Once again, I just want to reiterate what Debbie said and welcoming you all and if this is your first time We hope to get to meet you today and say hello formally. I think we're in store for a wonderful Talk, I've had the pleasure of visiting with our speaker this morning and Prior to her visit coming and she has such a wealth of knowledge We have so much to learn in this arena. So we're very very blessed and grateful For her joining us today, and so without further ado, let me introduce to you our speaker for today Dr. Karen Likens is the Director of Integrated Behavioral Health Partners where she specializes in system transformation and health behavioral health human service fields through strategic planning organizational development Evaluation and quality improvement Dr. Likens has led more than 70 research Evaluation technical assistance and strategic planning problem projects for federal agencies states foundations health plans and community-based organizations and clinics Dr. Likens works to develop strong strategic partnerships across the safety net Which enables community partners to overcome barriers to care coordination and achieve better clinical and cost outcomes Like I've walked into a room where I don't know anybody's which is always a little So I just want to take a little poll at the beginning here. How many of you are direct service providers? Okay, how many of you work in behavioral health? How many of you are primary care folks or on the medical side? How many of you have worked in integrated settings? Okay, so I'm actually speaking to experts Because as Mary up was saying I've been doing this work for a long time, but what I find is that Healthcare is local the hero all the local and every community has its own constellation Things that work and don't work. So what I'm going to try to do today is to share with you some best practices to share with you Share with you You know why we want to do integrated being rural health Different models best practices, and then I'm going to get a little bit into the issue of how do you know that you're making a difference? And I won't be spending a lot of time on that, you know, it's actually my favorite topic because I wasn't asked to talk about that But you know, I can't come into a setting and not talk about how do you know that you're making a difference? So that's why I just Detailed what I'm going to be talking to you about now in this country and actually Probably in most places around the world We have a problem of fragmentation And what we've done through in medicine and in our disciplines is we've actually separated the mind for the body And we don't really do a very good job of connecting them We also do the same thing with our systems. We have a clinical delivery system medicine We have different payment and financing streams that fund those different systems And then there are different expectations from the community regarding what providers are going to do and you know for those of you You know that there's a lot of stigma associated with behavioral health. And so that creates fragmentation as well And then we're training in education systems Trained people in disciplines. It's not Typical to get trained, you know, to work in a team trained to think you know Physician doesn't often get trained in behavioral health at least initially And so fragmentation is the problem and of course What fragmentation leads to? are ineffective strategies and And this slide will look all free to read but the The impact of fragmentation is that it actually produces bad outcomes and This pie chart on the left is showing you outcomes. These are the positive avoidable deaths in the United States 40% of unavoidable deaths are because of behavioral issues substance use smoking things like that Genetics also leads to that. Of course the environment intersects with genetics But you look at this in terms of health care And that's very small piece of the pie 10% so 10% of health care is Contributes to Our health is Affected by health care only about by about 10% Yet over here you see they'll be investing more money in health in medicine And that's not producing the biggest bang So part of what we want to do part of you know part of what? has been going on the last You know through Obamacare and and what's been happening at the federal level and also the state levels is of movement toward trying to Rejigger the system so that we are investing more in prevention. We're investing more in In integrated care, we're investing more in health homes and you know medical homes that kind of thing So there's a more holistic way of approaching health care so the idea here is that the solution would be integration and This is kind of a funny slide. I don't think it really works But the idea is to be able to wrap care around the patient The patient really needs to be at the center and this is person-centered care But this is also integrated care because you would have these different disciplines actually working together to support the needs of the patient Now what's missing here and you kind of see I've got social work What's missing here are all the community supports. It's all this work like you know What you do in the community as well the intersection with the criminal justice system with hospitals with churches and Schools, but they're shallow podiums, so that's why I'm So the idea Oh, sorry I'm causing my own problems. You didn't know that you were gonna be entertained by my scarf So Integrated behavioral health is a great strategy as I you know, this is like the big bang that I've been waiting to get to It's a great strategy for improving patient experience and also yielding better outcomes and there's a lot of evidence That shows that integrated care reduces stigma it increases access because of reduced stigma It also, you know is a very effective strategy for reaching vulnerable populations that typically are not going to You know have the means or the resources to be able to you know get to Behavioral health settings and so through primary care. That's a great avenue to get people, you know into the behavioral health services and in 2005 and the Institute of Medicine actually put out a report that said that Quality and quality in healthcare system are completely linked to integrated So what is Is that you probably have seen many different definitions and you may have your own definitions of what What I think is important in integrated behavioral health is that it's that intentional ongoing and committed Coordination and collaboration among all providers and the individual in treatment Bringing all of that together and you this is going to be a thing that you're going to hear from you because we can't do integrated care Without bringing the individual in It's also recognizing providers recognizing and appreciating the interdependence that they have with each other and the patient and client depositably impact health care outcomes and I emphasize the interdependence because You know in our society and this isn't necessarily a bad thing. It's just it becomes a challenge We tend to privilege the medical model. We tend to privilege medicine over other disciplines and Medicine is super important, but as you saw from that pie chart It's only contributing 10% to outcomes, but we're investing all of our resources there We need to realign things and so the idea here is to start thinking more Very differently and recognizing that there is interdependence Primary care physician can do his or her job so much better if they have other resources so that they Can actually attend to the physical health needs of the patient But if the patient is coming in presenting signs of depression They're not necessarily the best Person to be dealing with that and it's it works out so much better when they have somebody else that they can share the care with That was part of as part of this presentation. I'm supposed to be talking with you all about models and When Mary Beth had her and Debbie had first reached out to me and said you do this presentation today We want to hear about best practice models and what works and all that I realized that You know, that's not so easy because there are many different models, but As I said at the beginning all health care is local And so you can't just take a model off the shelf and stick it in, you know, there's no perfect recipe So the way that I'm going to talk about this today And for those of you who know that Myers-Briggs, I'm an INFP. So I'm kind of a big concept Person, so I'm not going to be talking so much at that level of the STJ You know, here's you here's the you know More of a linear way to go about this or that sort of thing I'm really going to be giving you kind of the big picture So if you can just bear with me, we've got three basic structures for ingrained care The first one is up there. It's the referral. So in that model, you would have behavioral health and Medical, so primary care by bi-directional referrals, so maybe somebody's presenting in a behavioral health clinic and they haven't seen a physician in years and you know We know that that population of the seriously mentally ill tended to die 25 years earlier than the average population So the idea here is that they would be able to be referred over to medicine and then the Congress The problem with that model is that often communication breaks down.  The second model is co-location Second model co-location That is a gold standard for a lot of people. It's a really wonderful way to think about it. It's where you have Primary care embedded with behavioral health or vice versa the problem with co-location is if you have No connection you know where you don't have shared Care plans where you don't have shared Electronic health records that sort of thing where you're you know, you can you can be co-located and still not be integrated Now over here with coordination and partnership. It's just a different version of these two Because it could be you know, these could be organizations that could also be within a clinic And the reason that I have a hard wire around that is that a lot of times what you see in these models There is there is intentional coordination and you know, we're gonna partner and we've got our ammo used and we're all happy and Then all of a sudden you started hearing about HIPAA and 42 CFR and oh my gosh, we can't possibly you know I can't share my notes with you, you know I'm gonna tell you no knock knock Can't tell you So This is another way to think about this This is just I just wanted to include this because really what we're talking about Are providers so in this first model, this is where you embed the amount of substance use Provider in primary care and services are in primary care and I know that that's kind of the model that you all have here It's great model over here is Really looking more on that For the seriously Mellie L population typically they are going to a behavioral health clinic and so it's bringing me The primary care into that environment or having some intentional coordination across organizations And I showed you that just because I think it's important to have us remember that there are people And we're talking about we're talking about patients, but we're also talking about providers How many of you are familiar with the fourth quadrant model? So the third quadrant model is actually This is a good way to think Remember I'm an INFP. So it's big picture if you think about a hundred percent of your population In this community at any given time Butter one there are gonna be people who have low behavioral health needs and low physical health needs Clutter to High-behavioral health needs low physical health needs butter in three Low behavioral health high physical health and plodering for high hot Now the reason that we want to think about that is when you're doing your playing when you're thinking about capacity Or behavioral health services and you know what you need to have in a primary care setting for example This is your population Usually, you know low Behavioral health low physical people coming in routinely for their exams that kind of thing Potter three is also your population You have people with high physical health needs that they don't really have you know that many behavioral health needs Up here quadrant two and quadrant four That's actually where we start seeing the need for true integration because in a primary care setting You really do need to have Being a real health providers to be able to address the needs of that population and the reality is that a lot of people In your in a primary in a typical FQHC or primary care clinic Actually are up there, you know people who have diabetes who also have depression things like that and That's really that becomes part of the rationale and really an important way to understand your population and to think about Population to say do we have the right mix of staff are we are there issues that we're not able to address? It doesn't mean that you need to necessarily be able to address everything in house But you need to be able to have the relationships in the community for referrals and that sort of thing and You know, I think it's at this point. I just want to remind everybody that According to the National Comorbidity Study yet study There's an estimated 29% of adults with medical conditions like diabetes who also have behavioral health conditions So it's a third of your population almost that has you know one chronic condition If they have one chronic condition, they're likely to have a behavioral health need This is way too small to To see in this it's even worse, but I wanted to include this And I can actually make the Citation available to you all this is from the substance abuse and all services administration and This is showing the spectrum of integrated behavioral health care and the idea here is that there's a developmental continuum of Integrated models so on the left-hand side we have It's coordinated and the key element there is communication and What you have there is kind of level one and level two are minimal and then increasing collaboration, you know across that would really be across organizations and then in this middle section, that's the co-location piece where you have Physical proximity, that's like a driving component of that so there's communication. There's also the physical proximity and Then on the far right we have the different levels that are associated with true integration and really the There are two key elements there the first is That there really is a differentiator the first is that their practice is really transformed the way that people Deliver services is changed So you have a scenario where you would have a primary care physician doing a warm handoff to a behavioral health clinician That's something that is very different Then what you would typically see, you know, this just where you have the co-location The second piece and this really is the differentiator across the board is the increased communication is the frequency of communication so on this far right side There's there is a far greater Frequency of communication between the primary care and behavioral providers. I forgot to mention if any of you have questions I don't mind being interrupted So I said before that I can't give you the Recipe for you know perfect integration and there is no perfect model But what we know from the research and what we know from you know The evidence-based out there and best practice models is that there are some core functions that are very much associated effectiveness and in fact there are eight of them That's what these are organizational mission and culture population health management a team approach patient and family education and engagement staff competencies that are beyond usual care Universal screening for the most prevalent behavioral health conditions Integrated treatment planning and the systematic use of evidence-based practices. I'm going to go through each of these So just you know, just keep in mind these are kind of the across all the studies You know the different models and that sort of thing these have been identified as Really the key functions the key elements that ideally would be present in whatever you're implementing So the first one and I was saying Mary that's earlier in a lot of ways I think that this is one of the most important I don't think you can have integration if you don't have an organizational mission and culture that supports Integration and it's really hard to measure and people don't typically measure it. Well actually it's not that hard to measure I mean things like you know Is it in your mission statement that you want to be holistic or you know Do you actually incentivize providers to to play nicely together and you know provide integrated care? Do you have shared care? shared like shared care plan or Accessible medical records that kind of thing So those are indicators of it, but we tend to forget it and it's You know so the idea here is that it's partly the mission that leadership actively supports it and promotes it across the Organizational functions, so there's that expectation and Then there's also In some of the best programs that I've seen and this gets to my comment earlier about the primacy of the medical model In the organizational structure of clinics where that are truly integrated and where the Commitment to integration is sustained. There's equal leadership. So you have a medical director But you know the behavioral health director that sits on the leadership team and it's part of decision-making you know making helping to make decisions about what fields are going to go into the The health information system, you know that sort of thing and then there's also this concept of the parity between the medical and the behavioral health providers on the team that their dependence that recognition that everybody has a has a role everybody is contributing to the health and good outcomes of patients the next component is population health management and This is you know something that increasingly I'm sure you've been hearing about it because it's been very much part of the ACA and the You know the broader work nationally and recognizing that we need to think Beyond one patient one patient one patient and get more into the mode of thinking in terms of population and In this case typically what you're talking about are you know, it's recognizing and I know that you have a grant Here we have a grant where you're targeting individuals with diabetes and depression and so that's you know, it's coming up with An intentional way of managing that population where you can demonstrate that you know through the integrated care You're improving your outcomes Typically with population health management You use registries so you can keep track of people and the registries Will have flags in them reminding people about appointments and you know They have lots of different functions, but then the registries also will allow you to be able to measure and look You know track outcomes over time team approach now this is this is truly the hallmark of Strong integrated model. It's where we're healthcare. We're you know, it's not a scenario where you have the primary care physician Making a referral out to behavioral health. It's where you actually have the providers working intentionally as a team and there's strong communication collaboration and coordination between those providers and recognizing that That sometimes in order to achieve you know the health outcomes that you want for somebody with diabetes Their depression needs to be taken care of like that's that's really the issue of you know, why they're not The outcomes are not Improving then there's the issues that competencies and this is tricky because If you think back to my earlier slides where I had education out there and training in our schools and our You know schools and professional schools. We don't typically train people to work in teams People learn this on the job How many of you in school learned how to work on a team? Excellent. Are you gerontologists, geriatrics or anything like that? Because that's that's one discipline where you know a lot of times there's recognition that you work on and disciplinary teams will be disciplinary teams But the you know, this is this becomes a challenge and so When you are hiring when you are engaging new staff in these types of services you really need to be aware that That You have to be aware of the blinders that they may have or the resistance that they may have coming into an environment because they're They've been trained to do something differently. So for example with behavioral health a lot of times behavioral health providers Have been brought up in a modality where they see somebody for 50 minutes 50 minute session Well, I've integrated here a lot of times you need to have refer sessions, you know, you might be seeing somebody for 15 minutes It depends on you know, how you set up your model There's also that issue of can somebody be interrupted because you know if you have two providers to be real health providers and a primary care Physician finds at has a has a client right there who could Could benefit from a warm handoff Can they interrupt the behavioral health provider who might be seeing somebody just to you know kind of say hello and say Okay, you know, I'm gonna make a point So this is where you know the the idea of staff competencies and workforce competencies Has to expand beyond what we would typically have in our expectations for any Discipline, you know, you're looking at Competencies that are related to the living of the work together and also being able to leverage across the team. There's that whole issue of being able to work to the top of your licensure and Ideally what you want is to be able to push down Certain work to other providers so that you know the physician can be freed up to do the Physical health medical care that's billable and then other providers can be Engaged to do work that's also billable, you know within their within their discipline so then there's universal screening for the most prevalent health and the overall conditions and This is actually related to the triple A how many of you know the triple A Okay, that's where we want to reduce costs By improving patient and provider experience and also improving population health It's related to what I was talking about earlier around the population health piece but the idea here is that In order to do that we need to screen we need to know what these conditions are and then they need to be able to be address and The best way to do that is to regularly and your universally screen for substance use disorders and different behavioral health conditions that present in primary care that really lead to very costly if they are not addressed they lead to costly outcomes like hospitalizations emergency department And then the idea here too is that the screening results are addressed in treatment plan So just because you've screened. I mean I've seen lots of clinics where They screen for substance use I'm sure that my scarf looks beautiful right now We're just going for substance use but those results don't make it into the chart They're like on the face sheet But they're not there so when the patient goes to see the primary care physician How would they ever know that they're you know, but they're drinking 20 glasses of wine a week or you know, whatever so it's a you know, that's that's part of the secret sauce with the With the integration and then there's a great treatment planning. I've been alluding to this as I've been talking it's this idea that every patient has a single integrated plan and ideally the patient has been part of making that plan setting goals and You know participating in it and that's a little weird on the medical side. It's not often that you involve It's not common practice to involve patients in you know, it's especially diagnosis that you're doing But the idea here is that you really have to think it think about the Individual the patient in a much more holistic way and be very clear about their context So if you have a homeless patient who comes in for services and you're making a prescription of You make a prescription that has to be Refrigerated they may not be able to do anything with that, you know, they may not have a refrigerator So it's really understanding of that broader context And you'd like to commercial So it's all this making sense and then finally this is actually Are you familiar with the meadows mental health policy Institute? Here in Texas so meadows has actually identified this as an increasingly important component this concept of systematic use of evidence And what I think is interesting is the way that they framed it they talk about it at two levels The first is evidence-based practices. So that would be things like the impact model and the collaborative care model Which I'm going to talk about in a minute But then they also talk about it at another level which are practices or techniques that are used in the models So that would be things like motivational interviewing cognitive behavioral therapy Those are all You know practices models Strategies that have evidence they have an evidence base. They're supported in the literature and by using evidence-based practices You know, you can Be more guaranteed that you're gonna have better patient out People are actually doing the practices the way that they are supposed to so just to review Before I move into a little bit more detail on things the key features of successful models and You know, I just gave you those core components which are really important But this is another way to kind of think about it is communication and it's having the word handoffs versus referrals because people You know honestly people do better when they have a more clear connection and get engaged in services The second is shifting in the scope making a shift in the scope of practice and and the approach to practice and That would be something like using a consulting psychiatrist Instead of expecting the psychiatrist to have a case load Extend their scope of practice that way Coordination and this is where you know having the primary care Physician be the prescriber instead of having two prescribers or having some you know intentional Collaboration between you know a psychiatrist or something like that in the PCP. That's an important component Engaging and engagement and activation you know when we think about recovery and when we think about the need for self-management skills engagement and activation are really critical components of effective Care and that's both on the the health side and it's also on the behavioral health side and when you bring the two together It's pretty important and then the final piece You know as I was mentioning before is the data-driven care if you're not measuring outcomes along the way You never know if you're really making a difference and I think that you know When I say this to To an audience with more of a medical background That seems like you know kind of a no-brainer because there's a lot of measurement that happens in medicine You have tests you have all these different things you can see if people get better in behavioral health culturally We haven't really done that much measurement, you know, it's kind of a new thing and It's really important as it turns out and you know, it's not that it's That that folks in behavioral health You know don't think that it's important. It's just it has not been really part of our culture to track outcomes And so that becomes You know one of the hurdles for integration So now I'm going to talk about the impact model. How many of you are familiar with this? Hey, excellent, and this is just I I'm Going I'm going to go into a little bit of detail on this because it helps illustrate what I'm talking about. This is a a model that was developed by Jurgen Initser at the University of Washington group Health Cooperative and it's associated very closely with with the collaborative care model and the thing about impact is that Jurgen's been developing it now for at least 20 years and it's been very well researched it's been implemented in any settings it started off as a target the elderly and depression and now it's been You know tested with many other populations and it's been shown to be very effective and in fact In it has been shown to double the effectiveness of usual care when it's done to To fidelity so it's pretty important in terms of being able to lower health care costs because it's very predictable And there are five key components to it There's communication Oops There are the five key components ladder in here you have a professional care manager Psychiatrists there's outcome management and there's that care So there's an expectation that people are going to get better. I mean, this is another kind of challenge in the context of the behavioral health We have effective strategies and You know people do get better, but there are disincentives within our system, especially for the seriously down the hill where People don't have a disability and there's not you know the system has kind of the perverse incentives to keep people You know there and there's not an expectation of recovery and improvement and so That's just a It's a challenge that's out there It's like a kind of a mental model that's out there that we can break down through integration and And I just know what you all kind of be aware of that and to hold on to that So in terms of the first component, this is Collaborative care and the idea here is that you have three main players on an impact team You have the primary care physician You have the care manager and then you have consulting psychiatrist, and then you often will have other Providers that articulate with the team, but these folks have you know the primary responsibility working together They're kind of a triumvirate and The idea here is that the primary care provider does the referrals and works with the care manager to develop the treatment plan And to implement the treatment plan and to do the prescriptions The and then there's also an assumption here that the patient or the client Has an active role as well because they would they would have a role in saying you know Yes, I want to take any depressants or no, I don't want to I want to try you know doing the talk therapy or you know so there's some agency in there and then both the care the care manager and the primary care provider consult with the psychiatrist and this in this context particularly if The treatment is not improving So the second piece here is the depression care manager and what I think is really important to note And this gets back to that kind of overarching piece of gift. I'm sorry. I had a quick question going back to that that slide prior to the So for that collaborative care that key component number one It's the primary care provider and like I guess a care manager So is more the same height is the psychiatrist not really are they just kind of consulting if there's no improvement So they're not really giving direct care to that They might be seeing they might be seeing the client but not as a major player, right? Like the PCP would be the one providing exactly the idea is to be able to leverage the psychiatrist time To be consulting and to be you know Supported to both the primary care physician on the prescribing side of things and then also with the care manager just in terms of you know advice on behaviors and that sort of thing so the in terms of workforce competencies this this first piece of with the Impression care manager what is really interesting about the impact model and this goes back to my point about all health care is local This has been tested in so many different places and so many ways that you know if you ask you're in what's who has to be the depression care manager, he would say will attend and You know they've tested it with nurses psychologists social workers license counselors, you know a variety of people This is where You know it depends on the reimbursement environment it depends on You know what the skill set is of the individual in terms of being able to do the care management for the population The roles of the care manager Educates the patient about depression Supports antidepressant therapies prescribed by the patient's primary care provider if it's appropriate that would really be more the nurse But it could also be the psychologist Coaches patients in behavioral activation and Pleasant events at scheduling Offers a brief six to eight session course of counseling such as problem-solving therapy Therapy that sort of thing Monitor suppression symptoms for treatment response. So it's measurement using PHQ nine at regular intervals to see if somebody getting better Complaints a big action plan with each patient was improved So as improvement is happening then you start talking about, you know, well, how are we gonna prove? prevent relapse and and that's very That's a very intentional step in this in this model and the typical case load is pretty high at 100 to 150 patients, but that's because you know, it is it is a very Targeted and Strategy where you have the primary care physician working with the care manager with the support from the psychiatrists and There are some similar roles like you can have the embedded behavioral health specialist the other behavioral health consultant I mean, they're these functions It's a function that's being provided as opposed to, you know, a specific You know position So it makes sense And this is in a primary care setting So the final three components The designated psychiatrist Consults to the care manager and the PCP on the care of patients who don't respond to treatments as expected so this also, you know gets into that whole art of You know being being aware of what expectations are you have your goal setting But you also are measuring so you can triangulate this information and you can find out, you know Is what we're doing for your depression working? Well, why not? You know, maybe maybe it's the the medication isn't working or maybe, you know, we need a different kind of conversation in our therapy sessions the fourth PCR is the outcome measurement as I have mentioned a couple of times and what you do is you measure very regular intervals throughout the course of treatment and Typically the PHQ 9 is used but there are other measures that people use You know, it's whatever works and whatever people are used to I mean I what I typically say when people say, you know, what's the best tool? I say what's the what's the tool that you're going to use and you're actually going to use it on in a routine manner because half the battle is actually doing the measurement and Then the final piece is this the set here and this is where you adjust treatment based on clinical outcomes and according to an evidence-based algorithm and You're aiming for 50% reduction in symptoms within 12 weeks And if the patient doesn't improve within that period of time, then you change the course of treatment another way that people talk about this is treat to target and Again on the medical side, this isn't so unusual But in behavioral health this concept is, you know, it's new. It's not it's not as routine. So Just kind of bring it all together and this is the this is you know the impact team yet the impact team identifies and tracks the prescriptions they're doing peace finding in a you know in a clinic and they Do the screening and referral and then in front of the diagnosis. They're proactive follow-up and tracking and Then the next piece is really that focus on the self-management because again If you think about that first slide in this model the patient is really part of the care team And so there you have education and a brief therapy to activate the patient and Then the supports for additional treatment include primary care That's the antipressant medications and especially mental health care and psychotherapy That's if you know if the person is not responding if the patient's not responding to what you're doing It may well be that they need more intensive services That wouldn't necessarily happen in the context of primary care unless you have a capacity This would be a scenario where you would do the referral out And then finally use mental health consultation for difficult cases and this is where again where you would bring in the psychiatrists for consultation There's also caseload supervision that happens here in consultation for the care managers Just you know, I mean I'm kind of widely saying oh this works. Okay. I mean it does work. It works really well but it requires a lot of attention and You get really great outcomes, but You know this is an evidence-based practice so I've given you a lot of information and You know as you're trying to think about like how do you want to? improve extend Scale up your your focus on integration and your integrated services You know I've given you a lot and That's kind of the camera that you ideally have would be like a super camera that does everything But you know who can carry that this is really what we use all the time for I mean who doesn't take pictures with their phone So One thing that I haven't talked about that is important in helping you focus and Think about you know, what are you trying to do? What are the problems that you're trying to solve with integration? it's this piece around partnerships and really being tuned into What are the problems that you're trying to solve in the community and I had asked Mary Mary that this earlier You know what are the problems that you're trying to solve? I mean that becomes like a key reason for thinking about you know How you're going to shape and grow your your efforts around integration because in this presentation? I've only been talking about integrated behavioral health and primary care. We haven't talked about social services We haven't talked about integration to the criminal justice system with schools with hospitals Those are all social services and the reality is that integrated care To be you know person-centered and to be responsive and to address, you know the whole needs of individuals There is a need to think beyond just that the clinic walls or what happens in the context of the clinic or just Across these two agencies It's really important to think more broadly about how you can do cross-sector team-based care and have a little coordination How you can have more coordinated and collaborative collaborative care across these sectors and and then finally, you know, it's that whole piece around thinking about the the screening and the evidence-based clinical practices that are You know that that could actually benefit and be extended beyond the walls of a clinic You know, how do you how do you take this into a school or how do you you know coordinate more intentionally with? hospitals as you're having care transitions How can that be more collaborative and you know? Help with the issue of readmissions I've mentioned a couple of times the the need to think about workforce here and That's actually a really serious issue You know, we've identified these new models. They've been tested but the They're really what we know and what policy the policies that are driving the uptake of these models It's really uphasing where we are with our workforce And so there is a lot of work that needs to happen and I mentioned this earlier. Most people get their training on the top We also have a scenario where you know, there are mental health provider shortages and that's not just I mean I'm sure that you haven't seen lots of nodding. It's national There are also You know the issue that I was mentioning before the distinct training in behavioral health versus medicine and Professional cultures and the treatment approaches that they come from that and then the last piece is this this issue where behavioral health providers are behind medical providers and their capacity to track treatment and You know the impact model is an example of how they can be changed But we just have to acknowledge that these are challenges and they're certainly not insurmountable, but This is where we have to think more creatively, you know, are there ways to use promotoras peer providers, you know, with different different Folks from different walks of life to build the functions that we were talking about earlier That's a couple more Challenges because I just think it's important to know what the challenges are and also recognize that they can be overcome One is the progress, you know, it's the progress in the practice transformation and the systems transformation that has been going on but There are a lot of issues with sustainability and spread, you know when you are doing programs that are supported through grants and Aren't necessarily Reimbursable, you know through a funding stream like Medicaid It can be challenging and so it's always important to kind of keep in mind The need to do the grant work because that allows for the innovation but then how are you going to pay for it when the grant ends and We're in a scenario right now. We're you know with We are we are going to have many changes as we know, you know with the new administration with the ACA and that kind of thing Nobody really knows exactly what's gonna happen But you know what I do believe is important to hold on to is the fact that it's gonna be pretty hard to go back From now we've created this body of evidence and a lot of people have gotten trained in these new ways of doing work That makes so much sense So I think that you know We have started to make the culture shift and now we just have to make sure that we have the reimbursement environment That can support that and that's why it's so important to be able to demonstrate your outcomes and Think about things like return on investment and think beyond return on investment within your fourth clinic walls Think about it in terms of you know, if you didn't have your program How many more people would be going to jail because of substance use issues or how many more people would be inappropriately using the emergency department So starting to we have to get creative about the way that we're being that we demonstrate value of our programs I do want to Acknowledge this piece which is the shipping from day collection for compliance to using data for accountability That's another issue for behavioral health providers You know most state programs They want to account widgets They're not really looking for Improvement or outcomes. It's how many units of service to be delivered and the same has been through on the medical side That's been changing more quickly But that's I think that that's so very much a value that has now, you know, it's out there I think we've all been starting to do it and that's going to be I hope You know at assuming that the ACA goes away. I'm hopeful that whatever it is replacing it Will continue to have that as a really important value Now I have this again another busy slide, but I wanted to just give you A framework to think about The fact that there are many assessment tools I mean if you ever are wondering wow, you know, how integrated are we, you know as a clinic or as a program There are assessment tools that you can use to figure out, you know, how do you know when you see it? How do you know integration when you see it and None of them are perfect I'd wait for the detail that's in this and I can provide a better version of this for you The detail in this I broke it up by the primary application, you know, when do you use it? What's it trying to do? so You know some of it is around readiness for integration some of it is for understanding your levels of integration assessment and Facility assessments that sort of thing the next the next row is on the structure and There I give you the count of how many items are in the instrument So some of them are very detailed like it has 65 items and over a hundred items compared to you know This one that has eight questions You know Sometimes less is more and sometimes it's not I mean it really depends on what's the question where you're trying to answer with it The third piece is the implementation approach and I've detailed, you know, how do you implement it? Many of them actually use the strategy of bringing different folks together in an organization to look at it recognizing that you know It's like the blind man on the elephant, you know, you can't get the whole without getting, you know, everybody's perspective There are some that are you know more of a more organizational self-assessment where one person could fill it out But if you ever do anything like this, I really encourage you to bring in more people The final piece is just getting a sense of the measure types So some of them are like her and yes, no questions. Some are using scales or decision trees But I wanted to I just wanted to make sure that you knew that there are ways to Kind of score your program and I don't mean that in a you know It's better or worse, but just kind of know where you are so that it helps with your strategy of moving forward and Recognizing that, you know, I mean on the individual level of patient level. We're talking about measurement And outcomes and that kind of thing But there are ways to kind of think about measurement and outcomes of the overall program By thinking about one of the characteristics that we have So this slide is really about lessons learned and you know, it's leveraging the tools for improvement and sustainability None of those models that I just showed you none of those tools are perfect and But and none of them have really been validated over time, but I still think that they're very useful Especially as you know, kind of getting a sense and having a bridgehead for conversations The other piece is that it's important to to define and document your model Like I was saying before I mean you want to know Is the model have we hit a stable place with our model or if this Social worker leaves is our model go to hell in a handbasket, you know things like that I mean that's that becomes another reason to do that and then it also gives you a way to talk about your model in a more structured kind of way and Then it's also important to define Your goals like I had said before, you know when you're when you're choosing a tool You really do have to step back and say well, what are what are we trying to accomplish with this integration piece? I mean, I know that you all have a focus on diabetes and depression and then you know my assumption is that There are many other behavioral health needs that have cropped up as they're not just Seen folks with diabetes and diabetes and depression So it's getting very clear on what are we trying to accomplish more broadly with Integrated behavioral health so this is This is just a reminder to us all The work that you do is essential and all of this is new and nobody really has the answers I mean, I've been doing I've been studying integration since the the mid 1990s But it keeps evolving and we keep learning more and more about it at that time. It was very much Thought that it was really, you know the clinical team that needed to be integrated as opposed to thinking about integration from the standpoint of organizational structures and You know what has been learned over time? Is much more about capacity and much more about these, you know, the importance of relationships and leadership and all those kinds of things But we're still learning and that again becomes part of your story and why it's so important to document it and be able to you know to create that narrative about what you're doing and how things have have improved or why things are different at this point You touch briefly on the importance of having shared electronic health records Integrated care. I've seen programs try to use Patient registry or disease registry for a similar purpose Could you say something about? whether that Registry should be an add-on or whether it actually can be used as a substitute for getting those records integrated Especially where there's more than one agency collaborating Yeah, yeah, that's a great question Do you want to hold the second question? That's a really great question because I was a little cavalier by saying oh, you know because that really is the ideal But we also have to be very clear that Organizations and systems have invested lots and lots and lots of money into legacy software systems and typically what you want to do is To the extent that you can extend them and use your duct tape or you know, whatever it is It's holding them together and the concept of interoperability Across these systems is very challenging. There are tools that Like registries that I've seen that are able to kind of help things meet in the middle There are also Cloud-based solutions where you know, especially for care management. I mean you're you're playing about the registries Can the registries be used? I would say yes and no it depends on the function of The functionality of what's contained in them. How easy is it to get the information out and To what extent can it really be used to support care? coordination care management typically in our You know electronic health records. We don't have something for care management might have notes or something like that But it's not information that you can really get out So it's I think that this is very evolving. I mean, I don't have a great answer for you on this I I think that you know it get it goes back to being very clear. What are you trying to do with this? My bias is that I think where we want to go with this is to make sure that the data that we're collecting the information That we're collecting actually is useful to the patient and is useful to the to all of the clinicians all the providers So that they can you know make decisions And then it's also really important from that broader standpoint from that population health standpoint to be able to then Look at the data in the aggregate and that is one of the big limitations with so many of our systems where you can look patient by patient but if I said 100% of your population what percentage have Diabetes depression who's getting better that becomes the function of the registry but that also can you know It can become a challenge for workflow. So that's that's a long way of saying it's very complicated There are solutions It's important to be very clear about what you're trying to do with it. So my second question I know that with IVH programs we often focus on the phq9 and depression And I'm just thinking about how anxiety is such so intertwined with depression and often comorbidity And I wonder are there IVH programs out there that are also tracking the GAD7 or something. Yes, and how common is that? That's in I do a lot of working in California, and that is at this point pretty common across the health centers to do both the GAD7 and to do The phq9, you know the tricky thing with the GAD7 or it really I mean anything beyond the phq9 There hasn't been great research to show Improvement whether whether these are whether these measures are really sensitive enough to show improvement and I Know providers who you know who swear by the GAD7 and say it's fine It's just that it hasn't been you know really tested in the literature, which is why you're not those indicators show up in some of the national standards and even state standards for outcomes So, you know, I would just invite you all to you know not be afraid I mean just because it's not on the NCQA list if there is a measure that you think can be Helpful for managing your population go ahead and use it Thank you I'm more on a macro level, and you see more success institutionally, you know like with accounting or organization or private insurance Well the caveat here is that I'm not from Texas and I don't know your system But what I've heard from Mary Beth this morning about The work that is being done here. It sounds like you have a lot of the right components And in fact you I mean my hunch is that you're doing it quite well. I think that some of the challenges are really making the business case of it and Taking it to scale so that more people can be served. I mean if you have you were carried out you were mentioning you have two New all providers. Yes embedded. I mean that's not a lot for a clinic that's seeing the number of lives That are being seen, you know when we I mean if we think about You know people that's just like that. I gave you earlier around You know 29% of the population that has chronic conditions has come word Feveral health issue that becomes a challenge In terms of the county piece Are you talking about like especially the animal health system right? like people Wondering, you know, there's probably cost You know, there's costs doing the model like this. It's challenging. So I was wondering is have you seen more success in institutional setting or with private insurance And I don't have a very like a super clear answer view on that because I would say it depends a little bit but Part of it is being clear about what are the reimbursement opportunities, you know, it's I mean if the goal is to move from Grants you have to think about what is reimbursable and under what conditions with Medicaid or Medicare and even private insurance, I mean understanding like what what private insurance will cover and then what behavioral health requirements Are going to match onto what what covers and what are the reporting expectations and that kind of thing So that definitely comes into play I think in the context of you know more of the institutional like we're thinking about county behavioral health services and that kind of thing The there are successes, but that's also, you know, and this is where I get a little harsh because I look at it in terms of People are dying 25 years earlier in that population and that's not okay, and that's been happening For a while. I mean it's been happening on the watch of our behavioral health county and state people and I have I have a lot of responsibility, you know in that space because yes, it's been fantastic We've had all these advances in psychotropic drugs and you know in the atypical anesthetics and that kind of thing the side effect profiles of those medications terrible and nobody really paid any attention and I've had too many conversations where you know where Counties realize oh my gosh, you know We didn't even we thought that this patient was doing great and then she dropped out at the age of 40 Because they were attending their you know their counseling sessions or you know that sort of thing But nobody was paying attention to the fact that the person had high blood pressure and diabetes and that kind of thing So I know didn't quite answer your question because I don't have a great Our clinic is on Frederick's Fourth Road and we serve adults who are severely mentally ill and about two years ago We integrated primary care. Yeah, and we've had great success our primary care services are of course Paid for by insurance is the clients have insurance, but also heavily supplemented by grants And so that's how we've had to get funding through that But we've got amazing success The way we get clients is often times referrals for high emergency care services and we've even seen their EMI indexes go down and We've seen really great successes And I don't know It's been really good in the county, but it is human far between and we are trying to access the most severe That's fantastic and that's the stuff of the right direction and now you know across the country We're seeing more migration bi-directional migration in that way and And it's very much in response because it does work. It's very much in response to this crisis and you know, Samza has been with this with the certified Community with CCBHC is certified Community behavioral health centers. I think they're you know, in fact, I think today they're announcing which states are going to be In the pilot for these and this is really moving. It's a movement toward making County behavioral health clinics more like FDHCs, which is really exciting. It should be a funding stream Yeah, another question You have not mentioned the cost Electronic health records integrating these with with paper health records I just read in the morning paper how the major cancer centers in Houston are having very difficult time with this and I'm only Extremely expensive with the physicians were taking a lot of their patient time just to learn the system So could you address that yeah? I mean, it's definitely an issue. I mean, there is a there is a Cost to transitioning the way that we keep records into the 21st century And there's no question about that and there have been federal funds that have financed a lot of that transition You know, but certainly not across. I mean there are still The example that you just gave I mean there's still many systems that are that are still using paper and it's You know, it's the best practice it has been you know demonstrated that you know the ideal scenario would be that you would have an electronic record and it certainly does facilitate information sharing and that kind of thing and the need to not have a physical facts or You know the filing in the medical records department that kind of thing But you know your point is really very well taken because it definitely is It's not insurmountable because there's the cost of purchasing the system And then there's also the just the level of effort that it takes on. Yeah. Yeah, absolutely but there are you know, I mean people have been doing it and You know there are It's a it is definitely a big hurdle But once the system has moved over, you know into the electronic space they Most people would say that the benefits our way the costs What I'm going to share the lead it was talking $40,000 a year just to keep the system going We have another question here and well actually it was a comment based off of Jennifer's I work with superior health plan the Medicaid provider and I work on the meeting on health site in about two years ago we started integration within the insurance company and so I think like she was saying there's such a positive outcome from that, you know We've noticed based off of our reports the decrease of hospitalizations the ER You know and what we found a lot of times It's just like you had shared earlier the lack of resources the lack of behavioral health providers You know a lot of paperwork and not enough time, you know San Antonio has a high homeless population and so we were able to work with one of the physicians there that Work, you know for physical health and we were able to help You know coordinate behavioral and physical because a lot of these members were going into the hospital but the integration I think here in San Antonio is definitely happening and So yeah, it's positive. It's such an amazing It's amazing how you can see how diabetes or liver issues can exacerbate Psychosis and behavioral health issues and being able to determine Hey, this is what can possibly be the root cause is really helpful to help the members become more successful That's great Another question and then we'll go to our final question over here And this relates to the measurement of the cost associated with or the benefit cost savings from the ER visits for the incarceration And so forth within a population initially He just talked about some of those ways in which you can correlate and track that but on a larger scale with for example Same incarceration in a community who doesn't you know many providers Trying to get our hands around how can we best measure that do you have an example you could share with us? I'm sure I think that The place to look for Evidence and for outcomes to measure and that I think would be the substance use literature I mean there have been many studies that have been you know done that are looking at the connection between substance use and Incarceration and that revolving forward and happens and that sort of thing and so the measurement You know comes down to being able to make those linkages. I mean pardon. This is another scenario where It's hard to track you have to do you actually have to do a lot of upfront work to say Okay, you know who's your population? This is my population. Where do we have any kind of overlap looking at history? But you know so There are indicators that you can track but there are Steps that need to be taken to To make that possible. It's the same kind of thing with the frequent users of the first two departments And it sounds like you all have that internal capacity Which is great when you have a health plan because you have the data on you know Who's using all the different systems and that's why the partnership piece becomes so important I mean 10 years ago I would never I didn't the health plan piece of it never even occurred to me and then all of a sudden and so I was working with lots of programs where you had a hospital and you had a community provider and a clinic and you know, we were jiggering all these things to get people to share data so that I could do the evaluation and look at the cost case and If you know it wasn't it was a lot of work and yes, you know We can demonstrate things but when you have the insurance company that really Creates it creates a big opportunity when you're talking about something like the criminal justice system, though You're talking about a completely different system. So Yeah, so that was a long way of not really giving you a great answer Except to say you can do it and you have to be intentional about it and it requires You know a desire to look for this and and then you know creating the relationships so that you can have that shared conversation and understanding what are the problems on the side of the criminal justice system that could be prevented by you know, the integration You know for substance use services I just wanted to mention that Methodist health care ministries is hosting integrated primary care behavioral health care networking group Wednesday, January 4th from 430 to 6 at our corporate offices 4507 medical drive in our board in our boardroom and everyone that it has an interest is invited It's open to doctors practitioners administrators whoever has an interest Thank you so much and thank you, Dr. Lightness, please let's go. I can shoot me here for a few minutes Additional questions or Thank you


The Bible says in latter time people will depart from the faith and the word that's used there is taste, pisteos, which is the faith. Why is that important? Because what it doesn't say is that people are going to depart from believing or they're going to depart from having faith. As a matter of fact, there is no such passage in the Bible that tells us that believers will stop believing. We don't have one. As a matter of fact, I challenge anyone who disagrees to find one passage where there's a person who stops believing. No, the Bible is clear and that's actually good news. In latter times, people will depart from the faith. In other words, what we know to be the truth, people will depart from that. And the reason why is because they'll be led away by these teachings of demons. So the good news is no one who is a true believer ever stops believing. They don't depart from believing, but people can depart from the faith, what we know is true.


What happens when you apologize to the narcissist? When you apologize to the narcissist They don't see you as being upright and upstanding They don't see you as being good or moral It doesn't make them admire or respect you They see your apology as a sign of weakness It causes them to lose more respect for you It makes them treat you even worse Because when you apologize to the narcissist You're just giving your power away to them and the narcissist will only use that power to abuse you They will only take advantage of it Whenever you give in to the narcissist They might appreciate it initially But then they will begin to treat you even worse They will have even less respect for you Which is why you cannot apologize to the narcissist Even if you did something wrong Stay in your frame Do not make excuses Just be honest about it and then if you want to You can try to make improvements in the future But you don't have to explain yourself Because if you do that You will only be digging yourself a hole You will be making the situation even more difficult Because when you apologize or try to explain yourself to the narcissist They will just see it as a sign of weakness And there's nothing they hate more than what they perceive to be weak people People who don't have a strength of character They may say that it's something they like or prefer But really they hate it Which is why you should never take a narcissist's advice Instead You should observe their behavior You should observe their actions You should observe what they do Because anything they say to you Is just a part of the manipulation Which is why you should watch what they do When you apologize They will just see it as a weakness They will just see it as something for them to exploit They might act as though they appreciate it But deep down they will resent you for it Because really They don't care if you're wrong or right They're only looking to see If you will stand your ground or not Because morally Narcissists don't care Narcissists lack morals and ethics That's something that only people with empathy will experience And it's not something that can be only reserved for whatever whoever they choose It affects every area of their lives If they have no empathy for you They have no empathy for anyone So morally The narcissist doesn't care if you're wrong or right They just want to see if you will collapse under pressure They want to see if you will give up your position to please them Which is something that you should never do When you are dealing with a narcissist Because it's a trap But when you stop apologizing to the narcissist They will start to treat you differently They may even have more respect for you Once you stop apologizing to them So many people who are with narcissists Are apologizing even when they're not wrong They apologize just for being alive Because narcissists will brainwash you into doing that If you let them There are enough people apologizing to the narcissist They are the victims in every situation that they encounter So stop apologizing to the narcissist Even if you did something wrong There are other ways to do that other than saying sorry Never apologize to the narcissist Because they will view it as a sign of weakness They will see it as something for them to exploit They will see it as you abandoning your reality In exchange for theirs Which is why you have to stop apologizing to the narcissist You have to stay in your frame And then you will demonstrate strength Then the narcissist will see That they can't pull you into their reality Which means that you will then be able To direct the course of events You will be able to steer the ship So that it goes in the direction that you prefer Rather than in a direction that is unfavorable for you Thank you for watching I hope this video resonates with you Please like, comment, share and subscribe If you would like to donate My PayPal link is in the video description Coaching inquiries You can email me at coaching at narksurvivor.uk Thank you for watching and I will talk to you soon


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Hey, John Crestani here. And in this video, I'm going to be showing you how to make $500 per day promoting evergreen webinar-based affiliate offers and funnels. Now, if you've been following marketing recently, you'll see there's all these webinars, right? All these webinars that are being promoted in the make money online space or the make money in anything space. And it's because they were. And in this video, I'm going to show you how to make money using or promoting these sorts of offers. I've made over 10 million dollars in the past three years with this sort of offer. And I'll show you how you can make a little bit of that money as well. Let's get into it. Hey, John Crestani here made over 10 million dollars the last three years promoting evergreen webinars. And if you do the never ending scroll on Facebook, you'll see a lot of people are promoting webinars. And it's because there's a lot of money in promoting webinars. 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