Welcome back everybody. I hope you enjoyed your break. So my name is Cecilia Echeverria. I'm the senior director for public policy strategy and operations at the Institute for Health Policy. And again, I want to welcome you all here. I'm really excited to support this panel. As we know, we just heard about the patients and consumers being at the center of our work. Again, we couldn't do this work without the providers. They're on the front lines grappling with the immediate needs of patients and thinking broadly about the larger systems that are needed to serve them. They're also the ones who really start to see partnerships form both within the care setting and in the community setting to help support and address patients' needs. The work is not easy as we all know and there are a range of challenges to being on the front line, including provider fatigue, vicarious trauma and other issues that are real. We probably could use the whole rest of the day to talk about provider issues, but we're lucky to have folks with us for the next hour or so. So I want to take this time to go ahead and introduce our panelists. Chunk Ngolia is Senior Vice President for Public Policy and Practice Improvement at the National Council for Behavioral Health, where he leads the national charge to ensure people have access to their potential to live full and complete lives. He plays a major role in federal and state policy advocacy and analysis in issues related to behavioral health financing and health reform. He holds a master's in social work from the Catholic University of America. Next we'll be joined by Dr. Glenda Ren, who is an associate professor, psychiatrist and health policy mental health services researcher at Morehouse School of Medicine, where she serves as director of the Kennedy Satcher Center for Mental Health Equity in the Satcher Health Leadership Institute. She holds a master's degree in health policy research from the University of Pennsylvania and a doctoral degree from Jefferson Medical College of Thomas Jefferson University. We'll also be joined by Uma Alualia. She's the director of Montgomery County's Department of Health and Human Services here in Maryland. Under the leadership of the department's core team, HHS developed a strong integration and interoperability framework across the HHS Enterprise and is considered a national leader in this work. She holds a master's degree in social work from the University of Delhi in India and a specialist post master's degree in health services administration from George Washington University. So I want to thank all the panelists for being here today and I'm going to welcome each of them to come up and share their views on the challenges and opportunities we face or they face in their systems. First, I'd like to welcome Chuck up. Thank you, Chuck. At least you didn't do it the other way. At least it was Chuck up and not the other one. So I have the pleasure of working at the National Council for Behavioral Health and we represent community-based mental health and addiction providers around the country, mostly not-for-profit. And I'm going to talk a little bit about workforce issues, what I was asked to focus on. First to put this in some perspective, I don't know if any of you have a hard time falling to sleep and maybe an alternative to Ambien is the World Health Organization put out a report a few years ago that talked about a global shortage of qualified healthcare professionals. And sometimes I think we get so focused into our own world that we think, well, there's a particular problem that we're confronting in behavioral health because people just don't want to work in our industry. And I think that's true, but it's also important to have some perspective that people would rather become investment bankers than work in healthcare. And I think that's a larger issue we've got to deal with as a country. And I've had the privilege, I travel all over the country talking to our members and one of the biggest issues that I hear is that they cannot attract a competent workforce. And the good news about being on the third panel of the day is that a lot of the themes that I think are evident in making it difficult for our members to attract a competent workforce have already been discussed. The most depressing one, of course, is can you offer competitive salaries? And we did a salary survey several years ago and I think the highlight for me was, you know, you could make more being a manager at Burger King than you can being a manager at a community mental health provider. And I would dare to say maybe you'd have less stress at Burger King that you're not dealing with people who have very complicated psychiatric illnesses, who lack adequate housing, family support, other issues that you're responsible for trying to address.  And this comes back then to something that Pete Early talked about in his remarks that I think at the heart of our problem is the way that our systems is financed. A system, I think, is a kind word, right? We have a variety of systems, at least 50. California has 58 of its own being, you know, a county-directed state in which there's no central authority or direction that is provided. And certainly, you know, underinvestment. But then also just the way we're, you know, kind of our fee-for-service system as states have gone to integrated managed care. Another word that Pete used this morning, which I think an awful lot about, is widgets. And I think as a consequence, mental health has become a widget economy. How many services do you need to provide in a day to break even? And, you know, I guess that's okay. I mean, I understand capitalism, but I also wonder then what does it do to things like engagement, to things like supervision, to things like trauma-informed approaches when your system does not actually reimburse you for any of that time? So certainly, those are all kind of the issues. I'd like to talk a little bit, at least about one way that we've tried to address that as an organization, because at the end of the day, you know, our organization exists so that people can get the help they need it when they need it in their community, and we want it to be of the highest quality.  But one of the small details they forgot to include in those manuals is how do you pay for it? So you've got, you know, lots of grants or pockets of innovation that happen across the country, but certainly that is not widespread. And I think about what Mary Gilliburty was saying earlier about how do you know that people actually have the competence to provide the care that is needed. So first of all, we want to see evidence-based practices more widely available. Secondly, we think about the variety of needs that people have and the different systems that they interact with. So care coordination is something that we think is really important. So how do people have access to employment training? As people leave hospitals, how is there a warm handoff that occurs to connect them to community-based care? I think all of you know, right, in unnecessary or unplanned readmission to hospitals, no matter what the diagnosis, is fueled by people who don't see an outpatient provider, whether or not that's a mental illness or a physical health condition. If you don't see an outpatient provider, you're more likely to be readmitted. So care coordination. And then also picking up on a theme that Pete talked about, 24-7 crisis response. Who's available in a community when someone is experiencing a mental health crisis? We can't always predict when that is going to happen. And diversion or kind of all those models that seek to work with police officers only work if the police have someone to take that person to, some place to take them to, right? It's diversion to something. And so we're thinking about all of those concepts and more when we came up with an idea that we've been pursuing legislatively called certified community behavioral health clinics, as codified in a piece of legislation called the Excellence in Mental Health Act. So first of all, that there be national standards that providers have to provide comparable services, that they need to be evidence-based, that there needs to be care coordination and 24-7 crisis response. And most kind of radically for our system that the reimbursement should actually be sufficient for people to do those things. I don't know what other part of healthcare where your physician is your loss leader. But as I travel to our, talk to our members now, they cannot generate enough revenue to pay for their physician's time. I was on the board of a clinic here in D.C. and we were hiring nurse practitioners so that we would lose less money. Not so that we would break even, but that we would lose a little bit less. So that doesn't make any sense to me. And so the model, the payment model that we've attached to these clinics is the same ones used by federally qualified health centers, a prospective payment system initially based on cost and a per-episode payment, but then it assumes then all that care coordination activity, which so many of our members now want to do but don't get paid for. And I'm happy to talk, you know, more about that later. So, but I think the most fundamental problem that we have when we think about workforce or capacity, access to care is actually having sufficient reimbursement. Eight states are currently implementing CCBHC model, and I saw a, with 21 states reporting so far, they're reporting having hired 600 new professionals since the beginning of this initiative. A significant number of psychiatrists, addiction care professionals, and that's only 21 clinics reporting. So I think we'll continue to see that number grow. So I think rational reimbursement, coupled with expectations and comparability, because I think the other problem we face as a system is that every state does things differently. I don't know how that advances us. So I'll stop and look forward to the questions later. Good morning, everyone. I'm going to echo Chuck's comment that a lot has been said already, so I'm going to hopefully add to the layers of what was discussed and I'm also going to reserve some of my time here for the discussion because I really think it's a good place in time for us to interact more. But when I was asked to speak about this question of what opportunities do we have for providers and delivery systems to transform care, I kind of had to take myself a couple of steps back and recognizing that we really have to first reconcile our means in our ends. Currently, in large part, the end is the provision of health care. That is the end that providers are working towards, payers are working towards, even advocates to some extent are trying to increase health care.  What do I mean by that? So in order to do this one way is making that leap from individual care and a focus on that alone to thinking about population health and having attention to population health, not only being the domain of public health systems or payers that are seeking to control costs, what I mean is that the providers of care, as well as the delivery system leaders, should also know the health of the population that they're serving for that. It requires things like measurement-based care and knowing who's benefiting and who's not benefiting. How can you truly align resources with need if you don't know who needs what? You do need that information. We also need to have meaningful quality measures that don't just count the widgets. In our work with criminal justice system in Fulton County, I was quite dismayed to learn that their quality measure that they use were the number of psychotropic prescriptions that were written. I was like, what is that a measure of the quality of? The paper that you use to write the prescription? I don't get it. I mean, that's literally the one measure that they had and that's really a problem. If you're going to make that shift, though, to try to see how can we achieve well-being in our population, how can we foster mental health, how can we really improve that in our communities, you will quickly find yourself thinking about the conditions in where people live, learn, work, and play. Because mental health, which we all have, we don't all have a thyroid mask, we may not all get diabetes, but we all wake up in the morning with some degree of mental health, hopefully enough to get you through the day. And therefore, we are all at risk for losing that. And because of that, it's more so than diabetes really influenced by the supports that we have in our environment, as was mentioned by Mary, to support the dignity of individuals and also providing equal opportunity for them to achieve their optimal health. This responsibility, if we really take this seriously, is beyond the scope of what the health care sector can provide. It requires intersectoral, multi-sectoral collaborations through transportation, education, labor. I think that's one aspect of what your committee is doing. I'm participating in the Healthy People 2030 committee. We talk a lot about the federal interagency workgroup and is it really functional? What are they really doing? That's at the federal level. Sometimes at the county and state level, there's more interest in collaborating across sectors. So I see a lot of examples of good innovations there. The second most important element in my view is actual access to health care. So I made my point about health, right? But improving the environments and addressing social determinants, they really go far in terms of prevention, but we persistently face a structural inequity in access to care. Millions of people today woke up uninsured or underinsured, and this is very problematic for many reasons, but when it comes to mental health, it really contributes to the critical failing in our system. And that really is that people are overworked but underutilized. I just have a quick example of this. I'm a psychiatrist and I have about 30% of my time where I see patients. So if you take the case of a patient, we'll call her Lynn. She waited 10 years to address her PTSD. She's now lost more than one job as a result of her being triggered by working with males in her workplace. Her marriage is on the rocks because it's impacted her intimacy and they're also at risk of losing their home because of the financial stress. Patients like then are typically booked on the hour or the half hour depending on if they're a new patient or not, but we all know that Lynn's going to need more when she walks in the door.  You're going to provide supportive therapy. You're going to go out of your way for care coordination, but you're also going to work well into the evening to close out your charts. I get hate mail all the time, not closing out my charts in time because you have to decide, am I going to go home? Am I going to finish the notes? In contrast, if you can imagine with me for a moment a future where that same doc spends four hours a week reviewing a registry of 300 patients that are being managed in a primary care team, that doc is going to feel good about themselves because of how many people they're able to help and they're also using their skills at the top of their ability problem solving a few very difficult cases. She also is going to still have that panel of patients and Lynn's going to come in, but maybe you only see one or two similar patients like that because the other patients in our future that we want were identified earlier in the progression of their symptoms by different systems of care. So maybe the school refers Lynn when her daughter shows up showing signs of behavioral problems. Or social services refers Lynn because she's seeking some type of public assistance and she does some type of assessment there. Her employer, before she lost her last job, might refer her when the supervisor notices that she's not being as productive as usual. And when Lynn recognizes her need for help, she's not tempted to put it off like so many people do for decades because they have no coverage or they're afraid of the high copay. So until we really embody that spirit of parity, we're going to continue to see disparity and it might actually get worse. So all these great innovations that you'll see here today, they're fantastic. Who's more likely to get those? The people that are already having some type of access to care that can, like me, can pay out of their pocket for care. I don't need to rely on my insurance. So we can speak later maybe about the importance of trauma-informed systems. I think that's really important as well as the challenges to implementation. So we have a federal law, but it's not implemented. So you're not going to see the benefits until these things are implemented. And then I also hope to speak about how we can think about innovation and how that's diffused and maybe the role of regulations and when are regulations helpful in advancing a system versus when can they stifle innovation? So I'll stop there. Good morning, everyone. So I think the 9% of the government folks stand sitting in this room talking to you about how the system is actually delivered at the county level. I do have a slide deck, so I hope that that works. My goal today is to sort of tell you a little bit about the public-private interventions or the system that exists at the local level and why it's important and why some of it works and some of it doesn't work and what we're attempting to do. So I actually am a great believer in county level government. I've worked at the state level, interacted with the feds. County is where those collaborations are most possible, right? Because the rubber hits the road over there. When that individual comes to the hospital and they're going to get discharged, they're coming into the community, it's the parents who are struggling, their spouses who are struggling, they're struggling. And we have a role to play as a community-based system of care and what does that look like? So let me start by telling you a little bit about our county. And this is relevant because somewhere, I think it was people who talked a little bit about the language access issues. We're a county of 1.404 million residents and 33% of our population is actually foreign-born. And a good 55% of our population is racial-ethnic minorities. So when I think about the Old Montgomery County of 20 years ago, this is not who we were. And so as a system, too, we're trying to readjust ourselves to be responsive to the community that we're serving. We're also age-friendly and dementia-friendly. I know someone spoke earlier about the need for dementia being part of this continuum. We're definitely paying attention to all of that. And trauma-informed care, because a lot of the immigrant populations that we're seeing are coming here having experienced significant trauma. But let's not forget the trauma of poverty. Everybody who spoke earlier had a parent who was willing to step up and advocate and be a voice for them. When you're experiencing poverty and you're already worn down, that becomes 10 times harder. On the flip side, you could get Medicaid if you were eligible and has the most generous benefit package. But if you have private third-party insurance, everybody talks about parity between mental health and primary care, behavioral health and primary care. Everybody talks about parity between private insurance and Medicaid. And I see over and over again children whose parents come in and voluntarily place their kids in foster care just so they can get the care that they need. And to me, that's completely unacceptable. And so there is a point at which we need to continue to have that conversation around parity, too. Montgomery County, as many of you know, is a very unaffordable community, right? So I just put that chart up there because to me, as we, as county government, made a decision to stay in the service delivery system, it was to respond to the needs of those who did not have the safety net, right? Because private sector, no matter what, isn't able to take the deepest of the deep needs. And there is a role for government in this. And so that's in housing costs. Housing is probably one of the single biggest barriers around treatment. Actually, we talk a lot about professionals. If there's this schizophrenic with diabetes who's homeless and showing up over and over again in the emergency room, you're not going to get them to pay attention to treatment unless their housing needs are met first, which is why I'm a huge proponent of housing first. And that's really where we need to start. So just a quick thing about our department. We were put together in 1994 from four county agencies. And the objective really was integrated, coordinated, comprehensive service delivery. Well, 22, 23 years later, we're still searching for the holy grail. But we're closer than we were when we started. So at least there's hope. Real quickly, one director, we're moving towards a single client record. So we do have a master client index and electronic health record and integrated case management system. So it really does. And we're a HIPAA covered entity overall. Doesn't help with 42 CFR or WAVA. Think about it. We were really close to implementing our integrated system and WAVA passed new restrictions on sharing of information. And we had to scramble to figure out what does this integration and our operability really look like. Think about the trauma if a woman has experienced domestic violence as depressed and not able to get the care that she needs. So this is our enterprise, which I think is kind of cool because we talked about all of these things, right? We have aging and disabilities, behavioral health and crisis, children, youth and family services where we have child welfare and juvenile diversion and early childhood services and early childhood mental health and toddlers and benefits, right? Medicaid and SNAP and public health which is its own continuum and homeless services. So we really are able to get that consumer walk in the door and serve them from a 360 no matter which door they walk in. So we have a screening for needs tool and so when you walk in, it doesn't matter whether you walk into a mental health clinic or you're walking into TANF eligibility or you're coming into maternity, you get asked questions around are you at risk of becoming homeless? Do you have a child with mental health needs or do you have developmental disability issues?  Whatever that is, we're able to wrap around. And it's what we're working towards and now with the technology, we're getting closer to the end goal. Let's talk a little bit. This is how we are envisioning our behavioral health continuum. So starting with promotion, prevention, treatment and recovery. And we just finished a huge strategic alignment effort. And the way, the errors are sort of misleading, it's really just four components to our continuum. Intake assessment, coordinated entry, crisis response and trauma treatment, wellness prevention, intervention and treatment and then forensic intervention and treatment. So we have sort of these four components of our behavioral health system, each of which we are paying attention to and resourcing. So we just had a legislative audit. What they showed, here are some of the strengths and the weaknesses in the system. We have significant prevalence of behavioral health disorders in the county, surprise. Our problems often start in childhood and will intensify if not addressed early. So this question of early intervention, early identification, early intervention. Funding for behavioral health is fragmented and it is restrictive. There are many uninsured and underinsured residents who need services in the county and that is a particularly tough issue. We really took advantage of the ACA and we have 72,000 more adults, families, households, no, individuals who are eligible who have insurance now today and we're very scared about what that walk back is going to look like. We also have another 42,000 to 50,000, 45,000 adults who don't have health insurance by virtue of their immigration status or anything else. And so how do we get care to those folks, right? Our state is a Medicare waiver state so this issue of re-hospitalization is a big one. So our hospitals are very, very engaged with us in how the delivery of behavioral health care would look, what it would look like. The county has a very strong forensic behavioral health services program and it's a partnership between Corrections and HHS. So I am very close to running out of time so we have a robust menu but our prevention promotion is less well-developed than treatment and so there you have it, right? How are we going to do early identification if we don't have a well-developed prevention promotion identification system huge shortage of therapists, psychologists, bilingual psychiatrists and therapists. We're competing. We're competing. The other day I saw an ad for the military, the veterans administration was hiring psychiatrists and offering them $330,000 in annual salary. We cannot compete with that. We just simply cannot. So we have a huge shortage of therapists and limited residential services and a lot of nimbyism in our community. I don't think I'm surprising anybody. It's true in many American communities. Don't put a grip on them in my neighborhood. Why do the ambulance keep coming to our neighborhood? Why are these people walking down the street looking disheveled on and on and on? We do want to build a medical home for integrating care between primary care and behavioral health, diversity response and continuous identification of cultural language competency needs. We spend hours thinking about this and an enterprise-wide integration that we need to continue to deepen, right? If sometimes people who are in eligibility don't fully understand why this person is not able to provide their paperwork or something else is going on or when their job is being impacted and they don't want information shared, all kinds of issues that require individual attention. So from a solution standpoint, we really want public and private integration to strengthen and to continue. The bulk of our services are provided by the private sector. So all the folks that from a workplace and workforce perspective, what's the development? What does that career progression look like? Responding to significant shifts in policy, our state has decided it's going to integrate wonderful behavioral health, right? Mental health, substance abuse, co-occurring, let's integrate the two, but then it's painful when you're going through it. Maybe we'll come out good at the end and we keep saying, we're already integrated. Take a look at our model. It has to happen the way the state is going to make it happen, right? So articulately about your proposition and the integration approach, I am a huge proponent. I've worked in silos and I can tell you if we can get this right, this is the answer. It should be the answer. And then youth suicide and opioid epidemic are the two priority areas for us. We heard about say the word, I think was it speak the word? Ours is be the one campaign. We just launched the be the one campaign, be the one to save a life, be the one to refer someone to treatment, and it's a huge opportunity for us with our public school system to do something with youth and children. So here's the last piece here, sort of our strategic efforts. We're integrating mental health and substance abuse, wellness prevention, intervention, treatment under the rubric of behavioral health. We have a community health improvement process that all our hospitals and our community based clinics and our payers are engaged in. Hard time bringing payers to the table. So those of you who are payers over here, Kaiser of course is there, but I wish others would come to do. We've identified three priorities for population health, behavioral health ranks among them, including health and our policy and chronic disease management. So we really have elevated behavioral health in our county. We're doing a strategic alignment process using appreciative inquiry as a conceptual framework and building a strategic roadmap. And that roadmap is ready to be released and overall the state has declared an opioid emergency and so that's consuming a fair amount of time. So that's a little bit about us. Thank you. So. Thanks. Thank you. So thank you all for your presentations and for joining. So I wanted to start us by asking if you had any reactions to the earlier patient panel and even to Pete Early's presentation just to start us off. I mean beyond, they were all fabulous, but I think they grounded us on really important things, right? I think Pete's panel or Pete's discussion talked about the reality that families face and how much, how our system, quote unquote, fails so many. And I think just knowing my own, people in my own family who've had similar experiences, you know, somebody in my family a couple years ago attempted suicide and I worked in mental health for 25 years and I never felt so powerless in my whole life trying to communicate with that facility, coordinate that person's discharge and follow-up care and I felt like I'm somebody who kind of knows something and I still felt totally powerless. What do other people go through every day? Yeah, I mean I was, I guess embarrassed for my field. I always am. I don't know who these psychiatrists are. Or how they're getting trained. Something is really fundamentally wrong and I think that I was telling someone earlier last week I was at James Madison University speaking to undergraduate health professional students, PA students, BSW students and the like and I was like, you guys are it man, my hope is on you. Because you are the generation that doesn't have to go down the path that's been laid out. You have a naturally innovative way of thinking and I think that it's gonna have to take something that we have not thought of yet in order to adjust this. We're not gonna get enough providers. We have to find better ways of task-shifting. We have BSWs that can't do things that a peer specialist can do because of turf wars, with scope of practice, with MSWs. Like how does that make any sense? You have LPCs and LCS Debuts fighting over things that make no sense. So, I mean this all goes to me speaks to the importance of leadership and all of us doing our part and not waiting for someone else to do something. We all have a responsibility to act but I also think we have to nurture that creative part of our mind because we just can't keep working with the pieces that we have trying to put together in different ways. It's just not gonna work. We have to really have something transformative that solves this issue. I think from where I sit the hardest part is everybody's well-meaning and trying to do a lot of good and we're still falling short and that's hard. We all get into these professions to make a difference. So I'm giving more of a benefit of a doubt to all of our colleagues, right? I think one of the things we are doing now with our universities at Shady Grove is to do multidisciplinary practicum training. It's like six weeks in the summer and we take about 16 to 20 students and we run them through pharmacy and social work and criminal justice and nursing and public health counselors, social work in an attempt and then we have them experience the county and its various aspects and so when they graduate or they come out they've got sort of more of this interdisciplinary feel. I think we do ourselves a great injustice by staying in our silos and in our lane. Families are messy and issues are messy and they need all of us to work together but I also think it's wrong for a vulnerable person or a client, a consumer language you use to carry a rolodex full of nurses and social workers and therapists that they have to interact with it's incumbent upon us to figure that out that should not be their burden and they should not have to tell their story over and over again, it's demeaning and that's why we have technology that can make all of that possible and so I think as professionals there is a place where we can go as systems to make improvements. Can I just say you also maybe think about was regulatory relief we have a system right now in some places in the country if you come in to care it's a 40 page intake interview that you have to go through that could take several hours and you have to tell very intimate things about yourself to somebody you've never met before and I always want to what end other than satisfying some requirement by a state that's information that's not used in any meaningful way to inform care so why are we making people do this? We've talked a little bit about this multi-sectoral partnerships when folks are in crisis and when they are in need of collaboration from those entities but I wanted to ask about this notion of prevention and the work with multiple partners different sectors we've heard schools I think mentioned WIC or TANF sites can you talk a little bit about the view of this sort of multi-sectoral prevention approach? So I'll start I think when you think we serve on an average about 97,000 to 100,000 households a year on an average our clients are using more than two services TANF and SNAP Domestic Violence and Homelessness Mental Health, Early Childhood Aging Service they're more than two services and that tells us that any one issue just responding to one presenting issue isn't going to get to a better alleviating the presenting issues so you have to collaborate you have to build partnerships our general we have an integrated practice model we find that housing tends to often be the common denominator and there are other issues always that destabilize the housing but if you could address the housing then you can start to make inroads into the other issues whether someone is re-entering the community from a prison system or whether they are in a shelter can we prevent homelessness from occurring and if not can we get them into housing quickly having said that then you need to make sure that people have money for food if they're worried about it's a massless hierarchy if they're worried about their basic human needs they're not going to pay attention to getting well whatever that well is and now if you were to do the prevention argument you'd say let's respond to these issues early if someone's coming for food stamps what are the needs do they have and wrap it around so that it is in three months later that the case worker hears that there's domestic violence possible risk of homelessness or there's depression in the family ask those questions up front and so to the degree that we're building a good so then we get into the prevention mode but we aren't paying attention to this promotion which is the education campaigns and the outreach and the many ways in which we've talked today that we're building voices heard and I think all of that then you have to sequence it and thread it in a way that makes sense I mean I'll just underline the point about accountability for outcomes if we can agree on the ultimate outcome that's really where you see merging of the multi-sectors they're all driving towards healthy communities that are safe where there is economic thriving where people are part of being connected these are the hallmarks of a healthy society and having often times multi-sectoral efforts fail because people are responding to the outcomes that they're held accountable for and there are all these barriers to collaboration that come about at the federal level certainly that's the case but even at the local level we see that so I think people accountable to pushing towards these multi-sector approaches it's hard work but I have a degree of impatience around accepting it the way it is I think that we need to stop accepting that it's hard it is hard but that doesn't mean that we can't find a way around it if we can get people activated motivated and engaged in agreeing on the shared outcomes and moving in that direction together simultaneously because you have pockets of programs and the person at the top doesn't even know they have a program for that all of that is where innovation and using information in a smarter way can help you to build efficiency so some people are happy with efficiency and you can do the right thing to give people what they need so everyone can have their values really strengthened by that approach I think the other opportunity that all this kind of approach presents is to normalize efficiency treatment I'm thinking about one of our members in Denver Colorado that when they were conceptualizing building a new center to deal with children and families that they brought in multi-sectorial partners but they also have a hydroponic farm and they're able to offer low cost food to that community and to they working with housing provider to help bring housing and this idea that first community didn't want this facility there and now like other parts of Denver are saying we build one of these in our neighborhood and then also mental health and addiction treatment is available there so they're also able to kind of meet people where they are respond to community needs but also normalize treatment so I think there's some other opportunities here so let me ask this question about meeting the needs of folks from diverse cultures as well we heard a little bit about Montgomery County and the diversity of the population you're working with how do you as systems as providers think about meeting the needs of the diverse populations that you might be working with and how do we improve that I think what gets measured gets treasured I speak to a lot of provider groups I always ask them how many of you have heard of the national standards and culturally and linguistically appropriate services and like a third of the room will raise their hand now if you talk to administrators they all know because they're checking some box off that they're doing it but how is there this huge gap so I think that having what is the measure that you're aiming for having it be integrated to me it all fits together trauma informed care you can't do that unless it's culturally centered integrated care no matter who you have is positive they're not going to engage the services so I think that they're threads of the same quilt and we need to also within ourselves stop being in our own silos like I'm trauma informed okay I'm integrated care okay I'm cultural care it's all the same thing so we need to start speaking together translating within our group of behavioral health so that we can be that one voice speaking externally to the people that are in charge and have never seen a person with a psychotic illness in recovery that they did wow you know that there are a lot of people that are making very important decisions that are still at that level of is recovery possible a lot quite a number of people that I've interacted with and I I'm not even I don't even get around that much it's scary wow that is I love Glenda's phrase what gets measured is treasured and I think one of the problems we have in behavioral health is we have way too many outcome measures that people are using and there's no standardization so from state to state county to county everyone is doing their own thing and we can't tell any kind of story or have no picture about what's actually happening because of that so I'm all for parsimonious approach to standardize measurement across the systems states so that we actually can improve care but right now we have the tower babble so in our county we have these we've got these entities called minority health initiatives and programs and they are responsive to the Latino community the Asian American the African American and the continental African and and Middle Eastern communities and you know it's the peer it's the peer recovery and the community health worker model that's going to get us there right so people don't trust large systems to care for them and as it is there's such a stigma and taboo around some of these immigrant communities around mental health and what it's going to mean for them very personally in terms of their marriage you know could they stay in it will they get kicked out will they be defenseless you know so many issues and so it is really that community health worker model I wish we would build it out more last year two years ago Ms. Siemens actually said that Medicaid would pay for the community health worker model but there's not standardization around you know certification what skills what competencies how did they get paid so there's a ton of work that we that we could easily do I think to get us there but we have to acknowledge that these communities don't trust easily and they're not going to come out there and say give me services and so I think the bar is much higher there there aren't enough bilingual therapists and social workers and psychiatrists and whether it's you know in medical practice and or behavioral health practice and so I think there's a lot of work to be done and significant mistrust thank you so I want to open it up for questions from the audience if folks have any go right ahead hi everybody Debbie Plotnick mental health America thank you couldn't agree more with everything that you've said that what we're looking at is the system where even when folks have private insurance they're kicked into the public systems and you talked about I really appreciate the infighting between the guilds if you will that's a real problem and I'm I'm noticing another issue that I'd like to hear you comment on and that is even within the provider systems and Chuck is right there are many of them we see the line items fighting with each other for example we see that we're not going to pay for a particular medication a particular therapy a particular kind of support and this happens both in the public and the private systems how we're siloed even within our silos it's true I mean I think that there's a big issue with the attempts to contain costs right and so until we reconcile the value of inputs and what works for whom when in which quantity and have standardized ways of answering that question we'll continue to face because of disparity and attention that mental health conditions are given compared to other health conditions of comparable magnitude we're always having to push back against that disparity in attention but but we do know what works so we do know that there is such a thing as evidence based practice that does improve outcomes and I think we need a stronger support from innovators and early adopters whether that's a state or insurer whoever wants to be the lab that's coming out of CMS but then after that after you've demonstrated you can't just keep doing that you have to find a way to get the early majority and that's now our usual care and there's a lot of places within models of care where we have over a hundred studies of what works but somehow the regulatory environment doesn't promote that or require that as the standard of care and I think we really have to fix that oh no no next question I'm Susanna Gopalin from congressional research service it's a question for Chuck the certified community behavioral health clinic demonstration such an interesting collaboration between CMS and SAMHSA that's occurred and if I understand correctly it's just a few months since the demo went live so I was curious it seemed like a very compressed timeline both for the states to figure out how to pay and certify these providers and for the providers to deliver this wide scope of services and I was wondering what are some of the themes that have come out in the eight states from these first few months and does it based on this little bit of experience seem to you that this two-year demo will produce perhaps a platform for wider system change in the way these services are covered in Medicaid again I wish we were eight months in right so most states actually didn't implement until June or July of this year so we're actually much sooner in and most of the clinics right now have just been hiring staff there are some new requirements around being able to provide addiction treatment so they've had to hire a lot of addiction treatment providers and rethink their systems about how to incorporate that so I think right now we're still on the early day of the meeting today Nashville of about 50 of these clinics getting together and talk so maybe by the end of the week I'll be able to answer your question more and you're also she played a huge role she was our attorney working on the early days of fighting with CMS over some of the regs so thank you Hi there I was hoping you guys could comment on the possibility and how we can prepare for population health and the sort of specific problem was that conference once this guy stood up and say like okay say I'm a primary care provider I'm fully capitated I have a tributed population I'm being paid based on outcomes what do I literally do when I get to work the next day but I think it's sort of the problem we have where it's like we're all and it's easier on a specialty care right because like people are presenting for to you with a specific issue and you know you're sort of supposed to be managing the set of issues but you just have like a blue sky population out in the world and you can you have the reimbursement and the flexibility to do what it is how do we in the room prepare people to be successful in that endeavor well I don't know if I have a I don't know if I have an answer for you but I think the biggest problem is attribution and I don't know that it's any simpler in specialty care than it is in primary care because I think specifically about our members and Medicaid and people have freedom of choice you know it's not so simple that you know you have total response you can claim total responsibility for this person because they have a lot of freedom and where they seek care but even you know kind of lower hanging fruit in large health systems in hospitals that not everyone I mean you take things for granted right not everyone's looking at racial and ethnic data within their hospital system to see oh how are these guys doing so if you look at the whole population without looking at those nuances you'll think you're doing fine but you're not noticing the disparity within your population and the eyes go to the numbers the 10 percent of the population consuming 20 to 30 percent of the it's like too late once you let it get that far but if you intervene early you can prevent that group not that group right there but the other group that's waiting to take their place and I think those are the things we have to kind of balance the big dream of what we'd like with the actual reality of the missed opportunities that really persist in our systems not taking that one I'm Mark Dresk and I'm a primary care physician in Southern California you had mentioned something about what we could measure is what is favored and doctors like me will basically encounter large meetings where we're urged to do more for patients with behavioral health problems and we're told about depression and it's so important with depression it affects jobs and livelihood and the economy and so on and they don't mention anxiety disorders and it's strange for people at my level because it's almost one to one we'll see a pure depressive disorder a pure anxiety disorder and so what I'm wondering is do you and it's even at the reimbursement level that's what's so interesting is that I worked on a couple of projects that related to how well the depressive disorders were reimbursed and then the anxiety disorders almost not at all so I'm just wondering if it's with research and having this clear measuring stick of the PHQ-9 and being able to look at its effect on functionality and presenteeism and absenteeism is that one particular reason that might be or is it that the anxiety disorders just have all those different types of anxiety disorders but we tend to see depression as one thing so I'm just I wanted to ask about your perspective on that. Yeah I'm sure Chuck you have something to say about this but I mean you know people don't have one thing come on right I mean anyone that actually sees patients it's a rarity that you're only going to get one thing and I personally struggle with this because of my you know background and looking at trauma work and PTSD and resilience like you know all the patients that are not recognizing PTSD they've been picked up for depression you know there's a lot of symptom overlap so I struggled with this myself but then I came around to say we're doing nothing you know so like can we start with depression you know as a starting point not an end point because I think we have to have multi-diagnostic tools and resources and primary care the list of things you have to screen for is more than anyone provider has time for so there's there's a lot of challenges with kind of thinking holistically about people and what might work well as like a population indicator it's probably a good indicator of the overall quality of behavioral healthcare how you're doing on that depression screening metric that depression remission and response metric so I think you just have to balance the trade-offs with what you measure and hopefully new ways of measuring can make it easier because you can engage patients in self-assessment and just push the data to your provider that would be way favorable right I know I completely understand what you're saying what sometimes happens even down road though is we have those collaborative care programs within our primary care if we teach them everything they need to know about depression but we haven't given them to skill the skills to help someone with anxiety disorder and someone comes through the door and their mood is actually doing pretty well we need to offer more so we've gone down that road too I completely understand what you're saying and I do agree with that but yeah so was there another comment that you had okay do you have a brief question I'm sorry I was talking to the gentleman behind you just to be sure we're getting ready for lunch so I want to make sure I don't stand too long between folks and food well that's why I'm here it's lunchtime I don't know it's not really a question it's kind of a question and comment but one of the things that Fresno State University Robert Wood Johnson fellow one of the things that I think it's important to recognize is that in many communities and I'll speak for my community Latino community is we already have systems of behavioral health or mental health in place the only issue is it's a disconnect from mainstream mental health care and I think that's important because how do we utilize what's already existing right we often see and I'll give you an example is that going back to training I think Glinda had mentioned that I think that's a big problem is that we are training you know for example social workers in my case these theoretical frameworks that are European and British so that's not the problem the problem is when you go out to the community and 80% are Latino and 20% are Hmong 5% African American there's a it just it's really difficult so how do we think outside the box and really begin to understand the role of culture the manifestations of mental distress and begin to create novel approaches to working with people of color I think that's our you know a huge step that we need to begin to look at so you know in the county though we've identified something called our equity initiative and it's exactly what Glinda was saying when you look overall Montgomery County is the healthiest county in the state of Maryland when you go underneath it and you start unpacking the data the outcomes for a minority population it's not as bad as the entire state but it's worse than that for the majority population and so we can rest on our laurels so we can say we're going to make efforts to close this disparity well if we're going to try to close this disparity it's wrong to assume that education stops when you get to a degree right so what is the workplace training capacity building around issues of identification of disparities disparity reduction working towards an equity frame and if we as a department we don't do budgeting decisions unless we ask what's the impact and we have an equity tool we've built and we apply that to our budgeting process and that's to say the entire system needs to respond it's not enough that our workforce is responding right it's not fully aligned and so the use of community health workers the class standard it's applying those to contracts but then here's what we don't do we apply the standards but we don't resource the contracts the contract value stayed the same for 10 years but we're expecting everybody to offer language access and to do culturally competent services well it's humanly impossible and so it's not a fair expectation to put on our contractors so we really have to think and we struggle with this right do we serve 100 people we say it's so cute to serve 80 people because we want you to take that money for the 20 people and apply it towards because there's no more money in this system so we want you to apply it to its culturally competent care and these are everyday decisions that we have to confront without any good I mean I don't have a good blueprint I'm just telling you that these are the kinds of things that we have to think through as we're operating and implementing a system of care that is under resource and it's cute it's not you know it's well meaning but it's not always responsive to the needs that are out there thank you thank you for the question so thank you for the panelists please help me give them a hand thank you all