Good afternoon. My name is Susumu Shrinka. I serve as Chief Medical Officer for the City of Philadelphia's Department of Behavioral Health and Intellectual Disability Services. We are honored to invite you to participate in this workshop this afternoon, titled Integrated Care and its role in reducing disparities. Now, in the era of COVID, I think we're all aware that there has been a significant uptick in demand for behavioral health services. We also know that COVID has laid bare the historical disparities in access to care, as well as in outcomes of all kinds of care for among minorities. And so this is an opportunity to discuss the potential for integrated care, which is an evidence-based model of treatment that has been shown to result in improved outcomes over standard treatment. Our panel is comprised of distinguished scholars, thought leaders, experts in this field, and will be giving us a pretty thorough overview of integrated care from various perspectives. Leading us in will be Dr. Lori Rainey, who is a psychiatrist and the owner of Collaborative Care Consulting, a national expert on the collaborative care model and the bi-directional integration of primary care and behavioral health. She's also an editor of two books on the subject, Integrated Care, Working at the Interface of Primary Care and Behavioral Health, and Integrated Care, a Guide for Effective Implementation. Dr. Rainey was a founding member of the APA's Committee on Integrated Care and has worked for many years to promote the implementation of this highly effective model of care. Dr. Rainey remains active in clinical work and has turned her efforts to working with another underserved population the Utah Mountain Health Center in Colorado. Our next speaker following Dr. Rainey will be Dr. Madja Jackson-Trish, who will be speaking on the promise of integrated care and its application in multiple systems, including the VA and other countries. Dr. Jackson-Trish is a highly accomplished academic leader and currently serves as the Assistant Vice Chancellor and UCSF Health Executive Advisor for Diversity, Equity, and Inclusion. She is a Health Sciences Clinical Professor of Psychiatry in the School of Medicine at UCSF and prior to this role served as the Vice Chair for the UCSF Department of Psychiatry, as well as the UCSF Health Vice President for Behavioral Health Services. Dr. Jackson-Trish has been named a winner of multiple awards and other honors, including in 2020 the UCSF Excellent Physician Award. She's extensively published as a researcher and has served as a reviewer for several journals. And our third speaker will be Dr. Hu, who is going to be presenting the work that she's done along with several colleagues around a systematic review of the collaborative care model and its outcomes in specific populations. Dr. Hu is an early career psychiatrist slash trainee who will be, in addition to presenting her work, will be sharing the perspective of how to effectively train residents and fellows in the integrated care model. She's currently a first year Child and Adolescent Psychiatry Fellow at Duke University, having completed her residency training at the Cambridge Health Alliance and Medical School at the University of Rochester School of Medicine. And so I will hand this over now to Dr. Rainey to lead us in. Dr. Rainey. Thank you, Dr. Soyinka, and welcome to everyone to this presentation today. We're really glad to be here. My role today is to give a brief overview of integrated care, and then we have great speakers that are going to go dive a little bit more into how it can work in diverse populations. Next slide, please. So I want to end, you know, and give a little bit of that background is just to remind people that when patients come into primary care, they don't separate their head and their body. They come in with all kinds of different chief complaints. If they come to see me, it's, Dr. Rainey, I'm depressed. Can you help me? But in primary care setting where we do the integration, folks come in with all kinds of different things. And you can kind of see some examples here of horrible stomach pain that might get worked up for ulcers, someone who can't get up in the morning. Maybe it's my thyroid. I wonder what's wrong. A man recently widowed who doesn't say a thing when he walks in about what's happened, but it pops up in other parts of the interview. A woman who's having a couple glasses of wine daily and thinks that's probably okay. You know, just some kind of common chief complaints that might come in in the primary care setting. If we go to the next slide, what we might end up with after we've seen them, we've done some really nice screening with PHQ-9s or GAD-7s, is we end up seeing kind of a different picture, right? Maybe our 67-year-old man has some distress that's going on, not necessarily diagnosable, but definitely some distress we might be able to address. Turns out the lady was drinking a couple glasses of wine a day. She's actually doubled the NIAAA safe drinking limits. We've got substance use disorder that needs to be considered. Turns out the guy with the 19-year-old with the stomach pains, he's in college and when he stands up to give a presentation, he gets really anxious. His stomach's hurting and he has social anxiety disorder. And then it turns out the woman that can't get out of bed, her TSH was normal. She doesn't have anemia. All her other tests were negative. Turns out on her PHQ-9, her score was high. And even someone with uncontrolled diabetes is coming in with a behavioral issue that's impacting their diabetes. If you look at the next slide, what you see is there's all kinds of ways to address these presentations in that primary care setting. The distressed person, maybe we do a brief intervention. Maybe just the PCP talks to them or maybe they have them speak to someone for a few minutes. The lady with the substance use disorder, maybe we have someone, a therapist or someone come in and do some motivational interviewing with them. The gentleman with social anxiety disorder, high GAD-7, maybe this is someone we can track and treat, have them in the registry, do something like the collaborative care model with them. The same with the woman with depression with the high PHQ-9 score and also with the person with diabetes, maybe there's some brief interventions, some motivational interviewing a behavioral health person could do about adhering to diet and exercise. So all kinds of different things. There's all kinds of things we call integrated care. These presentations can really go in lots of different ways. If we go to the next slide, what I want people to think about is what are these buckets? When we think about stepped care for integration, really at the very tip is specialty mental health services. Long before you get there, there's PCPs providing first-line treatment for a variety of behavioral health stressors. Then there's the PCP might receive some ad hoc consultation. Maybe you've got the mental health person on-site or off-site providing ad hoc. It could be a psychiatrist doing a curbside consultation or a behavioral health consultant who's actually in their clinic. You can have that support now by this on-site behavioral health person. In things like the primary care behavioral health integrated model, that's what the PCPs have. They have these folks that are literally in their clinics and are available for all kinds of consultation on brief interventions. Then if you go up to step four, a subset, these are all subsets of the set below, a subset of those people that are getting that support by the behavioral health provider, maybe they're appropriate like we showed in the slide for full-on collaborative care team and doing the collaborative care model of integration. Then for people in primary care who aren't appropriate for any of these four, those are the folks that we actually refer out to specialty mental health. Now you can see if this worked really well, we would end up reducing some of those referrals out to specialty mental health and really free up that workforce. Really think about all the different ways we can use integration is so important to this model. Even at that first line level of the PCPs providing treatment, how do we train them with things like Project ECHO and other things? Next slide please. When I think about integrated care, I really think about blended model. How do we blend all of these? If we have the resources, actually how do we blend them? Collaborative care is something I know a lot about. I teach about collaborative care but I also understand the primary care behavioral health model and the ways it could contribute to some of those other presentations that we saw in that previous slide. For collaborative care, we're talking about something that's much more measurement driven. We have a registry. The psychiatrist is reviewing that registry. I'm going to show you a few pictures of that in a minute. In the PCBH model, we have that ready support to patients and PCPs for a variety of things going beyond just who you might serve in the collaborative care model. You can see some quotes here from PCPs and others in primary care clinics who actually have access to both models and they're blending them. The reason I point out this slide is sometimes there's competition between this model of integrated and that model of integrated care. This is the psychiatrist model. This is the psychologist model. There's all kinds of stuff that goes on in my mind. The only model I've ever worked in is a blended model. If you've got the resources, it's fabulous to be able to do both for all those categories of patients we saw earlier. Next slide, please. When I think about effective integrated care, we always talk about these core principles. Again, all models of integrated care, they're team-based and most of them are doing evidence-based approaches. They're doing motivational interviewing, behavioral activation, those sorts of things. What sets the collaborative care model aside is really measure-based treatment to target and having a registry so that it can be systematically reviewed. I think all models of integrated care could actually benefit from these core principles. It doesn't necessarily have to be just collaborative care. I think if PCPs use PHQ-9s as routinely as they use hemoglobin A1Cs, that there would be a market improvement in their treatment even if they weren't doing the whole collaborative care model. Next slide, please. I just want to stress this a little bit, what I just said about around PCPs and others measuring care. This is actually the study that changed the care that I did as a psychiatrist. This came out in 2015. Basically, they gave psychiatrists. In this case, it was a Ham-D. Even for us, we think we know that people are getting better, they're well, but when they gave the psychiatrist, and again, in this case, the Ham-D, now we'd probably use the PHQ-9 tool, people got better faster and they got to remission faster. There's none of us, even those of us with the most training, we can really benefit from a tool. I was so happy when this came out because I put a PHQ-9 on the bench outside of my office, good old days, paper, pencil, and clipboard, and everyone did the PHQ-9 or the GAD-7 or whatever the tool was. This is actually the study that changed my practice back in 2015. Next slide, please. If we think about effective care, then here we go. We have this PCP being supported by, if you're in the collaborative care model, they're called the behavioral care manager. If you're in the PCBH model, they're called BHCs or behavioral health consultants. Right there at the elbow, a little old-fashioned, my slide's getting a little dated with that paper chart, but the lady in the red shirt is there supporting the PCP, seeing the patient in the exam room. This is just kind of a wonderful thing to be able to do, and then backing that PCP up. We're behind the scenes really helping them with measurement tools, psychiatric consultation, registries, and even training, making sure people are trained in integrated care before you start throwing people in the clinic and hoping for the best. Next slide, please. When I, you know, I like to kind of think about this as a continuum of care then, and the one thing I want to stress about this slide, you know, is that patients tend to go one way. When you get to behavioral health, you never come back, and we have to stop doing that because we have a crisis in the behavioral health workforce in this country right now, and I really want to stress to people that get what treatment you can in primary care. If you can do BHCs, behavioral care managers, do these brief interventions, and it works for the person, and they get better, great. If you have to refer them to either short or long-term specialty care, when they get stable, send them back to primary care, and preferably sending them back to primary care where there's integration in case they need some tweaks. In particular for psychiatrists, we have a lot of patients sent to us, we treat them, they get stable, and then we continue to see them for the next 10 to 15 years, refilling the same dose of medication or maybe a few tweaks. We like to keep a few easy patients in our schedule to help us with, have a little downtime with all the maybe people that need more services, but I want to say to folks this should be a two-way street. When the patient's stable, send them back, and if you can send them back to a primary care clinic that has integration, it's going to make it even better. Next slide, please. Actually, just to say that for that on that last slide, this is really true also of step down from inpatient psychiatric care. Adolescents, it's really hard to get a child psychiatrist. They'll often step back down to primary care after a suicide attempt, something where they've had a short stay in the hospital. They'll actually step back down to primary care, and what a great deal if that pediatrician had both a behavioral health person and either a child psychiatry access line, a child psychiatrist who was there, or they were doing collaborative care and had access to a registry around that. Next slide, please. Again, you're using your tools, right? You're using your measurement tools to say, is this the right kind of integrated care for this person? Are they getting better? If you're doing integration and the person's not getting better, your population's not getting better, then you need to switch it up. You need to really rethink what you're doing. This slide kind of demonstrates measuring change over time for someone that's in an integrated care program. This is sort of classically the collaborative care model, but this should really be done no matter what you're doing. If you're doing the PCBH model and you're working with a person with diabetes to help change behaviors around exercise and diet, the question is, did their A1c drop half a point? Yes or no? I'm going to measure change. If you help someone with tobacco cessation, how many people did you help quit smoking? If you help someone with sleep hygiene, did they sleep two hours better a night? Just really kind of think about measuring what we're doing in integration, and if we don't, the biggest problem we have in integration is payers don't want to pay for it because they can't figure out what the value of it is. If you look at a slide like this, here we have, we could absolutely show this to a payer, to a clinic, to a patient, the kinds of changes that we can get in an integrated care program. If you look at this, two crucial data points are, in the case of depression and anxiety, a 50 percent reduction in PHQ-9 scores at 6 and 12 months, or remission. Depression remission at 12 months is popping up all over the place now as a performance metric. Medicare ACAs, Medicaid ACAs, qualified health centers now have depression remission at 12 months as one of their required measures. That's really starting to pop up everywhere. You're not going to get there if you're not constantly measuring and changing treatment if the person's not getting better. If you look at this list, you can see who got better. The green is anyone that had at least a 50 percent reduction. You can see a few remissions, PHQ-9 less than 5, and you can actually see who's getting worse and who's not getting any better. We need to do something different. What this shows you when you can visualize it, you can really see who's not getting better, where are the care gaps, and what do I need to do next? Also, no one falls through the cracks. If I got you on a list, good luck, because I'm going to be able to find you, call you. You're not going to just disappear because you no-showed for an appointment. Next slide, please. This measurement piece is really important. When we think about how this works for psychiatry, remember that slide before where we showed the psychiatry doing consultation and the registry review? If we do those pieces, and most of you probably know that the new collaborative care code is not so new anymore. We call them behavioral care managers. What we end up with in primary care is these behavioral care managers. They're actively treating patients with brief interventions. The patients that are getting better are the ones the psychiatrist is reviewing, and then the psychiatrist is giving the PCP and the care manager tips on what to do, recommendations, advice on what to do next. All of a sudden, you're a psychiatrist. I think we have a workforce shortage for psychiatrists is what I'm told. I absolutely believe it. It's a national problem. If you do it this way, where you've got that backup and that review of the registry, all of a sudden, a single psychiatrist in an eight-hour day can cover about 300 patients, keep track of them, and see what's going on. There's a lot of bang to the buck with integration with certain models. Next slide, please. It's really a great role for psychiatrists. Then remember, I talked earlier about really kind of what those measures should be. This is actually a whiteboard outside of my office in one of my tribal clinics. They just all did it by hand, what the alcohol screens, depression screens, what the clinic goal is, how each provider is doing, are they hitting their goal or not. I just love it. These are the kinds of things we're going to get paid for now and in the future, performance bonuses, value-based payment. We have to be ready. If you're doing integration, think about it. It's not just screening patients. You do have to screen them to find them. That's one of the first process metrics on this list. After that, what happened? Right now, there's been a whole lot of focus on screening. You have to intervene. You have to be able to say, did the person get better or not? Once we screen, what did we do and did that work? Did you follow up with the care manager? Did the psychiatrist review the registry? if they did, did they make a recommendation? Did the PCP implement the recommendation? And then those quality metrics I told you about before, these are national quality form. These are needed metrics. These weren't just made up. These have a real – they're clinically significant response and remission. We also want to look at things like patient satisfaction and functionality and PCP satisfaction and total cost of care. Those are all great things, too. But these hardcore outcome metrics, I think, are really super important in terms of demonstrating whether or not our integrated care worked. Next slide, please. There are CPT codes for collaborative care if you do everything. So if you look down at the bottom, outreach and engagement to the patient, that's a person that's screened positive. Assessing them, you keep administering that validated tool. Once a month at a minimum, you've got a PHQ-9. You're putting the data in the registry and the psychiatrist is reviewing it and you're tracking. And you're doing like setting a behavioral activation goal this week and following up on it next week. So you're doing those evidence-based brief interventions. And most of you that have been looking at these codes, they're based on minutes, 70 minutes the first month, 60 minutes for subsequent months with some add-on codes. They're based on the time that's spent by that behavioral care manager. They offer pretty good reimbursement and 20 states of Medicaid agencies are now reimbursing the codes. So we're almost to an all-payer model for being able to do measurement-based care and psychiatric review and registry. It's really kind of cool what's happened with these codes. And we're really seeing quite a bit of uptake on them at this point. Next slide, please. I just want to end with, since we're talking about diversity in this presentation today, is that I have been working with the Indian Health Service and Sister Skye on 12 grantees at tribal clinics across the country who implemented integrated care in tribal clinics. And you're going to hear a lot today about how there really is a sense in diverse populations that there's quite a bit of uptake in acceptance of integrated care. There's a lot of sometimes stigma. And I work with an American Indian population. There's quite a bit of stigma around behavioral health. They would actually call the hall down to behavioral health the walk of shame, that kind of stigma. And to be able to bring the behavioral health services into the primary care clinic has been profoundly effective and outcome-changing. These are the first grants ever for integrated care with the Indian Health Service. And it's been a privilege for me to be able to work from Alaska across the, mostly in the west where the reservations are, to be able to work with these tribes on integration. So from a diversity standpoint, I've been quite impressed with what integration has been able to do. Thank you very much. Thank you, Dr. Rainey. And we will proceed to the next talk, which is by Dr. Madja Jackson-Trish. And she will be speaking, who will be speaking to us on the promise of integrated care applications in other countries and systems, as well as I think a pretty unique perspective on how our colleagues in primary care view and implement and work with these interesting models. Dr. Jackson-Trish, over to you. Thank you very much, Dr. Sayenka, for that really nice introduction. And thank you, Dr. Rainey, for your introductory overview of collaborative care. And now what I'd like to do is talk about a little bit about the evidence base for collaborative care to reduce disparities and inequities. And you'll find in the literature, when you begin to read it, you'll see it's sometimes called collaborative care. It's sometimes called integrated care. Functionally, they both mean about the same thing. And if people ask some questions about that in the discussion part of our talk today, we can give a little bit more detail about that. So the next slide. So what I wanted to do is not sort of busy up the slides with all sorts of references. Most of the references, in fact, all of the references to the talk that I'm going to give today are in the article that I and two of my other co-authors wrote. It's published in Psychiatric Clinics of North America. It was in 2020, the September edition. And it was talking about achieving mental health equity, collaborative care. The article was a review of the literature, sort of a rapid review of literature to try to see what the evidence is for collaborative care reducing inequities. And I hope you'll see from the talk today that we're building a robust evidence base for it. The next slide, please. So some basic principles, which I think it never hurts to go back over again because sometimes it gets lost a little bit in the conversation. But health equity is the principle that holds that optimal health is a human right. And that elimination of health disparities, and I've added including mental health disparities, is a society's ethical responsibility. And I can say that again, it's a society's ethical responsibility. So next slide. So there's growing evidence for the efficacy of collaborative care as a model to really reduce the burden of mental disorder and illness. It's been systematically evaluated in randomized controlled trials and has shown to be more effective than usual care for improving quality of care and outcomes in the following conditions, depression and anxiety in adults, including those with comorbid conditions and substance misuse. And in the beginning years, we wondered about that with, if it would help with comorbid conditions. But in fact, we're finding that that's really definitely the case. Depression in seniors has definitely improved. And a lot of the work that Juergen Unnser has done has shown that. It's a good model for depression in adolescents. And there's early evidence, very, very early, only a few articles showing that collaborative care principles may work for serious mental illness because it's being studied in schizophrenia. And there's great promise here. So the next slide, please. So here are some of the early studies, and you'll see they go back to 2000. The UCLA RAND Partners in Care Study. I was also involved in that study. It's a randomized controlled trial of collaborative care for depression in primary care. And it was one of the very early randomized controlled trials. And what we found in looking at African-American and Latinx patients is that both groups had improved quality of care for depression. We did enhance a lot of the education for primary care doctors and had consultation available for them and found that it really was a definite improvement in the general quality of care for depression. There was improved mental health quality of life at both the two-year and five-year follow-up. The intervention clinics showed greater improvement in African-American and Latinx clients than non-Latinx white patients. And that was actually a surprising finding. And we weren't exactly sure why that was, but it showed great promise. And then at the 10-year follow-up showed that racial ethnic patients in the intervention arm that facilitated cognitive behavioral therapy had significant improvement in mental health related outcomes compared with care as usual. Again, I said, this is one of the early studies. And so people were very surprised about cognitive behavioral therapy and that promise. But of course, the years since then, we have found that cognitive behavioral therapy is really quite an effective treatment and for many groups is a first-line treatment of depression. So next slide. So just continuing, the next study I'm going to talk about is the Improving Mood Promoting Access to Collaborative Treatment, the IMPACT study in 2002, which studied older depressed adults. And that found that collaborative care had roughly equivalent benefits for racial ethnic groups compared to whites. This was a really important finding because it showed the equity that could be achieved, meaning that you could have roughly the same equivalent benefits. And there was some question about that at the time of the study in 2002. A recent systematic review of interventions to improve initiation of mental health care for racial ethnic groups have found, number one, increased rates of initiation of treatment, and that's for both medication and psychotherapy in four of the seven studies of collaborative care compared to care as usual. Now, when I say care as usual, I mean that there is not a collaborative care model. The people come in and see their primary care provider and disclose or are found to have a disorder, and then they're just treated as usual. We found enhancing with collaborative care made a very big difference. For Asian Americans, there's growing evidence of effectiveness of collaborative care in general medicine clinics, including those with culturally sensitive strategies. There was a question at one point whether routine care and collaborative care that didn't focus on culturally sensitive issues, whether that would be as effective, but it was found to be equally effective. There's great promise in indigenous Native American groups and where studies are showing growing evidence of effectiveness of collaborative care in general medicine clinics, including when used with culturally sensitive strategies. Also, there's similar findings in VA. One of the comments I'd like to make is that the VA was one of the very early adopters of the collaborative care model and actually had pilots that started in the 1990s about integrating psychiatrists into general medicine clinics. It wasn't as developed as what you see with the AIMS Center in terms of how it was structured, but we also found at that time that some of the comments that I'm going to make about primary care docs really enjoying having behavioral health people in the clinics were found at that time from the VA work. The first one was called the Pilot Ambulatory Care and Education Project, and then it became the Ambulatory Care and Education Program. It was at the VA at the San Fernando Valley, which is a UCLA-affiliated VA. A lot of that work in their articles by Lisa Rubenstein and others, and some of those are referenced in the article that I mentioned to you. We also found similar findings in non-English-speaking populations with the use of interpreters. You can see that I think it's going to become, hope it will become, a standard model of care as we move forward. Okay, the next slide. Now, one of the caveats about all of this good news is that there's one study, Prevention of Suicide in Primary Care Elderly Collaborative Trial Study of Collaborative Care for Depression. They found that the intervention that they did, the prospect study, was more effective for white than other racial ethnic groups. That's something that we need to keep in mind and try to figure out why in this particular study that we didn't get an increase in equity among those groups. We'll have to look at that. That's being studied as we speak and will be a future thing that we'll need to follow. Okay, the next slide. Other collaborative care work that's informed by the CC framework or the collaborative care framework. This means that it's not the formal model that you see with AIMS or the models that Dr. Rainey talked about, but they've taken elements of collaborative care and worked with that, and those are also showing promise. In Los Angeles, there's a witness for wellness project and study. This was led by researchers from UCLA. Dr. Kenneth Wells is the principal investigator in this. It was really the inauguration of community-based participatory research, and they called it community partners in care. If you remember when I talked about one of the early randomized controlled trials, it was partners in care. This was a community partners in care where they actually partnered with an African-American community and community group to bring the principles of collaborative care, using it in primary care, and also having community-based people work with the project. Mostly what happened is that the community workers would go and help what we call socialized treatment of behavioral health conditions in the community. Dr. Rainey mentioned stigma in terms of some of the Indian reservations. There also was a lot of stigma in terms of the African-American population in Los Angeles. I was involved in this study very early on and helped develop some of the patient education materials around stigma. We actually were able to involve local artists to help with that, and it was really a very successful project. Some of the people became co-authors in some of the papers written about the community partners in care. That was one model that we think shows great promise in terms of disseminating into various communities and ethnic and racial communities. Also, in post-Katrina New Orleans, and New Orleans is back on our minds again because they've had another bad hurricane, not as bad as Katrina, fortunately, but post-Katrina, there was really a decimation of all of the services, mental health services, and bringing those back. There was a lot of work to try to figure out how to get care to a very challenged population with a lot of stress and trauma. That study had found that it was really important to develop community health workers. Some of them were not licensed, but they were trained by the researchers. They collaborated with community leaders as partners in delivering the interventions, which were basically assessments and treatment. There was extensive use of non-licensed community health workers and the outcomes. There are some studies about that, and you can refer to the article that I wrote. In the interest of time, I won't go into all the detail of that, but these studies are showing great promise in terms of the use of allied health workers in a collaborative care framework. There are two international studies that have been published, one from Ethiopia. The collaboration was with training pastoral women to participate in some of the interventions. There are studies also that are coming about where I know in some of the Southern African countries, they've talked about having a mentor on the bench where they've trained some of the older women in the community, the elders who are quite highly respected, to just sit on a bench. Someone who may be troubled can just sit on the bench and talk with the person and then find out what kind of resources are available to them if they need more care. Also, in India, there's a use of lay counselors, especially for depression and anxiety, in a collaborative way. I think the model shows great promise in terms of increasing access and in helping with equity. Like Dr. Rainey, I've been involved in collaborative care for a very long time and was actually a part of that early study that I talked about with the VA, with the pilot ambulatory care and education project, and was one of the psychiatrists who was part of that team that I talked about in primary care. Over the years, I found that that partnership has been welcomed to help meet the overwhelming need to address behavioral health disorders that commonly first present in primary care. As we know, in primary care, there are significant time constraints with a relatively short visit time, 10 to 15 minutes, sometimes less than that, to explore key issues and significant issues like depression and anxiety. I know that a lot of the clinicians feel like they can at least bring that up and get some help with being able to refer to a psychiatrist to talk over some of the other issues and to get some help with direction about treatment and assessment and what the meaning of the symptoms are, and also input around medications, the best medications to start, and how to assess that. So just pretty universally, I've found that primary care clinicians are really very happy and relieved to have psychiatrists involved. The other thing that with some of the studies and also my anecdotal experience working in primary care clinics is that they really enjoy having access to timely, appropriate consultation for questions about treatment, especially when assessing treatment resistance. That's one of the ones that is very, very hard. It's hard for, you know, psychiatrists to assess that, but it's particularly hard for primary care clinicians because they're not really sure how to assess the other kind of parameters that they need to do. And having a psychiatric partner and a collaborative care framework to help them with that is really welcomed. And I found that overall, it's considered a very, very important resource. At one point in one of the clinics that I worked in, where there was an issue about funding, one of the leaders floated saying, well, maybe what we need to do is, you know, get rid of the psychiatrist. Maybe we don't have enough money to pay for them. That was before, you know, people started having the codes that we can bill for in primary care. And the biggest hue and cry came from the primary care clinicians because they said, no, this is really essential to our practice because they're actually seeing so much depression and anxiety. And they realized that it made a significant proportion of the number of patients that they were seeing, a number of the complaints that were coming in. And they felt that it was really key to have a psychiatric partner. So the next slide. So now the next, the future, I think, is in needing to disseminate collaborative care. Number one, to academic medical centers, that is happening. At UCLA, there've been some articles that have been written recently about the success that UCLA has had with implementing a collaborative care model at UCSF. We have been working with integrating collaborative care into the training as well as to the treatment in our primary care clinics. We're incorporating it into both medical and psychiatric training programs, and it's being welcomed by trainees. And there's an expanded use of technology. Dr. Rainey talked a little bit about that in her presentation, but that will help us in measuring the quality of care for all populations of patients and to expand access to behavioral health treatment for all patients as well. And I do think that that may be my last slide. Thank you, Dr. Jackson-Trish, for that very, very thorough presentation. And we'll go on to Dr. Jennifer Hu's presentation, and she'll be, again, reviewing, going over her review of the literature on collaborative care, as well as presenting the perspective of the trainees and sharing some thoughts on how to effectively train new psychiatrists in this model. Dr. Hu. Thank you so much, Dr. Sriyanka, for that introduction, and thank you, Drs. Rainey and Dr. Jackson-Trish for your wonderful input and expertise on collaborative care. So like Dr. Sriyanka mentioned, I will be talking about a couple of different topics today, the first being a systematic review that I did with some of my colleagues, and the second, a perspective on collaborative care within training. So our question for the review was, will it work for racial and ethnic minority adults? And I think both presenters before me certainly touched upon this. We were really interested specifically in looking at collaborative care for depression outcomes and looking at whether or not collaborative care was effective, particularly within primary care settings, although there have been a few studies which show that collaborative care works quite well in specialty settings as well, for example, oncology or cardiology. And Dr. Rainey already went over some of the core components of collaborative care, and that's really how we were defining it in our review. This was our crystal diagram, which I'm sure most, if not all of you are familiar with. It shows the databases we went through and the articles we eventually included. And I believe in the previous presentation and this one, there's probably a lot of overlap in the references here. Ultimately, we included 19 reviews in our systematic review, 10 of which were randomized control trials and nine observational studies. And these were all published between 2005 and 2020. Now to answer a question, there were a few different ways of comparing the effectiveness. And in the next couple of slides, you'll see how those comparisons were set up. So here, there were quite a number of studies looking at usual care versus collaborative care, both for samples of minority patients. Unusual care in this case is how we were defining it previously. Somebody presents to a primary care office, gets screen positive for some kind of mental health care and that is referred to specialty mental health care. So looking at this comparison, this is what we found. There were five randomized control trials that showed that collaborative care was more effective than usual care for minority patients in three observational studies. There were also two randomized control trials that showed no difference and two observational studies, which did not show any difference. Now in thinking about racial and ethnic minority patients, one of the questions we had that has already been brought up is whether or not there was a cultural component. And these will be highlighted in blue, as you can see here. So four of the eight studies which showed that collaborative care was more effective had a cultural component. And then three of the four that showed no difference had a cultural component. So looking at this data, we concluded that collaborative care certainly has a potential to reduce depressive symptoms in these groups. But that cultural components are likely secondary to having a really well implemented program. In this slide, there was a slightly different take on the comparison. So this was looking at minority adults and white adults, both in collaborative care and seeing who benefited more. So here we have one randomized control trial that showed that minorities benefited more in two observational studies. Two observational studies which showed no difference. And then one study which actually showed that white adults benefited more over the long term course of how long they were followed for. And I believe in this case, it was two years. Again, we were interested in the cultural component and these are highlighted again in blue. So looking at this data, we deduce that collaborative care would work just as well for minority adults as it does for white adults, if not better in some cases. But the data here is limited. There were only two randomized control trials and four observational studies. I've mentioned cultural components a few times and I just wanted to briefly go over what we mean by that. And I'll start by saying as a caveat that we did not come up with our own definition and we based it more on the original authors. These are what was considered a cultural component. And there is a very, very broad spectrum from what you can see here. So it ranged from bilingual educational materials, which some of you might not even quite consider a cultural component to more intensive interventions like having culturally adapted interview protocols, having culturally appropriate therapy and then having ethnically matched clinicians. I mentioned earlier that having a well-implemented program is most important, but this does beg the question of what does a cultural component offer? And there was one study which specifically looked at this question. It was black Americans both in collaborative care but one model had a cultural component and the other one didn't. And what the authors found was that the patients in collaborative care with a cultural component found their care manager pretty helpful at identifying their concerns and helping them adhere to treatment. And the cultural component in this study was having ethnically matched clinicians and then having a pretty broad array of educational materials that featured black patients and black clinicians talking about their experiences to try and reduce that stigma. So here we see that culturally sensitive care can enhance relationships and there is a very, very broad spectrum of what is considered culturally sensitive care. So key takeaways from our review, collaborative care intervention certainly do seem to have the potential to improve depression for this group of patients and a well-implemented program. So one that follows all of the four criteria that Dr. Rainey mentioned earlier is likely better than focusing primarily on culturally sensitive care. Some ideas for a future investigation. I think one of the big limitations of our study was we look at all kinds of demographics together. And again, each minority group is going to have their own needs. There was also like you saw a huge variety of what is considered a cultural adaptation. So certainly more research can be done on that and maybe even kind of developing a quality metric of determining the different intensities of cultural components. How do we better recruit minority patients into these studies? That was one of our observational studies actually had hoped to be a randomized control trial but had such difficulty recruiting minority patients that they ended up being an observational study. I meant to include a slide on actually the demographics represented and I apologize I didn't include it here but the majority of studies included Hispanic, Latinx and Black Americans and then Asian-American patients with a particular emphasis on East Asians actually as opposed to South Asians and then very little representation from kind of Native American, Alaskan Indian patients. So certainly more data for those that are less studied. I will also say that all of our studies with the exception of one, which was based out of the VA were majority if not all women. So certainly more data on minority men and how we can best help them. And lastly, the inclusion of virtual components especially during this era of COVID. There were six studies that included some kind of virtual feature and all of them seem to be effective in improving outcomes for minority patients. I'm going to shift gears a little bit here and just talk about collaborative care training. And this is just my perspective. I'm curious to learn about what others have implemented and experienced. There is no specific ACGME requirement as far as I know about collaborative care training. Although having a collaborative care rotation would certainly tick off a lot of those boxes for systems-based care and population-based care. So my rotation was a half-day clinic every week embedded in a primary care clinic and it was entirely virtual because of COVID. And that seemed very similar to a lot of my co-residents at other institutions. Typically a half-day clinic every week and either primary care or sometimes a women's health and OB-GYN as well. I really appreciated being able to experience collaborative care. I think that with value-based payments and kind of the changing role of psychiatrists having that exposure early on in my training was really important because it is a little bit of a different skillset collaborating with a team, providing recommendations to another physician and kind of being able to think about all of the resources that you have when you are working with that team. I would love to learn more about what collaborative care looks like as a career. That was something that I feel like we didn't get a lot of exposure to in my training. So certainly, you know, collaborative care full-time or collaborative care, you know, kind of embedded in that more inpatient, outpatient setting and a mishmash of different things. I also just wanted to highlight a few resources that I found very helpful in learning more about collaborative care. So the AIM Center based out of the University of Washington has some really wonderful modules for trainees and the APA also has their Get Trained in the Collaborative Care model as well which are free modules, I believe, that people can access to help learn more about this. And I just wanted to briefly thank everybody who was involved in the review and the study and both of my training programs for their support. Thank you so much. Thank you, Dr. Hu for walking us through that very thorough review of the literature. It's really exciting to see your findings and, you know, pointing out, I think you've identified several opportunity questions that, you know, hopefully future research will help to answer. So very much, and very much appreciate the outstanding presentations by the other panelists, Drs. Rainey and Jackson Trish as well. The next section of our talk, of this workshop we'll flip over to just a discussion around various other questions that remain outstanding around the collaborative care framework. You know, I think Dr. Rainey talked about this quite a bit, but I think there's still questions around implementation, payments, staffing, particularly, you know, in right now, in this very moment, where staffing is in behavioral health and across all industries really is so challenging. And then I think there are questions about the potential applications to special populations. So women, individuals with SMI, which Dr. Jackson Trish touched on, individuals with autism, which are a growing population, co-occurring mental health and substance abuse conditions, pregnant individuals who are pregnant, homeless. Dr. Hu touched on the applying the collaborative care model using telehealth. And I think, again, given the real profound shift in the behavioral health delivery system and industry during COVID, that's a question that's just so ripe for exploration. And then I think there's the broader question of COVID and how the collaborative care model itself can be used to even more intentionally address the access problems that have risen as a result of, or that I should say have been exacerbated by the increased demand from the trauma of COVID. And we know also that there are questions around social determinants, not that the collaborative care model can be used to treat social determinants, but is there any interplay between, say, warm handoffs from behavioral health treatment or services to services that address social determinants? And then obviously there are the longstanding, I think, questions in all of healthcare around access and quality. So I think lots of questions still to answer, and I'll just invite our distinguished panelists to jump in on any one of those, and we can sort of walk through them one by one. I can walk through them one by one again. You know, I would just like to chime in on what happened with COVID and collaborative care. We have really nice studies that show collaborative care can be done remotely. You don't, it's nice to have a warm body in a clinic for a warm handoff, but what we learned during COVID, because all of our behavioral health people were offsite, they were at home, they were somewhere else. We learned all kinds of tricks in Zoom rooms and all kinds of ways to do an electronic handoff, a quick phone call, let the behavioral care manager know. So collaborative care chugged along during COVID when other forms of integrated care were stopped in their tracks, because they were so dependent on the warm body dancing between the exam rooms, kind of giving the PCPs whatever they need. In collaborative care, we have organizations that are doing this completely remotely at this point, where your care manager is someone who calls you or video conferences you. You're able to do all the work, the psychiatrist reviews the registry, you build a code, and the person's not even in the clinic. So it was one of the models that was ready to, was shovel-ready, they call it, for COVID. And we were able to keep going. Yeah, we had a similar experience at UCSF is that it was a relatively smooth transition to do that, because a lot of the work had been done virtually anyway. And so it just expanded. I think the lesson, though, for a lot of the clinicians is that the patients really liked it, because we really thought that there was gonna be some resistance to it, not at all. And in San Francisco, where there were issues with parking and parking fees and things like that, people were actually relieved to not have to do that and fight traffic. So it worked very, very well. I think it's a really adaptable model. Well, and adaptable to all kinds of different people who do be the care manager. And I love the research. I was looking at your paper on all in India, Africa. The Texas Lone Star Program that's getting ready to launch, they're gonna use all kinds of different community health workers and people to do collaborative care across Texas, because good luck finding a social worker in the remote corners of Texas or remote corners of our country. So I think it's adaptable, too, to a very different workforce. We think psychologists, social worker, we need to think much broader. I think we'll get there. We're sort of just in the early phases of the dissemination of collaborative care as a model. And once people learn about it, I think they'll see that, especially with the issue with access and the fact that we have a real shortage of behavioral health people anyway, clinicians, that it will work. I think it's very exciting time for collaborative care. And also what I think is interesting is now, in my early days in the VA, we actually had a similar thing to primary care where we had a general internist who was actually located in the psychiatry clinics that's at the Brentwood VA. And so that was kind of an early reverse model, but we found that that was very good because for the same token, we had, by the same token, we had difficulty getting a lot of our seriously mentally ill patients to want to go to general care. And so they were not getting good healthcare in terms of their primary care. And so we did that. That's not been disseminated as much, but I think that's the next phase is in terms of talking about how to do that and training people to be able to do that. We had that for a time at Cambridge as well, kind of the reverse behavioral home model. I think there were also, some studies got really creative in terms of how they included a virtual component. So thinking about computerized CBT modules, there's certainly some evidence for that. When we think about just general access, therapy has also been really tough to come upon during COVID. And certainly in thinking about access more broadly, I think we've all seen that our no-show rates are way down during this era of COVID and telehealth. Yeah, I worked out on the Mountain Ute reservation today and my no-show rates almost nothing because I can reach people at least by telephone. The other thing I was thinking about when you were presenting, Dr. Hu, is in that Indian Health Service, the 12-tribe grant that we did, what we considered a cultural component was what did you refer the patient to in your integrated care program that's different than traditional Western therapy? So we had sweats, we had powwows. During COVID, we had the virtual powwows going on. There was a great Facebook page where people were doing individual powwows, them or their kids, and putting them on this Facebook page, which was amazing. We were doing virtual feeding, regalia making. So what we call the cultural component was really bringing in, we had traditional healers who were available, really bringing in that component. Drum groups, what can we refer you to besides someone to do behavioral activation? Behavioral activation for that person was powwow groups, was singing, was regalia making. So we had bundles of sage on the counters for people to pick up and take home and burn. That's kind of what we thought of the cultural component. And I was just thinking too about you saying earlier, Dr. Shoyinka, about including the social determinants to health. So we call it three-way integration, primary care, behavioral health, social services, and then four-way integrated care in our grant for those three plus cultural. So we call it four-way integration. You can keep going, right? Dental's next, and vision. One would argue that that is the vision. That's really where you want to end up, because how do you parse one thing out from the other, right? They are all interconnected. Yeah. It's a more holistic approach, and we're hopefully getting towards that in medicine. It was sort of whole, and then it got splintered off, and we're so siloed in terms of our different professions. But hopefully that tide is turning, and we're going to move back towards a more holistic view and holistic assessment of patients. I heard someone say, when we drop the word integrated, we know we're there. We don't have to say it anymore. Yeah, right. Care, health care, we don't have to say integrated. Right. Let me just extend this a little further, this idea of integrated care and COVID. So we know that in the last, I think for everybody really globally, 2020 was a seminal year in many ways. It wasn't just COVID. It also was multiple traumas. There was the widespread social unrest. There was a pretty difficult election cycle, I think, for many reasons. There was the reckoning with racism, fresh reckoning with racism globally, really, following the death of George Floyd. I'm curious to know what innovative applications of the integrated care model were used or considered in addressing this sort of global trauma that we've all gone through, if any. Yeah, I don't know if I could think of any innovative ones. Maybe Dr. Rainey can. We were so busy just trying. The innovation really had to do with the use of telehealth and those models and trying to figure out how to do group therapy with telehealth, which is a whole other kind of thing and addressing people's concerns about Zoom and group therapy. I think that was the one that actually suffered more than some of the others. So most of the innovation had to do with figuring out how to do telehealth and get devices to people who didn't have devices, things like that. But in terms of the model itself, I don't know. Well, I mean, I think one of the things that happened is big tech is getting into it, right? Silicon Valley is working their way in. So you used to have one group. I won't name names, because I'm not supporting any particular group. You had one company that was doing it and looking for hedge fund, venture capital, whatever all those great words are around. And it's tech people starting it, not psychiatrists, not behavioral health people. Someone who had a family member who attempted suicide and couldn't get help. I'm going to start a new app. I'm going to build an app and I'm going to do something and maybe I'll do collaborative care. Now there's like 10 companies in the business. So we've really seen an explosion of this and it being backed by venture capital. So will we see more of that? I have a sneaky suspicion we might see a lot more of that as an innovation around it. And then otherwise, what I saw on the reservations was things like the virtual powwows. And I would wonder what other folks did to supplement, to make it a bit different. And are people going to publish on this so that we can actually see, could you hold to fidelity? Could you hold to those outcomes Dr. Hu was talking about and still do these other things? Do I need to do behavioral activation? Or if you got into a drum group, that is equivalent to evidence-based behavioral activation. I think it's going to be interesting as you were saying, Dr. Hu, to see more studies and see what ends up happening. But I think technology companies and what's happening with kind of Silicon Valley approach and apps and registries, that's what I see exploding out there. I don't know if it's a good thing because their incentives are different. They want to build the company up and sell it for billions and walk away and go do something else. The incentives are very different than what we're thinking about on an individual healthcare system level where the healthcare system simply wants to meet their needs versus an outside tech company wanting to build it, sell it, move on. That's just a different mentality. That's what I see. Yeah, we're certainly living and seeing a lot of that and it's not just around integrated care. I think those trends are holding, you know, certainly starting popping up around wellness and crisis services and so on. So it's certainly an interesting time. I think the other thing you saw was we couldn't screen anymore. The screening rates plummeted. You couldn't hand out a PHQ-9. You couldn't do it in the kiosk or the iPad in the waiting room. And we had to get clever. I think you're going to see a lot of apps where you can push out a PHQ-9 and the person can push it back. The care managers will tell you one of the biggest things they do is play phone tag trying to get a PHQ-9 so they can build a collaborative care code. So I think you're right. I think we're going to see even more stuff, the online CBT, the online, like, you know, Headspace and those, you know, self-management apps. But then also the ability, if I just wish I could do a PHQ-9 by text, you know, there are apps that'll do that. There's a nice study out of Montefiore with Valera app, I think. They use that to do collaborative care and repeat that PHQ-9. So I think we're going to get clever and make it actually more efficient. I think that was maybe part of what COVID taught us is we're spending a lot of time playing phone tag. We got to figure out how to make this more efficient. The technology is going to help us with self-management and with measurement-based care, I do believe. Yeah, I think that will help. During COVID now, one thing that we did at UCSF is developed a chatbot, and we used chatbot technology, developed algorithms to help screen our employees for a disorder and to get them into treatment. And that's something I think that's going to be expanded because it's really a good use. People could use a QR code or go online and go in and do a screening. And so we didn't have a PHQ-9 and got seven built into that, but it would be easy to do that in the next iteration of that. I think that's clearly going to be here soon. And while we're talking about innovation, I'm just curious to know your thoughts about some of those special populations or I should say maybe distinct conditions. Are there any studies or any interest out there in looking at the application of the integrated care model to individuals with autism, co-occurring mental illness and addiction, which we know is increasingly common, perinatal mental health, which is a burgeoning field now? I wonder what you would say. Yeah, I think there's innovation everywhere. The SPIRT trials getting ready to be published, which was PTSD and bipolar, two things we would never quite think we could do this with, and the results of that are out. There's the NIMH Foresight Study now for opioid use disorder. How do we give suboxone, buprenorphine? There's no reason why you can't use collaborative care to do that. You can measure urine or the brief addiction monitor. I think we're somewhat limited sometimes by the measurement tool. So, what am I going to use to do measurement-based care with autism? I don't know. I'm sure there's a tool out there, but I get stuck there. Even with the opioid use disorder, the only tool I could find for measurement-based care is the BAM, the Brief Addiction Monitor, and that wasn't quite getting it what I wanted, but I had trouble. So, if we stick with the easy stuff, PHQ-9, GAD-7, PCL-5, we're good, but when you get into these other conditions like autism, what tool do I use for measurement-based care in the registry review? If I flip it over and say, let's use it for the physical health of the STMI, sure, A1C, BMI, blood pressure, sweet. I've got measurement tools, but that's where I get a little hung up, is how do I keep moving it into diagnoses where I don't have a measurement tool? Because that's at the heart of collaborative care is measurement-based care. That's where I get a little stuck. I think I would venture to say that all of those are in development and people are thinking about it, but we just don't have the evidence yet for some of those early studies and conceptualization of studies and funding, which is a problem. Getting a lot of those kinds of studies funded is going to be, I think that will help when we get a good case for that, and then educating the public about it. When people start saying this really works and this is helpful and it increases my access, then we'll get more uptake and for other conditions. Collaborative care within pediatrics, I think, is more in its infancy, although the need is certainly there. Depression, anxiety, we already have really great screening tools, and then ADHD as well, a very common presentation. Then, like you mentioned earlier, Dr. Jackson, the reverse model for our patients who do come to SMI clinic but really need that more medicine care, I think, could also be a really great innovative tool. You do see a lot of work in the perinatal space right now. There's a lot of coordination you have to do because if a woman shows up in her first or second, if she's in her second trimester, right on the edge, and she shows up, before you know it, she's going to deliver, and how do I then hook that back into primary care or where she's going to go after that? It's a little bit trickier in terms of the coordination, but definitely we're seeing quite a bit in the perinatal space. I haven't seen cardiology, oncology, there's all kinds of folks that do it, but I want to respect the PCP space around this too. If you get so far out, the pulmonologist is doing it, everyone's doing it, poor PCP sitting there. If we want healthcare to work in this country, the PCP needs to be the captain of the ship. They need to be in the center of the person's care. I think we have to be just careful about how we spread it around because the PCP's patient's going to come back from OB on Prozac and they're going to go, why is this? What did they do over there? I think the coordination piece is super important once you move it out of primary care. I think too that the primary care doctors are the most interested in collaborative care. The uptake in cardiology clinics and transplant clinics and things like that probably isn't as much because they expect those conditions to really be treated in primary care. For primary care to be the gatekeeper for a lot of the access to those other conditions. I think for me, I'm a consultation liaison trained psychiatrist. This all falls in that wheel right of consultation liaison and I think building on that and that relationship is going to be a good way to go. I was just thinking, Dr. Hu, about what you said about pediatrics. There are things that blossomed before collaborative care did like the child psychiatry access lines like MCTAP and the big PERSA grants that are out there in 20 states right now. Given the pediatricians, a dial-a-doc number was great, but collaborative care is definitely the next step because we don't know what happened after they had that one call with the psychiatrist on the child psychiatry access line. That's actually one of the concerns about the program is does it work and they know that that's missing data. ECHO and the psychiatry access lines, they have problems with we don't know the person got better or not, the ultimate question. Pediatrics started with that, but I agree with you. ADHD, adolescent depression, we got so many anxious kids out there right now, GAD-7, scared scores. We can do this in pediatrics and I'm seeing a lot more of it at this point. That's a great point. I'm just keeping an eye on the clock and I think we are actually past our time by a little bit. I'm going to invite each one of our panelists to share a few final thoughts on this topic. I guess what I would say is that I'm a champion and I'm hoping that we can see broad dissemination. I think there's great promise in terms of increasing access for all populations and making sure that we can reduce health disparities by ethnicity, race, and really get more people treated, which is the important thing. I think as people see that treatment works, the stigma will go down. I would just say we've got a highly evidence-based model. We're approaching 100 randomized, we used to say greater than 80, now we say 100 randomized consult trials across ethnicities, across diagnoses, across payer groups. Someone was mentioning the role of the psychiatrist. It's such a fun way to practice. It really changed my personal joy in practice and also the PCPs because I know that they really have a lot of appreciation and respect. My hope would be that we recognize who the larger workforce is and really begin thinking about where do lay people, all kinds of folks, pharmacists, where does everyone else fit in? Because if everyone started paying for collaborative care, we don't have the workforce to do it. We're lucky not everyone pays for it yet because when it happens, the floodgates are going to open and we're not going to have the staff to do it. To be more flexible and creative about who can actually do it. As someone very early in my career, I'm really excited to see what the future looks like and very grateful to be here. I learned from all of the experts here. Just a few things that came out of the review that I wanted to highlight. There were some differences in emphasis on medication treatment versus therapy treatment. When we think about stigma, I wonder if that played a role in terms of the depression outcomes. Then like Dr. Rainey mentioned earlier, thinking about screening tools, but also are there ways that we can make that more applicable to these very diverse populations that we work with? Well, so one would say that integrated collaborative care is an idea whose time has come, given the confluence of factors that we've been discussing on this forum today. I just want to thank everybody for your amazing presentations, your insights, the wisdom you've shared here tonight. Like you, I look forward to seeing this model be expanded even more broadly, be supported, be tested across and really become the dominant model of psychiatric practice for the appropriate populations over time. Thank you very much. We'll just end there. Now, we'll open the floor to the audience for your questions. Thank you.

Integrated Care

Reducing Disparities

Measurement-based Treatment

Collaborative Care

Primary Care

Diverse Populations

Psychiatrists

Depression

Anxiety

Special Populations

Health Disparities