Welcome to the 2021 Mental Health Services Conference. On behalf of the APA membership, we are so glad you're here. We have a great program in store for you on a variety of critically relevant themes, including integrated care, burnout, climate change, racism, and social determinants of mental health, and so much more. The past few years have been difficult for all of us. Political tensions, a renewed national focus on racism and social justice, social unrest, climate change, and, of course, the devastation wrought by the COVID-19 pandemic have had a huge impact on our mental health and highlighted the need for change within the American health care system. In light of these issues, our work together this week is more important than ever. We have gathered for this conference because it is a space where psychiatrists and all mental health professionals can connect, find practical advice, and get inspired to influence systems-level change on behalf of our patients and the public. Through our collective knowledge and combined efforts, we can take meaningful action to address the social determinants that affect mental health in America and work to implement policies that will enhance our practices and support health equity and better health outcomes. In a few moments, you will hear from Dr. Miriam Delfin-Rittman, Assistant Secretary for Mental Health and Substance Use at HHS and Administrator of SAMHSA, as well as the State Mental Health Commissioners of Texas and Washington, Sonia Gaines and Dr. Carrie Waterland. I am very excited about this session, which will focus on how we can increase access to care and how federal funds can support innovative, sustainable services that help vulnerable populations get evidence-based care. Once again, welcome to the Mental Health Services Conference. Please take this opportunity to learn from our distinguished presenters and have conversations with your colleagues. I hope these connections inspire you to take what you learn here and put it into practice in your home communities. Thank you. I'm now pleased to introduce APA CEO and Medical Director, Dr. Saul Levin. Thank you, Dr. Pando. Welcome, everyone, and thank you for joining us at the 2021 Mental Health Services Conference. I've always had an affinity for this conference because it was the first APA meeting I attended in my residency days. I was thrilled to discover a place where psychiatrists from all over the globe had gathered to share their knowledge, expertise and insights about what is happening on the front lines of mental health care and what we can do to improve our systems for our patients and their families. This conference brings together mental health professionals from all across the country with diverse backgrounds and expertise to share in conversations and develop ideas that will have a tremendous impact on our patients and communities. The topics we will discuss include structural racism, equity, climate change, serving rural populations, and have deep dives as we go through this meeting. These are important, and I'm glad you're here to help delve into them and help guide APA. I want to thank the Division of Education for their hard work in putting this meeting together, and in particularly the Scientific Programs and Office of Online Learning. Special thanks is due to the APA Scientific Program Committee, called the SPC, chaired by Dr. Sarah Vinson and her team. The SPC has put together a timely program full of vital information. The issues we will cover affect everyone who has a stake in treatment and prevention of mental health and substance use disorders in our country. The social factors we will discuss impact every part of the health care delivery, as well as patients' outcomes in America. I'd like to thank the SMI Advisor and SAMHSA for both co-sponsoring this conference and developing some of the sessions you will see here over the next two days. Most of all, thank you all for attending and for supporting the mission of APA. Without our member psychiatrists and our partners in mental health care and substance abuse care, none of what we do would be possible. I hope that you will take what we learned here over the next two days and use it to support policies and practices that will help ensure a more equitable and a healthy nation. Thank you. Now I'd like to introduce our Scientific Program Committee Chair, Dr. Sarah Vinson. Dr. Vinson. Good morning. Thank you for joining us for this virtual conference. I'm hardly objective, but truly believe that you are in for a fantastic program. It is so exciting to see the 2021 Mental Health Services Conference officially here. It has been an absolute pleasure to work with our Scientific Program Committee over the past six months to create this program. I would be remiss if I did not also recognize the great work of the APA staff, and I'd also like to thank Dr. Pinder and Dr. Levin for their support of this meeting. The Scientific Program Committee carefully curated a program that will provide you not only with information, but also with actionable tools regarding the socio-political determinants of mental health. We'll talk about inequity, climate change, rural populations, structural trauma, racism, and many more topics that impact our patients and our professional practice. These are all broader societal issues with tremendous implications for mental health and mental health care. Wrapping our minds around them, let alone tackling them, is not for the faint of heart. But I truly believe that mental health clinicians can make a difference and have an obligation to do so for those we serve. These are not ordinary times. We need each other as a professional community, and opportunities for connection have been far too few as of late. With that in mind, this will not be your typical scientific online meeting. You will have many opportunities to engage with the content, your colleagues, and share ideas and experiences during the conference as part of the deep dive sessions. To stay connected afterward, please join our conference LinkedIn group. Look for a message from the conference with the link. This will provide an opportunity to continue the connections after the conference through the Mental Health Services Conference LinkedIn group. Today and tomorrow, please take advantage of all this exceptional conference has to offer. As Dr. Pinder previewed, the session coming up with Dr. Dolphin Rittman is a must-see. And tomorrow, Harvard Economics Professor Dr. Peter Q. Blair will be joining us for the plenary. He has truly invaluable perspective and expertise to share with us about the interplay of economics, policy, recovery for those with mental health issues. He will be sharing with us about the interplay of economics, policy, recovery for those with mental illness, and mental health care professional practice. Thank you, again, for joining us virtually for what is sure to be an extraordinary meeting. I look forward to our conversations today, tomorrow, and in the months and years to come. While wrestling with many of these topics in this conference may be uncomfortable for some, the alternative of allowing an inequitable status quo to be unacknowledged and unaddressed is simply unacceptable for those who want to lead in creating a mentally healthier society. I trust that you entered the field and that you're here today because that is a goal we all share. Now, to our APA president, who will officially open our conference. Dr. Pinder. And now for a little tradition, the ringing of the IPS bell. Many of you know the predecessor to this conference was known as IPS, the Institute for Psychiatric Services. It was originally founded in 1949 by Dr. Daniel Blaine as a place where clinicians could discuss solutions to issues that were arising in mental hospitals. He was presented with the bell in 1968 as an honor for this contribution to the field. And ever since then, it has marked the beginning of the conference. I'm now pleased to honor that history and tradition. Have a great day. Thank you. Today's plenary session will consist of presentations from a triumvirate of highly accomplished speakers from widely separated parts of the country. Let me give you a thumbnail on each before we get started with the program. First, we will hear from Miriam Delphin-Rittman, who holds a Ph.D. in clinical psychology. She currently serves in Washington, D.C. as Assistant Secretary for Mental Health and Substance Use in the U.S. Department of Health and Human Services. She previously served as an advisor to SAMHSA, as well as Connecticut Commissioner of Mental Health to the Department of Health and Human Services. Welcome. Next, we will hear from Sonia Gaines, who holds a master's degree in business administration. She currently serves in Texas as Deputy Commissioner for Intellectual and Developmental Disabilities and Behavioral Health. Previously, she served for more than 25 years in a variety of roles in the community mental health system. Welcome. And rounding out our program, we will hear from Carrie Waterland, who holds a Ph.D. in forensic psychology. She currently serves in Washington State as Division Director of Behavioral Health and Recovery at the State Health Care Authority. Previously, she worked in the State Senate, as well as in the Department of Social and Human Services. As well as in the Department of Social and Health Services, as well as in the Department of Corrections. Welcome. So, let's get started with this outstanding program. Dr. Delphine Rittman, the floor is yours. Thank you so much. And I believe I have my, I believe my slides were sent ahead, and happy to go through those. So, and while we're waiting, you know, I just have to say it's such a pleasure to be here and to be part of this conference and this important conversation. And appreciate the invitation, Dr. Pender and also Dr. Levin. And really just want to commend you for taking on social determinants of health. And sociopolitical determinants of mental health. We know that this is such a critical area, especially now. And that the social determinants, it's really a complex interplay across them. And I'll speak a little bit about that. About some of the ways in which there's a complex interplay across the various social determinants. And then also we'll share about some of SAMHSA's programs. And initiatives really that are geared towards helping to promote health equity. And addressing various social determinants to ultimately be able to promote improved health outcomes in communities across the country. Our grantees are doing such innovative work here. And so I definitely want to be able to share about some of those funding initiatives. So. Dr. Pender, I don't know if you all have the slides. If I can try to share them myself. If I can pull them up if necessary. Let's. And that sounds like a good idea. Let's try to do that. OK, so let me let me go into my files and get them. OK. OK. See if this will work. OK, try to go back to the. Screen. OK. OK. OK. OK. OK. OK. See, I'm not sure it's letting me go into my own files here. Now that that's not working. Is it possible for you to email them? Yeah. Yep. I can definitely do that. And my apologies if you did not receive them. No, no, no, no problems. OK. So. You're going to send them to S. Grossman. At psych dot org. OK. Oh, here we go. Yeah. And she's going to. Load them. She's our trustee. I just sent them to S. Grossman. I just sent them. OK. She's our trustee. I.T. person. OK. Who keeps everything running. Sorry about that. Not sure what happened there. We have we have plenty of time. OK. And. I'll ask the audience to to be patient. Get another cup of coffee. We'll get there. We're going to get there. I'm not sure if they were received. I mean, I can also just speak to them. But I just sent them. So you should. I'm not sure if they were received yet. If you'd like to do that, you know, maybe begin to speak. Yeah. Yep. I'm happy to do that. And and and she'll catch up. OK. That's good. Yeah. Thank you. So, you know, one of the first slides I was going to show really talks about the HHS definition of social determinants of health and then the five different domains that the social determinants of health can be categorized within based on the HHS definition. So essentially, HHS has defined social determinants as the conditions in which the environments where people are born, live, learn, work, play, worship and age that affect a wide range of health functioning and quality of life outcomes and risks. And then these different components of social determinants of health can be broken down into five different overarching domains. The domains include education, access and quality, health care, access and quality, economic stability as a key domain, neighborhood and built environment and also social and community context as as key domains. Interestingly, in terms of some of the work at SAMHSA, we have aligned our pillars of recovery with the social determinants. So we often view the four pillars of recovery, if you will, as as health, home, purpose and community and have consciously aligned these with the social determinants of health. As I said earlier, we know that these social determinants and pillars, if you will, are it's a complex interplay across them as as what we know contributes to overall sort of health or well-being. And if there is one or more areas that are off, then that does ultimately impact overall well-being. So, for example, we know that having access to high quality mental health care alone isn't enough to well-being if communities lack, for example, access to education, transportation or housing. And so, again, strong interdependence across these different areas. Next slide, please. So I'll go a little bit quickly through these so we can have a discussion. So what I wanted to talk about is, you know, I'm going to weave in social determinants as I talk about some of our priority areas and different initiatives and funding streams we have in place that address different aspects of social determinants of health. I wanted to lay some initial groundwork and sort of initial information by sort of discussing our priorities and cross-cutting principles. These are priorities that I've put in place since I was confirmed in June, and we're conceptualizing them as our near-term areas of work. And then there are four cross-cutting areas as well. So, for example, and these are not in order of importance, enhancing access to suicide prevention and crisis care. You know, that's such a key area of work, particularly now as we're coming off the last 18 months of the pandemic. Also, promoting children and youth behavioral health is another key area of our work. We know children and youth have had a particularly difficult time over the last 18, 19 months. Preventing overdose, another key area. Again, we know that, unfortunately, the overdose rates have continued to increase, and so this is a high area of priority for SAMHSA. Integrating primary care and behavioral health. We see health care integration bidirectionally in terms of integrating primary care in behavioral health settings, and within behavioral health settings, integrating primary care is very critical. And so doing some work in that area as well. And then using performance measure data and evaluation. SAMHSA collects a lot of data, and so a goal is to really use that data to be able to have a sense of patterns and trends and quality in terms of our funding initiatives. Our cross-cutting areas are equity. Increasingly, equity has been a long-time priority for SAMHSA. It's definitely a priority for the administration and a passion area of mine. And so we see this as an area that will undergird all of our work. Other areas are workforce, financing, and recovery in terms of our cross-cutting areas. And we recently announced a recovery, Office of Recovery, that will be, again, part of the work of all of the centers. Next slide, please. Again, just a little bit more background information. I mean, you've all seen a lot of this data, but certainly we know over the last year, we've seen significant increases in a range of behavioral health across both mental health and substance use. Indicators that suggest that there are challenges. People are struggling with respect to mental health. Over the past year, we've seen increases in emergency department use, increases in, unfortunately, as I mentioned, drug overdose. We've seen increases in young people visiting emergency departments. Suicide rates have also increased. And so quite a bit of work and some of our recent funding that has been put forward as a function of the President's American Rescue Plan and as well as the COVID relief funds passed by Congress are focused in these areas. And we also did some work to have them overlay with our priority areas as well, which get at many of the key areas of need right now. Next slide, please. So just a few examples, again, in terms of preventing overdose, an area of work we have there is harm reduction. This is another area, we're talking social determinants and in terms of ensuring that the communities and services and supports are culturally responsive and sort of community-based to be able to ensure access and quality. We'll soon be releasing a funding stream related to harm reduction where we'll be geared towards essentially implementing harm reduction programs and initiatives at the community level to be able to address overdose. And then again, that's due and funded through the American Rescue Plan resources. In terms of enhancing access to suicide prevention and crisis care, 988 is gonna be a significant piece or is a significant piece of that work. And 988 essentially will be the national suicide crisis, crisis line that will go live July, 2022. It's a game changer really in terms of how we think about crisis responsiveness and ensuring that people have access to services and supports when and where they need it and when they're in crisis. So that is a significant area of work and priority for SAMHSA now. I'm also promoting children and youth behavioral health. Project AWARE is an initiative that we have funded across the country to include within tribal communities that is geared towards promoting awareness and resiliency within educational settings. So it's a school-based initiative that provides training for teachers and educators around recognizing when children are struggling and then strategies around connecting children and families to services and supports as necessary. Integrating primary care and behavioral health, SAMHSA funds the National Center of Excellence for Integrated Health Solutions. And again, this is a TA, a center that offers technical assistance around the country around implementing integrated care services and supports. And then in terms of our performance and data, priority area, we implement disparity impact statements. And I'll talk a bit about that through the next slide. So next slide, please. So I'm gonna now speak about a number of different specific initiatives that get at social determinants of health. We're often thinking about this. We know that it's not just enough for a person, as I mentioned earlier, to be able to access behavioral health services, but it's critical to also look at what are the other aspects, particularly as it relates to social determinants, that we can impact to be able to essentially implement or take a whole health approach. So some of the programs and initiatives that I'll address now, we'll get into that. Next slide, please. So the disparity impact statement. So we're currently in the process of revising our disparity impact statement initiative. This essentially is a policy initiative that captures information and encourages grantees, discretionary grantees, to develop plans around how they'll address disparities that may be present among individuals that they may be serving within that particular grant award or grant initiative. And then the grantees have to develop a plan for how they'll address those disparities, in particular using the National Cultural and Linguistic Competence Standards. And the OMH, so the Office of Minority Health, has recently put out a behavioral health guide to the class standards. And so what we're working on now is putting together additional recommendations and strategies and working across HHS to further expand and evolve this initiative. But currently, discretionary grantees are required to do a disparity impact statement to address how they'll address and promote equity among populations that they're working with that may be experiencing disparities. Next slide, please. So one document that we're letting grantees know about is the Behavioral Health Guide to Implementation of the Class Standards. This document, we've been so pleased to see this come out and are collaborating with Office of Minority Health around its dissemination. But essentially what this guide offers is it provides concrete feasible implementation strategies for behavioral health providers around implementing the class standards. And as we know, the class standards are, again, the 14 standards that if implemented at an organization and really at a system level can help to promote health equity and reduce disparities. So we're excited about this resource. Next slide, please. So these are just a few additional examples that get at addressing different aspects and different components of social determinants of health within our various funding streams. I won't go into great detail, but just wanted to provide a snapshot. So for example, we have our Substance Use and HIV Prevention Navigator Program for diverse racial, ethnic, and cultural groups. Essentially, through this program, navigators work directly with individuals to help them navigate and access services and supports. So we see that's a real key way to be able to enhance cultural responsiveness. The navigators are often individuals who have navigated services themselves. They often will share their own stories of recovery. It helps to give people hope and it helps to really enhance the context, awareness, and competence of this program because the individuals have gone through services and supports themselves. Another example, excuse me, is our First Responder Program. And this is a program where first responders are participating in training around implementing, excuse me, implementing Narcan and other overdose reversal medication. And we know that's so critical for first responders on the scene to be able to have life-saving medication. So this is a training program around enhancing the skills of first responders. We also have the PPW Program that's a Pregnant and Postpartum Women Program. Same thing, this is a program that offers residential services as necessary for women. Women can keep their children with them. So it gets at that home part of recovery. We talked about health, home, community, and purpose. So it's a community-based program that offers residential services and supports for women needing substance use services. So those are just a few examples of initiatives. Next slide, please. And then I also wanted to share about the ReCAST Program. So this is another program that is implemented at the community level. It's geared towards communities that have experienced trauma or cultural unrest. And the goal is to assist high-risk youth and families to essentially work together to improve behavioral health of residents, to reduce trauma, and to be able to put in place sustained community change. So this initiative, the innovations that we've seen with this at the community level, in terms of the ways community members have been able to bring together a range of different groups from city officials to healthcare officials, community members, to address many aspects of social determinants of health and behavioral health. And so we're real pleased with this initiative and the outcomes that we've seen. Next slide, please. And then the final program I'll talk about is the Food and Mood Project. So I think there is one more. One more forward and right after that, yeah. So our Food and Mood Project, this essentially is an initiative, it's a collaboration between our region at seven and eight regional administrators and also the USDA's Mountain Plains region. It promotes emotional wellness and reduces the impact of mental health and substance use for K through 12 populations by implementing strategies that address essentially the intersection between behavioral health and food insecurity. And so real creative work happening here around looking at the impacts of food insecurity on behavioral health, but then also the community level developing innovative strategies for addressing food insecurity from a community participatory perspective and then addressing behavioral health and emotional wellness in connection. Next slide, please. So I'm looking forward to our discussion. I know we have time at the end, but just know that SAMHSA, we are here to be partners with APA. We look forward to ongoing collaborations as it relates to the social determinants of health. You know, our challenge is for ourselves and across the department is that, you know, it's time to be bold. It's time to sort of move forward with bold action and approaches. And so I invite you all to sort of be bold and with us and in terms of the creative work that you're doing across the field. And know that we're partners and I look forward to our ongoing collaboration across behavioral health, but certainly in terms of addressing the social determinants of health as well. So thank you. Thank you so much, Dr. Delfin-Rittman for an inspiring and fulsome presentation and we'll have much discussion at the end. Our next speaker is Ms. Sonia Gaines. And I will turn the floor to you. Good morning, everyone. Greetings from Texas. And I wanna first start out by thanking APA for inviting me to be a part of this wonderful conference. Thank you so much, Dr. Pinder and Dr. Lever. I also wanna take an opportunity to thank Dr. Whitman. First of all, congratulations on your new role. And I just wanna tell you how much in Texas we sincerely appreciate all the support of SAMHSA. It has definitely made a huge, huge difference, particularly during this pandemic. And I just can't say enough great things about how appreciative we really are. You'll get to hear about some of the awesome things we're doing with some of the most recent dollars that were expended. All right. You're welcome. All right, so let's start out with the first slide. I think it's important to give people a little bit of background about Texas. We're a big state. We cover close to almost 300,000 square miles. And if you look at this slide, you can see some other states can actually fit into Texas. But Texas is actually made up of 254 counties and 70% of them are rural. Now, many of you know that our population is close to 30 million Texans. But if you look at New York and you look at Florida, Florida has a population of about 20 million and likewise with New York. So it's a very, very large state. And sometimes that actually is both, a challenge and a blessing, particularly in some of those outlying areas in terms of making sure that we have services that are available in all of those areas. Just a little bit about our service delivery system. We actually work with 39 local mental health authorities that are geographically located all throughout Texas. And we call them, those are our community mental health centers. They are foundational to everything that we do in terms of the delivery of mental health services. All of them are certified community health clinics, which has been incredible in terms of positively shaping our service delivery system. And again, thank you, SAMHSA, for your support in that regard. My budget is about $1.5 billion. And between both mental health and substance use, we're serving a little over 3 million Texans on an annual basis. Next slide. The other thing I want to share with you is that one of the things that Texas has done that I think has been really instrumental in shaping what our service delivery system looks like is a number of sessions ago, that actually it started out in 2013, there was some legislation that created our first statewide behavioral health coordinator. I actually came to Austin to work in that role. And then fast forward, we were working with, at that time, it was 18 state agencies. And today we have 25 state agencies that we work with. That group has put together a statewide behavioral health strategic plan that is a five-year plan. We're about to publish our second addition to that plan. So we've had at least five years of experience. And this slide shows some of the focus areas like increasing coordination, focusing on prevention and data sharing. I can tell you that this has been one of the most foundational and prevalent initiatives that we have in Texas that has really been very, very positive in terms of providing a roadmap on identifying gaps in services, as well as strategies and approaches that we use in terms of implementing new services as well. Next slide. This is just a glimpse at some of the progress that we made. And just to give you an example, when I first came to state government, we didn't have a clue as to even how much money we were spending across all of the state agencies, particularly when it came to state funding. And today we have an inventory that outlines what all of those agencies are spending. This, and it's little over, it's close to about $4 billion on an annual basis. So it's pretty substantial dollars that are flowing through those different entities. In addition to that, we expect clear coordination among them so they meet on a quarterly basis or more often. Very oftentimes they coordinate responses to different situations, whether that be COVID-19 or natural disasters or criminal shooting events that may occur. And again, this slide just shows some of the progress that we've had across the years. And you can see it's been pretty substantial. Next slide. The other thing, I wanted to talk a little bit about some of the innovative programs that we have initiated here in Texas that really kind of fuel the fire for multiple streams of funding, where we're not just totally relying on state funds to develop or continue services. So one of the initiatives that came about in the last several years is the development of what we're calling these behavioral health matching grant programs. One of the first ones that I actually, my team and I worked on is a program called the Texas Veteran and Family Alliance. That program is focused on providing supports to both family members and their veterans and their family members that may have mental health conditions and need extra services and supports. You can see another one that we have there is a community mental health grant program. And that one is just general data-driven mental health service system promoting wellness and recovery. And then we have one that's really focused on the community mental health program, and then we have one that's really focused on justice-involved individuals as well. And then finally, one called Healthy Community Collaboratives, where we pretty much work on recovery and housing stability for persons that may be homeless. Collectively, these matching funds equate to about $282 million of state dollars. But one of the things that was required is that depending on the number of people in a county, the size of the county, there were matching dollars that were also required. So you can see through those matching dollars, there's a little over $100 million that actually were helpful in matching up these services. Next slide. This slide gives you an understanding about how the matching dollars work. As I mentioned earlier, Texas is very large. We have a number of rural areas as well as the urban areas. And so for those urban areas that had a population of 250,000 or greater, we expected a 100% cash or in-kind match. And if they had a population between 100,000 and 250,000, they required a 50% cash match. And then finally, if a community had a population of 100,000 or less, they only required a 25% match. And I will tell you, over time, we have tweaked this to, I think we went from a 25% to a 25% match. And we finally got to a place where it is workable. What we found is that some of the smaller, more rural areas, particularly those that are below the 250,000 mark, sometimes had difficulty actually acquiring those match dollars. But we've found, because initially we started out with everything being 100% match and realized that that was not workable. This design has really worked well for us. Next slide. The other thing I wanna talk briefly about is we really have figured out a way to tap into multiple streams of funding when it comes to a number of the initiatives that are active in our community, including some of the federal funds that are available. So I'm just gonna give you an example of a program that I think is pretty awesome and I have personally had the opportunity to visit. There's a program in the Houston area that is a collaboration with 911. The staff, the mental health staff from our local authority are actually co-located with the 911 folks. And they're co-located and they answer dispatch calls. And sometimes those calls are moved over to them if it has a mental health component to it. With the understanding and with the goal of diverting those calls that don't need to go to law enforcement that could be actually handled by mental health professionals. And this is an example of when we looked at the funding of this particular program, about half of the funding is provided through state government. Another close to 50% of the funding is provided through their community, their county commissioner's office. And then there are a couple of donors that also play a role in how this particular initiative has been funded. And I'm really pleased to say that since the start of this program, they've diverted over 7,000 calls that would have normally involved law enforcement. And when you think about the number of hours that that equates to, it's over 11,000 hours that law enforcement did not have to get involved in a particular case. So I just wanted to demonstrate here, you know, how, in this case, we have, you know, four different streams of funding that are actually supporting this initiative, including some federal funds, which include Medicaid and 1115. Next slide. This is another initiative. I just want to briefly mention, Dr. Whitman had mentioned some of the challenges that every community, you know, across the nation has experienced in regard to COVID-19. We've also had an opportunity to capitalize on our infrastructure that exists here in Texas. And one of the things I'm very pleased to say is that we did have some foundational crisis services that exist in all of our local authorities. And so when COVID, the pandemic occurred, we were able to quickly respond. And one of the things that we have had great success with was standing up what we call our COVID-19 support line. So that line now has been in existence for a little, almost two years now. And basically the calls are answered 24 hours a day, seven days a week by a mental health professional. We actually partnered with one of our largest local authorities in the Harris County area, which is in the Houston area. And essentially we're able to utilize some federal dollars that we received to help stand this up. And we were literally able to stand it up in two weeks by again, capitalizing on that basic foundational infrastructure that existed. So far, that call line has taken over 18,000 calls and it's been very, very helpful in pointing people in the right direction and providing 24 hour support. As many of you know, most folks were isolated at home. And so through this number, people can call and talk to a mental health professional day or night. We were also able to stand up a support group, a virtual support group for frontline health care workers that was also very, very successful. Next slide. So I wanted to just quickly mention some of what we're doing in regard to the federal funding that we received, the HR 133, as well as the American Rescue Plan Act that many of us are calling ARPA. When we combine both our substance use dollars and the mental health dollars, I believe Texas received the second largest amount totaling over $450 million. And because of some of our thoughtful planning that I mentioned earlier, both the partnerships that we have and the strategic planning that we do, we were able to give some thought about what were some of the things that we need to address in response to COVID-19. And because of those connections with those partners, it was very clear some of the focus points that we needed to put some resources into. So I mentioned that we have a really great foundational crisis service system here in Texas, but we realized as a result of COVID-19 that we need to build on that. A part of our crisis system also includes mobile prices, our outreach services, as well as the 24-hour call centers that I mentioned earlier. So we're actually looking to expand those crisis services, particularly our mobile services that have historically been funded solely through state funds and have been funded over a decade ago. And so, again, thinking about what our needs were around COVID-19, we're expanding that. Another initiative that we're doing is around housing. We recognize that during the pandemic, many folks were faced with losing housing or at risk of becoming homeless. And so we're actually tapping into some of those programs, those grant program grantees that I mentioned earlier that, again, already have a tremendous infrastructure in place. And so we're looking at some housing vouchers and some navigators to help people get connected to housing and also mental health treatment as well. And then the third thing that's listed there is outpatient capacity expansion. I think Dr. Whitman did a great job of highlighting some of the challenges that we all have seen and recognize from a mental health standpoint. And I think one of the things that we all recognize is having immediate access to services will likely result in people getting engaged sooner and not needing to be connected to those inpatient services and jail and incarceration. So we're really excited to be able to expand our capacity. And I can say, because of some of our efforts today, we have a minimal wait list and that has really been instrumental in some of the success we've had with treating people on an outpatient basis as opposed to inpatient. And then the next thing that you can see listed there is the coordinated specialty care. I know many of you are well aware of that service dealing with early onset psychosis in individuals aged 15 to 30. We had already had tremendous success with that program here in Texas, more than a 90% success rate. So we were very pleased when we saw that SAMHSA required a set aside for that service, which will allow us to expand our efforts to several more sites in Texas. Then the last thing on that slide is peer recovery. We do quite a bit with peers here in Texas. We're a big, strong believer in that. We've had lots of success with that. We also have a director of peer services and he's done a tremendous job. And so that because of CCBHC and some of the other efforts that we've looked at, the peer recovery support is a part of all the service delivery system that we have in place here. Next slide. And then finally, this just highlights some of our initiatives around substance use with those federal funds to address the impact of COVID. We have a huge initiative around public awareness campaign, as well as community development, overdose prevention and crisis response. Again, some more access to treatment. This will allow us to have some more treatment to expand our treatment footprint across Texas, which if we only looked at the dollars that we were receiving, which in Texas, 75% of our funding for substance use is actually federal dollars. And so having these additional dollars allowed us to address some of the gaps that we're having, particularly in some of the rural areas. And then the other thing that we're doing is focusing on expanding virtual services. I think we all have been thrusted into like an involuntary situation. And I think we've all come to realize that the virtual services are even have a greater benefit than what we could ever imagine. We've gotten a lot of positive feedback from our substance use service providers, which we have a little over 300 of those providers that many, because of the virtual services, we saw a huge benefit in our show rates, a greater show rate as a result of those services. So really, really grateful that we're able to move forward with that. And then the last two things, recovery support, and again, some more support when it comes to housing initiatives. On the housing side, both for mental health and substance use, we're actually creating a website and a call center, very similar to the COVID support line. So lots of exciting, exciting things that are happening in Texas. Next slide. And that's it. And in closing, I wanna say again, thank you to APA for inviting us to be a part of this wonderful conference. And I would be remiss if I don't take the opportunity with so many physicians and mental health professionals on the line to invite you to come to Texas. If you're looking for a great place to work, Texas is incredible. Dr. Sani is our medical director. You have my email there if you're interested in more information. We also have a website called mentalhealthtx.org. It is a tremendous resource. It's been a tremendous resource for us here in Texas, and it actually has some nuggets of information that might be helpful, as well as free training that could be made available to other professionals that you might work with. So again, thank you all. Dr. Pender, I really appreciate it. Thank you. Thank you so much. I think it's really good to hear how so much is being done on a state level in Texas and how much you and all of your team is doing and what's possible. So thank you again for that wonderful presentation. Thank you. Our next speaker is Dr. Keri Waterland. And without further ado, I will turn the floor over to you, Dr. Waterland. Thank you so much, Dr. Pender. I am not sure how to follow the amazing women that I just did, but I'm gonna go ahead and give it the old college try. So thank you so much. Thank you to the APA. Thank you, Dr. Pender. Thank you, Dr. Levin. Commissioner Gaines, very tough act to follow. And Assistant Secretary Rittman, thank you so much for, I think, setting such a great stage about social determinants of health, recovery, the Office of Recovery that's newly created, and just the commitment around recovery principles that SAMHSA is really continuing to support us as commissioners in moving forward. So thank you so much. Without further ado, I am here to talk about some of the ways that we are improving behavioral health services in Washington State. And we in Washington combined substance use disorder and mental health over 10 years ago to create our behavioral health system, and have since grown to really be a Medicaid expansion state, full bi-directional integration, and whole person care is really what we're all about in Washington State. So I'm fortunate to be sitting here and I'm fortunate to be situated with our Medicaid services and really focused on physical health, behavioral health, and the fact that behavioral health care is health care. So really excited. Next slide, please. I am gonna walk you guys through four of our programs in Washington State today. Two are kind of ones that have been around for a little bit of time, since the 2017, 2018 times, even a little bit earlier. And then two that are really kind of came to fruition as a result of the pandemic. So those things that we'll go through right there in order on the slides in front of you. And so without further ado, we'll go right into our Foundational Community Supports Program. Next slide, please. Here's our landing page. Foundational Community Supports is something we're really proud of in Washington State. Next slide. But what is it? Foundational Community Supports is a result of an 1115 waiver for us in Washington. And in 2018, we began providing targeted services that are really for supportive housing and supportive employment for eligible Medicaid beneficiaries. So these services really identify people in need, help people obtain appropriate housing and employment, and provide support so that individuals can maintain their housing and or gain employment or maintain employment. So these are not things that replace services that are currently available. This is not paying for room and board, but this is giving that support and that structure. These are really innovative services that we know and we have our outcome data that are showing and demonstrating the positive health impacts that a safe, secure housing environment can really have for individuals. Next slide. All right, well, who qualifies for our FCS program? As I said before, it's an 1115 waiver, so must be Medicaid eligible. Supportive housing has some age requirements in that it's 18 and over because you gotta be able to sign that lease on your own. Supportive employment is 16 and over because we can have folks starting to work at the age of 16. So we kind of combined some things on this slide and said that people need to meet a medical risk factor. And there's actually, it's kind of a two-pronged approach. You gotta meet a health needs-based criteria and be expected to benefit from these supported services. And then you also have to meet at least one risk factor. And a risk factor looks like maybe two-plus residential stays in a 12-month period. We have provided some links for folks in these slides. So if you wanna go and learn a little bit more about the work that we're doing in Washington State around the Foundational Community Supports Program, go ahead and click on that reference guide. It's a really kind of fun way to learn a little bit about the work that we do. So next slide. We are really, really proud because to date, since 2018 up to date, we've served and enrolled more than 20,000 individuals for FCS programming. As I said, our early results are showing really statistically significant improvements in employment rates and earnings, as well as increasing transition out of homelessness and houselessness. And so again, we've provided some links, but I'm gonna read a really quick success story because in true behavioral health fashion, I wanna drive this home and really make sure that we all know that there are people on the receiving end of these services who are sharing then successes back with us. And so this is Ruby's success story. And I won't go too long and too much into detail, but we do have permission to share this. So Ruby says, when I was approved for support and employment through Compass Career Solutions, my life was so broken. I was living in a women's shelter with two of my young daughters. I was told that I would have to leave. My time had run out. I reached out to my case manager, my housing consultant, and my Compass Career Solutions employment consultant to ask for advice on what I should do. All three of those communicated with each other and came to the shelter to have a meeting with the shelter manager and asked if there was a way that I could stay. There was not. And so all of those individuals rallied around and the human resources manager at a processing plant in Pasco and Washington basically said, hey, we have a place for Ruby. And so by the end of the day, the Career Solutions employment consultant had worked to have the manager get an offer letter. And basically we got something from Ruby now saying, I can now say I've been working at the Pasco Processing since the end of April. I started as a packer and now I am a tote scaler and have a set shift. So none of this kind of odd shifting. I've got a set shift. My employment consultant has been a great blessing and I'm glad to have a chance to prove that I can be a great employee. Feels good to move up due to my good work. And this program has been a blessing to me and my girls. I'm always treated as an equal. I feel respected. Thank you. So we're really excited about foundational community supports and the supports that it's giving to our Washingtonians. Next slide, please. So kind of shifting a little bit, I'm gonna go with the youth angle now and look around at our wraparound with intensive services, also known as our WISE program. Next slide. We love our landing slides in Washington State. So what is WISE? WISE is this team-based approach that has care guided and driven by the family unit. So this team-based approach has natural supports like family, friends, religious leaders, as well as professionals that really form a team. They work with the youth and the family. And some of the professional supports are our CPS workers, school counselors, other counselors, as well as our peer supports. So we too in Washington, much like Texas, really, really see the value of peer supports and are excited about partnering and pairing peer supports with treatment and individuals who have similar experiences to kind of move that nothing about me, without me, and seeing someone with similar experiences on the other end of the table forward. So we really embrace that in WISE. In WISE, the family really sets the goals to meet that need and individualized plans are really important. Individualized plans are really helped, are really created to help find strengths. So all of these individualized care plans are based on the strengths of the family and the youth. WISE services are available in locations and times that work best for families. And we also, as part of this WISE wraparound service, provide crisis services to individuals 24-7 who are part of this program. Next slide, please. So we know that WISE is, the last slide said a volunteer service. It's available to Medicaid-eligible children and youth who are 20 years of age and younger. But how do people get into it once you do know that you qualify? So in Washington State, 13 is the age of consent for youth to seek out their own treatment and their own services. So if a youth is over the age of 13, that youth can ask for a WISE screening on their own. And in Washington, we use the CANS, which is the Child Adolescent Needs and Strengths Screening Tool. So really excited about that. A 13-year-old can ask to be screened into the WISE program. If under 13, permission from a parent or guardian is needed, or a parent or guardian can really refer any of their kids to this program. Again, that wraparound service. And we can go from there. If a child is eligible, then they are assigned a WISE provider agency, there's a team, there's coordinated care. And if not eligible, then we refer to other behavioral health services that we have in the community. Really is appropriate based on that youth and the family's individualized needs that we've really assessed through that CANS. Next slide. We know that WISE has 82 program sites. We have 39 counties in Washington state. And again, provided some reports for folks. If you wanna look into this, we do know that we've got some pretty promising results on WISE. Behavioral and emotional needs decrease, families are feeling more engaged. And we see that there's a lot of strengths that we've identified in the WISE program. So we've got a lot of good results. A lot of strengths that we've identified that have increased through the work of WISE. Next slide, please. All right. now we're on to, so those first two programs I talked about are things that kind of existed before the pandemic. And now I wanted to talk to you about two things that we created or strengthened as a result of the pandemic. One of those is telehealth in Washington State. Next slide, please. So what we did in Washington State as a result of the pandemic is we really looked at how we were billing for our telehealth services. And we worked to have evening and weekend hours, kind of getting a little bump in pay. We know that folks, a lot of people may not be available during regular work hours, or it may have contributed to stress to try to find out how to be available during regular work hours. So we looked at how we could provide and increase the ability to do telehealth services. We also have a legislative mandate that requires that telehealth training be provided and be completed by all of our behavioral health providers in Washington. And so we really leaned in on a couple different things around that to make sure that we were supporting our providers. Next slide, please. So some of the ways that we did this is we provided laptops, Zoom licenses, and phones to key providers who did a lot of behavioral health services, primarily with our Medicaid population. But also, we have behavioral health administrative services organizations in Washington State, and many of those are funded through our block grant work. And so we also made sure that providers who are out in the community that needed access to Zoom licenses that were HIPAA and 42 CFR compliant, as well as laptops and phones, were able to gain access to those. And so that was something the health care authority provided. We also, as I said, we had that legislation that has folks really getting training on telehealth and telemedicine. And so we contracted with, we have the luxury of having a great academic institution in Washington State, our University of Washington, but we contracted with the University of Washington's Harborview Medical Center, and they have a behavioral health institute. We all worked together on telehealth and telebehavioral health training for our providers in Washington State to help folks through that. Now there's a legislative mandate that you have telehealth training, and we're in a pandemic where a lot of our work and behavioral health providers, you know, we depend on rapport that we strike, right? We all know that. And so we wanted to figure out how we could support folks also in, how do you build rapport in that telehealth environment? So that was one of the focuses on the training that they really wanted to hit hard. So next slide, please. And here's one that we are really proud of in Washington State and similar to Texas, right? We wanted to send a message to our residents that it is okay to not feel okay. And it's something that I think we have been saying pretty loudly throughout the entire pandemic. But this is one of the things that we say in regard to Washington Listens. The entire idea of this is to break stigmas in the time of COVID and those stigmas of asking for some support, of acknowledging that now it's a really weird time and emotions are running high. And that's completely normal. So we developed Washington Listens. Next slide, please. So Washington Listens is the way that healthcare authority worked to secure federal funding through FEMA and SAMHSA. So this is the way that we used our crisis counseling assistant and training program grant, again, through SAMHSA and FEMA. We really thought that we wanted to provide a free service for our Washingtonians. We wanted to provide an anonymous service for our Washingtonians and we wanted to provide just a line where folks could call in who weren't in crisis, who were just needing to quite simply talk to someone and connect with someone. And we know that so much of recovery and so much of feeling supported during that pandemic is really focused on that connection. And so that's where we wanted to really lean in. How could we help people connect? This line also, if someone calls in and they do need a little bit more than just that talking point, this line does refer to mental health counseling, substance use disorder treatment services, problem gambling services, eating disorder services. So our entire array of services offered in the community, we do have an ability to refer to those services as well. Next slide. Wonderful. So here's the number that we have for Washington Listens. We also have provided the website in case anybody wants to go and check it out. These services also are provided virtually as well as in person. So we do have the ability to deploy folks to go and find and support individuals out in the community through this. And next slide. Wanted to point out with Washington Listens that over 120 counselors and team leaders and regional partners have been hired as a result of this work to staff lines. And so individuals who maybe lost their jobs as a result of COVID-19 who were looking for work, 120 employees as a result of this line. And we're really, really proud of that. Just like Texas's line, this is something that we are wanting to continue. We in Washington State looked at the federal legislation around 988 and just took it one step further and decided that in Washington State, our 988 line was really going to be our crisis line and our crisis service line in addition to the National Suicide Prevention Lifeline work. So we are looking at creative ways of making sure that individuals know there are lines that you can call in crisis. There are lines that you can call where you're just wanting to talk with someone. But really in Washington State, we want to make sure that if you pick up the phone and you call any one of those numbers, we'll get you to the right person. So if somebody calls 988 once it's up and running and it's not a call that would rise to the 988 level, we really want to figure out how can we get that person over to the Washington Listens line or another line where it may just be a conversation that somebody wants to have and a connection that someone wants to have. And I will take you to the next and almost last slide, I believe. So here's a couple different, again, resources for folks if you want to check these out, if you want to look into them. And I hope that this has been a good kind of really, really quick dive into four of our distinct programs that we're very proud of in Washington State that are really focused on getting all of our Washingtonian services in the community. So last slide, please. And here's all of my information. So if anybody wants to contact me or just reach out to learn any more about these great and amazing programs, I would love to talk with you again. Before I end, thank you so much for the honor of coming to talk about our programs in Washington State. And really, really appreciate it. Thank you. Thank you so much, Dr. Waterlin. That was so much information. And again, it's wonderful to hear of a state that's doing so much and in collaboration. So if I can get all of the speakers back on camera. There you go. And unmuted. Okay. We got everyone. We have about 15 minutes or so for some questions and answers and a roundtable discussion. So the first thing I'd like to ask all of you to comment briefly on if you had to choose your and rank your priorities, could you choose the top three, approximately, you know, two or three? And what do you need to achieve those priorities? Several of the questions that have been submitted have to do with funding, staff shortages, reaching people without access, and some limitations to programs. You know, like the child support program right now that's due to run out in December. So I will call on you, or does anyone like, would anyone like to start? I'll start. I'm happy to start. Yeah, it's a great question. It's a great question. And as you know, I, at the top, I outlined sort of five priorities that we have in four cross-cutting areas. So I'm going to assume that my cross-cutting areas can still stay. So, you know, equity, recovery, workforce, and finance. So that's, those are sort of cross-cutting. But in terms of the top three, I would probably say, you know, certainly addressing, continue to address overdose. That, I would say, is, you know, continues to be a national challenge area. I would say youth, addressing youth behavioral health, children and youth behavioral health is a key area. And suicide prevention and crisis responsiveness, because the implementation of the 988 line, which is really a combination of both suicide prevention and addressing crisis, is a national transformation. So that's certainly a priority area. That means the two that I didn't mention are the data, you know, data, you know, and performance, and also integrated care. Those are important areas as well. But the top three, if I had to, would be those three. And then I'll cheat and sort of keep those cross-cutting areas in terms of recovery, workforce, finance, and equity. So you have really big programs, which is wonderful. So just what do you need to accomplish those priorities? Or perhaps you don't? Yeah. Well, I mean, we do. We do. You know, I just see us as all in this together. I mean, it's such an honor and privilege to be here with the, you know, both commissioners that presented. What I need and what SAMHSA needs is certainly those really important partnerships that we have. We disseminate the, you know, resources, but I just so appreciate the work that's happening at the local and community level to implement our priorities and to address the areas that the grants are getting at. So, you know, certainly need those partnerships. And one thing I'm interested in is we also want to be able to have our resources reach segments of the community, maybe that haven't applied for grants. And so that's an area of need and interest that we're working on. We want to expand our pool of individuals that are implementing. Well, oftentimes we know they're already implementing innovation at the community level, but we would love for them to become SAMHSA grantees. Thank you. And Ms. Gaines? Sure. I'm happy to comment on that. It's kind of like someone asking, what do you want for Christmas, right? Yeah, we have, there's a number of priorities. One, I didn't get to talk about earlier, but in Texas, we have had an 1115 waiver that has been, you know, a big part of our service delivery system here. And we are hoping to get an extension on that waiver. We're still waiting to hear back, but that waiver encompassed like half a billion dollars worth of our mental health service delivery system. So we're very optimistic that we will hear back soon, that we will get an extension on that because it has huge implications if we don't. The other thing is the implementation of the federal funds that we're so grateful to have, right? But, you know, a half a billion dollars in implementing, that's a lot of money. It's a lot of money to put on the ground in such a short period of time. And, you know, one of the things that I will bring up, and I think I heard someone talk about it earlier, is the challenges that we have when it comes to workforce. So it's one of those things where we can have all the money in the world, but if we don't have people that are, you know, attracted to doing the work, that's going to make it a challenge. So, and I know that the dollars, and Dr. Whitman, again, we're very, very grateful. I know that those dollars were focused on services, you know, the dollars that came to us from SAMHSA. If there's any possibility or opportunity for, whether it's this pot of money or dollars that come down the pike, to really be able to focus on, you know, workforce. And when I talk about that, I'm talking about like, you know, retention and attracting people. You know, we're competing. You know, I went to a convenience store the other day, and they had a big old billboard saying, you know, we're going to give you a 401k, we're going to give you three weeks vacation, and we're going to start you out with $20 an hour. Okay, well, in social services world, you know, that would be a pretty big deal for someone just starting out, right? And then they don't even have to have all the education. And so if there's anything that could be done around workforce, that would be tremendous support, both on the substance use side and on the mental health side. And then I would echo some of the other, you know, we talk about 988, that's coming down the pike. That's very critically important. We're so excited about that initiative here in Texas. We're getting all geared up. Some of the work that we're doing around the new federal funds will not only help mitigate some of the challenges with COVID-19, but actually, you know, create a stronger foundation and preparation for that coming in the next year. And then the last thing, it's not so much that I need anything, but it's just on my priority list. And my goal is to get all of our local mental health authorities certified as community behavioral health clinics. We're well on the way to that. We have 75% of them. We actually have our own certifying entity that we have worked with SAMHSA on. So it's almost like a Texas, you get a Texas seal certification. It, you know, adds a little pizazz to it, gets people excited. So we're well on the way to that. And that whole thing, that whole initiative with CCBHC has been a game changer for us in Texas. We are so, so grateful for the support that we've gotten, you know, on a federal level from that. So, so those are my priorities. Thank you. Thank you. Good job. And Dr. Waterland. Yeah, well, I can't say that those are not my priorities as well. I completely agree. Especially around, I think that that conversation around 988, right, and, and how each state is doing things a little bit differently. But it seems like we are all really looking at what an opportunity we have, and how we can use that federal legislation as a jumping off point for states and really addressing, how are we going to ensure that our residents of our individual states are getting support in a crisis situation and getting the services that they need, when they need them? So I think that's one of mine is that crisis, 988, and really, not a want, because it's already happening. But that support from the federal level and from SAMHSA to say, what do you guys need? So thank you for that. We in Washington, I'm so glad Commissioner Gaines that you mentioned CCBHCs. We in Washington did not take advantage of that opportunity when it first kind of came to light. And so now we're working on how we can really, really infuse CCBHCs in Washington State. We have a couple sites, but as far as you know, that statewide. So that's something that we're going to be focusing on in Washington. And Commissioner, I will be leaning out to you and talking about how I can learn on that level from you, what an exciting thing. So our push really is exactly, I think, what we're talking about today. And what we need, I think I'll ask, because I've got a lot of our doctors, our MDs on the line, is that support with bi-directional integration that Dr. Ritman mentioned at the beginning, right? That bi-directional integration, what does that mean? And so I think my ask is, how can we incentivize and get excited about if somebody comes in with a physical health need and a behavioral health need comes to light, how can we just get that connection that same day, that same building, that same, just down the hall? So that's the exciting piece. And I think of me is the ask of how can we partner the medical field, the behavioral health field, the physical health field, and really just be there for the individual? Because what I've learned is the individual says, I don't care if you're behavioral health or you're physical health or you're an MD or you're a PhD, I just want to talk to the right person. And so that's my ask is, and my wish list is, how can we all learn from each other and incentivize that fun bi-directional stuff? Thank you. Thank you so much. We're just about finished with our session and there are many, many positive comments about how inspiring this program was, how each of you offered so much information and so much hope for the future and just how much you're all doing. We're really proud to collaborate with you and the collaborations that are going on are also wonderful to hear. So unfortunately, I tried to cull through the questions and grab sort of the key essentials, but we didn't get to them all, but we're going to have to stop. And again, I want to thank the assistant secretary and the two commissioners for your time and your presentations and all of your good work that you do every day. I imagine you wake up every morning and say, okay, we're going to do this again. And we hope for the sustainability of all of your programs. So thank you for your stimulating presentations and to our audience for your thoughtful questions and rave reviews and positive comments of this session. And we'll stop here. I hope the participants enjoy the rest of the day, the breakout sessions and the deep dives. Enjoy. Thank you. Thanks. Take care. Thank you.

2021 Mental Health Services Conference

integrated care

burnout

climate change

racism

social determinants of mental health

Dr. Miriam Delphine-Ritman

Sonia Gaines

Dr. Carrie Waterland

structural racism

equity

serving rural populations

Dr. Saul Levin