STEP LC - Module D and Pop Health Approach - Session 6

Transcript

• 00:00Of of the overall
• 00:02population health model and also,
• 00:05our very exciting next steps
• 00:07to try to build a
• 00:08statewide learning health system in
• 00:10Connecticut. So,
• 00:11and I really appreciated
• 00:13the
• 00:14questions we've had so far.
• 00:15It's,
• 00:16it's really exciting to be
• 00:18talking with all of you
• 00:19about,
• 00:21what we're seeking to to
• 00:22build and are very actively
• 00:24working on,
• 00:25for Connecticut.
• 00:28So,
• 00:34the the the first is
• 00:35really, I I think is
• 00:37a challenge. It's an enduring
• 00:39challenge for us
• 00:40at Step, and I I
• 00:41think it's familiar to
• 00:44any agency in the state
• 00:45that's trying to,
• 00:47discharge or transfer
• 00:49care from their service to
• 00:51another service given all the
• 00:52challenges
• 00:53in that process, but also,
• 00:56workforce shortages and the stresses
• 00:58the systems are under.
• 01:01So just to reorient you,
• 01:02we're talking about the the
• 01:04final step in our care
• 01:05pathway, the the red or
• 01:07care transition module.
• 01:09And step like many other,
• 01:12first episode services
• 01:14was constructed as a time
• 01:15limited service. And the idea
• 01:17being that after two years
• 01:18of care, we aim to
• 01:20graduate most of our patients
• 01:22to
• 01:23usual care services in the
• 01:25communities in which they live.
• 01:27The expectation
• 01:28being that
• 01:29most will have recovered enough
• 01:31functioning and be
• 01:32in symptomatic control to be
• 01:34able to
• 01:36leverage,
• 01:37usual care services and return
• 01:39to,
• 01:41their vocational
• 01:42personal trajectories.
• 01:44And only a very small
• 01:45fraction
• 01:46will require,
• 01:49the wrap around services within
• 01:50the public sector system.
• 01:52And for us, that's CMHC.
• 01:55And that has in fact
• 01:56been the case for us
• 01:57over the years that we've
• 01:58had to
• 02:00transition less than ten percent,
• 02:02straight from step into a
• 02:03chronic care service at CMHC.
• 02:07And for others, I've been
• 02:08able to transition them to
• 02:10usual care.
• 02:12However, this is remains a
• 02:14challenge and a work in
• 02:15progress for us.
• 02:18And I'm gonna say a
• 02:18little bit about it, but
• 02:20I'm hoping that the final
• 02:21part of my presentation today
• 02:23will really offer a more
• 02:25sustainable solution to this challenge
• 02:27of
• 02:28what to do,
• 02:30with individuals who've
• 02:32recovered quite a lot of
• 02:34function.
• 02:35When you transition them to
• 02:37usual care, how can we
• 02:38maintain the gains that they
• 02:39have
• 02:40enjoyed in a in a
• 02:41first episode service?
• 02:49So, this is returning to
• 02:50a slide I've I've shown
• 02:51before. Currently,
• 02:52best practices that we currently
• 02:54have in the state,
• 02:55Many of you
• 02:56may know the prime clinic,
• 02:58which is a research clinic
• 02:59focused on,
• 03:01ways to identify people who
• 03:02will eventually convert to a
• 03:04psychotic disorder
• 03:06and to investigate approaches to
• 03:07delay or ideally even prevent
• 03:09the onset of psychosis.
• 03:12And that remains best practice,
• 03:14which is
• 03:15really a research endeavor to
• 03:17try to develop knowledge that
• 03:19could be then implemented.
• 03:21After the first episode,
• 03:23we have,
• 03:24actionable evidence to implement
• 03:27early intervention services that has
• 03:29been the subject of of
• 03:30this,
• 03:31over these sessions before
• 03:33where we can provide both
• 03:35early detection and coordinated specialty
• 03:38care
• 03:40with structured assessments and formulations.
• 03:42So modules a through c
• 03:45that we know,
• 03:47and there's considerable evidence now
• 03:48to to support this idea
• 03:50that it will improve
• 03:52trajectories, outcomes, distress, reduce risk
• 03:55for suicide, and so on.
• 03:58The dotted line from there
• 03:59to what I've called lifespan
• 04:01care for what will for
• 04:03most people be a chronic
• 04:04illness that will require management
• 04:06just like diabetes
• 04:08or asthma.
• 04:10But it's a dotted line
• 04:12because I think this is,
• 04:14an a gap in our
• 04:16services,
• 04:18not just in Connecticut, but
• 04:20really around the world,
• 04:22that people who leave these
• 04:24early intervention services,
• 04:27tend to not,
• 04:28in general,
• 04:30retain the gains they've often
• 04:32made unless they're transitioning to
• 04:34services that are strong and
• 04:36ready to accept them into
• 04:37care.
• 04:38And so,
• 04:40Denmark is a good example
• 04:41where
• 04:43most usual services have now
• 04:44been
• 04:47improved to a level
• 04:49very close to the original
• 04:51early intervention service,
• 04:54that was developed,
• 04:55at the OPUS center.
• 04:58And so
• 04:59they have in some ways
• 05:00an ideal setup nationally where
• 05:02they would transition people
• 05:04from a receiving service to
• 05:05another service
• 05:06close to where the person
• 05:08lives that's,
• 05:09as good in quality and
• 05:11is able to engage people
• 05:12effectively.
• 05:13But this is not the
• 05:14case in most of the
• 05:16rest of the world, and
• 05:16so
• 05:17we're often in a challenging
• 05:20position transitioning young individuals after
• 05:22building a very strong alliance
• 05:24with them and their families
• 05:26to a new service that
• 05:27is always, even in the
• 05:29best of circumstances, a challenging
• 05:31transition to make.
• 05:33So at step, I'm I'm
• 05:35gonna just describe
• 05:36our first pass at
• 05:38trying to improve on this,
• 05:40and it's a it's some
• 05:41data from a paper we
• 05:43published, and I'll just orient
• 05:44you.
• 05:45We began tracking,
• 05:48how people did after discharge.
• 05:51And so we described this
• 05:52as their transfer status, which
• 05:54is
• 05:55at three months where they
• 05:56confirmed to be in treatment
• 05:58at some
• 05:59behavioral health agency or private
• 06:02provider,
• 06:04or were they not in
• 06:05treatment? So they were confirmed
• 06:06to not be in treatment.
• 06:08And there was a third
• 06:09category where we essentially lost
• 06:10track. We're not able to
• 06:12confirm
• 06:13whether they had landed in
• 06:14treatment or not.
• 06:16So those are the three
• 06:17categories of transfer status.
• 06:19And another,
• 06:22categorization we used was disposition,
• 06:24which is,
• 06:25did we have an opportunity
• 06:26before they left our clinic
• 06:29to refer them? Did they
• 06:30engage with us in a
• 06:31process where we could talk
• 06:32to them about where they
• 06:33prefer to go and
• 06:35a more ideal,
• 06:37transfer process?
• 06:38There were some who refused
• 06:40to engage with that, and
• 06:41so they left,
• 06:43with our full knowledge that
• 06:45they had not received any
• 06:46referral from us,
• 06:48often because they did not
• 06:49believe they needed care when
• 06:51they left the clinic.
• 06:52And then there were some
• 06:53that were lost to follow-up
• 06:55that in the process of
• 06:56planning their discharge,
• 06:57we lost track of them.
• 07:00Some individuals moved away.
• 07:02A very small percentage were
• 07:04incarcerated,
• 07:06and there was one individual
• 07:07who was who was deceased
• 07:09before we had the opportunity
• 07:10to transfer them. So you
• 07:12can see that in disposition,
• 07:13we were tracking our internal
• 07:15processes of whether we had
• 07:17a chance to engage individuals.
• 07:19And in the transfer status,
• 07:21we were tracking really the
• 07:22outcome of this process. Did
• 07:23they actually land,
• 07:25as measured by whether or
• 07:27not they were in treatment
• 07:28three months later?
• 07:30And the two columns, pre
• 07:32PDSA and post PDSA. So
• 07:34PDSA refers to plan, do,
• 07:36study, act, and this is
• 07:37a term for
• 07:38an approach to quality improvement
• 07:40where we go through cycles
• 07:41of planning,
• 07:44deploying,
• 07:45studying the effect of the
• 07:46intervention, and then assessing whether
• 07:47it worked to try to
• 07:49improve the rates of people
• 07:51being confirmed in treatment.
• 07:53And you'll see that we
• 07:55were able to improve the
• 07:56number of individuals who were
• 07:58confirmed in treatment three months
• 07:59later. We went from thirty
• 08:00seven point two percent to
• 08:02fifty four point one percent.
• 08:04We were also able to
• 08:07confirm
• 08:08more clearly that there were
• 08:09a significant percentage, twenty point
• 08:11two percent who
• 08:12were confirmed to not be
• 08:14in any treatment three months
• 08:15later, which is concerning.
• 08:17And we were able to
• 08:18drop the number of people
• 08:19who were unknown from as
• 08:21almost, you know, more than
• 08:23half before we started this
• 08:25process
• 08:26to around a quarter of
• 08:27individuals. So certainly
• 08:29better, but not where we
• 08:31would want to be. And
• 08:32it illustrates in some ways
• 08:33the challenges of,
• 08:36affecting this handoff with individuals
• 08:38that were in care, but
• 08:39now are at risk of
• 08:41dropping out, falling out, not,
• 08:44continuing with care.
• 08:46And you'll see below the
• 08:47trends in in disposition
• 08:50are really our own internal
• 08:51process metrics on how we
• 08:53were doing. And we were
• 08:55able to, for instance, have
• 08:56the number of people who
• 08:58refuse to work with us
• 08:59by instituting some approaches like
• 09:01beginning to talk about discharge
• 09:03planning,
• 09:04you know, ideally three months
• 09:06before,
• 09:07people reach the two year
• 09:09mark of care.
• 09:11And in terms of looking
• 09:12at
• 09:14transfer status, measuring transfer status,
• 09:16we found that calling people
• 09:18one month after they left
• 09:19us was helpful
• 09:21in reminding them of where
• 09:23we had referred them,
• 09:25troubleshooting a little bit around,
• 09:28accessing the service we had
• 09:29sent them to, sometimes calling
• 09:31the receiving service to try
• 09:32to see if they could,
• 09:34help,
• 09:35reach out to this individual.
• 09:39And that tended to help
• 09:40us improve the three month
• 09:42outcomes of
• 09:44confirming that individuals were in
• 09:47fact in treatment.
• 09:49So,
• 09:51you know, this is a
• 09:52sort of a persistent challenge
• 09:54for us. We continue to
• 09:55look at this and try
• 09:56to find ways to improve
• 09:57connections with care.
• 09:59But but it's something we
• 10:00can talk about more and
• 10:02and much, of course,
• 10:03obviously, depends on
• 10:05the individual's understanding of their
• 10:06need for continued care, the
• 10:08supports they would have from
• 10:09family,
• 10:10but also
• 10:12the ability of the receiving
• 10:13clinic to be able to
• 10:14engage someone,
• 10:16who has who has been
• 10:16in care and is accustomed
• 10:18to a certain kind of
• 10:20service
• 10:20that, it might take
• 10:23a while to engage the
• 10:24person in with a new
• 10:25clinician
• 10:27around. So
• 10:28so I'll stop there, and
• 10:30I'm happy to be interrupted
• 10:31with questions because I'm gonna
• 10:32shift now to talk
• 10:34more about our population health
• 10:36approach. Yeah. Please, Sheila. Go
• 10:37ahead.
• 10:41So I do have a
• 10:42question about,
• 10:44how much time and who
• 10:45you,
• 10:46refer to and what your
• 10:49transition process is because,
• 10:52you know, I agree with
• 10:53you that for first break,
• 10:56people,
• 10:57you know,
• 10:59and they're young adults, you
• 11:00know, they don't wanna have
• 11:02a diagnosis. They don't wanna
• 11:03be in care. But I
• 11:05just wondered,
• 11:07if, if you meet with
• 11:09the,
• 11:10you know, now that we've
• 11:11got, you know, all of
• 11:12this, you know, virtual setups,
• 11:14is it,
• 11:16is this the time to
• 11:17make a more intensive,
• 11:19transition time that lasts, you
• 11:21know, one, two, three months
• 11:23so that you can increase,
• 11:25the rate of, people who
• 11:29smoothly,
• 11:30get handed off to another,
• 11:33program?
• 11:36Yeah. So our our transition
• 11:38process, that final module now
• 11:40is at least three months
• 11:41long in, you know, for
• 11:43those who agree to engage
• 11:44in that process with us.
• 11:47We have sometimes extended care
• 11:49for an additional year
• 11:52for those individuals who were
• 11:53so poorly engaged with treatment
• 11:55in the first two years
• 11:56that it it's very difficult
• 11:58to even engage in a
• 11:59conversation about transition in care
• 12:01when they've never quite
• 12:03fully engaged in care with
• 12:05us.
• 12:05So, so we've added that
• 12:07extra year. We've we've had
• 12:08to find ways to make
• 12:09sure that it's used selectively
• 12:11because otherwise, it becomes hard
• 12:13for the service to
• 12:16retain enough staff time to
• 12:17take in new referrals.
• 12:19Mhmm. But but, yeah, we've
• 12:21we're still sort of,
• 12:23trying different ways of addressing
• 12:25this challenge of,
• 12:28what is in some ways
• 12:29a good
• 12:30a good news moment. Right?
• 12:32That these are individuals who
• 12:33are ready for a step
• 12:34down in services for the
• 12:35for the most Exactly.
• 12:38But they're at a risk
• 12:39of dropping off, which is
• 12:40which would not be a
• 12:41good thing. So,
• 12:43yeah. Yeah. But, I mean,
• 12:45it's a it's a great
• 12:46question, and I I think
• 12:48we'll return to it. Actually,
• 12:49in some ways, our
• 12:51our hope in building a
• 12:52statewide network
• 12:53is that as people move
• 12:55around, which young people are
• 12:57more likely to do, they
• 12:58leave to go to college,
• 13:00sometimes in a different part
• 13:01of the state, sometimes out
• 13:02of the state, which is
• 13:03a a different challenge. But
• 13:05they're often moving within the
• 13:06state, finding their own home,
• 13:08leaving their parents' town.
• 13:10And the hope is that
• 13:11we would be able to
• 13:12share and continue their care
• 13:13across a network of clinics
• 13:16where it's a bit more
• 13:17of a seamless transition in
• 13:19terms of the care model,
• 13:20the willingness to engage, the
• 13:22sharing of clinical information across
• 13:24the sites,
• 13:25which I think
• 13:27once we were to build
• 13:28that would be a more
• 13:28sustainable way to do this
• 13:30Yes. Versus
• 13:32we're currently doing, which is
• 13:33much more of
• 13:35a ad hoc personalized
• 13:37approach for each patient leaving
• 13:39to each receiving clinic,
• 13:41which can work very well
• 13:42when it does. But if
• 13:43the person decides to not
• 13:44go to that clinic,
• 13:46all that work,
• 13:47needs to be redone by
• 13:48the patient and their family
• 13:49with a different clinic.
• 13:51Yeah. And and I would
• 13:52think that if you're taking,
• 13:54you know, three months you
• 13:55know, I know
• 13:57I know you mentioned that
• 13:59only about ten percent,
• 14:00go to the,
• 14:03you know, state, run services,
• 14:06but those are probably the
• 14:07ones that, need a more
• 14:09intensive
• 14:10transition plan.
• 14:14Yeah. But there it's, for
• 14:16it's easier because we are
• 14:17in the LMHA.
• 14:19So we're really talking about
• 14:20transferring people from,
• 14:22you know, a team that's
• 14:24sitting on,
• 14:25in the same floor to
• 14:27another team in the same
• 14:28floor of the same building.
• 14:29Nice. Even so even so,
• 14:31it's still a challenge sometimes.
• 14:33But,
• 14:34at least there, the patient
• 14:36and family don't experience this
• 14:38as as big a disruption.
• 14:40Exactly.
• 14:43So yeah.
• 14:44And and I think that's,
• 14:45you know,
• 14:46this is another,
• 14:48interesting
• 14:48point. But for the subset
• 14:50who are
• 14:52treatment refractory or have very
• 14:53adverse social determinants and need
• 14:55a lot of supports around
• 14:57entitlements,
• 14:59housing support,
• 15:01it it makes sense even
• 15:03if their illness is not
• 15:05as severe that they remain
• 15:07within the, public sector.
• 15:09Exactly.
• 15:11So
• 15:13so those tend to be
• 15:15easier
• 15:16to plan for because it's
• 15:17within the agency for us
• 15:18Mhmm. Even though they also
• 15:20can take quite a lot
• 15:21of time because even those
• 15:22teams are pretty,
• 15:24stretched for resources sometimes and
• 15:26have wait lists and so
• 15:27on. Certainly.
• 15:30Yeah. Thank you for that.
• 15:31Thank
• 15:32you. Joe, can I just
• 15:33ask one other question?
• 15:36You know, I noticed
• 15:38in your,
• 15:40in the slide for the,
• 15:44from the clinics of North
• 15:45America
• 15:47that
• 15:49and that you had also
• 15:50discussed the issues,
• 15:52in Denmark. Now my understanding
• 15:54is that,
• 15:56since
• 15:58the greater availability
• 16:00of cannabis in Denmark,
• 16:02that they've noted that there's
• 16:04an increase in,
• 16:06diagnosed in the incidence of
• 16:08schizophrenia,
• 16:10you know, over the course
• 16:11of the last five to
• 16:12six years changing from one
• 16:14percent to four percent.
• 16:15So I just wondered,
• 16:17if, that had been,
• 16:20through for, your clinic as
• 16:22well.
• 16:27No. It's a good point.
• 16:28We we don't have
• 16:30the you know, it has
• 16:32cannabis
• 16:33increased the incidence
• 16:35of psychosis in Connecticut? I
• 16:37don't know the answer to
• 16:38that, and we, at Step,
• 16:40don't have the ability to,
• 16:43you know we haven't seen
• 16:45an increased flow, for example,
• 16:48over the last four or
• 16:49five years, even though we
• 16:50have seen an increased prevalence
• 16:52of cannabis use amongst people
• 16:54coming to our
• 16:56but but,
• 16:57I think that that's another
• 17:00my expectation is that we
• 17:01will see an in an
• 17:02incident increase in incidence of
• 17:04first episode cycles. We probably
• 17:06already have seen it. We
• 17:07just haven't,
• 17:09detected it in our ten
• 17:10towns yet.
• 17:12Thank you.
• 17:15Yeah.
• 17:20So moving I think this
• 17:21is a a
• 17:23the slide is to just
• 17:24remind me and and to
• 17:25return to this that we
• 17:26had talked about the introduction
• 17:30steps,
• 17:32framework for designing an early
• 17:34intervention service is really informed
• 17:36by this population health model.
• 17:38And to my mind, it
• 17:40really has three key elements,
• 17:41which I think
• 17:43are a very good fit
• 17:44with what local met lead
• 17:46mental health agencies,
• 17:48around Connecticut already do and
• 17:50probably do better than most
• 17:52other,
• 17:53providers of care across medicine,
• 17:57which is one that there
• 17:58is a commitment to a
• 18:00geographic catchment, which is a
• 18:02kind of a promise
• 18:03to people in a region
• 18:05that they can come to
• 18:06this place, to access care.
• 18:11So I I I believe
• 18:12that's necessary to be able
• 18:13to organize a statewide network
• 18:16where
• 18:17each agency
• 18:19is taking ownership of a
• 18:20region in a way that
• 18:21makes it easy to
• 18:23decide where to send whom
• 18:25for care.
• 18:26I understand the caveat to
• 18:28that, of course, is clinical
• 18:29capacity and so on. But
• 18:30but in essence, that's one
• 18:32piece of population health that
• 18:33we already have built in
• 18:35and baked into our
• 18:36statewide
• 18:38public sector mental health system.
• 18:41The second is that we
• 18:43we are trying to intervene
• 18:44across all determinants
• 18:47of health,
• 18:48because we wanna
• 18:50improve all health outcomes. So
• 18:52we're not just interested in
• 18:54getting
• 18:55medications into people to reduce
• 18:57symptoms,
• 19:00but we are interested in
• 19:01engaging in all the things
• 19:02that could get in the
• 19:03way of them returning to
• 19:05a full
• 19:06functional
• 19:07and active life in their
• 19:09communities.
• 19:10This is a very ambitious
• 19:12goal,
• 19:13but I think to patients
• 19:14and families,
• 19:15this is an obvious goal
• 19:17that it they are
• 19:19while symptoms might be very
• 19:20distressing or why it's while
• 19:22some particular aspect of behavior
• 19:24like substance use may be
• 19:26very problematic
• 19:28for a family
• 19:30and or a patient.
• 19:32The goal in the end
• 19:33is what we all want
• 19:34from,
• 19:35treatment for any chronic illness,
• 19:37which is that the illness
• 19:39becomes
• 19:40the footnote
• 19:42and the rest of the
• 19:43goals and the plans of
• 19:45the person can take on
• 19:46front stage.
• 19:48Particularly so with
• 19:50chronic mental illnesses that strike
• 19:52young adults where their orientation
• 19:54is to to actually get
• 19:55back to their lives. The
• 19:56last thing they want to
• 19:57be is a chronic patient.
• 20:00But this means though thinking
• 20:01about determinants
• 20:03like, of course, behavior, social
• 20:05environment,
• 20:07and,
• 20:08we can talk more about
• 20:09this, but we've made,
• 20:12attempts at step to try
• 20:13to look for ways in
• 20:15which we could track this
• 20:16better. And it's become clear
• 20:18that these things are better
• 20:20tracked at scale that is
• 20:21across the state rather than
• 20:23in small regions where it's
• 20:24possible to look at census
• 20:26data
• 20:26and ask questions like,
• 20:29does a particular
• 20:31deprivation
• 20:32in a rural part of
• 20:33the state mean
• 20:35that a person has, for
• 20:36example, a longer delay to
• 20:38care? And if so,
• 20:40this needs to be addressed
• 20:41not in a clinical way,
• 20:43but with a more of
• 20:44a public health approach,
• 20:46ways to, make it easier
• 20:47for people to gain access
• 20:49to transportation
• 20:50or a change in the
• 20:51way that clinical services configure
• 20:53to provide more services via
• 20:54tele mental health. Just one
• 20:56example of as we think
• 20:58statewide,
• 20:59we need to be willing
• 21:00to look to be flexible
• 21:02on the ways in which
• 21:02we address
• 21:04relevant determinants in different regions
• 21:07that are going to have
• 21:07an impact on outcomes that
• 21:09we care about.
• 21:10And also thinking about disparities,
• 21:13which,
• 21:14is baked into the measurement
• 21:16of outcomes, which is while
• 21:17we do wanna improve outcomes
• 21:19on
• 21:20average, which we have at
• 21:22staff,
• 21:22we've also been looking very
• 21:24carefully at whether those land
• 21:26across all genders, across all
• 21:28racial backgrounds,
• 21:31across
• 21:32socioeconomic status.
• 21:34Again, something that becomes even
• 21:36more relevant at a statewide
• 21:37level
• 21:38where
• 21:39these disparities could be addressed,
• 21:43but may not be something
• 21:44that one clinic can do
• 21:46alone, but might need to
• 21:47be addressed at a more
• 21:48regional public health level.
• 21:50So I realized that sounds
• 21:51abstract, but I'm happy to
• 21:52to talk more as we,
• 21:54go forward with this.
• 21:56Keeping this framework in mind,
• 21:57though,
• 21:59we we we
• 22:01are we have
• 22:02in step,
• 22:04designed what we call learning
• 22:06health system that's really built
• 22:08to expand into a network.
• 22:10And
• 22:11the
• 22:13I apologize. I jumped ahead.
• 22:14So so what I mean
• 22:15here is I realized this
• 22:16is a
• 22:17a busy network slide, but
• 22:19I'm gonna use my arrow
• 22:20to try to point my
• 22:21way through. So
• 22:23one starts as we have
• 22:25with stakeholders
• 22:26telling us
• 22:28what
• 22:29values,
• 22:30what they value specifically
• 22:32or would value about a
• 22:33service like ours.
• 22:35So what I mean by
• 22:36that is it could be
• 22:37the case that
• 22:39what the criminal justice system
• 22:40would really value about an
• 22:42early intervention service
• 22:44is that
• 22:45it reduces the amount of
• 22:46time their staff need to
• 22:47spend in behavioral incidents in
• 22:49the community.
• 22:50That's the metric that they
• 22:51would be looking for this
• 22:52service to improve,
• 22:55which might be
• 22:56different from the values, for
• 22:57example, of behavioral health agencies
• 23:00or, for example,
• 23:02hospital,
• 23:02systems that would value
• 23:05reducing
• 23:06overloaded emergency rooms with individuals
• 23:08who are not in care
• 23:10because they keep
• 23:11being referred and never connect
• 23:13with care, and so they
• 23:14end up back in the
• 23:14emergency room.
• 23:16As you might imagine, putting
• 23:17together a stakeholder group would
• 23:19result in
• 23:20a list of potential outcomes
• 23:22that different stakeholders would value.
• 23:25And
• 23:26a clinic,
• 23:27like an early intervention service
• 23:29would need to convert those
• 23:30into
• 23:31actual objectives that could be
• 23:33measured. So if the long
• 23:35list of things that people
• 23:36would want the service to
• 23:37help with in any given
• 23:38community,
• 23:40there's probably a shorter list
• 23:41of things that one could
• 23:43actually measure
• 23:44accurately and reliably and feasibly.
• 23:47And that's what STEP has
• 23:49done.
• 23:50So we we leveraged the
• 23:51process in which we
• 23:53derive these outcomes,
• 23:55converted them to measures,
• 23:58and then put them into
• 23:59a list of data elements
• 24:00that we now collect from
• 24:01everyone coming into our clinic
• 24:04when they enroll
• 24:05and then every six months
• 24:06at a minimum over time.
• 24:09And we've converted those,
• 24:11data elements,
• 24:14and into,
• 24:15you know, we we WIPs,
• 24:17I apologize for all the
• 24:18acronyms here, but that's a
• 24:19works in progress group that
• 24:21meets every week in our
• 24:22clinic,
• 24:23where we think of ways
• 24:24to convert that data into
• 24:27visualizations
• 24:29that can then be shown
• 24:30back in a display,
• 24:32to clinicians in our team
• 24:34and compared to standards or
• 24:36benchmarks that have been achieved,
• 24:38either by our own clinic
• 24:40in the past or by
• 24:40other
• 24:43best practice clinics around the
• 24:44world
• 24:45that can help us understand
• 24:46if we are meeting those
• 24:48international standards in the way
• 24:50we deliver care.
• 24:52So this next slide might
• 24:53make this a little bit
• 24:54clearer, which is
• 24:56here's the current list of
• 24:58objectives that step uses,
• 25:02as a way to guide
• 25:02the measurements we make. And
• 25:04then
• 25:05on the third column on
• 25:06the right are the standards
• 25:07we measure ourselves up to.
• 25:09Now this is a version
• 25:10we published in twenty sixteen.
• 25:12We've adapted it a little
• 25:13bit, but not a lot.
• 25:15There tends to be a
• 25:16lot of agreement in general
• 25:18about the kinds of,
• 25:20measures
• 25:22sorry. The kinds of objectives
• 25:24that our service like ours
• 25:26should meet and be able
• 25:27to improve upon.
• 25:31This this,
• 25:32specification of our system of
• 25:34care
• 25:34is something that we can
• 25:38review with our clinicians
• 25:40and use as a
• 25:42a prod in some ways
• 25:43and a catalyst to think
• 25:45about
• 25:46improvements in our quality of
• 25:47care,
• 25:48especially when
• 25:49our outcomes are lagging.
• 25:53And this is how we,
• 25:55have tried to use
• 25:56population health based outcomes to
• 25:58drive improvements in care processes
• 26:01at
• 26:03step. So the
• 26:05I'll we can talk more
• 26:06about this, but there are
• 26:07some implications for this, which
• 26:08is that it allows your
• 26:09care to be individualized
• 26:11to each patient.
• 26:13What you're trying to do
• 26:14is not to provide the
• 26:16same care to everyone,
• 26:17but rather what you're trying
• 26:19to do is make sure
• 26:20your care processes improve outcomes
• 26:22across the population you're treating
• 26:24so that
• 26:25if you are providing care
• 26:27that tends to, on average,
• 26:29result in many more relapses
• 26:32at six months than a
• 26:33clinic like yours should based
• 26:35on the the reported literature
• 26:37from best practice clinics,
• 26:39then it it's
• 26:41it's a reason to think
• 26:42together as a team about
• 26:43what could be done to
• 26:44improve on that. It may
• 26:45be that you need to
• 26:46increase,
• 26:48the amount of education provided
• 26:50to family members around the
• 26:51importance of antipsychotic treatment.
• 26:54It may be you need
• 26:54to increase the use of
• 26:55long acting injectables
• 26:57or clozapine.
• 26:59It could be any number
• 27:00or all of those, and
• 27:01that could vary across clinics.
• 27:03But the point is the
• 27:04processes
• 27:05are disciplined by,
• 27:08outcomes. And if,
• 27:10and if the outcomes are
• 27:11very good, one could spend
• 27:13one one's attention on other
• 27:14processes.
• 27:17So this means that fidelity,
• 27:19kind of like adherence to
• 27:21a medication,
• 27:22is not the goal,
• 27:23but rather it's a means
• 27:25to potentially improving the outcomes
• 27:27of the clinic. And sometimes
• 27:29it's irrelevant,
• 27:31that there isn't one way
• 27:33or one care process by
• 27:34which
• 27:35success is guaranteed because
• 27:37patients are very different from
• 27:38each other, have very different
• 27:40needs.
• 27:41And the needs of across
• 27:43regions of the state,
• 27:44will also likely be different
• 27:46in terms of the the
• 27:47determinants of whether or not
• 27:49someone will come to the
• 27:50clinic or not. And so
• 27:51it makes very little sense
• 27:52to legislate
• 27:54one way of doing things
• 27:55in terms of care processes.
• 27:58I could say more about
• 27:59this, but I think the
• 28:00advantage of this outcomes based
• 28:02approach
• 28:02is that it also makes
• 28:03very transparent to stakeholders
• 28:06what it is we're trying
• 28:07to do as a as
• 28:09a clinical service, but also
• 28:10across the network,
• 28:12and
• 28:13brings in allies in the
• 28:15community who understand what it
• 28:17is we're trying to do
• 28:18and might be able to
• 28:18help
• 28:19with some of those determinants
• 28:21that are outside the control
• 28:22of the clinic, for example.
• 28:26So so to get concrete,
• 28:28this is what, it looks
• 28:29like to our clinicians,
• 28:31when we display
• 28:33the data to them. So
• 28:35on the left, you'll see
• 28:35all the objectives.
• 28:37This is a screenshot from
• 28:38an informatics system that we
• 28:40have developed and built at
• 28:41step.
• 28:43And as one example, this
• 28:45is the duration of untreated
• 28:46psychosis,
• 28:48and we've tracked on the
• 28:49x axis
• 28:50by quarter of admission. So
• 28:54the
• 28:56the first, data point on
• 28:57the left is all individuals
• 28:59admitted in the fourth quarter
• 29:00of two thousand fourteen,
• 29:02and we track this across
• 29:04all the quarters,
• 29:06over time.
• 29:07And it's possible to then
• 29:08see whether this metric,
• 29:11has been improving or getting
• 29:13worse,
• 29:13over time.
• 29:15The two horizontal bars that
• 29:16may not be very easily
• 29:17visible
• 29:18are the benchmarks.
• 29:20So the aspirational benchmark is
• 29:22seventy five percent, which means
• 29:23that the best clinics around
• 29:25the world have been able
• 29:26to get three quarters of
• 29:28their patients
• 29:29into care within twelve months
• 29:31of psychosis onset. And that's
• 29:33what we would want to
• 29:34aspire to.
• 29:35Whereas the,
• 29:37achievable benchmark
• 29:38is a benchmark that any
• 29:40clinic can choose based on
• 29:41its prior performance,
• 29:43so that anything lower than
• 29:44that would suggest
• 29:45that they need to consider
• 29:47their care processes again.
• 29:49So this kind of model
• 29:50of using outcomes that are
• 29:52benchmarked against
• 29:54international standards
• 29:56to track your own clinic's
• 29:57performance,
• 29:59is run through
• 30:01all the different objectives.
• 30:02So you'll see the same
• 30:04pattern where here we're looking
• 30:05at
• 30:06hospitalization
• 30:07rates,
• 30:08for people admitted in two
• 30:10thousand sixteen, seventeen, eighteen, and
• 30:11we have data that runs
• 30:12all the way till, till
• 30:14this year.
• 30:15And you could see that
• 30:17the percentage of individuals admitted,
• 30:20in the six months before
• 30:21is quite high, and it
• 30:22does drop as you would
• 30:24hope and expect
• 30:25in the next six months
• 30:26and then again in the
• 30:27next six months.
• 30:29And you can see that
• 30:29in twenty sixteen, we were
• 30:31not quite where we needed
• 30:32to be. We improved on
• 30:33that in twenty seventeen. So
• 30:35it gives a clinic a
• 30:36kind of a dashboard of
• 30:37where they are with respect
• 30:39to an outcome
• 30:40to be able to understand
• 30:41whether they need to do
• 30:42something different around that outcome
• 30:44based on how they perform,
• 30:46in in a in a
• 30:47previous
• 30:48period of time.
• 30:51Just one more example, here
• 30:52of vocational engagement.
• 30:54So these are the percentage
• 30:55of individuals who are at
• 30:57least in part time school
• 30:59or work or looking for
• 31:01for school or work.
• 31:03And you can see some
• 31:05variability around this metric. But
• 31:07in a younger population,
• 31:09this is a very important
• 31:10measure of overall functioning and
• 31:12something that we we track
• 31:13again in the clinic.
• 31:15So,
• 31:16we have this for all
• 31:17the objectives, and I'm happy
• 31:18to talk more. But the
• 31:19the, what do we do
• 31:20with this data when we
• 31:22discover that
• 31:23our performance is not as
• 31:24good as it should be
• 31:25in a particular
• 31:27quarter or a year. And
• 31:28what we use is an
• 31:29approach that's been published and
• 31:31used quite a lot,
• 31:33and is available actually,
• 31:35in free training modules at
• 31:37the Institute for Healthcare Improvement.
• 31:40But it's a formal way
• 31:41essentially of doing quality improvement
• 31:43to decide,
• 31:45on an aim, which as
• 31:46an example here is to
• 31:47reduce the duration of untreated
• 31:48psychosis.
• 31:49And we went through this
• 31:50exercise in our clinic a
• 31:51couple of years back where
• 31:53we decided that
• 31:54the part of the delay
• 31:55that the clinic could
• 31:58control and improve upon,
• 32:00was really the time between
• 32:02when eligibility was determined and
• 32:04when they had their first
• 32:05visit in the clinic.
• 32:07And we found that there
• 32:08was a lot of variability
• 32:09in terms of wait times
• 32:11even though,
• 32:12we were obviously very motivated
• 32:14to take patients in. There
• 32:16can be a lot of
• 32:16ambivalence on the part of
• 32:17patients and families to come
• 32:19to care. And in that
• 32:21mix,
• 32:22there can be delays of
• 32:23up to weeks or even
• 32:24months.
• 32:25So we decided to focus
• 32:27on that as one measure
• 32:28to target and to bring
• 32:29it down to less than
• 32:30seven working days between when
• 32:33a person was determined to
• 32:34be eligible for our service
• 32:35and when they began actual
• 32:36treatment with our clinicians.
• 32:40And we discussed,
• 32:41within the team, a whole
• 32:42series of potential ways
• 32:44that clinicians suggested
• 32:46might help drive this down
• 32:48to less than seven days.
• 32:49I'm listing a few.
• 32:51There were many, many cycles
• 32:52of improvement
• 32:54where we tried,
• 32:55changes in the way we
• 32:56screened individuals,
• 32:57how we determine eligibility,
• 33:00when we got consent. So
• 33:02for example, we began consenting
• 33:04individuals
• 33:05while they were still on
• 33:06an inpatient unit
• 33:07because because we found that
• 33:09if we had contact even
• 33:10if by Zoom
• 33:11before they left the unit,
• 33:13they were much more likely
• 33:14to show up to their
• 33:15first appointment with us. And
• 33:17so that became a routine
• 33:18part of our admissions process.
• 33:21So we went through several
• 33:22plan to study act cycles
• 33:24where we tried many of
• 33:25these changes
• 33:27over time.
• 33:28And we published this as
• 33:29as one example of how
• 33:31of what will happen, which
• 33:32is
• 33:33the red bar is the
• 33:35average delay before we began
• 33:37this quality improvement initiative,
• 33:40and the pink bar shows
• 33:41the average delay after. So
• 33:42there was a drop off.
• 33:44The dotted green line was
• 33:45the seven day standard we
• 33:47wanted to meet.
• 33:48And each dot here is
• 33:50a patient,
• 33:51who is admitted. And you'll
• 33:52see that on average, we
• 33:54were able to reduce the
• 33:55delays, but there were still
• 33:56some individuals who had very
• 33:58long delays.
• 34:00You know, in one case,
• 34:01ninety nine days, it looks
• 34:02like.
• 34:03Am I right? Yeah.
• 34:05Some outliers.
• 34:06And these were very challenging
• 34:08outliers that I'm sure many
• 34:09of you are familiar with
• 34:10where despite all our efforts,
• 34:12there was a lot of
• 34:13ambivalence about coming into treatment.
• 34:15But on average, we were
• 34:17able to, with changes in
• 34:18our,
• 34:19front door processes,
• 34:21reduce wait times.
• 34:23So this is this is
• 34:24the kind of,
• 34:25process improvement that can follow
• 34:27from awareness of what the
• 34:29outcome is and then setting
• 34:30an aim to to reduce
• 34:31it.
• 34:34This is a sort of
• 34:36a a slide that I,
• 34:37have,
• 34:39developed from work by Michael
• 34:40Porter, a health economist.
• 34:42And it's it's surprising even
• 34:44to health care providers to
• 34:45hear this, but
• 34:46most of the measures that
• 34:48are used to measure the
• 34:49quality of care across medical
• 34:51conditions
• 34:52have very little to do
• 34:53with patient outcomes,
• 34:57which is to say that
• 34:58what services
• 34:59are evaluated
• 35:00upon
• 35:01is not how well their
• 35:03patients do,
• 35:04but rather on a whole
• 35:05host of other measures,
• 35:07most of which are process
• 35:09measures that have to do
• 35:10with
• 35:11the adequacy of documentation,
• 35:13the implementation of various activities
• 35:15that are related to health
• 35:17care provision,
• 35:18a whole bunch of patient
• 35:19experience measures which are important.
• 35:23However, it's it's quite remarkable
• 35:24that very few,
• 35:26are related to things that
• 35:28we would recognize as the
• 35:29kinds of outcomes that we
• 35:30would care about ourselves as
• 35:32patients.
• 35:35So in some ways, the
• 35:36learning health system approach is
• 35:37pushing against the status quo
• 35:41in that it forces services
• 35:43to commit to a set
• 35:44of outcomes,
• 35:46not an unwieldy very long
• 35:47set, but a manageable set,
• 35:50and really thinks about whether
• 35:52those outcomes have been delivered.
• 35:55But it
• 35:56it it sets,
• 35:58a kind of a a
• 35:59common bar,
• 36:00that allows,
• 36:03clinics to say, we are
• 36:06a specialized service,
• 36:08not because we engage in
• 36:09lots of activities,
• 36:11but because we have a
• 36:12track record of producing the
• 36:14kinds of outcomes
• 36:15that put us,
• 36:17in the same peer group
• 36:18as clinics that have the
• 36:20best outcomes for for this
• 36:21particular population.
• 36:24So for those who are
• 36:24interested, I put the I
• 36:25put the reference below.
• 36:27But the point that this
• 36:28paper makes very well, I
• 36:29think, is that when we
• 36:30think of the quality of
• 36:31health care,
• 36:32we should think more and
• 36:33more about its ability to
• 36:34produce the outcomes we want,
• 36:36in which we value
• 36:41rather than simply engaging in
• 36:42lots of activities
• 36:51rather than simply engaging in
• 36:52lots of activities.
• 36:54That may
• 36:58know that what we're very
• 37:00actively working with,
• 37:02the Department of Mental Health
• 37:03and Addiction Services and DCF,
• 37:06and partnering with think about,
• 37:08which is
• 37:09how we might disseminate this
• 37:11early intervention services model,
• 37:14across the state.
• 37:16And we we've used internally
• 37:18the term project one sixty
• 37:19nine because there are hundred
• 37:20sixty nine towns in Connecticut,
• 37:21but we're very open to,
• 37:24to a better brand as
• 37:25we begin to think about
• 37:26launching this.
• 37:28So just to recap, you
• 37:30know, Step has demonstrated that
• 37:32we've both been able to
• 37:33improve quality as an outcomes
• 37:35of care
• 37:36and access across this defined
• 37:38catchment. It's only ten towns,
• 37:40but it's about a population
• 37:42of about four hundred thousand
• 37:43residents overall in these ten
• 37:45towns.
• 37:46So this it has been
• 37:47really import important that this
• 37:49is a public academic partnership.
• 37:52The services have been funded
• 37:53through public grants,
• 37:55but the research has been
• 37:56funded through NIH research studies
• 37:58that have documented the effectiveness.
• 38:00And the question is, can
• 38:02this be leveraged towards unmet
• 38:04needs statewide?
• 38:06Not replicated because I don't
• 38:07think every
• 38:09the the same model should
• 38:10be applied everywhere. But how
• 38:12can this overall care pathway
• 38:14be integrated
• 38:16so that,
• 38:17individuals anywhere in the state
• 38:19have access to the same,
• 38:21improvements in access and outcomes.
• 38:26And so, I mean, statewide,
• 38:27this is really another way
• 38:28of saying this is the
• 38:29opportunities. We have
• 38:32current approaches
• 38:33that we have,
• 38:34tested at step
• 38:36for both early detection and,
• 38:39coordinated specialty care
• 38:41that we know can improve
• 38:42access and outcomes,
• 38:44early in the course of
• 38:45the illness.
• 38:48I wanna step back and
• 38:49give you a little bit
• 38:50of, information that's exciting about
• 38:52the national scene. So
• 38:54before two thousand eight, there
• 38:55were actually very few
• 38:57first episode services that were
• 38:59actually providing care to all
• 39:01comers.
• 39:02There were other clinics that
• 39:04were research clinics that were
• 39:05really,
• 39:06conducting clinical trials on selected
• 39:08samples,
• 39:09but there were very few
• 39:11that were actually doing this
• 39:12work,
• 39:13in a in a broader
• 39:14way.
• 39:15But
• 39:16it there's been a really
• 39:17tremendous this slide is already
• 39:19out of date,
• 39:21partly related to federal funding
• 39:23initiatives,
• 39:25that were teeing off of
• 39:26research studies done at STEP
• 39:29and and by the RAISE
• 39:30group.
• 39:31There was a very rapid
• 39:32unusually rapid implementation
• 39:34of first episode services,
• 39:36which the NIMH has since,
• 39:39termed as coordinated specialty care.
• 39:41So that's
• 39:42module c in our care
• 39:44pathway.
• 39:46So this has been really
• 39:47good news in some ways.
• 39:48I think it suggests that
• 39:51evidence can move to practice
• 39:53much quicker than most people,
• 39:55had assumed.
• 39:56But it's also raised an
• 39:57obvious
• 39:58set of questions and concerns
• 40:00about the quality of these
• 40:01services.
• 40:03And partly in response to
• 40:05this good news, but also
• 40:06this concern,
• 40:08the NIMH hosted a meeting
• 40:09in two thousand seventeen that
• 40:11was really organized around this
• 40:12question, which is, can we
• 40:14actually build a national ecosystem
• 40:16that
• 40:17implements best practice for all,
• 40:19but also
• 40:20helps us try to answer
• 40:22questions about,
• 40:24developing new treatments? Because there
• 40:25was an acknowledgment that a
• 40:26lot of good can be
• 40:27done just implementing what we
• 40:29know, but we clearly need
• 40:30to also improve our treatments,
• 40:32and there's an opportunity to
• 40:33do both.
• 40:35Step was a was a
• 40:36participant in this,
• 40:38in this discussion, and it
• 40:39really it resulted in a
• 40:41large
• 40:44initiative, by the, by the
• 40:46NIH
• 40:47that has built,
• 40:49collaborations amongst about a hundred
• 40:51and one clinics
• 40:52like STEP across the US
• 40:55that are trying to collect
• 40:56information
• 40:57to inform
• 40:58improvements in care. So this
• 40:59is very much actively going
• 41:01on as we speak.
• 41:04The the the position that
• 41:05STEP has taken,
• 41:06is that we should do
• 41:08this as it's been done
• 41:09in other conditions like cystic
• 41:11fibrosis and pediatric
• 41:13cancer,
• 41:15which is the opposite of
• 41:17what I'm displaying here in
• 41:18some ways. And this is
• 41:19what,
• 41:21myself and others have called
• 41:22the pipeline model,
• 41:24mostly to critique this approach,
• 41:26which is that
• 41:27one develops a model of
• 41:28care to reset site, for
• 41:30example, at a site like
• 41:31STEP,
• 41:32and then builds these pipelines
• 41:34to
• 41:36enforce implementation of that model
• 41:38across
• 41:38other community services.
• 41:40And the expectation is that
• 41:42they won't be able to
• 41:43do it as well as
• 41:44the pioneer research site. There's
• 41:46gonna be some leakage of
• 41:48what the active ingredients are
• 41:50of that treatment.
• 41:51And so you need to
• 41:52police these sites for fidelity
• 41:54because the expectation is that
• 41:55they're doing something
• 41:57wrong,
• 41:57and you need to make
• 41:58them do it like you
• 41:59did it,
• 42:00because that's what will drive,
• 42:02the outcomes.
• 42:03So I I think that
• 42:04this is on face
• 42:06doesn't make any sense, but
• 42:07also empirically
• 42:09does not appear to actually
• 42:10result in necessarily better outcomes.
• 42:13But it has been the
• 42:14guiding approach to implementation
• 42:16for many conditions.
• 42:20So we we think of
• 42:22early into, of learning health
• 42:24service systems as really an
• 42:26an a very different approach.
• 42:29And this is where
• 42:31the science, which is the
• 42:33the knowledge about what works,
• 42:35is only one of four
• 42:36elements that will allow for,
• 42:39innovation and improvement in in
• 42:41outcomes.
• 42:41So we we wanna think
• 42:43simultaneously also about informatics,
• 42:45databases,
• 42:46visualizations,
• 42:48the the kinds of incentives
• 42:50that would help services and
• 42:51clinicians deliver this care,
• 42:54and and a culture that
• 42:55allows for
• 42:56the use of this data
• 42:58to reflect upon outcomes and
• 42:59to share them in an
• 43:00environment where the goal is
• 43:02actually to improve care
• 43:04and not merely to,
• 43:06you know,
• 43:09meet sort of current regulations
• 43:11around billing and coding, for
• 43:13example.
• 43:15So this allows for a
• 43:17a, also, a very wide
• 43:18way variety of ways to
• 43:20actually disseminate this.
• 43:22So one could imagine a
• 43:24spoke that's within a health
• 43:26care organization
• 43:27that delivers a specialized early
• 43:29intervention service. And this is
• 43:31the model that STEP has,
• 43:32which is we are really
• 43:35a a team within,
• 43:37an LMHA or CMHC.
• 43:39And we're quite separate in
• 43:40some ways,
• 43:41in the way that we,
• 43:44admit patients, our eligibility criteria.
• 43:47Although we rely on the
• 43:48health care organization for much
• 43:50of our physical,
• 43:51infrastructure.
• 43:53One could imagine another approach
• 43:54where the staff members in
• 43:56the spoke are more fluidly
• 43:58shared with the health care
• 43:59organization that the clinicians are
• 44:01shared, but the patients and
• 44:03families experience care within a,
• 44:07a coherent team structure.
• 44:09And one could also imagine
• 44:10freestanding early intervention services that
• 44:12aren't part of a large
• 44:13health care organization
• 44:15that might be a better
• 44:16fit for
• 44:17areas that don't have,
• 44:19large behavioral health agencies, for
• 44:21example.
• 44:22The the point, I guess,
• 44:23is that,
• 44:24this approach where there's a
• 44:26focus on measuring population health
• 44:28outcomes
• 44:29and then deciding how to
• 44:30improve care processes
• 44:32allows for a very wide
• 44:33variety of ways in which
• 44:35one can implement,
• 44:37these services.
• 44:39I'm putting up this slide
• 44:40because we are involved at
• 44:41STEP in consulting with,
• 44:44Ohio. And,
• 44:45in many ways, this is
• 44:46a lead state that has
• 44:47already funded eighteen CSC teams.
• 44:51We
• 44:52based on population data, they
• 44:54would have approximately twice the
• 44:56number of first episode cases,
• 44:58compared to a state like
• 44:59Connecticut.
• 45:00And they've made a commitment
• 45:01to improving both access and
• 45:03care
• 45:04by,
• 45:05engaging us to help bring
• 45:07these eighteen
• 45:08clinics
• 45:10into a learning health system
• 45:11based approach where
• 45:13they would all collect data
• 45:14in the same way on
• 45:15outcomes,
• 45:16share those outcomes with each
• 45:18other, and then share lessons
• 45:19on how to improve those
• 45:20outcomes to drive
• 45:22ideally all the clinics towards
• 45:23the standards that, we have
• 45:25published as benchmarks,
• 45:27for this population.
• 45:29So I've I've put in
• 45:30a reference there. This is
• 45:31a a project very much
• 45:32in progress right now,
• 45:35and it's
• 45:36it's one that we hope
• 45:37to,
• 45:39replicate
• 45:40in in Connecticut.
• 45:41So I I think this
• 45:42is my last slide, Laura.
• 45:43Yeah.
• 45:44And we'll have, hopefully, some
• 45:45time for for discussion.
• 45:50But what we are what
• 45:51the the map here, which
• 45:53we have up and is
• 45:55we can make available to
• 45:56all of you
• 45:57is
• 45:58just a rough map we've
• 45:59drawn up of the five
• 46:00different regions in the state
• 46:02where one can hover over
• 46:04a particular region. In this
• 46:05case, we've done it for
• 46:06region two
• 46:07and get a rough estimate
• 46:08based on the age distribution
• 46:10of that region, how many
• 46:12new cases of psychosis one
• 46:13would expect.
• 46:15The the red icons are
• 46:17all the different lead mental
• 46:18health agencies, both state owned
• 46:20and private nonprofits.
• 46:22And the aspiration is to
• 46:23try to build a network
• 46:24wherein
• 46:26we would all, as agencies,
• 46:27share
• 46:29our,
• 46:30outcomes for this population
• 46:32and,
• 46:33build a network where we
• 46:35could allocate resources towards
• 46:37regions that are for a
• 46:40variety of different reasons,
• 46:41having,
• 46:43less optimal outcomes either in
• 46:44terms of access or care
• 46:46quality.
• 46:47So this I hope this
• 46:49overview has been helpful.
• 46:51We are currently in the
• 46:52phase of thinking through various
• 46:54ways in which we could
• 46:56make this happen. And the
• 46:57the current,
• 46:59approach right now is to
• 47:00is to begin these kinds
• 47:02of workforce development initiatives to
• 47:04provide some
• 47:06overview and orientation to the
• 47:07care model,
• 47:09to begin to offer a
• 47:10variety
• 47:11of educational resources that, Laura
• 47:14has already mentioned, and that's
• 47:15on our learning health collaborative
• 47:17website,
• 47:18directed mostly at clinicians, but
• 47:20also,
• 47:21public facing workshops for family
• 47:23members.
• 47:24We will soon be launching
• 47:26in July a consultation service
• 47:29that will be open to
• 47:30clinicians anywhere in the state
• 47:32who wish to call us
• 47:33to talk about,
• 47:35any aspects of care for
• 47:36early course, schizophrenia.
• 47:39And then we hope in
• 47:40the near future to think
• 47:42about,
• 47:43specific,
• 47:44request for proposals where we
• 47:46might engage,
• 47:48all of your agencies, any
• 47:50who are interested
• 47:51in
• 47:53adding to your current models
• 47:55of care to reach,
• 47:56improved outcomes for these patients.
• 47:58So
• 47:59resources for staff or training
• 48:01or specific interventions that are
• 48:03missing from your current,
• 48:05toolbox that you'd like to
• 48:07implement.
• 48:08So I'll stop there.