing fee for service or global payment for the whole like a wrap rate as we were talking about? At the center, we're doing global payment, so they pay us for the full service of that person in many ways, or if they pay for a site visit, they're talking about the social workers and the front desk staff and the whole service that we provide. Is the administration and budget unified? Is the space, instead of being exclusive, co-located? What does that look like in COVID? Are the records merged? Is it an interdependent team? One thing I thought was interesting is seeing this. The role of the psychiatric consultant really comes into play. That was on a global level, what does integration look like? In terms of a psychiatric consultant, what does it look like? I'm somebody who has a private practice and who works at the center, so I basically do both of these. There are advantages and disadvantages to each. We're not always saying that integrated care is better in every metric. I think it is better, but I think that there are some ways in which there's a benefit to traditional mental health. There's individual case-based care versus population-based integrated care. Is our constituency the patient or is our constituency more the community plus the patient plus the primary care doctor or the team? Is it comprehensive versus episodic care? I think one of the differences in a traditional mental health setting is it is dyadic, just within two people. Dr. Haddon was talking about the dyad of the community and the whole center, but when we talk about it, we just really mean one person to person. In a traditional mental health setting, you really get small panels and you're able to delve really deeply into that care and the confidentiality is higher. Those are particular differences. In integrated care, you do sacrifice some confidentiality because there's a team looking at these notes, and in particular with psychiatric stuff, psychiatric issues, that can be negative to some patients, but I think in general, we can all be on the same page. Also, there tends to be larger panels and shorter-term interaction with these patients because it's a team effort. A lot of you can see more people and have more of a panel there where we all work together. Again, sometimes in certain situations, the traditional mental health, maybe some people prefer, but in general, for our purposes and to serve a community, we're talking about integrated care being superior. Now, in terms of, like we said, basically 50% of the behavioral health patients are being seen by primary care, so we really have to support those primary care doctors by integrating because they're really seeing a lot of these patients and they don't have the expertise always to know how to handle things. What we want to do and really the latest data that we have as psychiatrists, we have a stepped model here where basically levels one to three are more primary care alone supported by intervention briefly by a behavioral health consultant. That would be more step one would be your traditional depression, maybe one medication, that kind of thing, very stable versus as you go up, obviously, the psych needs get higher. By four or five, you're really talking about a consistent intensity of psych symptoms that require an integrated care model. Then by five, you're really talking about them seeing an independent psychiatrist or even on the same team, but also being followed by psychiatry. Then really being even referred out at times to an integrated, to a more intense model, so inpatient, IOP, detox, rehab, that kind of thing. In terms of the LGBT Center, I just wanted to give you an idea of what are some of the joint programs we do where this comes into play. I know Dr. Haddanum had a great graphic of exactly the workflow of how it works. It's pretty similar for the LGBT Center. In terms of certain programs, I just wanted to say where do we work together in terms of this, where does the overlap happen, where we're always working together or where particular issues come up that really need integrated care. One is medication assisted treatment. It is funded by a grant from HRSA, our program. We have primary care providers. We have the peer navigators that were spoken about, that really are people who walked in the shoes of our patients. We have the enrollment specialist. We have therapists and psychiatrists. We do biweekly meetings, case conferences, and same-day enrollment for that program. One of the advantages of that is doing the same-day enrollment where you really have, in the morning, they come in, they see the therapist, they do an intake, they see the primary care, they see a psychiatrist, and they leave with Suboxone or some type of medication. You get a full one-day workflow, which I think is really convenient. As we say with these patients who are difficult to follow up with and sometimes have chaotic lives, it's very effective to get people onto medication. Whether you're using buprenorphine or you're using methadone or naltrexone, or what your choice is by the end of the day. We'll go into successes and challenges at the end. I just wanted to get through a couple of these. Then in terms of the integrated clinic protocols, another one where it's a joint partnership with the Los Angeles County Department of Mental Health. There's one general meeting a week and one billing operations meeting a week. Their primary care providers are involved, primary care nursing, case managers, therapists, and psychiatrists. There's weekly case conferences on that as well. This is more of a wraparound service, and it has integrated care. It's a model for people who have chronic mental and physical health issues and more intense case management for those patients. There are grants available in this program, in particular for moving costs, for equipment, durable medical equipment, all those kinds of things, even phone bills, things like that, just to keep people supported and connected to our program. That's one of the models that we use. The last step would really be the quality control. How do we decide if this is working? Obviously, we talked about the data already. There's a lot of joint meetings, a lot of communication that is involved with this. There's also regular supervision of psychiatric and medical providers that allows us to make sure that everyone is really honoring the integrated care model, they're really communicating well, and we create more opportunities for them to do that. Again, some of the opportunities are here as well. A lot of other joint meetings that we do, all of these are multidisciplinary meetings. We talk about MDCC a lot, which is multidisciplinary case conferencing. We do the staff meetings, P&T committee meetings. We have a C2 prescriber work group meeting that specifically talks to the prescription of benzodiazepines and opiates and stimulants. We have a specific protocol for that. We have a team pharmacy, as well as medical and psychiatric that works on the protocols around that. We really try to integrate as much as we can in terms of the protocol side of it and also the administration side, as well as the care delivery side. How does the communication look, especially in terms of the pandemic? We do run Cisco Jabber throughout the day. We have ad hoc meetings all the time, really, approximately at least once every other week, but mostly a lot more often than that. We have a health services meeting with psychiatry that's biweekly. At this point, we have a psychiatric operations meeting that's also monthly that, again, we talk about what kind of ways can we make the care delivery better in terms of workflow. We have obviously email and the Follow My Health patient portal as well. We're not really in person that much anymore, but again, as we get back in person, there'll be a combination of this and the in-person care delivery. Some of the successes of our program that we have increased psychiatric volume by four times. Now, we have over 2,000 patients in psychiatry. We have increased compliance. We have better outcomes for patients and higher provider satisfaction, as we said in the quadruple aim, what were we trying to do. Now, this model is being used for diabetes, for, as we said, controlled medications, et cetera. We're really trying to replicate this in terms of what we've done in certain areas to all of the areas of care in particular, but we certainly have integrated model in general, but this more targeted specific models, I think, are very helpful as well. Some of the challenges, and we've gotten better at this, the injectable medications, we now are really, we've gotten ramped up with that, so that's working. The challenges are still there, really space limitations when we're in person, and the overlap of responsibility that can create gaps. One thing that it really requires good communication is when we can all prescribe medications or when multiple people on the team can do the same thing is that we don't duplicate that and we're able to, when certain conditions come up, turf it to the right person or make sure, okay, psychiatry will handle this or medicine will, so that kind of is really important. So, yeah, that basically is the presentation, so definitely I, like the other presenters have mentioned, I thank you all for letting me present here, and I definitely am looking forward to the Q&A session, and, yeah, I'd be happy to answer any questions more specifically about how the LGBT Center does things or how people can implement this in their own facilities.

community leadership

frontline care

collaboration

social determinants of care

psychiatry

primary health

behavioral health services

person-centered care

integrated care

mental illness

LGBTQ population