STEP LC - Overview of EIS - Module C - Session 5

Transcript

• 00:02So for today, we're gonna
• 00:04be continuing
• 00:05with module c that we
• 00:07started on last week,
• 00:09continuing treatment in coordinated specialty
• 00:11care.
• 00:12Go to next.
• 00:20So as we started last
• 00:21week, these two sessions are
• 00:23really focused on covering
• 00:25step care in general, really
• 00:27the bulk of it. So
• 00:28talking about the structure, processes,
• 00:30as well as outcomes,
• 00:32that we focus on.
• 00:34So last week, we started
• 00:36to overview those six core
• 00:38elements of care, which I'll
• 00:39remind us of,
• 00:41as well as introducing
• 00:43discussions about different processes
• 00:45that we engage in in
• 00:47our,
• 00:48step care model,
• 00:50as well as, you know,
• 00:51elements of kind of culture
• 00:53and,
• 00:54team cohesion and things like
• 00:56that.
• 00:57So we'll continue with those
• 00:59discussions today. Next.
• 01:03And everyone's favorite
• 01:05favorite image, but just to
• 01:06really hammer home that we'll
• 01:07be focusing on module c
• 01:09of the care pathway today.
• 01:17And we'll,
• 01:18outline these elements on the
• 01:20next slide.
• 01:23So as a reminder of
• 01:24what we started talking about
• 01:26last week, steps care model
• 01:28is,
• 01:30offers a variety and really
• 01:31a menu of psychosocial services
• 01:34for all of our,
• 01:36participants. So, really,
• 01:37this is based on
• 01:40folks' phase of illness,
• 01:42their needs, their preferences,
• 01:45and various other elements.
• 01:47So these offerings are available
• 01:49to everyone in the clinic.
• 01:50Some a bit more standard
• 01:52than others.
• 01:53But last week, we overviewed
• 01:56what psychotherapy
• 01:57looks like,
• 02:00support for employment and education,
• 02:02family support and education, as
• 02:04well as coordination with community
• 02:06supports, as well as within
• 02:07team coordination.
• 02:09So today,
• 02:10we're gonna focus,
• 02:11more so on
• 02:13pharmacotherapy
• 02:14and health promotion,
• 02:15as well as,
• 02:17discussing a bit of what
• 02:18our kind of longitudinal
• 02:19evaluation
• 02:20process looks like.
• 02:22So I'm gonna hand it
• 02:23over,
• 02:24to doctor Sreehari
• 02:25to, start us off with
• 02:27pharmacotherapy.
• 02:30Thanks, Laura. And I,
• 02:32know that Laura had covered
• 02:34some of the other elements
• 02:35of coordinated specialty care last
• 02:37week. So
• 02:39this is really the the
• 02:40second session on it, and
• 02:43I have just a few
• 02:44slides,
• 02:46with the hope that we'll
• 02:47have time,
• 02:48after the rest of the
• 02:49session to
• 02:51take questions or have discussions
• 02:53about the entire module
• 02:55c. So all the elements,
• 02:56not just what we're talking
• 02:58about today.
• 02:59So for for pharmacologic treatment,
• 03:03it's useful to think about
• 03:04what their current targets are
• 03:06given our current evidence base.
• 03:07And
• 03:08the the major target really
• 03:10are the so called positive
• 03:11symptoms, sometimes also called psychosis,
• 03:14somewhat confusingly, but people are
• 03:15often referring to,
• 03:17delusions, hallucinations, and disorganization
• 03:21that are really the most
• 03:23rapidly
• 03:24and,
• 03:26routinely responsive to current antipsychotic
• 03:29treatment.
• 03:30The negative symptoms, unfortunately,
• 03:32we don't really have good
• 03:34evidence for any pharmacotherapies
• 03:36that reliably target these. Although
• 03:38in some trials and in
• 03:40some patients, there can be
• 03:41improvements in these symptoms,
• 03:43and we can talk about
• 03:44this more.
• 03:46There are cognitive deficits that
• 03:48we've spoken about that are,
• 03:50a part of the illness
• 03:52from many individuals with chronic
• 03:54psychotic disorders
• 03:55for which so far pharmacotherapies
• 03:58are not a reliable tool.
• 04:00There are several in development,
• 04:02but since we're speaking here
• 04:04about what's available for current
• 04:06application in coordinated specialty care,
• 04:09I've grayed that out.
• 04:11And then finally, broadly, affective
• 04:13dysregulation. So depressive and manic
• 04:15symptoms can be part of
• 04:17the syndrome of schizophrenia spectrum
• 04:19disorders.
• 04:21And here,
• 04:22antipsychotic
• 04:23medications
• 04:24can actually help,
• 04:25confusingly,
• 04:27but we can also
• 04:29use,
• 04:29adjunctive treatments
• 04:31from these other disorders. So
• 04:33antidepressants,
• 04:34anti manic agents can also
• 04:36be helpful in managing,
• 04:38symptoms and distress in chronic
• 04:39psychotic illnesses.
• 04:42Another sort of principle around
• 04:45managing
• 04:46with pharmacotherapy
• 04:48is,
• 04:49something I know Laura had
• 04:50all already talked about. Individuals
• 04:52early in the course of
• 04:53these illnesses will often cycle
• 04:55in and out of different
• 04:56phases.
• 04:57And this also means that
• 04:59the goals for pharmacotherapy
• 05:01will shift
• 05:02based on the phase that
• 05:03the person is in. The
• 05:04most obvious example, of course,
• 05:06is that when people are
• 05:07brought into the emergency room
• 05:08in the midst of an
• 05:09acute
• 05:10decompensation,
• 05:11The the goal is often
• 05:13initially to reduce aggression, hostility,
• 05:16and, of course, to reduce
• 05:17symptoms. But sometimes,
• 05:20combinations of treatments might be
• 05:21used at high doses
• 05:24to really target
• 05:25aggression
• 05:27that might not be used
• 05:29obviously in in the next
• 05:30phase when individuals are,
• 05:33are aiming towards
• 05:35stability and preventing relapse.
• 05:38And likewise, in the recovery
• 05:40phase where often lower doses
• 05:41can be used and sometimes
• 05:43even, antipsychotics
• 05:45can be tapered off in
• 05:46a in selected patients.
• 05:49So the strategy will vary
• 05:51based on the phase,
• 05:52of treatment,
• 05:54that the patient is in.
• 05:57And then this is a
• 05:59a high level,
• 06:01set of sessions. So I'm
• 06:03listing out principles,
• 06:05not to be intentionally vague,
• 06:07but to point out that
• 06:08for many of you who
• 06:09are either
• 06:11leading or overseeing or managing
• 06:13care or providing care, I'm
• 06:15hoping this will all look
• 06:16fairly familiar,
• 06:18and we adhere to these
• 06:19principles at at Step as
• 06:21well.
• 06:23I should probably mention just
• 06:24a couple, which is
• 06:27that we we like to
• 06:28favor
• 06:29using interventions that have been
• 06:31actually studied in rigorous trials
• 06:34first.
• 06:35And when we've exhausted those,
• 06:37we move to more theoretically
• 06:39based interventions
• 06:41or relying on clinical experience.
• 06:42And so what I mean
• 06:43by that is often first
• 06:45line agents for
• 06:47psychotic symptoms or depressive symptoms
• 06:49or manic symptoms.
• 06:52We have several of them,
• 06:54and so we tend to
• 06:55reach for ones that have
• 06:56survived clinical studies,
• 06:58before we reach for more
• 07:00unconventional treatments that sometimes individual
• 07:03patients may already be on
• 07:05when they come to us.
• 07:06And we reserve those only
• 07:08for those who do not
• 07:09respond to first line treatments.
• 07:12And we can talk about
• 07:12that more.
• 07:14There are several agents, for
• 07:15example, that have been studied
• 07:17to treat cognition
• 07:19that unfortunately
• 07:20have not survived
• 07:21clinical trials,
• 07:22and yet individuals will often
• 07:24be using them or be
• 07:26asking for them.
• 07:28And
• 07:29it is certainly permitted for
• 07:31prescribers to use medications off
• 07:33label, but we prefer to
• 07:34start with ones that have
• 07:36a good solid evidence base,
• 07:38in human studies.
• 07:41I won't read the rest
• 07:42out, but I put this
• 07:43up in part because I
• 07:44knew we were gonna leave
• 07:45this on the website as
• 07:46a recording so individuals could
• 07:48pause and look at the
• 07:49list.
• 07:50And I'm happy to take
• 07:51questions about it. Another one
• 07:52I should point out though
• 07:53is, treating to remission, which
• 07:56is that in early COVID
• 07:57patients, this is a very
• 07:59reasonable goal
• 08:01to drive,
• 08:02positive psychotic symptoms to remission.
• 08:04And this sometimes takes
• 08:06persistence around getting to a
• 08:08good enough dose,
• 08:10which is optimal to reduce
• 08:12symptoms while also managing side
• 08:14effects.
• 08:15But in fact, somewhere,
• 08:17north of seventy five percent
• 08:19of patients
• 08:20with our current medications, mostly
• 08:22first or second line, can
• 08:24reach remission within the first
• 08:25six months to a year
• 08:27of,
• 08:27psychosis. So,
• 08:29this is something that we
• 08:30we try very hard to
• 08:32to achieve.
• 08:34Doctor Sheheri, there's a question,
• 08:37just saying looking for clarification.
• 08:39When you mentioned combination treatments,
• 08:41are we referring to multiple
• 08:42antipsychotics
• 08:43or antipsychotics
• 08:45mixed with other medications such
• 08:47as antidepressants or mood stabilizers?
• 08:50Yeah. Great.
• 08:51All of the above. And
• 08:53part of the rationale is
• 08:55we know that when you
• 08:55add a second medication,
• 08:57the risks of nonadherence
• 08:59start going up exponentially. And
• 09:01when you add a third
• 09:02and a fourth, this is
• 09:03not just in patients with
• 09:04psychosis, but all of us.
• 09:06Medication regimens that are that
• 09:09include multiple medicines multiple times
• 09:11a day can be very
• 09:12hard to
• 09:13adhere to.
• 09:15So one then ends up
• 09:17with very unreliable doses of
• 09:19multiple medicines over time, and
• 09:20it becomes difficult to figure
• 09:22out which medicine is causing
• 09:23what side effect,
• 09:25especially given that some of
• 09:26our medications are the most
• 09:28difficult to take early on
• 09:30when the body is beginning
• 09:31to adapt. And so stopping
• 09:33and starting and forgetting just
• 09:35adds to the side effect
• 09:36burden, and then you have
• 09:37a patient who's
• 09:39demoralized and unhappy. And and
• 09:41then looks like they failed
• 09:43a trial of a medication
• 09:44when they haven't even actually
• 09:46had an adequate dose for
• 09:48long enough. So
• 09:49so so all of that.
• 09:51It it I didn't say,
• 09:53I I wouldn't say that
• 09:54we completely avoid combination treatments,
• 09:56but we try very hard
• 09:57to limit them and use
• 09:59one medicine
• 10:00at a time if we
• 10:01can get away with it.
• 10:06Any other,
• 10:07we can come back to
• 10:07this, of course, so I'll
• 10:08keep plugging on, but feel
• 10:09free to to interrupt.
• 10:11So, again, at a high
• 10:12level, this is roughly,
• 10:14what we try and follow.
• 10:16There are published algorithms that
• 10:18have been implemented in clinics
• 10:21and that have shown,
• 10:23greater rates of response and
• 10:25remission,
• 10:27and better progression
• 10:29to to second line agents
• 10:31and then clozapine.
• 10:33So I think there are
• 10:34ways to police,
• 10:35prescription practice in a service
• 10:38that will result in better
• 10:40practice and outcomes for patients.
• 10:43And at step, we the
• 10:45way we do this is
• 10:46not through,
• 10:47some kind of formal algorithm,
• 10:49but really
• 10:50a a culture of practice
• 10:51where we are constantly reviewing
• 10:53our medication choices with each
• 10:55other as a clinic and
• 10:57amongst prescribers,
• 10:59and, of course, trying to
• 11:00follow the principles I I
• 11:02put in earlier. But in
• 11:03general, for early psychosis, the
• 11:05good news is that
• 11:07any of the, agents available,
• 11:10both first and second generation,
• 11:12are appear to be equally
• 11:13effective at driving towards remission
• 11:16as long as the individual
• 11:17patient can tolerate that medication.
• 11:19So sometimes the game is
• 11:20to find a medication for
• 11:22which the patient is best
• 11:24able to tolerate the side
• 11:25effects.
• 11:26I put accept olanzapine
• 11:28not because it's any less
• 11:29effective, but because its
• 11:31impact on weight gain is
• 11:33so dramatically worse than the
• 11:34other medications that,
• 11:36it would be a shame
• 11:37to try it first and
• 11:38end up with someone who
• 11:40is in remission but who's
• 11:41gained thirty pounds in the
• 11:42first three months. And then
• 11:43you have to figure out
• 11:45what to do next. Take
• 11:46them off this medicine and
• 11:47and transition them.
• 11:51If they don't respond to
• 11:52the first medication, it's entirely
• 11:54reasonable to try another. The
• 11:55people often favor trying something
• 11:57from a different class,
• 11:59but I found sometimes they're
• 12:00just trying a different medication
• 12:02that's better tolerated,
• 12:04that for which the individual
• 12:05patient feels subjectively better,
• 12:08which can be idiosyncratic
• 12:10amongst individual patients. Some like,
• 12:12the sedating and slowing effects
• 12:14of something like Seroquel, and
• 12:16others prefer Abilify because it
• 12:17makes them feel less sleepy.
• 12:19So,
• 12:21it's worth trying a second
• 12:22agent and getting it, to
• 12:24a to an optimal dose.
• 12:26And then there are caveats,
• 12:27of course. So,
• 12:29we can talk about this
• 12:30more, but clozapine, of course,
• 12:32is severely underutilized.
• 12:34Individual patients,
• 12:37who would be responsive to
• 12:38clozapine often go through unnecessary
• 12:42trials,
• 12:43beyond
• 12:44a second trial, a third
• 12:45trial, a fourth trial, and
• 12:47then get put on multiple
• 12:48antipsychotics
• 12:49when
• 12:50the evidence is very clear
• 12:51that for individuals who've tried
• 12:53who've gone through two trials
• 12:54and not remitted,
• 12:56clozapine is really the best
• 12:57medication. So it should at
• 12:59least be discussed and often
• 13:00needs to be discussed many
• 13:01times before
• 13:03families and individual patients will
• 13:05feel comfortable proceeding.
• 13:07And, of course, injectable medications,
• 13:10the long acting injectable medications
• 13:12are a great tool, and
• 13:14we,
• 13:15will often move to this
• 13:17even in the first trial
• 13:18or sometimes the second trial.
• 13:20If we find that a
• 13:21person has responded to oral
• 13:23medications,
• 13:24it
• 13:25the question should be why
• 13:26not an LAI in those
• 13:28situations. It's,
• 13:30allows individuals to not have
• 13:31to remember, of course, to
• 13:32take it every day, but
• 13:34it can also save individual
• 13:36individuals from
• 13:37exposure to others if they're
• 13:38living in community settings and
• 13:40colleges and dorms
• 13:42where they don't have to
• 13:43carry pill bottles around, can
• 13:44come into a clinic once
• 13:45a month and get an
• 13:46injection.
• 13:48And it also allows us
• 13:49to use much effectively much
• 13:51lower doses with much lower
• 13:53side effects than oral medications.
• 13:55So,
• 13:56we have a very strong
• 13:57preference
• 13:58and try very hard to
• 13:59educate,
• 14:00patients and families to move
• 14:02towards an LAI
• 14:03once they've responded to an
• 14:05an oral, medication.
• 14:09And we can talk more
• 14:11about this. There are some
• 14:11individuals who don't respond to
• 14:13clozapine.
• 14:14And at that point, we
• 14:15have moved beyond
• 14:17the evidence from clinical studies,
• 14:19and we end up having
• 14:20to use combination treatments based
• 14:22on
• 14:23mechanisms of action, ideas that
• 14:25might be helpful for an
• 14:26individual patient.
• 14:28And then if that fails
• 14:30too, ECT can be quite
• 14:32effective in those situations and
• 14:33is worth considering.
• 14:35And I would say if
• 14:37that isn't available or if
• 14:38an individual patient hasn't responded,
• 14:41beyond stage five, it makes
• 14:43sense to look, for clinical
• 14:45trials of which,
• 14:46if you're near an academic
• 14:48center, could be enrolling subjects
• 14:50who could then try experimental
• 14:51treatments in a much safer
• 14:53environment,
• 14:54than in ordinary clinical practice.
• 14:59And we've got one more
• 15:01med related question that was
• 15:02relevant.
• 15:04So just wondering if we,
• 15:06generally speaking,
• 15:08doing more favors starting an
• 15:09injection while a client is
• 15:11inpatient or trying it through
• 15:13the outpatient prescriber.
• 15:18Yeah. That's a great question.
• 15:20It's
• 15:21it's great if individuals can
• 15:24be loaded on an LAI
• 15:26after having shown a response
• 15:28on an inpatient unit.
• 15:31It it certainly helps us
• 15:33a lot when we begin
• 15:34to engage someone that they
• 15:35have already begun in LAI.
• 15:38So
• 15:39that would require though communication
• 15:41and collaboration with an inpatient
• 15:43unit,
• 15:44and
• 15:45sometimes reassuring them that you
• 15:47are able to continue in
• 15:49LAI.
• 15:50But we've also started individuals
• 15:52in the outpatient setting on
• 15:54on LAI. So, I don't
• 15:56know if that answers the
• 15:56question, but but any any
• 15:58pathway to an LAI is
• 16:00good. There are some barriers
• 16:02that we can talk about,
• 16:03one of which unfortunately often
• 16:04is insurance coverage.
• 16:08But but, yeah, if if,
• 16:09an individual gets admitted to
• 16:11a hospital
• 16:13and you as an outpatient
• 16:14provider have a sense that
• 16:15they have responded to a
• 16:16medication,
• 16:18it's a great time to
• 16:19engage with the inpatient team
• 16:21and
• 16:22help collaborate with them and
• 16:24the family to get them,
• 16:26started on LAI,
• 16:28you know, before they leave.
• 16:32Any anything else, Laura? Any
• 16:33other questions?
• 16:35No. Thank you.
• 16:40So I think this is
• 16:42almost my last slide, and
• 16:43I put this up again
• 16:44intentionally. It's it's a very
• 16:46long list. I won't go
• 16:46through it. But the point
• 16:48I'm I was trying to
• 16:48make here is that, of
• 16:49course,
• 16:50pharmacotherapy,
• 16:52for people with schizophrenia spectrum
• 16:54disorders,
• 16:57can accomplish a lot in
• 16:58terms of positive symptom remission.
• 17:01As I mentioned before,
• 17:02it can't do much for
• 17:04cognitive symptoms or negative symptoms.
• 17:06And so
• 17:07it's very important to integrate
• 17:09these interventions with all the
• 17:11other components of coordinated specialty
• 17:13care.
• 17:14But within,
• 17:16just the pharmacotherapy
• 17:17domain, there are opportunities
• 17:19within a collaborative like this
• 17:21where we need to bring
• 17:22clinics together
• 17:25to think about more systematic
• 17:26ways to,
• 17:28tackle problems that we all
• 17:30know keep coming up. And
• 17:32I've listed a few here.
• 17:34There are ways to think
• 17:35about,
• 17:37care pathways. In other words,
• 17:38sort of standardized
• 17:40processes that can help all
• 17:41of us
• 17:43improve on problems like clozapine
• 17:45underutilization.
• 17:47So there are tools available
• 17:48that can help clinicians educate
• 17:51patients and families with standard
• 17:52language, for example.
• 17:55And then there are ways
• 17:56to jointly screen for rare
• 17:58side effects across,
• 18:00state a statewide network like
• 18:02this
• 18:02where we can all be
• 18:04helpful to each other in
• 18:05how to actually utilize these
• 18:06screening measures appropriately
• 18:08and educate patients and families
• 18:10about risks.
• 18:12So,
• 18:13adherence is another, obviously, a
• 18:14very common challenge, and there
• 18:16are many different ways that
• 18:18can be helpful for different
• 18:19patients using visiting nurses, doing
• 18:21pill counts. But these are
• 18:23the kinds of challenges that
• 18:24I think sometimes
• 18:25if you're in a larger
• 18:26network,
• 18:28it it's useful to do
• 18:29together and share tools around
• 18:31this that can help everyone
• 18:33try out these different approaches
• 18:35that they may not, as
• 18:36a clinic, have tried before,
• 18:38but they may be,
• 18:39a, sort of an activation
• 18:41barrier to getting it started.
• 18:42If you don't have the
• 18:43materials printed out,
• 18:45it takes a lot of
• 18:46work. But if one clinic
• 18:47has it printed out, these
• 18:48can be shared. So
• 18:50part of my excitement is
• 18:51is that I think
• 18:52we all are probably,
• 18:55using creative ways to tackle
• 18:57some more more of these
• 18:58problems in pharmacotherapy.
• 19:00And by pooling our knowledge,
• 19:02we could probably all do
• 19:03better as a network,
• 19:05in getting at these. And
• 19:07none of this is,
• 19:09is requires
• 19:11any special,
• 19:13equipment
• 19:13or,
• 19:15or tools, but it it
• 19:17does require sharing sort of
• 19:19standard
• 19:20lessons and and maybe
• 19:22informational materials and so on.
• 19:24And I can say more
• 19:25about this later because we
• 19:27are
• 19:28soon gonna be,
• 19:29launching, I'm hoping in July,
• 19:32a consultation service out of
• 19:34step for
• 19:35clinicians across the state to
• 19:36call just to curbside around
• 19:38some of these challenges with
• 19:40not just pharmacotherapy, but we
• 19:41expect many of them will
• 19:42be around pharmacotherapeutic,
• 19:45issues.
• 19:47So, so we're back here
• 19:50to where we started. And,
• 19:52the other component,
• 19:54we're gonna address is longitudinal
• 19:56evaluation. So
• 20:00we we regard sort of
• 20:02keeping an open mind and
• 20:03continuing to evaluate as a
• 20:05core
• 20:07value at step,
• 20:09and it it varies, of
• 20:10course, across the modules. So
• 20:12in module a,
• 20:14where we're often engaged with
• 20:16families and referral sources
• 20:19before they arrive in the
• 20:20clinic,
• 20:21we are gathering a lot
• 20:22of information that's very helpful
• 20:24in evaluating
• 20:26the the patient, but also
• 20:27understanding their delays, their pathways
• 20:29to care, understanding
• 20:31the network that they had
• 20:33to travel through to get
• 20:34into the clinic.
• 20:35And also the interactions with
• 20:37family members in the course
• 20:38of engaging a person into
• 20:39care can provide incredibly valuable
• 20:42information about the concerns, the
• 20:44capabilities,
• 20:44the issues that family members
• 20:46have, and the environment
• 20:48from which the patient is
• 20:49coming to the clinic.
• 20:51So it our assessments really
• 20:53and evaluations begin before the
• 20:55person hits the front door.
• 20:57When they are in the
• 20:58clinic, it looks a little
• 20:59bit more like a traditional
• 21:01clinical evaluation that I'm sure
• 21:02you're all engaged with.
• 21:04And the idea here, of
• 21:05course, is to
• 21:07to conduct a careful differential
• 21:09diagnosis to rule out,
• 21:11secondary causes of psychosis that
• 21:13we'll be covering in more
• 21:15detail next week. I know
• 21:17we flipped the modules because
• 21:18of of my absence last
• 21:20week, but we'll be talking
• 21:21about module b in more
• 21:23detail.
• 21:24We also engage in a
• 21:26more pluralistic case formulation.
• 21:28So not just what illness
• 21:30the patient might have and
• 21:31the differential diagnosis of the
• 21:33different possibilities,
• 21:35but also who they are,
• 21:36what sort of behavioral issues
• 21:37they have or are having,
• 21:39and their own life story
• 21:41and how to, build a
• 21:42narrative
• 21:43that helps make the best
• 21:44sense of how to, improve
• 21:46their
• 22:00improve their capability in the
• 22:02world. So,
• 22:04that point,
• 22:05we have a formal presentation
• 22:07in our clinic
• 22:09of,
• 22:09an overall assessment that includes
• 22:12the workup and differential diagnosis
• 22:14so far, a case formulation,
• 22:16and a chance for other
• 22:17members of the clinic who
• 22:19are not the primary caregivers
• 22:21to weigh in and critique
• 22:23and raise questions about management,
• 22:26in in in a sort
• 22:27of a a case conference
• 22:29mode, but really as a
• 22:30way of allowing the primary
• 22:32clinical team to get a
• 22:33second opinion from within the
• 22:34team
• 22:36on on managing various issues
• 22:37as they've come up.
• 22:39So so that can that
• 22:40happens at three months, and
• 22:41then every six months, we
• 22:43have a standard over, overall
• 22:45review of of,
• 22:46progress in the case.
• 22:48And we
• 22:49you know, with these illnesses,
• 22:52the best diagnostic tool is
• 22:54longitudinal
• 22:55follow-up. So
• 22:56there are individual
• 22:59cases where it's very hard
• 23:01to figure out the relative
• 23:02contribution of substance use versus
• 23:04personality dysfunction versus the primary
• 23:07psychotic illness. And this is
• 23:09only clear
• 23:11as we get to know
• 23:12people over time. And so
• 23:13it's important to
• 23:14revisit the formulation,
• 23:16periodically within the team setting
• 23:18to make sure that we're
• 23:19providing
• 23:20the best care. So
• 23:21I I think that Laura
• 23:23wanted me to just remind
• 23:24us and all of you
• 23:26about the importance of
• 23:28continued evaluation in a clinic
• 23:29like this even while it's
• 23:30organized around
• 23:32a group of, disorders that
• 23:34fall within schizophrenia.
• 23:36We recognize there's a lot
• 23:37of heterogeneity
• 23:38within that comorbidity
• 23:39with other,
• 23:41substance use disorders and behavioral,
• 23:43disorders.
• 23:44And so we we try
• 23:45to keep that as part
• 23:47of our ethos in the
• 23:48clinic and keep reevaluating,
• 23:51in a team whether we're
• 23:53missing something or need to
• 23:55address something we hadn't picked
• 23:56up at the initial assessment.
• 24:02And,
• 24:04so,
• 24:05the last slide here I
• 24:07I think this is the
• 24:07last slide. Yes. Good.
• 24:09Is to return to this
• 24:11issue of of culture and
• 24:13how important
• 24:15it is.
• 24:17I know Laura talked a
• 24:18little bit about Huddl, which
• 24:19is one of my favorite,
• 24:21meetings in the clinic.
• 24:22It's a chance to do
• 24:23many different things, but also
• 24:25to
• 24:26make sure that the values
• 24:27that we espouse as a
• 24:28service that is inclusive, open,
• 24:31providing the most effective care,
• 24:34is accessible
• 24:35to families and patients where
• 24:36we're constantly reevaluating
• 24:39is actually happening in the
• 24:40course of care,
• 24:42even as we're discussing,
• 24:44issues that arise that might
• 24:46be acute and
• 24:47require a change in the
• 24:48plan,
• 24:50and a chance to also
• 24:51assess how the team is
• 24:52doing and whether they feel
• 24:54supported and whether they're managing
• 24:55under,
• 24:57the the stress of having
• 24:59to provide
• 25:00lots at different times to
• 25:02different people who may be
• 25:03cycling in and out of
• 25:05stability and recovery and then
• 25:06relapse again.
• 25:08We try to use our
• 25:10data that we collect as
• 25:12part of these assessments,
• 25:14to help clinicians
• 25:15understand their impact on the
• 25:17population's health. So
• 25:19the goal here is to,
• 25:22help everyone see
• 25:24what the clinic is able
• 25:25to accomplish
• 25:26in terms of reducing relapse
• 25:28and rehospitalization
• 25:29and improving
• 25:30vocational outcomes.
• 25:31And I'll say a little
• 25:33bit more about this at
• 25:34the last session where we
• 25:35will talk a little bit
• 25:36more about how we use
• 25:38the structured assessments we collect
• 25:40to help the clinic navigate,
• 25:43and get feedback on what
• 25:45it should do in terms
• 25:46of its care processes.
• 25:48Such that if we discover,
• 25:49for example, that our rates
• 25:51of
• 25:52smoking have been going up
• 25:54quarter on quarter,
• 25:55we can have a discussion
• 25:56at the clinic level about
• 25:57what we might do,
• 25:59around smoking cessation efforts and
• 26:02and educational efforts with our
• 26:03patients. So it's a shared
• 26:05project together
• 26:07to use data to help
• 26:08everyone improve population outcomes.
• 26:13And
• 26:13we we've tried
• 26:15over the the years to,
• 26:18connect our clinicians to activities
• 26:20for their own professional development,
• 26:22CME, but also
• 26:23inviting discussions into the clinic
• 26:25to talk about difficult cases,
• 26:29presentations,
• 26:30and opportunities to present at
• 26:32local conferences where clinicians
• 26:35have acquired specific expertise
• 26:37that they can use to
• 26:38teach others.
• 26:40And I'm hoping actually that
• 26:42one big growth opportunity for
• 26:43our step clinicians over the
• 26:44next few years will be
• 26:46interacting with,
• 26:48with all of you in
• 26:49your clinics and sharing,
• 26:51lessons they've learned as as
• 26:53expert clinicians with others, their
• 26:55peers,
• 26:56which I think can be,
• 26:58a huge value add to
• 26:59the to the work that
• 27:01we do together and can
• 27:02prevent,
• 27:03we hope, you know, the
• 27:05kind
• 27:07of, demoralization
• 27:08that can sink in if
• 27:09you feel like you're you're
• 27:10not getting adequate feedback or
• 27:12you're not getting better
• 27:14at your job.
• 27:16So I'll stop there because
• 27:17I'm anxious to give us
• 27:19as much time as possible
• 27:20to to
• 27:21to engage.