Yale Psychiatry Grand Rounds: April 30, 2021

Transcript

• 00:00Everyone today, today's ground red rounds,
• 00:03which is jointly sponsored by the Division
• 00:05of Prevention and Community Research,
• 00:07the psychology section and the Diversity,
• 00:10Equity and Inclusion Committee.
• 00:11It's my pleasure to introduce
• 00:13our speaker Doctor Ever,
• 00:15Arthur C Evans Junior,
• 00:17who's the Chief Executive Officer of
• 00:19the American Psychological Association,
• 00:21the leading scientific.
• 00:24Professional organization representing
• 00:25psychology in the United States with
• 00:28nearly 100 and 22,000 researchers,
• 00:30educators, clinicians,
• 00:31consultants and students as members.
• 00:34APPA promotes and disseminates
• 00:36psychological knowledge to benefit
• 00:37society and improve lives.
• 00:39A mission consistent with
• 00:41Doctor Evans's life work.
• 00:43Doctor Evans is a clinical
• 00:46and community psychologist,
• 00:47a policy maker and healthcare innovator.
• 00:50Who previously served in public
• 00:52policy positions in Philadelphia as
• 00:54Commissioner of the Department of
• 00:56Behavioral Health and Intellectual
• 00:58Disability Services and in Connecticut,
• 01:00where he served as Deputy Commissioner
• 01:02of the Department of Mental
• 01:04Health and Addiction Services.
• 01:05In both positions,
• 01:06he left the transformation of their
• 01:09respective behavioral health systems
• 01:10and their approach to serving a
• 01:12wide range of individuals with
• 01:14complex needs over his tenure.
• 01:16The money each agency saved was reinvested
• 01:19into improving and expanding services.
• 01:21And employing innovative
• 01:22strategies to reach more people.
• 01:25Doctor Evans has always been
• 01:27an unconventional leader,
• 01:29employing science research,
• 01:30community activism,
• 01:31spirituality,
• 01:32traditional clinical care
• 01:33policy and cross systems,
• 01:35collaborations to change the status quo,
• 01:38and behavioral health to improve lives.
• 01:42Doctor Evans is held faculty
• 01:44appointments in our Department
• 01:46at the University of Pennsylvania
• 01:48School of Medicine and is an author
• 01:50of over 50 peer reviewed articles
• 01:53and numerous chapters reviews,
• 01:54editorials.
• 01:55He has received national and
• 01:57international recognition for his work,
• 01:58including the American Medical Association's
• 02:00top Government Service Award in Healthcare,
• 02:03the Lisa Mohair Tortoise Award
• 02:05from Faces and Voices of Recovery.
• 02:07The Visionary Leadership Award from
• 02:10the National Council of Behavioral
• 02:12Health and was named an advocate
• 02:13for action by the White House,
• 02:15is office of National Drug Control policy.
• 02:19A major emphasis of his career has been
• 02:21equity and social justice and need to serve.
• 02:24Multiple has received multiple awards
• 02:26named for the Reverend Doctor Martin Luther
• 02:29King Junior for his work in this area.
• 02:32Doctor Evans holds a doctorate in
• 02:33clinical Community psychology from
• 02:35the University of Maryland Masters
• 02:37degree in experimental psychology
• 02:38from Florida Atlantic University,
• 02:40where he also completed his
• 02:41undergraduate work and in his
• 02:43alumnus of our departments,
• 02:45doctoral Psychology Training Program,
• 02:46where he completed his internship in
• 02:48clinical and Community psychology.
• 02:50I'm pleased to have him join us
• 02:52today to speak to us about addressing
• 02:55the nation's behavioral health,
• 02:56the need for a population health perspective.
• 03:00Arthur
• 03:09I think you're on mute. Yeah,
• 03:10thank you. Sorry I I was trying to do
• 03:13screen share an on you at the same time.
• 03:15There was a little much so then we just
• 03:18have to get you into the slide show mode.
• 03:20OK, can you see my screen?
• 03:22I could see it but I can
• 03:24see all of your slides.
• 03:26OK sure yeah OK good.
• 03:28There were perfect, alright,
• 03:29so you have sound and you have
• 03:31visual so thank you very much Jack.
• 03:34I'm really happy to be here.
• 03:36I wish I could be there in person.
• 03:38For those of you don't know me.
• 03:40I know one question that is on your mind and
• 03:43let me just dispense of that real quickly.
• 03:46It's not Sally's or Pepees,
• 03:48it's modern and it's the clam pizza.
• 03:50One of the things one of the many
• 03:53things that I miss about being in
• 03:55New Haven where I was for many years
• 03:58so I don't have any disclosures.
• 04:00What I want to talk about
• 04:03today is population health,
• 04:05but I couldn't do this in this talk
• 04:08without paying homage to Tom Kirk,
• 04:11who you all know it was.
• 04:14Commissioner Ann passed away last year.
• 04:17Tom was one of the kindest people
• 04:20I have ever met, an with greatly,
• 04:23greatly influenced me and my career.
• 04:26My thinking, and you'll see vestiges of.
• 04:29Tom,
• 04:30throughout my talk and you'll
• 04:32see his influence on my career
• 04:34and how I've approached my work.
• 04:36Now.
• 04:36One thing that I do want to
• 04:39point out about Tom's impact.
• 04:41It was not only on in Connecticut,
• 04:43but it was really,
• 04:45nationally and internationally because
• 04:47he was the first commissioner in the
• 04:49country to adopt recovery as a frame for
• 04:52how we thought about and delivered services.
• 04:54And many people were talking about it.
• 04:57More and more program level,
• 04:59but understood that you have
• 05:01to change systems.
• 05:02In order to really have the
• 05:04impact on people's lives,
• 05:05and that's something that has stuck with me.
• 05:09Today we're facing multiple pandemics,
• 05:11and it's really a perfect storm when we
• 05:14think about the impact on our mental health.
• 05:18First of all, we started with a pandemic,
• 05:21which we know had significant.
• 05:24Impact on our mental health.
• 05:26The fear,
• 05:27the anxiety.
• 05:27If you remember in the very beginning
• 05:30there was a lot of uncertainty,
• 05:32but we do a stress in America survey
• 05:35each year and we saw for the first
• 05:37time after doing the survey for over
• 05:40a decade of the stress levels in
• 05:42America go up appreciatively right
• 05:44at the beginning of the pandemic.
• 05:46But then after the pandemic started,
• 05:48we discovered that we had these inequities
• 05:50and that there were certain communities,
• 05:53communities of color that were
• 05:54being disproportionately impacted.
• 05:56And so the impact on those communities,
• 05:58the increased loss and grief that
• 06:01those communities were facing in
• 06:03addition to the anxiety caused
• 06:05by being at greater risk than
• 06:07the rest of the population.
• 06:09Added to that that psychological
• 06:11distress that people were experiencing
• 06:14and then on top of that we had then the
• 06:16economic downturn,
• 06:18where millions of people lost their jobs.
• 06:20People lost their businesses,
• 06:22and we know from decades
• 06:24of research that that.
• 06:26Those kinds of economic stressors have
• 06:29an impact on suicide rates and an
• 06:32mental health rates and then on top of that,
• 06:35during the summer we started to have
• 06:38these incidents related to racial
• 06:41justice and what our stress in America
• 06:43survey shows is that those incidents not
• 06:46only affect people of those communities,
• 06:49but they have an impact on the broader
• 06:52population and then we had a very tumultuous,
• 06:56very tumultuous.
• 06:57Political environment culminating in
• 06:59January 6 with the attacks on the capital,
• 07:02which again was another set of stresses
• 07:05that we were able to document so we
• 07:08really have this perfect storm of a lot
• 07:11of issues and these layers have created
• 07:14a really unique set of circumstances.
• 07:17It's showing up in the data,
• 07:20so I've mentioned are stress
• 07:22and stress in America survey,
• 07:24which shows that 80% of Americans
• 07:26are saying that they are experiencing
• 07:29significant stress from the pandemic is
• 07:32showing up in our Health 6 and 10 people
• 07:36are reporting undesired weight changes,
• 07:38either gaining too much weight or
• 07:40losing weight that is undesired.
• 07:42And in fact the the weight changes
• 07:45were on average, about £60.00 for.
• 07:48I'm sorry, £29 for those who who.
• 07:54Gain weight and actually it was close to
• 07:57£60.00 for about 10% of the population,
• 08:00so some really massive weight gain
• 08:02for some individuals are the the
• 08:04medium was about 15 pounds of added
• 08:07weight that was not desired.
• 08:09Racine it in terms of sleep disturbances,
• 08:12people filling that they're not getting
• 08:14enough sleep or or too much sleep.
• 08:17We're seeing it in terms of increased
• 08:20alcohol use to manage one stress,
• 08:22and we're seeing it in.
• 08:24Symptomatology the rate of
• 08:26mental health symptoms,
• 08:28anxiety,
• 08:28and depression in particular is
• 08:31about three to four times what
• 08:34it was before the pandemic.
• 08:36We've seen increased overdoses.
• 08:39An increases in intimate partner violence.
• 08:43But we also have to put this
• 08:45in the context of how what was
• 08:48happening before the pandemic,
• 08:49and it suffice it to say that.
• 08:53Are milk behavioral health systems in
• 08:55the country were not really keeping
• 08:57up with the needs of the population
• 09:00and we had some some significant
• 09:03challenges like retention programs.
• 09:04Most of you know that the modal out
• 09:07number of outpatient sessions is 1.
• 09:10Most people come,
• 09:11they leave and we know that if
• 09:14you're not in treatment for a
• 09:17sufficient time that we're not going
• 09:20to get the outcomes that we need.
• 09:23That we have challenges around
• 09:25engagement of people having the
• 09:27right amount of treatment in
• 09:29transitioning from levels of care from
• 09:32between different levels of care.
• 09:34So.
• 09:36We have this perfect storm of
• 09:38issues that have created a really
• 09:41significant challenge for our country
• 09:42when I was growing up in Florida.
• 09:45As a little boy,
• 09:46we used to have these really
• 09:48intense thunderstorms.
• 09:50Lightning the Sky would get
• 09:52dark and and these intense
• 09:54rains and then you know a couple of
• 09:57hours later you would come out and the
• 10:00the the family dried up pretty much
• 10:02all the rain and if you very large
• 10:05building you couldn't even tell that.
• 10:07Sometimes if you had gone through
• 10:10this particular rainstorm.
• 10:11But then we also had tornadoes and
• 10:15hurricanes, and when you came outside,
• 10:19the world had changed.
• 10:22What worries me is that.
• 10:25I think many people in our population
• 10:27think that we have gone through a
• 10:30rainstorm when what we've really
• 10:32gone through is a hurricane,
• 10:33and our lives are going to change forever,
• 10:36but we certainly know that in the short term,
• 10:39over the next three to five years that
• 10:42we're going to be dealing with the
• 10:45results of chronic stress for over a year,
• 10:47and all of the things that I've
• 10:50laid out for quite some time so.
• 10:53No, the whole point of my talk
• 10:55is this is that we can no longer
• 10:57afford to do the same things and
• 11:00expect different results.
• 11:01I believe we have to change our
• 11:03paradigm not only because of the
• 11:06longstanding issues that we've had
• 11:07in our in our service systems,
• 11:10but because of this collective
• 11:12trauma that we've gone through as
• 11:15a nation in the long term.
• 11:16Impact that that's not going to have,
• 11:19and so I want to propose that
• 11:21our field needs to really adopt
• 11:24A population health framework.
• 11:25And I'm going to explain what that means
• 11:28and why I think it's so important for our.
• 11:32Our field.
• 11:33But if I'm going to ask you to
• 11:35adopt A new paradigm,
• 11:37at least I will start with what is
• 11:39the current paradigm.
• 11:40And this is what I think the the
• 11:42current paradigm is for our field.
• 11:46I I refer to it as a black box paradigm.
• 11:49This is the mental model that most
• 11:52of us who are trained in the field
• 11:55have and that is that we create a
• 11:58black box that could be a clinic.
• 12:00It could be doctor's office,
• 12:02it could be a hospital and the way the
• 12:05paradigm works is this people get sick.
• 12:08They come to us.
• 12:10We figure out what's wrong with him.
• 12:13We diagnose them.
• 12:14We treat what's wrong and
• 12:15we discharge them as you.
• 12:17Well people, that's a basic paradigm.
• 12:19So now if I were with you many people,
• 12:22many of you know that I am a Baptist,
• 12:26and when when I present I have to talk and I
• 12:29expect you to talk back and the first world.
• 12:33That's a little harder.
• 12:34So I'm going to tell you what you
• 12:38would have said if I were there.
• 12:40What you would say if I asked
• 12:42you to critique this paradigm,
• 12:44he would say,
• 12:45well, first of all,
• 12:46it doesn't really line up with the
• 12:48science of what we know about how
• 12:51mental health and addictions work.
• 12:52This is an acute care model for
• 12:54what we know are chronic conditions.
• 12:57You would probably say, well,
• 12:58you know many people never come to treatment,
• 13:01and so.
• 13:01This passive model of waiting
• 13:03for people to come to us actually
• 13:05doesn't work for a lot of people.
• 13:08We know that half the people who
• 13:09have a mental health diagnosis are
• 13:11never going to come to treatment,
• 13:13and 90% of those with a substance use
• 13:15problem or not going to treatment.
• 13:17So most of the people with behavioral
• 13:20health conditions in New Haven and
• 13:21every year the other place in the
• 13:23country are not coming to this black box.
• 13:25You would point out that when people leave,
• 13:28they're not well,
• 13:29and one of the challenges we
• 13:31have in our field is that.
• 13:32There is a Cliff.
• 13:34Often when people leave treatment
• 13:35and people don't get the
• 13:37immediate support that they need,
• 13:38the long term support that they often need.
• 13:41You would point out that it is a
• 13:43box and that that metaphor works
• 13:44well for what happens in many
• 13:46treatment programs because one of
• 13:48the things that we require people
• 13:50to do is to go to the right box.
• 13:53So if you have a core occurring
• 13:55condition and you go to a substance
• 13:57use box or a mental health box and
• 14:00that particular box doesn't have
• 14:01the expertise to deal with your.
• 14:03Problem sometimes we put the
• 14:05onus on the person.
• 14:07One of the things I started to do
• 14:09when I was when I was still doing
• 14:12active clinical work is to watch
• 14:15my language and not use language
• 14:17like recalcitrant or the person
• 14:19isn't ready or all of those kinds
• 14:22of that kind of language,
• 14:24because that's putting the honest
• 14:26on the person as opposed to us
• 14:29looking at are we meeting the needs?
• 14:31Have we modified our program in such a way?
• 14:34To respond to the unique needs
• 14:37of individuals,
• 14:37well, we could spend another 20 or
• 14:4030 minutes critiquing this metaphor
• 14:42and all of the reasons why this
• 14:44mental model doesn't work for mental
• 14:47health and substance use conditions.
• 14:49But I want to point out one thing
• 14:51that I think is the biggest challenge
• 14:54is it constrains our thinking
• 14:56because the focus is on treatment.
• 14:58If you ever watch.
• 15:01Television the talking heads
• 15:03from our field who come on.
• 15:05And you know,
• 15:06after some tragedy or something
• 15:08and they're talking about
• 15:09the need for mental health.
• 15:11What almost invariably people will
• 15:14say is we need more treatment.
• 15:17That's the solution if we get
• 15:19more people into treatment will
• 15:21solve this problem of untreated
• 15:23mental health issues and so forth,
• 15:25and I have spent my entire career
• 15:27over 30 years now believing in trying
• 15:30to get funding for treatments deal.
• 15:32Believe in treatment,
• 15:33but I want to suggest to you that
• 15:36treatment alone is not going to address
• 15:39the magnitude of the problems that we have.
• 15:42The 80% of the population that
• 15:44is saying I'm stressed and it's
• 15:46starting to affect my life.
• 15:48Or the people who are untreated
• 15:50and are not coming into treatment.
• 15:52And so I want to start to make a case
• 15:55for a different way of different
• 15:57paradigm than that black box model that
• 16:00we are most of us are trained under.
• 16:04So here is one way to look at the population.
• 16:07If you look at the population about 25%
• 16:10of the population has a mental illness.
• 16:13About 5% have a severe mental illness.
• 16:15We spend most of our money on that top 5%,
• 16:19about 80% and about 20% sold.
• 16:218020 rule here and about 20% on
• 16:23the 80% of people who don't have
• 16:26a severe mental illness.
• 16:27But we we miss or we don't spend any
• 16:31resources or very little resources on this.
• 16:345% of the population that doesn't
• 16:36have a diagnosis as mental health
• 16:38professionals we know that mental
• 16:40health is more on a continuum
• 16:43as opposed to a binary.
• 16:45Either we have a mental health couns or
• 16:47not and that we're moving up and down
• 16:51that continuum over the course of our lives.
• 16:54And some of us crossed that
• 16:56that that diagnostic threshold.
• 16:58Some of us are in recovery ourselves.
• 17:01But the problem with this paradigm?
• 17:04Is that many of the people who are
• 17:07in the 75% will be in the 25% some
• 17:11other point that in the future.
• 17:13But because we've ignored them and
• 17:16we've not tried to do any kind of
• 17:19early intervention,
• 17:20many of those people access
• 17:22treatment much later in the process.
• 17:24And when it's much more difficult
• 17:27to treat folks,
• 17:28let me give you another problem
• 17:31that our field has.
• 17:32Many of you know that that.
• 17:35Healthcare itself only accounts for
• 17:36about 10% of the variance in our
• 17:39health status that other things,
• 17:40particularly behaviors,
• 17:41have a much greater impact on where
• 17:44we live has a much greater impact.
• 17:46Robert Wood Johnson says.
• 17:47You know,
• 17:48our zip code is a much better
• 17:50predictor of our
• 17:51health status than our genetic code.
• 17:53Context matters are behaviors matter,
• 17:55and they matter.
• 17:56And when it comes to our health,
• 17:59much more than health care,
• 18:00but this year, we're going to spend
• 18:03about 3 1/2 trillion with a T.
• 18:05On healthcare and the question
• 18:07is that if that only accounts for
• 18:0910% of the variance in our health,
• 18:12what are we doing about
• 18:14those other areas that?
• 18:15That we know impact on health.
• 18:17The impact on our behavioral health.
• 18:19And I want to suggest to you that
• 18:22that there are things that we can
• 18:24do outside of health care that
• 18:26can have a profound impact on
• 18:28people's behavioral health status.
• 18:30Now we talk about a lot of those
• 18:32as social determinants and we
• 18:34know that many of these things can
• 18:37have a major impact and I'll give
• 18:40A at least a couple of examples
• 18:42of that in the presentation.
• 18:44Now, at this point,
• 18:45I would probably say to you are you
• 18:48with me and I can't see your face,
• 18:51but if you could just virtually nod.
• 18:53If you're still with me,
• 18:55I would appreciate that.
• 18:56I need a little bit of feedback here.
• 18:59Alright, so so.
• 19:00So what I've made the case,
• 19:02so I hope I've made the case that we
• 19:04have significant problems and we have
• 19:06a paradigm that is not equipped to
• 19:08deal with the magnitude of the problem.
• 19:11The complexity of the problem,
• 19:12and the known issues that we have with
• 19:14the way we've dealt with these issues.
• 19:16So I'm going to offer a different way,
• 19:19and this is what I mean by a
• 19:21population health approach.
• 19:23If you took that same population
• 19:24and you divide it into three
• 19:26people who are diagnosed,
• 19:28that's at 25% that we talked about earlier.
• 19:30But we also know in our communities
• 19:32there are people who may not have
• 19:34crossed that diagnostic threshold,
• 19:36but they're at greater risk.
• 19:37And if we spend a little
• 19:39time in about 10 minutes,
• 19:41we could identify most of the people
• 19:43in our communities who are at greater
• 19:45risk for having mental health challenges.
• 19:47And the question for us is what?
• 19:49What are we going to do about that?
• 19:52And then?
• 19:53There are people who are relatively healthy,
• 19:55so despite everything that
• 19:57I've I've talked about,
• 19:58there are still people who are doing
• 20:01quite well in our communities,
• 20:03so our strategies would look like this for.
• 20:07People who are in that top part of the
• 20:10paradigm, the pyramid it would be.
• 20:12How do we create effective and
• 20:14efficient clinical Care now?
• 20:15I think this is really important
• 20:18because when ever people talk about.
• 20:20Population health or using public
• 20:22health strategies in mental health,
• 20:24they hear that as we're going to
• 20:26turn away from our traditional
• 20:28work and now we're going to focus
• 20:31on the broader population,
• 20:33nothing could be further from the truth.
• 20:35Hospitals are a an important part
• 20:38of a public health system.
• 20:40Treatment is an important part
• 20:41of a public health or population
• 20:43health approach to mental health.
• 20:46And if we're going to have a really
• 20:49good population health approach.
• 20:51We have to make sure that treatment is
• 20:53as effective and efficient as possible,
• 20:55but we also should be and this is where we
• 20:58start to expand beyond the black box, right?
• 21:01And we're starting to get out of our
• 21:04four walls and starting to look at well.
• 21:07Who are those people in our community
• 21:09and how can we either mitigate risks,
• 21:11lower the risk that people are actually
• 21:14going to develop a problem, or a minimally?
• 21:16We are intervening at the earliest point.
• 21:19That's our goals for that group.
• 21:21And then.
• 21:21For people who are relatively healthy,
• 21:23it's how do we help keep people healthy?
• 21:27And for me this is in my work.
• 21:30In Philadelphia is probably one of the
• 21:32most interesting and exciting things,
• 21:34because it's something that our
• 21:35field has not done historically is to
• 21:38look at how we keep people healthy.
• 21:40We do that on the physical health side.
• 21:43We talk about exercise,
• 21:44we talk about wearing a safety belt
• 21:46where we talk about things to avoid so
• 21:49that we decrease our risk for cancer.
• 21:51We actually know quite a bit about the coral.
• 21:54It's of good psychological health.
• 21:56The question is.
• 21:57As a field,
• 21:58how are we helping to educate
• 22:00the public about that?
• 22:02So as many people as possible can
• 22:06stay psychologically healthy?
• 22:07So what I'm going to do at this point?
• 22:11The rest of my presentation is what I've
• 22:13tried to do is make a conceptual argument,
• 22:16but what I want to do is to give
• 22:19you a concrete examples of how
• 22:21we can actually do this,
• 22:23and I'm going to pull very heavily
• 22:25from my work and Philadelphia prior
• 22:27to me going to a PA where I was
• 22:30Commissioner essentially a single
• 22:32payer behavioral health care system,
• 22:34whereas Commissioner my Department had
• 22:36Medicaid dollars to state and local.
• 22:38Grant dollars children and adults,
• 22:41substance use mental health.
• 22:44So that's sort of the whole range
• 22:47of services,
• 22:48and so I'm going to pull different
• 22:50examples just to illustrate how
• 22:52we can as a field implement a
• 22:55population health approach.
• 22:57So let's start at the top of the
• 22:59pyramid and talk about effective
• 23:01and efficient clinical care.
• 23:06So most of you know that that we have a
• 23:08gap between what we know from the science
• 23:11and what is widely practiced in the field,
• 23:14and one of the things that we tried
• 23:16to do in the Philadelphia system is
• 23:19to close that gap so that we had as
• 23:22much of our system operating and using
• 23:24evidence based treatment approaches.
• 23:26These are just some of the
• 23:28initiatives that we use,
• 23:29and I'm going to take one of them
• 23:31and sort of illustrate why it's
• 23:33important for us if we're trying to.
• 23:36Improve clinical care to be very
• 23:39systematic about implementing
• 23:41evidence based treatment strategies
• 23:43and so one of the people we work
• 23:46with was Aaron Beck and trying to
• 23:48get CBT throughout our mental health
• 23:51and or behavioral health system.
• 23:53And so we were implementing
• 23:56in all kinds of settings and.
• 23:59Substance use in children settings,
• 24:01outpatient, inpatient,
• 24:01and one of the challenges,
• 24:03and I should say this 'cause I know
• 24:05there are a lot of people who are
• 24:07probably listening is very interested in.
• 24:09Ebp's aren't thinking around
• 24:14EBP implementation.
• 24:16Transition and transform overtime
• 24:17in the very beginning we were very
• 24:20focused on training clinicians
• 24:21and then we figured out that,
• 24:23you know, training clinicians.
• 24:24It's not where it's at.
• 24:26We really need to think about how we build
• 24:28capacity at the organizational level.
• 24:30And then we evolved to really what we
• 24:32need to be thinking about is how do
• 24:35we create an evidence based treatment
• 24:37system and so over time would happen
• 24:39is we started to ask the question,
• 24:41not how do we get more EVP's
• 24:43out into the system,
• 24:45but how do we use EVP's to address
• 24:47the challenges that we're having?
• 24:49In the system and so that sort of
• 24:52frame that frame that change in that
• 24:55framework actually really was quite useful.
• 24:58And here's an example.
• 25:00So we had a service called extended
• 25:02Acute Inpatient Program 00 hospital
• 25:05based programs for people who did
• 25:08not get better after a traditional
• 25:11impatience day and so historically
• 25:13those people would have gone to state
• 25:16hospitals or when those beds closed,
• 25:19we built those.
• 25:20Services I was long term longer
• 25:22term beds in the community,
• 25:24but what happened?
• 25:25Overtime was the length of stay
• 25:27started to go up.
• 25:29To the point where we had some
• 25:31people that were in inpatient
• 25:33units for six months up to a year,
• 25:36sometimes more than a year.
• 25:38And you can imagine that's not
• 25:40good for anyone,
• 25:42particularly people who have
• 25:43very serious mental illnesses.
• 25:45So we did, was we use a mill.
• 25:48You approach using recovery
• 25:50oriented cognitive therapy.
• 25:52Train everyone on the unit,
• 25:54including the people who
• 25:56brought out the food.
• 25:57The lease on the concepts,
• 26:00and here are some of the results
• 26:02that we got by doing that.
• 26:05We cut the length of stay in half.
• 26:09We reduce the salt,
• 26:10we reduce restraints and seclusion.
• 26:12We reduce the need for I am medication.
• 26:16We reduce.
• 26:17Well we increased the
• 26:18number of people moving
• 26:20out of that very high.
• 26:22$700.00 a day service. Into the community,
• 26:25and it was simply by using what the
• 26:29science says around one of the best
• 26:33approaches to treating people want
• 26:35to share with you another strategy.
• 26:39Using financial levers just go
• 26:41through this one pretty quickly.
• 26:43This is a you could look at the
• 26:46numbers on the left side there.
• 26:48Those are actually hospitals.
• 26:50This is sort of sample data.
• 26:54Going across, going across the
• 26:57columns are things that we measured
• 27:01providers on and what we did was to.
• 27:06Measure providers you know
• 27:07they get a green, red,
• 27:09yellow took the top performing providers,
• 27:11paid them a performance payment
• 27:13if they met certain criteria.
• 27:15Now what was interesting about this
• 27:18is that hospitals we've been saying
• 27:20to hospitals for years that we need
• 27:22you to improve your continuity of
• 27:24care rates and essentially what
• 27:26they said back to us as well.
• 27:29You know,
• 27:30we really can't do anything about that.
• 27:32That's the outpatient system.
• 27:34Our role is to treat.
• 27:36You know the cute illness and
• 27:38then to discharge.
• 27:39And it's really up to the
• 27:41outpatient system to pick people up.
• 27:43Well,
• 27:43interesting thing happens when we
• 27:45started to pay for performance.
• 27:47So the first year we did it and
• 27:49because we paid providers based
• 27:51on their their volume and their
• 27:53and their revenue,
• 27:54some of the providers are top performers.
• 27:56Actually got hundreds of thousands
• 27:59of dollars in performance payments
• 28:01in the first year.
• 28:02Well,
• 28:03the provider who was at the
• 28:04bottom of the distribution,
• 28:06obviously doing performance payment
• 28:08comes into us and you know,
• 28:10says you know well,
• 28:12what can I do around improving
• 28:14continuity of care.
• 28:15So we shared with him some of
• 28:17the things that some of the other
• 28:20providers were doing really interesting.
• 28:22Thing was at the very next year
• 28:25that same provider was at the
• 28:27top of the distribution and so
• 28:29this notion that people couldn't
• 28:31do couldn't make these changes.
• 28:34Actually change it pretty quickly.
• 28:36Once we introduced financial
• 28:38incentives and let me just show
• 28:41you a few other levels of care.
• 28:43This is the dropout rate.
• 28:45So for ASD or autism spectrum disorder,
• 28:48these are services for children
• 28:50had 2/3 of people of the children
• 28:53in those services dropping out
• 28:55after two sessions or fewer.
• 29:00We introduce pay for performance and
• 29:02you can see the dramatic decrease,
• 29:05so improving retention rates.
• 29:06This is the transfer rate from
• 29:08residential programs to inpatient
• 29:10program programs for children,
• 29:12and so we're trying to do is get
• 29:16those providers to do a better
• 29:18job of managing those children
• 29:20and not just referring them out.
• 29:23And you can see what happens once you
• 29:27introduce financial incentives or this.
• 29:29Other data that shows.
• 29:32Contact of targeted case management
• 29:35services for people in patient.
• 29:38So another strategy for
• 29:41improving clinical care.
• 29:46We also have to make sure that we're
• 29:49not only using evidence based practices,
• 29:52but we also need to individualize and
• 29:55have strategies for those things that
• 29:58we know have are related to outcomes.
• 30:01So what you're looking at here is
• 30:04penetration data and penetration data
• 30:06is simply the proportion of people who
• 30:10are in a an insurance program who are
• 30:13accessing the behavioral health benefit.
• 30:15So if you have Blue Cross Blue shield,
• 30:18typically 3 to 5% of people who
• 30:21have Blue Cross Blue shield will.
• 30:24Access to behavioral health benefit
• 30:25well in the Medicaid program,
• 30:27it's actually pretty high,
• 30:28so like 20% and you could see
• 30:30that it was improving overtime for
• 30:32both children and adults.
• 30:34But if you disaggregate that data,
• 30:36you get a very different picture.
• 30:39What you see is that for
• 30:41whites and Hispanics,
• 30:42pretty high penetration
• 30:43for African Americans,
• 30:44half of that and for Asians half of that.
• 30:48So disaggregating the data on
• 30:50based on things that we know affect
• 30:52outcomes is extremely important.
• 30:54Then the question is, well,
• 30:56what do you do about that?
• 30:58In this case,
• 31:00some researchers at University of
• 31:01Pennsylvania, I mean Rothbart and her.
• 31:04Colleagues.
• 31:05Did the interesting thing,
• 31:07but they did what you see here is a map
• 31:10of Philadelphia an explain this real quickly.
• 31:13What she did was she did a Geo mapping
• 31:15and she mapped the utilization
• 31:17rates were African Americans that
• 31:19where providers were an essentially
• 31:21what this data told us was that.
• 31:23In the areas where we had high
• 31:26concentrations of African Americans,
• 31:28we had low utilization rates
• 31:29and what explained that?
• 31:31Or one of the things that explained that,
• 31:33was that we also had fewer providers.
• 31:36Given the density of people that
• 31:38we had in those communities.
• 31:40So the solution here was to then
• 31:42do RFP's in those particular
• 31:43areas where where we had a higher
• 31:46concentrations of African Americans
• 31:48low utilization and I point that out
• 31:50because a lot of times when we're
• 31:53thinking about how do we help.
• 31:55Communities of color or routes
• 31:56that were not being well served.
• 31:58We talk a lot about cultural competency,
• 32:01but sometimes it issues are at the
• 32:03systems level and the only way we're
• 32:05going to know how to address those issues
• 32:08is to have that systems level data.
• 32:10Now we did in fact require that those
• 32:12providers be culturally competent,
• 32:14but cultural competence in the absence
• 32:16of dealing with the structural issue
• 32:18was not going to get us there.
• 32:23So those are examples
• 32:24from a real life system,
• 32:26but at a PA we are adopting this
• 32:28population health approach as well,
• 32:29and so as I go through,
• 32:31I just want to share with you a couple of
• 32:34examples of things that we're doing at a PA.
• 32:37One of the major things that we're doing is.
• 32:41Especially during the pandemic,
• 32:43is really looking at the issue of
• 32:45Tele Health and making sure that
• 32:47we are that Tele health services
• 32:48are available to people because
• 32:50we know that that will make a huge
• 32:53difference in people's access to care.
• 32:57So what about risk? So if.
• 33:00Tomorrow we gave you the keys to the
• 33:02mental health system and said look,
• 33:03we want you to implement a.
• 33:05A population approach?
• 33:06How would you think about the
• 33:08at risk communities or at risk
• 33:10individuals in the community?
• 33:11So I think there are two
• 33:13ways that we think about it.
• 33:15I think about it.
• 33:16One is what are things
• 33:18that put people at risk?
• 33:20And are there groups
• 33:21that are at greater risk?
• 33:23And so one of the things
• 33:25that we know puts people at
• 33:27risk is experiencing trauma,
• 33:28particularly childhood trauma.
• 33:29So most of you probably
• 33:31familiar with the Aces studies,
• 33:32and so one of the things that we did well,
• 33:36this is a map of Philadelphia.
• 33:37What you see here are evidence based
• 33:40treatment programs throughout the
• 33:42system that we built up over a few years.
• 33:45So after a federal grant,
• 33:47what we did was we started to
• 33:49screen children for traumatic stress
• 33:51in pediatric settings in either
• 33:54pediatric primary care settings
• 33:56or even mental health settings
• 33:58and what we found is about 30% of
• 34:01those kids in Philadelphia were
• 34:04screening positively for traumatic
• 34:06stress and once we identify them
• 34:08we were able to refer them to.
• 34:11These are men in space.
• 34:12Treatment programs is probably one
• 34:14of the most important things that I
• 34:17felt that we did in my tenure because.
• 34:19Those of you particularly work
• 34:21in substance use programs,
• 34:22but mental health programs as well
• 34:24know that that there are a lot of
• 34:26people that were treating in late
• 34:28adulthood who had experienced early
• 34:30childhood trauma that was never identified.
• 34:32Many of those individuals
• 34:33develop substance use problems.
• 34:35They don't develop other problems.
• 34:36It really changes their life trajectory.
• 34:38And so if we can be systematic and
• 34:40identifying those children early
• 34:42on and getting them connected
• 34:43to the services that they need,
• 34:45it can make a big difference in their lives.
• 34:48Another strategy we started to think
• 34:50about trauma from a public health
• 34:52standpoint from not just thinking about it.
• 34:54As something where we treated an
• 34:57individual but more like a contagion
• 34:59that was in a community and that we
• 35:01needed to have Community level interventions.
• 35:04So one of the strategies that we
• 35:06employed was just making sure that
• 35:08whenever there was a traumatic
• 35:10event in the community,
• 35:12we sent people in the community
• 35:14who were trained in psychological
• 35:15first aid to provide support to help
• 35:18educate people about what a normal
• 35:21trauma response was and to give
• 35:23people resources so that if they.
• 35:25Started to experience difficulties
• 35:27that they could get connected to
• 35:29care earlier and that work actually
• 35:31transitioned over time and it
• 35:33moved from professionals.
• 35:35Quote unquote going into communities
• 35:37doing that work to training people
• 35:39in those communities themselves to
• 35:41be peer to provide peer support to
• 35:44their other neighbors when these
• 35:46events happen.
• 35:47And so in the city after every major
• 35:50kind of traumatic event where there
• 35:52was a shooting in a community, or.
• 35:56Building collapse or whatever it
• 35:58was there was almost
• 36:00always a behavioral health response to that.
• 36:04So that that is.
• 36:07A something that happens to people
• 36:09that puts them at greater risk.
• 36:12Homelessness is an example of a social
• 36:16determinant that can have a profound
• 36:19impact on people's mental health so.
• 36:23One of the strategies that we
• 36:25employed was using multiple pathways
• 36:28off of the street that was really
• 36:30grounded in this notion that the
• 36:33best way to help people who are
• 36:35homeless is to give them a house or
• 36:39to provide housing for them and so.
• 36:43In a partnership that was set
• 36:45up by the Mayor of Philadelphia,
• 36:48then Michael Nutter,
• 36:50he negotiated about 200 Section
• 36:528 vouchers and So what we did
• 36:55is we leverage Medicaid dollars
• 36:57by providing services.
• 37:01Compare that with housing dollars to
• 37:03provide housing for individuals who
• 37:05are living on the streets and not just
• 37:08people who are living on the streets,
• 37:10but people who were who
• 37:12were chronically homeless.
• 37:13That means that they have been living on
• 37:16the Street seven, 10-15 years sometimes.
• 37:19Most people in most communities
• 37:21give up on these individuals.
• 37:24But a really interesting thing
• 37:25happens when you change the approach,
• 37:27because what we have been doing is the black
• 37:30box model of let's get people into treatment.
• 37:33Let's stabilize them and then
• 37:35we can if we stabilize them.
• 37:37Perhaps they can get a job
• 37:38and they can get housing.
• 37:40That was the model that we were
• 37:43using that was a failure.
• 37:44It helped some people,
• 37:46but for most people it didn't work.
• 37:49Interesting thing happens when you
• 37:51can go to someone and say look,
• 37:53we're using a housing first model.
• 37:55For example,
• 37:56we can get you directly into housing.
• 37:59Will you go?
• 38:00Many more people were able to many more
• 38:03people agreed to go into housing support
• 38:05of those people with mobile services.
• 38:08But we also created other pathways because
• 38:11that pathway doesn't necessarily work
• 38:13for people who have chronic longstanding
• 38:15substance use programs with problems,
• 38:17and so for them we created a different
• 38:20pathway which relied on long term
• 38:23residential care up to a year.
• 38:25I remember when we ran a managed care
• 38:28program and when I said to our staff.
• 38:31We're going to authorize people for
• 38:33up to a year in residential care.
• 38:35I saw a lot I rolling.
• 38:37I was like what is he talking about is like,
• 38:40yeah,
• 38:40well,
• 38:40we know from the research that the
• 38:42longer people stay in these programs,
• 38:44the better shot that they have.
• 38:46And for people who've been living
• 38:48on streets for a very long time,
• 38:50that was very important.
• 38:51Turns out that most people
• 38:53didn't need that long,
• 38:54but just the psychological stress
• 38:56that we removed from people
• 38:57within people told us this.
• 38:59It was like, OK,
• 39:00I'm in a place I can get better before I.
• 39:03Move out well at any rate,
• 39:05what we're able to do is to
• 39:07get people into housing 89%.
• 39:09When we looked a year later,
• 39:12we're still in housing,
• 39:13but let me show you a little
• 39:15bit of the cost data.
• 39:17This shows you the first, really.
• 39:21Light blue bar. Over here I'm just
• 39:23going to take one of the pathways.
• 39:26These are different pathways.
• 39:27You can see the different costs based on
• 39:30the clinical presentation of the individuals.
• 39:32This is a harm reduction
• 39:34strategy that we use.
• 39:35You can see that two years before the person
• 39:39was house they were causing about $85 a day.
• 39:42Then as we engage people you can
• 39:45see the costs start to go up.
• 39:47But look what happens the
• 39:49year that the person's house.
• 39:51$18.00 a day.
• 39:52So we ended up saving literally
• 39:54millions of dollars.
• 39:55People were able to get into
• 39:57housing and be successful.
• 39:59The streets of Philadelphia
• 40:00were better because,
• 40:01you know, we were able to
• 40:03get people off the streets.
• 40:05It is a win win and it was simply by
• 40:08understanding that treatment alone,
• 40:10even though many of the people who are
• 40:13homeless have mental health issues,
• 40:15was not going to get us there.
• 40:17We had to deal with the social determinant
• 40:20of housing and when we do that.
• 40:22We can get pretty dramatic effects.
• 40:25One other example,
• 40:26this is about the population.
• 40:28I've talked about things that
• 40:30make put people at risk,
• 40:32but sometimes we have populations
• 40:34that are at risk and one of the
• 40:37roots is men and boys of color.
• 40:40And so we understood this group
• 40:42will know that that many of the men
• 40:45of color are disproportionately
• 40:47have behavioral health challenges,
• 40:49or disproportionately incarcerated.
• 40:50They just personally end up in hospital.
• 40:53Urgency Department as opposed to treatment,
• 40:55and so we we decided we were going
• 40:58to try to change the change that
• 41:01dynamic and one of the ways we
• 41:03wanted to do that is it sort of
• 41:06change the narrative around mental
• 41:08health for men and boys of color.
• 41:10These are Asian American,
• 41:12Latin X and African American.
• 41:14And here's just one example of that.
• 41:16Using storytelling as a strategy
• 41:18with this group,
• 41:19we put out a call to ask men if they
• 41:23would be willing to tell their story.
• 41:27And we use different language.
• 41:28We didn't talk about mental health,
• 41:31we didn't talk about psychopathology.
• 41:33What we talked about is your
• 41:35stories around mental strength.
• 41:37And we talked about psychological well
• 41:39being and psychological health and not
• 41:42sure that people were going to do it.
• 41:44Actually,
• 41:45men from all kinds of backgrounds
• 41:47ended up volunteering to do this.
• 41:50We coached them from that.
• 41:51We were mental health people.
• 41:53We we partnered with a.
• 41:56Storytelling organization First
• 41:57person arts in Philadelphia.
• 41:59We got a popular,
• 42:00uh well known person from the city.
• 42:03The person up here at the top is a.
• 42:08Actor from a program called Empire is
• 42:11actually from Philadelphia and so we got,
• 42:14you know,
• 42:15celebrities to have a little star power.
• 42:18Interesting thing happens,
• 42:19so we have these storytelling events.
• 42:21These men from different cultural
• 42:23backgrounds telling stories,
• 42:25their stories of psychological health.
• 42:27First time we do it,
• 42:29we get about 300 the Phillip division.
• 42:32So it's 300 people come out
• 42:34Friday night and we always have
• 42:36a top back where people have an
• 42:40opportunity to talk to the audience.
• 42:42About what they heard or the
• 42:44audience to talk to that to the
• 42:47presenters about what they heard.
• 42:49The first time we do it with 300 people,
• 42:526 next time we do it 600 people.
• 42:55The next time we do it,
• 42:571000 people and what started to
• 42:59happen is many of these individuals
• 43:01and there were other events,
• 43:03but the what started to happen
• 43:05is that we started to change the
• 43:08narrative around mental health and
• 43:10mental Wellness for men of color
• 43:12an so that we could get people
• 43:14one more activated around their
• 43:16own mental health but
• 43:18also seeking out help when they.
• 43:20Needed it similarly for people.
• 43:22This something that we're
• 43:24doing at a PA which is too.
• 43:28Create tools for frontline health
• 43:31care workers to help them manage their
• 43:35stress envivo on during their shift.
• 43:38It's based on psychological science and
• 43:42what we essentially done is to say.
• 43:45Here's an exercise that you
• 43:47can do to manage your stress.
• 43:49Here's the science behind why it works,
• 43:52and it's another strategy to try to reduce
• 43:55risk of people developing other problems.
• 43:58OK, so homestretch,
• 43:59let me just give you the last group here.
• 44:02Keeping people healthy and thinking about how
• 44:05do we work with communities who are healthy.
• 44:08So one of the strategies that we're actually
• 44:11doing at Appa is working with leaders,
• 44:14CEOs, and.
• 44:15Political leaders,
• 44:16and the reason that we're doing that
• 44:18is that as a leader, if you're a CEO,
• 44:21if you're a school Superintendent,
• 44:23if you're a teacher.
• 44:25The way you conduct your work and the
• 44:28way you do your work and create a
• 44:31toxic environment or it can create an
• 44:35environment that's more psychologically
• 44:37healthy and so one of our strategies
• 44:40is to help leaders understand the
• 44:42coral it's of environments that
• 44:45create psychological health.
• 44:46In fact,
• 44:47we have a program called psychological,
• 44:49psychologically healthy workplaces,
• 44:51and it's based on the science around
• 44:54what we know about what actually.
• 44:57You know the environments that
• 44:59actually create psychologically
• 45:00healthy work environments?
• 45:02Interesting thing is that.
• 45:04That CEOs get that this pandemic has had
• 45:07a big impact on them on their workforce,
• 45:11and they're actually paying a
• 45:13lot of attention to it.
• 45:15So it's another strategy where we,
• 45:17as mental health professionals,
• 45:19can have an impact on larger groups of
• 45:22people simply by helping leaders in
• 45:25those other systems and organizations
• 45:27understand how their role can
• 45:29promote people's mental health.
• 45:31Another strategy is just to go
• 45:33out into community,
• 45:34so getting out of the black box,
• 45:36going into communities,
• 45:38doing community screenings when we when
• 45:40we first started doing this we started.
• 45:43Going to train stations,
• 45:44libraries and people said, you know,
• 45:46look people are never going to
• 45:48go up to a table in Philadelphia.
• 45:51That's about mental health and
• 45:53talk to someone,
• 45:54let alone do a screening.
• 45:55Turns out that actually people do an.
• 45:58In fact, people are wanting that
• 46:00they will come up and they'll say,
• 46:02well, you know, I've been,
• 46:04you know, feeling pretty depressed.
• 46:06Or you know my husband or my
• 46:08daughter is having problems.
• 46:10How can I get help and almost?
• 46:12Every time that we did this,
• 46:14there was at least one person who
• 46:16came up to the table who was suicidal.
• 46:19I always wonder what would have
• 46:21happened if we weren't there that day,
• 46:24and what happens every day?
• 46:25Because we're in our black box when
• 46:28the problems and the challenges
• 46:29are are in our communities.
• 46:31I have a belief that inherent
• 46:33in every community is wisdom to
• 46:35solve its own problems.
• 46:37These are members of the Burmese
• 46:38and Bhutanese communities in
• 46:40Philadelphia. Very small immigrant
• 46:41community and it's easy to.
• 46:43Miss these folks, but if you go to
• 46:46these communities who often have
• 46:48significant mental health challenges
• 46:50and you expect them that they're going
• 46:53to come to our traditional treatment
• 46:55approaches or treatment systems,
• 46:57that doesn't work.
• 46:58It's an unrealistic expectation,
• 47:00but if you go to them and
• 47:03you ask those communities,
• 47:05what are the challenges that they're facing,
• 47:07and what did they believe the solutions
• 47:10are they those communities can help.
• 47:13Designed the interventions that
• 47:15their communities need and in the
• 47:17case of the Burmese and Bhutanese
• 47:19communities they said look,
• 47:20let's create rather than asking our
• 47:22people to go to traditional programs.
• 47:25Let's take a mental health professional,
• 47:27embed them in the places where
• 47:29our people are already going.
• 47:31In this case a storefront program
• 47:33where people are going for
• 47:35English as second language.
• 47:36That kind of thing and that mental
• 47:39health professionals either help people
• 47:41within that context or they help to
• 47:43connect them to a culturally competent.
• 47:46Provider,
• 47:46that's a solution that.
• 47:49He never would have come up with,
• 47:51but because we were going to
• 47:53listen to bring our resources,
• 47:55our expertise and marry that with the
• 47:57knowledge and wisdom from the community,
• 47:59we were able to get a solution
• 48:01that reach many more people.
• 48:03And so here's my last example.
• 48:05This is this is a mural.
• 48:07If you ever been to Philadelphia,
• 48:09will see murals all over the city.
• 48:11This is taken from about a mile
• 48:14away so it gives you a sense of
• 48:16the size of some of these murals.
• 48:19Which are actually painted by the community,
• 48:22the city's mural arts program.
• 48:25Goes into communities.
• 48:27They engage people around a topic
• 48:29and then the community comes up
• 48:32with the concept and they actually
• 48:34paint the mural well.
• 48:36When I first heard this,
• 48:38I got really excited because we
• 48:41were struggling with this idea
• 48:43about how do we engage people?
• 48:46How do we engage people around
• 48:49issues around mental health an?
• 48:52And so I asked,
• 48:53if you know,
• 48:55could we partner around some mental
• 48:57health topics and we actually started
• 49:00a collaboration that actually is
• 49:02still going on today and some of
• 49:05the topics that we started to engage
• 49:08communities around where issues
• 49:10like recovery and trauma is one
• 49:14of the first ones that children's
• 49:16trauma or in the Latin X community.
• 49:19Talking about immigration and the
• 49:21impact and the struggles that
• 49:23communities have around immigration,
• 49:25this is one on suicide over 1000
• 49:28people worked on this mural and if
• 49:30you could look over to the right
• 49:33you can see these portraits so many
• 49:36of the people were family members
• 49:38of people who died by suicide.
• 49:41Some of them were were people who
• 49:43were survived suicide survivors.
• 49:45These portraits are people who
• 49:47died by suicide. It was a way of.
• 49:50People who came together to talk
• 49:53about their experiences honoring
• 49:55their family members and friends
• 49:57who died by by suicide.
• 49:59And, you know,
• 50:00one of the things that happens with
• 50:03suicide is that many of the families you
• 50:07know pretty isolated because of that.
• 50:10People don't talk about it is
• 50:12openly and so over the course of
• 50:15over a year there were series of
• 50:18workshops around suicide and suicide.
• 50:21Prevention and people coming
• 50:22up with this this concept.
• 50:24There were a lot of firefighters who
• 50:26had had probably about five or six
• 50:29firefighters who died by suicide,
• 50:30and you know the previous couple of
• 50:33years and a lot of them participated so.
• 50:36Just another example,
• 50:37and this is one last example.
• 50:39This particular one is in a methadone clinic,
• 50:42and because the community and the
• 50:44methadone clinic worked together
• 50:46on this mural, it actually changed
• 50:48the dynamic between that provider,
• 50:50an the community and I always said,
• 50:52you know,
• 50:53if we were to go into community and say hi,
• 50:56I'm doctor Evans,
• 50:57I'm here from the mental health Department.
• 51:00Would like to talk to you about
• 51:02suicide or have a community meeting.
• 51:04You know we get like.
• 51:06Three people and two of them
• 51:08would be related to me,
• 51:10but you know,
• 51:11when you can use the resources that
• 51:13are already in the community and make
• 51:15those connections that can make a big
• 51:18difference in our ability to reach people.
• 51:20And I just want to say and give
• 51:22a public shout out to Jack teams
• 51:24who evaluated this and this.
• 51:26This program and essentially found
• 51:28that even for people who were not
• 51:30directly working on these murals,
• 51:32it had an impact in the community.
• 51:34So thanks to Jack for demonstrating
• 51:36that we were on the right track with.
• 51:39This work?
• 51:39So that's what I mean by population health.
• 51:42So what I hope I've done is to share with
• 51:45you conceptually why I think it's important,
• 51:48but also to demonstrate that it can be done.
• 51:51But we can reach people
• 51:53that were not reaching.
• 51:54We can make a difference in the
• 51:56outcomes that people can get.
• 51:58We can.
• 51:58We can make a difference in the lives
• 52:01of children and people that frankly
• 52:03a lot of our society has given up on.
• 52:06But it's going to take us being willing
• 52:09to push out of our black boxes into.
• 52:11Innovate and to frankly take some risks.
• 52:14So about now people will say,
• 52:16well,
• 52:16you know how do we pay for all of this and.
• 52:22The first thing my first response is
• 52:25how we think is free and just as we have
• 52:28a mental model and we're training on
• 52:30mental model to think that people should
• 52:32come to us and we should treat them,
• 52:35we can have a different model that that
• 52:37is about how we can take our expertise
• 52:40and use that expertise in all kinds of
• 52:43settings in all kinds of different ways.
• 52:45But we also know that there is a
• 52:47paradigm shift in how Healthcare
• 52:49is going to be financed,
• 52:51and while now we have a fee for service.
• 52:54Paradigm which generating more revenue
• 52:56means just doing more services,
• 52:59independent of the outcomes that people get.
• 53:02Increasingly,
• 53:02our healthcare system is moving
• 53:05to a pay for performance or a a
• 53:09performance based way of financing.
• 53:11In particular putting healthcare
• 53:13systems at financial risk.
• 53:15Where where you know provide assistance
• 53:18will be given a pot of money.
• 53:21A population of people and.
• 53:24When that happens,
• 53:25it changes the financial incentives.
• 53:27Now there is a very strong incentive to
• 53:30provide effective and efficient care.
• 53:33There's a very strong incentive
• 53:35to reduce risk and to intervene
• 53:37at the earliest possible moment.
• 53:39There's a very strong financial
• 53:41incentive to keep people healthy,
• 53:43and so over time we're going to see
• 53:46as accountable care organizations,
• 53:48health homes,
• 53:50those kinds of alternative payment
• 53:52arrangements start to emerge.
• 53:55There will be a very strong
• 53:57financial incentive to do this.
• 53:59Going to end with just a
• 54:02couple of words about.
• 54:04Implications obviously for our field,
• 54:06we have to start thinking about
• 54:08how we work further upstream,
• 54:10how we address social determinants.
• 54:12We need to have more research in this area.
• 54:15We need to be training our our
• 54:17folks around how to pay attention
• 54:20to social determinants.
• 54:21We don't have to solve all of these problems,
• 54:24but we have to include them in
• 54:27our conceptualizations of how
• 54:29we work with people.
• 54:30We have to partner with other people who can
• 54:33help us address some of those determinants.
• 54:36But if we don't think about them,
• 54:37we're not we're going to miss that.
• 54:41We have to look at how we
• 54:43help keep people healthy.
• 54:45I'd like to see more research on the
• 54:48recovery process an and helping us
• 54:50to better understand strategies that
• 54:52we can employ to keep people healthy.
• 54:55So the point is that I think we have
• 54:58a lot of room here to change our
• 55:01system and I want to end with this.
• 55:04You know,
• 55:05yell is one of the Premier academic
• 55:07medical centers in the country,
• 55:09right in the world.
• 55:11For that matter,
• 55:12and if we're going to make these
• 55:15kind of changes,
• 55:16it's going to take the yells of the world,
• 55:19helping to do do that.
• 55:21The picture you're looking at is
• 55:23what the people who were doing the
• 55:25first recovery walk in Philadelphia.
• 55:27They had about 150 people,
• 55:29and these people understood that that
• 55:31we needed to change the paradigm if
• 55:34we're going to make a difference in
• 55:36people's lives, and so they were
• 55:38trying to put a face on recovery, Anne.
• 55:43And to change the paradigm so that
• 55:45people wouldn't be ashamed of being
• 55:48in recovery that same walk today
• 55:51looks like this like 26,000 people
• 55:53that come and all kinds of people,
• 55:56not just people in recovery.
• 55:58These early pioneers were really
• 56:00important in helping to shape and
• 56:03change the paradigm and the way I
• 56:05see are moved to population health.
• 56:08It really is about a movement.
• 56:11It was really clear to us.
• 56:13As we got into the later stages
• 56:15of this work that that it was more
• 56:18than just changing our thinking,
• 56:20it was really changing how we relate
• 56:23it to the community and bringing
• 56:25the community into how we work.
• 56:31A huge difference in a lot of people's lives,
• 56:34and I think that as a field we can
• 56:36keep pushing the envelope to do that.
• 56:39So with that, I'm going to say thank you
• 56:41and we'll see what questions folks have.
• 56:47Thank you so much Arthur.
• 56:49Just a really. Inspiring talk that
• 56:53you gave every time I I hear you,
• 56:57I learn something more and inspired
• 56:59by you so there's opportunities
• 57:01for folks to ask questions either
• 57:04directly or through the chat.
• 57:06Be happy to monitor that and and pass that
• 57:09along and so as you develop questions,
• 57:13I have one I can get you started
• 57:15with with Arthur is so you're
• 57:18talking about a change effort,
• 57:21a significant change effort.
• 57:22And you need both people that are staff
• 57:26and partners and allies to help do it.
• 57:29But then you're also going
• 57:31to encounter individuals.
• 57:33Systems that resist it.
• 57:34What have been some of your
• 57:36strategies to deal with both of those?
• 57:39Those
• 57:40dynamics? That is such a great question
• 57:42and is reason why I always in my talks
• 57:45about talking about a movement when you
• 57:47know one of the strategies we employed
• 57:49was to engage the faith community.
• 57:51We had these really large conferences
• 57:53and one day one of the members
• 57:56of the was actually a clergy.
• 57:58He stood up and said,
• 57:59you know, Doctor Evans,
• 58:00you all were trying to change the system,
• 58:03but what you really did was you.
• 58:05You created a movement and I was
• 58:08like that really crystallized for
• 58:09me because there was a point at
• 58:12which it was clear that we were
• 58:14no longer driving the train that
• 58:16there had been enough change in
• 58:18the community that people were.
• 58:22Working differently and
• 58:23approaching issues differently,
• 58:25we had nothing to do with.
• 58:28And I wish I had known that before because
• 58:31I would have been much more intentional
• 58:33about trying to build the choir.
• 58:35We now we we actually did that because like
• 58:37the first picture I showed you is just
• 58:40a few people who kind of believe in this.
• 58:42I mean, I'll tell you,
• 58:44I'll tell you this story.
• 58:45When I when I went to Philadelphia,
• 58:48they really didn't trust me right?
• 58:49Because, you know,
• 58:50at the time I I was working for a.
• 58:53Republican governor and a really
• 58:57heavily Democratic state.
• 58:59The city can be pretty parochial,
• 59:01and you know they're like you know what's
• 59:03this yell stuff you know and you know
• 59:06Republican Connecticut would you know?
• 59:07Would you know?
• 59:08And there was a lot of this.
• 59:10You know, folding of the arms
• 59:12when I was talking about recovery.
• 59:14And you know some of these new
• 59:16ideas and so there was a really.
• 59:18But there was a really small
• 59:20group of people who were really
• 59:22committed to these ideas.
• 59:23They were already ahead of me right
• 59:25there ahead of where I was thinking,
• 59:27like really pushing,
• 59:28and that group just grew and grew.
• 59:30And grew in one of the reasons
• 59:33that it grew was because.
• 59:35It was about giving voice to people who
• 59:37hadn't had voice before it was about.
• 59:40We did a lot of work around peers,
• 59:42an empowering people to, you know,
• 59:44we really took to heart that idea
• 59:47of nothing about us.
• 59:48Without us, you know.
• 59:49So we engaged communities.
• 59:50So at some point it was less about
• 59:53us trying to change and more
• 59:55about people in the Community,
• 59:57saying this is what we want.
• 59:58This is what we need and they were
• 01:00:01driving and they were saying to
• 01:00:03the providers you need to make.
• 01:00:05These changes,
• 01:00:06so I think it's about thinking
• 01:00:08differently about it.
• 01:00:08How do we engage people?
• 01:00:10How do we give people voice?
• 01:00:12How do we empower people?
• 01:00:13And yeah,
• 01:00:14we there are technical things and
• 01:00:16I showed some of the technical
• 01:00:18things that we did,
• 01:00:19but I think what really changed was
• 01:00:21people who would lived experience
• 01:00:23who just said we got to do this and
• 01:00:26they put the pressure on a lot of
• 01:00:28people who were resistant in the beginning.
• 01:00:32We thank you. Other
• 01:00:34questions for Doctor Evans.
• 01:00:42Hi, could you say more about
• 01:00:44the work that you've done with
• 01:00:46the believe it was CEOs and
• 01:00:48organizations and how they help them?
• 01:00:50Think about organizations and
• 01:00:52health promoting environments?
• 01:00:55Yeah, we we got a PA where
• 01:00:58we actually spend quite a bit
• 01:01:01of time talking to leaders,
• 01:01:04mayors, working with National
• 01:01:07Governors Association or.
• 01:01:09School superintendents,
• 01:01:10through the PTA, and so forth,
• 01:01:12and what we're trying to do is to
• 01:01:14help educate them about the role
• 01:01:16that they can play in creating
• 01:01:20psychologically healthy workplaces.
• 01:01:21In fact, we can send folks if you're
• 01:01:24interested in that that we can send
• 01:01:26you some information about that.
• 01:01:28But there are five domains that
• 01:01:30we look at that we know are
• 01:01:32related to healthy workplace.
• 01:01:34We actually give award each year.
• 01:01:36We didn't do it last year during
• 01:01:38the pandemic, but you know,
• 01:01:40corporations like Marriott and
• 01:01:42other corporations like that have
• 01:01:44received that award because they.
• 01:01:46Done, I've been very intentional
• 01:01:48in those five domet domains
• 01:01:50in helping their work places,
• 01:01:53so one of the domains,
• 01:01:55for example,
• 01:01:56is employee engagement as an example and so.
• 01:02:01We think that that's a really important
• 01:02:04thing that we can do as a mental
• 01:02:07health field to help individuals.
• 01:02:08We don't have to necessarily
• 01:02:10just provide direct services.
• 01:02:12We can also help those organizations
• 01:02:14change their organizational climate.
• 01:02:18Thank you bye bye. I'd love to see more of
• 01:02:21that. Thank you. OK, I think does
• 01:02:24everyone have access to the chat?
• 01:02:27Yes. I have a colleague on who
• 01:02:32might be able to get into the chat.
• 01:02:35A link to the the psychologically
• 01:02:38healthy workplace work.
• 01:02:41Great will look for that.
• 01:02:45Other questions comments.
• 01:02:58Great talk. Really enjoyed it, thank you.
• 01:03:03Good, thank you.
• 01:03:08I have another question.
• 01:03:10I'll just jump in again.
• 01:03:12Can you say more about what
• 01:03:14AP is doing around racism?
• 01:03:16I know I read a lot in terms
• 01:03:19of reports and studies,
• 01:03:20and if you could
• 01:03:22just kind of give an overview of maybe
• 01:03:25some of the things that
• 01:03:27you're doing or finding.
• 01:03:28I think that would be really helpful.
• 01:03:31Sure, so right after George Floyd's death,
• 01:03:34we made a real long term commitment to
• 01:03:37addressing issues of race and racism.
• 01:03:40We have a multi pronged commitment.
• 01:03:42First of all, Appa has been involved
• 01:03:45in these areas for quite a bit of time,
• 01:03:48but one of the things that we noted
• 01:03:52is that what happens is we have these.
• 01:03:56Incidents the public pays a lot
• 01:03:58of attention to these issues.
• 01:03:59They go away out of the news media.
• 01:04:02It's kind of quiet.
• 01:04:03Then another incident happens and
• 01:04:05we pay attention and then sort of
• 01:04:07this up and down and we decided
• 01:04:10after George Floyd's death that.
• 01:04:12This is a real systemic issue for
• 01:04:14our nation and that we needed to
• 01:04:16make a long term sustained have
• 01:04:18a long term sustained effort,
• 01:04:20and so we've done a couple of
• 01:04:22things in the aftermath of that.
• 01:04:25One is that we put together a a group to
• 01:04:28look at the psychological science around.
• 01:04:32Policing and whether there are
• 01:04:34things that we know and things
• 01:04:37that we can recommend that will
• 01:04:40reduce the likelihood that.
• 01:04:45Police will use a kind of force
• 01:04:48and violence that they're using
• 01:04:50with African Americans, men,
• 01:04:53and in particular the one group
• 01:04:56so that that group is ongoing.
• 01:04:59There's an initiative around HealthEquity.
• 01:05:02We're looking at again,
• 01:05:04a long term strategy around.
• 01:05:06First developing recommendations around
• 01:05:09things we can do as a field to improve
• 01:05:14HealthEquity and then to work with
• 01:05:16a partner with other organizations.
• 01:05:18To do that.
• 01:05:19We're also taking a look at ourselves
• 01:05:21because one of the things that
• 01:05:24we've heard consistently from
• 01:05:25communities of color is that our field
• 01:05:28psychology has contributed to some
• 01:05:30of the things that we we've seen.
• 01:05:33You know where they were talking about.
• 01:05:36Some of the eugenics movement we
• 01:05:38actually have people who were a
• 01:05:40PA presidents who were part of
• 01:05:42the eugenics movement, so.
• 01:05:44We we're we're not.
• 01:05:47We're also culpable as an organization,
• 01:05:50and so one of the things we are doing
• 01:05:53is taking a systematic look at our role.
• 01:05:56Our field's role in
• 01:05:58perpetuating racist ideas,
• 01:05:59and we're going to be engaging in a process
• 01:06:03to not only to identify that to make amends,
• 01:06:06but then to to really take
• 01:06:08on some of those issues.
• 01:06:11And we,
• 01:06:11you know,
• 01:06:12we suspect that that's going
• 01:06:14to mean that we're looking at
• 01:06:16issues like pipeline issues and.
• 01:06:18Who's coming into the field?
• 01:06:20We're going to be looking at research.
• 01:06:22Who are the people who are?
• 01:06:23Who are the editors of journals were
• 01:06:26already starting to look at that?
• 01:06:28And how do we diversify our field,
• 01:06:32and in particular those kinds
• 01:06:34of positions so that we have a
• 01:06:38field that is not only anti racist
• 01:06:41but also one that really?
• 01:06:44Incorporates the diversity of of our nation,
• 01:06:47and so it's pretty exciting the
• 01:06:49the to see the level of support we
• 01:06:52right after George Floyd's death
• 01:06:54have been the previous president.
• 01:06:56I have been doing town halls with
• 01:06:59our membership an right after
• 01:07:01George Floyd's death.
• 01:07:02We did a town Hall and the platform that we
• 01:07:06were using cannot hold all of the people.
• 01:07:09I mean,
• 01:07:10people really across the spectrum.
• 01:07:12From researchers and clinicians just.
• 01:07:14Across the field really felt strongly
• 01:07:16that this is something that we needed
• 01:07:18to take on as a as an organization.
• 01:07:22Thank you. I know Alyssa thank you
• 01:07:26very much for posting in the check the.
• 01:07:30Psychologically healthy workplace
• 01:07:32awards link so people can can follow
• 01:07:35up on an other thing that's mentioned.
• 01:07:37There's a question in the chat that can read.
• 01:07:41There's been talk about moving away
• 01:07:43from fee for service for decades,
• 01:07:45but yet it persists in part due to the lobby
• 01:07:48of hospitals and professional organizations.
• 01:07:51What makes you optimistic about future
• 01:07:53changes toward more population based focus?
• 01:07:56Well, I think I think it's going to be
• 01:08:00hard because as the question indicates
• 01:08:02that there are a lot of forces that
• 01:08:06want to maintain the status quo.
• 01:08:09The problem is if you look
• 01:08:11at health care inflation,
• 01:08:13it's been running about twice the
• 01:08:15inflation in the general economy,
• 01:08:17and it's been doing that for
• 01:08:20for a few decades now.
• 01:08:22So what's happening is that
• 01:08:24a greater and greater part.
• 01:08:26Of our GDP is being taken up
• 01:08:29by the healthcare dollar.
• 01:08:31It puts our our industries at a disadvantage.
• 01:08:34If you take a car, for example,
• 01:08:37and you look at the costs of producing
• 01:08:40a car in the US in the same,
• 01:08:43the cost of producing the same
• 01:08:45car in a foreign country of big
• 01:08:48chunk of the cost for a car in
• 01:08:51the US is related to healthcare
• 01:08:53unrelated to the actual vehicle.
• 01:08:57At some point we're going to reach a
• 01:09:00point where it's going to be untenable
• 01:09:03for us to continue to finance healthcare
• 01:09:06the way we have historically done that.
• 01:09:10Whether that will happen in
• 01:09:12the next five years.
• 01:09:14Next 10 years, whatever,
• 01:09:15that's that's a question I.
• 01:09:17I'm hoping that it happens sooner.
• 01:09:20I mean, we've already seen some.
• 01:09:23Some examples of that
• 01:09:24accountable care organizations,
• 01:09:25and you know,
• 01:09:26if you follow that research that you
• 01:09:28know that that's been a mixed bag,
• 01:09:30so maybe that's not the right model,
• 01:09:32but but I do think that the financial
• 01:09:35pressures on our health care system
• 01:09:37at some point is going to really
• 01:09:39force us to to make a change.
• 01:09:41And and I think when it happens,
• 01:09:43it's going to happen like managed care.
• 01:09:45So those of you who are around
• 01:09:47in the 90s when managed cares
• 01:09:49just started to emerge,
• 01:09:50especially when it started to
• 01:09:52move into the public sector.
• 01:09:54If you recall that those changes
• 01:09:56happen pretty quickly over a
• 01:09:58pretty short period of time, so.
• 01:10:01We'll see, I'm hopeful that that will happen,
• 01:10:04but but even if it doesn't,
• 01:10:06I think that systems have more
• 01:10:08of an ability to work in this
• 01:10:10way than they probably realize.
• 01:10:12You know, we were able to do that,
• 01:10:15and in Philadelphia,
• 01:10:17I think that most systems
• 01:10:18have some ability to do that.
• 01:10:21I do think that the.
• 01:10:23The medicalization that is making
• 01:10:25moving more and more of the public
• 01:10:28dollar into Medicaid is a problem
• 01:10:31because it is a fee for service.
• 01:10:33Treatment oriented service and I know why.
• 01:10:38Service systems do that,
• 01:10:40but what it does do is that it.
• 01:10:43It gives commissioners systems
• 01:10:45administrators less flexibility to
• 01:10:47do the kinds of things that we often
• 01:10:50need to do to reach reach people.
• 01:10:55Great, well thank you so much Doctor
• 01:10:58Evans for speaking with us today
• 01:11:01and really gives us a lot of food
• 01:11:04for thought for next steps around
• 01:11:07behavioral health systems so I know
• 01:11:09some some students will be joining you
• 01:11:12briefly for a follow up afterwards,
• 01:11:15but I want to thank you again
• 01:11:18for coming and say farewell.
• 01:11:21Well, thank you. It's good.
• 01:11:22I wish I could be there in person.
• 01:11:25I spent 16 years and you haven and I
• 01:11:28have very fond memories and it's great.
• 01:11:30See I see a lot of old friends
• 01:11:33Deborah and other people on here and
• 01:11:35sambol I saw but a bunch of folks so
• 01:11:38it's good to see all of you, Ann.
• 01:11:41I hope after this pandemic I get
• 01:11:43a chance to come down and just
• 01:11:45hang out with with folks.
• 01:11:47And thanks John for inviting me
• 01:11:50as well and Jack for having me.
• 01:11:52It's an exciting time and I hope
• 01:11:55I again I get to see you all
• 01:11:57in person sometime soon.