So, if you could turn to the person on your left and let them know if they have quinoa in their teeth, it would be a great service to all of us, right? Yes? Exactly. Okay. Just kidding. So if you haven't already, please go ahead and participate in the poll. We've got some interesting requests in terms of financing sustainability funding. There's a bit of a theme, silos, the Rubik's Cube policy generally. So, we'll give folks another second to go ahead and send in their thoughts. And in the meantime, I would like to go ahead and introduce our moderator for this session. Linda Rosenberg is president and CEO of the National Council for Behavioral Health. Under her leadership, the National Council has become the nation's largest mental health and addiction education and advocacy association with 2,900 government and not-for-profit member organizations serving 10 million Americans. The National Council helps secure passage of the federal parity law and the Comprehensive Addiction and Recovery Act, CARA. Advanced the integration of behavioral health and primary care leading to the creation of a Medicaid health home option, ensured passage of the Excellence in Mental Health Act, and introduced mental health first aid in the U.S., which we did hear a little bit about earlier, but thank you, I just attended a training myself. So, without further ado, Linda Rosenberg. I don't know if I should stand or sit, but I just want to congratulate Kaiser Permanente for really a great day. You know, I didn't come here expecting to be inspired. I expected to learn, but I actually will leave inspired. It was not a morning of complaining and whining. It was a morning of solutions of all kinds. And of course, I think you left the hard part for us. I see all that focus on funding and payment, which we haven't discussed, but we will. We have a panel of experts in that area that I hope will answer some of those questions or at least put some solutions on the table. I'm going to introduce all three of our esteemed panelists, and then I'm going to say a few words as each of them will. They're going to take five to seven minutes to talk about the three themes that either they think need to be underscored because they heard them this morning or they feel didn't get adequate attention and want to bring it to your attention. So we have Bradley Carlin, Dr. Carlin is Vice President and Chief of Mental Health and Aging at the Educational Development Center, EDC. They were actually here yesterday for the National Suicide Prevention Alliance. And again, Kaiser Permanente, a wonderful host with great food, by the way. Healthy and good, so that's always a bonus. He previously served as National Mental Health Director for Psychotherapy and Psycho Geriatrics for the VA, where he led the nation's largest dissemination of evidence-based psychological treatments. He's a fellow of the American Psychological Association and past president of the Society of Clinical Psychology. Our next panelist is Dr. Ron Mandescheid, a longtime colleague and friend. He is the Executive Director of the National Association of County Behavioral Health and Developmental Disability Directors, known as NACBID. He is also the CEO and the Executive Director of the National Association for Rural Mental Health, and he's also an adjunct professor at the Department of Mental Health Bloomberg School of Public Health, John Hopkins University. So he has a lot of jobs. He is a busy man, but he is also a very strong and inspiring thinker. Throughout his career, he's emphasized and promoted and was an early champion of the family and the consumer voice and needs to get credit for that. Dawn Hunter looks like she is an attorney by training, but we're not going to hold that against her. Actually, attorney and the whole issue of privacy is something we haven't touched on here, but is another important issue. She is a Deputy Cabinet Secretary for the New Mexico Department of Health. She has oversight of four program areas, including public health, epidemiology, the state laboratory, and licensing. Ms. Hunter is the former Policy Director and continues to oversee the policy office, including directing legislative activities for the agency. In her current role, she leads strategic planning and guides quality improvement and performance management. So without further ado, why don't we start and give us some comments. Good afternoon. All right, I guess we'll try that again. Good afternoon. Good afternoon. All right. Well, first, I want to say that I appreciate the opportunity to be speaking at this time, which is right about when your levels of dopamine and norepinephrine are at their lowest level of the day. So I will do my best to keep you engaged, speaking of engagement. And I also want to just acknowledge Cecilia, Rebecca, Samantha, and the team for such an incredible job and talking for them a few weeks leading up to this conference. And they just did an amazing job in actually a very short period of time. So maybe we could just give them a round of applause. We need entities like this that will actually rise above guilds and bring us together and have a conversation and provide leadership. I think if we had more of these types of events, we wouldn't have so many words up there. So with that said, I'm delighted to be speaking today. And of course, you know, we don't have too much to say, right? My understanding is that this panel goes until next Wednesday. Is that right? So hopefully we'll spark some ideas for conversation. So I lead work with public and private health care systems to improve mental health care delivery. And I have a particular focus on improving quality and strengthening the mental health care workforce. And more specifically, my passion is in implementation and systems change, including how to design and structure mental health care systems to maximize impact and improve the outcomes and experiences of mental health providers through competency-based training, systems change efforts, and also the experiences of patients. And I'm particularly interested in helping systems realize the potential and impact of evidence-based psychological treatments. I'll say a little bit more about that in a moment, as well as system changes to enable the delivery and sustainability of these treatments. So it's more than just training, and I'll talk more about that in a moment. Neither are sufficient both are necessary. So a few themes that certainly came out, I think, loud and clear to all of us today are things like community outreach and engagement, interdisciplinary identity and practice, broadening our conceptualization of the workforce. And I'd like to provide some reflection and perhaps words of urgency in terms of optimizing and more fully leveraging our mental health care workforce, which I think relates certainly to some of the themes that were mentioned throughout the day. First is improving mental health care quality by raising the treatment bar and more fully bringing to bear evidence into routine clinical practice, and systems really struggle with that. We have a quality problem in mental health care. And the gap between what we know works and is actually delivered is far greater, not only than research, but what we would see in almost any other area of health care delivery. So let's imagine, for example, you have diabetes and you walk into the office of your PCP or your endocrinologist, you can be assured that you would receive the first line grade A recommended treatment or at least be offered that for that condition, which of course is typically insulin. But let's say you have PTSD or another mental health care condition and you go either to your primary care provider or you do find your way to a mental health provider, the vagus odds on your receiving the grade A recommended treatment or anything probably close to that is quite low and the public isn't necessarily aware of that. You're likely to receive medication, maybe an antidepressant medication, maybe an anxiolytic perhaps, which for many conditions have very limited efficacy, at least as a monotherapy. At the same time, we know there are treatments that work, non-pharmacological treatments, evidence-based psychological treatments, often recommended at the highest level, but they're very rarely delivered on the clinical front lines and there as a result are considerable missed opportunities in mental health care, amazing missed opportunities in mental health care. We've not leveraged what these treatments have to offer and that's because of barriers at a number of levels. We've heard about the need for training, not just training, but competency-based training. We need to have systems that are structured, organized and contain a culture that's consistent with evidence-based treatment. It's not typically the case in most systems where treatment is usually tended to focus more on supportive or palliative type care in the VA where I had the privilege of working for quite some time before my current role. We led a national effort to realize the promise of these grade A treatments, these evidence-based psychological treatments that really helped to transform as part of a larger transformation process, a system like many systems that typically provided more palliative supportive care, so case management, medication management, maybe some supportive psychotherapy, but limited grade A treatment. And we saw that after training more than 11,000 providers of VA's continually doing, making systems changes, increasing the culture to an evidence-based treatment culture and having clinical infrastructures in place to support the delivery of those treatments that you can considerably move the needle and helping many, many veterans reclaim their lives. And there's opportunities in other systems as well. At the consumer level, and we heard a little bit about consumers and patients today, and I'm hoping that can be more of a focus of the mental health care community in the future. There's very limited awareness of these treatments. Mental health remains a black box. The term evidence-based means nothing to most individuals. The acronym CBT, ACT, IPT, et cetera, is word salad, is dizzying for most folks. So this, I think, is a failure of the mental health care community as a whole in marketing, if you will, treatments, especially non-pharmacological treatments. I will leave you with a question, and I have a few more comments, and that is, when's the last time you saw a commercial for psychotherapy? So we need to do a better job of promoting the pull as well as the push in getting treatments to the clinical front lines and getting individuals to actually seek out those treatments. We're doing work with VA now that we just launched through a soft launch online called treatmentworksforvets.org designed to promote the pull as we push these treatments out into the clinical front lines. There are many veterans who are not accessing these treatments because they don't know what they mean. They don't know how they're different from any other treatment. When you go for a sore throat, you're not told that there's an evidence-based treatment and a non-evidence-based treatment. Individuals typically expect they're going to receive the evidence-based treatment. So beyond taking a more intentional, planful approach to getting these treatments into the clinical front lines through systems change, training of providers, and also meeting patients where they are, systems... It's critical that systems also engage in developing strategic organization of staff and delivery processes. This is what I mean. First, moving away from a one-size-fits-all approach to mental health treatment, being more intentional, being more strategic, and being more individualized. So using low-intensity and early intervention approaches, like... Certainly mental health interventions and primary care, but even lower-level approaches when appropriate, as well as using peers. I'm so glad that there was a focus on peers today and peer support specialists. They have a lot to bring to the table. Meeting individuals where they are. Most clinical settings, that's not necessarily the case. It's not structured in a stepped-care fashion to be able to do that. And at the same time, there's also a need to ensure that providers are not functioning as generalists to a large extent. Most providers function... mental health providers function as generalists. So there isn't structures in place so that they are providing specific kinds of services for specific problems, which not only puts a lot on the shoulders of the providers, but it's not necessarily an efficient way of providing care. So being more structured and thoughtful. Third, to leave you off with some thoughts about thinking about clinical processes, and there was some discussion about this today, that precede the actual initiation of treatment. I think the mental health care sector is going to focus increasingly on concepts of treatment readiness, treatment engagement, getting individuals to a point where they're most likely to benefit from treatment and where treatment is likely to be most impactful. And this has been a critical area for VA where engaging veterans into care is particularly challenging. And so if you're interested in some of the resources that we've developed working with VA, they're in the public domain, we developed a brief treatment intervention called the shared decision-making session, which is a shared decision-making process for informing but also engaging veterans in care. It's a toolkit also available online at treatmentworksforvets.org, or you can contact me. But these kinds of areas of focus prior to beginning therapy or other treatment, which is typically how the first or second session begins, but actually having a conversation and a way to engage patients before treatment begins, is going to likely set forth a journey that will allow individuals to be more engaged and also to receive better outcomes and have better experiences in care. So I look forward to the discussion and welcome your questions and ideas. And again, thank you for being part of the conversation. So I want to thank Kaiser for inviting me, but I particularly want to thank Kaiser for taking on mental health. Not everybody's willing to do that and get into the kind of complexity that we're talking about here today. I also want to point out there's a brand-new issue of the American Journal of Preventive Medicine on the behavioral health workforce. I will get the link each to Kaiser so that you all can distribute this to everyone. This is produced by the Behavioral Health Workforce Research Center at the University of Michigan that's funded by HRSA and by SAMHSA. So in my comments today, I was thinking about this, and I don't want to just give you a standard comment about various things you could do. I think we need to put this in a context. I want to begin with a particular thing and then go a particular way. I want to begin with this is the best of times. It's the very best of times for behavioral health care. Why is that the case? Because we now have parity. We now have parity. Next, Wednesday is the 10th anniversary of the parity legislation. We need to celebrate that. We have the Affordable Care Act. The uninsurance rate in behavioral health has fallen from 30% in 2014 to 15% right now. We know that treatment works. It's no longer dubious. We know that people do recover in the community. These are huge, huge changes that we need to celebrate. On the other hand, it's also the worst of times. Behavioral health is still a stage four system. So we do nothing for you about prevention. We do nothing when you have a very minor disorder. Two weeks before you die, we start doing something for you. That's terrible, absolutely terrible. We're a backwater and we're also an object of stigma. So we can continue talking among ourselves here, but I'm going to try to shift it. I'm going to go to one of the words that was picked up over the noon hour here. Policy. We need to have a policy framework and we need to agree before we walk out the door today that we are going to work on that policy framework and put it together. And all I can do and the few minutes I have is point out some things that might be part of that policy. And I was assigned three topics, so let me take those topics first. So on the issue of peer support, we absolutely must support peer support. Let's set as an agenda, we want 25% of the workforce to be peer supporters within five years. 25% of the workforce. The Cochrane Collaborative says peer support is as effective as care from professionals. We need to pay attention to that. Baby boomers. Linda and I are baby boomers. We're not going to fade off into the distance. We don't want our other providers who are baby boomers to fade off either. Baby boomers are the biggest group among behavioral health providers. The average age of a psychiatrist right now is about 59 years. The average age of a psychologist is about 54 years. Those are large numbers compared to a lot of other disciplines. So how do we keep the baby boomers involved? I think we keep the baby boomers involved by inviting them to do supervision. Some people want to come back and volunteer. Other people want to continue to work on a part-time basis, but they don't want to any longer work 60 or 80 hours a week, which is what people in this field do. So we ought to make the commitment that we are able to retain at least a quarter of our baby boomers who are retiring before they actually exit stage left. Telehealth. There's a huge opportunity in telehealth. Telehealth is not what you thought it was years ago. Years ago, telehealth was a TV camera linked by a wire to a TV screen somewhere. Telehealth now is much broader. It depends very heavily on whether you have good internet connections. We can't have telehealth in the rural areas until we assure that every child, adult, and elderly person has a good, fast-speed internet in rural areas. So our fundamental agenda here on telehealth can't get to telehealth if we don't take on the earlier policy agenda here. Scope of practice. Another big issue in the field. What I mean by that is most people in behavioral health do not practice up to the level of their own scope of practice. We need to investigate. Why is that the case? How do we get into the issue of changing that in some way? Maybe we make the commitment that half of the people work up to their scope of practice within five years. I'm making that up. We need more work on that. Mental health and opioids. Another huge issue. So everybody talks about opioids in one context. We talk about mental health in another context. We don't put them together. So if you tell me you have depression, I'm going to tell you you are three times as likely to do opioids. Three times. So knowing that relationship, would it not make sense that you actually do something about depression to prevent the onset of opioid use? You go to the hill, look at the opioid bill that was just passed, look at the 306 bills that were behind it. There was not a single word about that linkage. We need to make the commitment that when we work in these fields, these fields work together. And that's a classic example of that. Self-management. Self-management is coming into its own. And it has the feature of self-managing your own care. There are now a number of good demonstration projects doing this. But also self-direction of your life.  I don't want to have other people telling me what to do. I want to have some choice in where I live. I want to have some choice in my job. I want to have some choice in who my friends are. These types of things are very important. So we need to make the commitment to helping move the agenda of self-management, self-care, and self-direction. And I could go on and on and on here. Let me just say a couple of things on the other side. Integrated care. A lot of people talked about integrated care this morning. We need to make the commitment that at least 20% of the population we serve have access to integrated care within five years, as an example. And I could go on, but I'm going to stop and say, my agenda here is to have all of you sign on to the Doing a Policy agenda. I'm just kind of giving you a couple of bullets here. And that we move this in a consistent, collaborative way on the Hill. Now that the cabinet hearing's over, there'll be more oxygen on the Hill to do these kinds of things. And we need to move that agenda. This is an urgent agenda because we are in crisis regarding our human resources. So thank you very much, Chair. Hello, everyone. So I'm super excited to be here and really appreciate the invitation. I really enjoy what I get to do in state government, and what I hope to do is to give a perspective on what we do on the state government side of things. And I want to start with a question, which is how many people are familiar with your state health agency organization, whether it's centralized, decentralized, or a hybrid? So most people don't, so thank you for those of you who do know. So in New Mexico, we're completely centralized, which means all of the state health agency that's in Santa Fe, which is where I work, governs public health activities for the entire state. So even though we have health offices throughout the state, they all report back to Santa Fe. The reason I mention that is because every state differs. So in some states, behavioral health is part of the state health agency. In some states, it's an independent state agency. And that is often influenced by whether or not the people who are leading those agencies are political appointees. And so some of the agenda is often driven by political priorities. And so that's something that needs to be considered and that's a reality for everyone involved in behavioral health, particularly in New Mexico. So in New Mexico, our state behavioral health agency is actually in the Human Services Department. I'm at the Health Department. But we partner extensively with them. About 15 years ago, behavioral health was in the health agency and then it transitioned over. So I want to go into a couple of things that stood out to me that I thought were significant. And I will start by saying that when I started out my career, I actually worked in Child Protective Services and I was a counselor slash teacher for ECRA-DEWS Alternatives. And then I eventually transitioned into foster care case management. And that was significant to me because at the time, I had an undergraduate degree in English literature. And I had done a lot of volunteer work with at-risk youth. It was something that was really important to me. So when I was looking for work, that was what my tendency was to pursue. I was grandfathered into the system because I had been working for several years, but now it's not possible to get a job doing what I was doing if you don't have a certain degree. And I think that's an important consideration for potentially excluding people who may have the skillset to do the job and maybe don't have the appropriate credentials to tie back to something that we heard earlier today. I think it's important to think about who are the other people who are touching the lives of people with behavioral health issues. And I really appreciated the consideration of the public health workforce being part of the public health workforce because we're doing the same kinds of work. What are we doing at my department of health? We do suicide prevention. We work on ACEs through our family health bureau. We're doing domestic violence and sexual assault prevention work. So we're doing a lot of the things that support the behavioral health workforce but not necessarily employing behavioral health practitioners. And so I think it's important to consider what those people are doing, what your state health agency or behavioral health agency is doing that can support that work. I will say that it's really interesting. We do have some data on the public health workforce that shows that people with master's in public health aren't coming to state government. So I don't know where they're going, but they're not coming to us. And so they're out there and they're doing work. And so think about ways that we can engage those people who are not working for state agencies. Another thing that state agencies are doing throughout the U.S. is looking at the no wrong door approach. So no matter where you enter the system, even if you come to us at the Department of Health through our WIC program, through our maternal and child health bureau, we're making sure that you're getting the services that you need. And we're referring you to our behavioral health services division if that's what's most appropriate. Another thing that stood out to me that I think maybe wasn't discussed a whole lot is the idea of expanding evidence-based models into other areas. We heard the beauty and barbershop idea. And so one thing that I would point out is that we know we have some really great models for reducing infant mortality that we have done through that same venue. And can we look at that as a model for how we might address other public health needs? I also know that there's a ton of attention on opioids right now, but in many states, methamphetamines continue to be the priority. And so when we look at creating infrastructure to address the opioid epidemic, it necessarily needs to address just addiction generally. And the kinds of services that we're providing for substance use disorder across the board. Another example is we many states receive funding for Zika surveillance. And what we have looked at in New Mexico and other states have done the same thing is to look at how we can use the funding that we received for Zika surveillance to improve surveillance for neurological disorders generally. So there are ways that states can leverage the funding they receive to support improvements across the infrastructure that they have. The last thing I want to point out is I think a lot of people don't know what their state agencies do. And so I think it's like my opportunity to say what can state government do for you? And so we do a lot of things. We do regulation and licensing. Many states including New Mexico certify community health workers. We do that in New Mexico through the Department of Health. We also license school-based health centers. I heard the question about adolescent health behavioral health services. We do that through our school-based health centers system in New Mexico. We also recently just issued a draft regulation on crisis triage centers. That's a really important way for communities in New Mexico to take control over the services that are provided. We just had a public hearing and that's the way the public can give comment back. And I think there will be some revisions to that rule but we hope for it to be finalized soon. We also have we support infrastructure. So all those councils and committees are created in statute. Those are often assigned to state agencies to administer. So we're the ones bringing together stakeholders making sure those groups meet and that work is getting done. And then we report back to the legislature often on what kind of work that we're doing. I see finance was on the on the word what do we call it, wordboard? Word cloud and sustainability. So one thing I want to say is we're often asked the state agencies if you're not the state Medicaid agency what are you doing to leverage Medicaid? In New Mexico close to 50% of our population is covered by Medicaid or which is significant. And so we really want to look at how are we making sure that those individuals are getting the services that they need. I think I read a recent workforce committee report that said that one quarter of behavioral health providers in New Mexico do not accept Medicaid as a primary payer. And so we also have things like we have behavioral health investment zones. In New Mexico we're looking at behavioral health investment zone collaborative and that's to fund non-Medicaid services for behavioral health and again a way to empower communities to use funding that they receive to address community identified needs. I also want to mention briefly supporting our own workforce so we look at things that we can do to train our people appropriately. So we're looking at mental health first aid how we can be a trauma-informed organization which we heard a lot today. Also importantly cultural competency we've heard a task force recently that issued a report on addressing the health needs of sex and gender minorities in New Mexico. It was really important because as part of that we issued some policy recommendations and one of those things is how do we include training requirements across our licensing boards for cultural competency and I'll say very briefly that we have one licensing board that has an explicit requirement for cultural competency training and I don't think that's adequate. If we don't have people who are properly trained people in our demographic then we're not really going to be meeting their needs effectively. And then I want to say maybe we can get into it more in a second is just to close on the idea of collaboration as a policy lever. So not just going to the same meetings with other people but also like how do we create multi-organization or cross agency performance measures and be held accountable for the same common goals. So in New Mexico we often say I'm not the only agency we're not the only agency at health but we're also responsible for behavioral health. We also have our behavioral health services division. We have our children, youth and families department. We have our aging and long-term services. We all are working toward the same goals. So we really need to create a set of measures that create common accountability for what kind of work that we're doing and I'm over time so I'm going to close there. Thank you so much. Can you put the words back up the word salad that was a question that is related to what people really want. The big words are financing policy, sustainability and funding. And so let me begin with you. An expert really in implementation science worked at the VA I think closed the gap between what we know works versus what people get but in many ways that's a closed system. Now you're working with Kaiser Permanente another relatively closed system. What's your view for how we do that with the thousands of systems that exist across this country? Thank you for that question Linda. So there certainly has been I think in my own field clinical psychology bear some other responsibility here. Too much focus on what works and not enough focus on how to implement. So we focus so much on the what and too little on the how. And there's this whole other field as Linda just alluded to of implementation science that has really helped to empirically establish what are mechanisms for and processes for getting what we know works into clinical and other settings and how to sustain those. And so I think really bridging those two worlds is critically important to close the gap and that's what we endeavor to do in VA. We're doing that now in Kaiser. We just finished up some work in Hawaii which has gone very very well and however you're correct Linda it is very much kind of a system by system process. Now our approach is to work with systems we've been fortunate to do this with two of the largest systems in the country to develop some centralized capacity on how to do this. Implement the how implement the processes, implement competency based training programs, implement patient level engagement strategies and pretreatment processes to get patients to these treatments etc. And then our hope is then to be able to back off so that we're not as much as we love doing this work continuing to work with those systems indefinitely. But develop processes and competency based training programs and so forth that can then help the system move from this more centralized approach to pushing these treatments out into the front lines to more decentralized processes. Training the trainer processes and other processes so establishing kind of hubs if you will and proof of concept within systems and then providing for and training folks to be able to spread that and sustain it. Sustainability is crucial over time but again it's a system by system process I think one of my main reasons for leaving VA was because I was really passionate about trying to export what happened in VA to other systems but we need more people doing this kind of work more people bringing implementation know how to to mental health care. We have way too many treatments I think I'll be honest with you I'm a big proponent of evidence based treatment but all the different acronyms I alluded to earlier you saw all the different kinds of resources have been developed are great but we need to focus more on how to actually do that work flows and what the IOM recently recommended because they saw what VA was doing and said we need to do this it's actually to give Tom Intel credit his hope to actually spread this IOM ultimately concluded that ideally there would be some type of coordinating body or some type of entity that could help to get these processes and implementation know how into a variety of different systems we're not quite there yet we're moving system by system but I think we're making some inroads so so Ron just to piggyback on that one of the things you know many of our members of federally qualified health centers and we worked hard to encourage behavioral health organizations to become federally qualified health centers they went through a similar process years ago led by the Institute for Health Care Improvement in Massachusetts to close that gap between what works and what doesn't and it included some of the mental illnesses I think depression anxiety do people understand the payment system in the specialty mental health public sector where many people with mental illnesses go because they are driven into poverty often by their illnesses so I want to comment on your procedure so there were 27,500 procedure codes in Medicaid for behavioral health 27,500 so if you are dealing with a problem of complexity it needs to be radically changed so on the issue of financing I think you know the classic story is and that's changing a little bit as a result of the ACA a person from family somebody in a family develops a disorder they first exhaust their insurance then they exhaust their personal resources then they go into the public system and maybe the public system is able to help them or not we need to change that trajectory of people's life that is absolutely tragic just very recently I was doing some work on parity and we wanted to find out some cases of parity violation that we could put in front of President Obama's task force on parity I remember one particular case of a woman in New Jersey who said I have two teenage boys they both have serious mental illness and I've exhausted my credit card my credit card is maxed out at $21,000 and I've had to borrow $150,000 to pay for their care there's something radically wrong with that so I think we need to again to go back to policy in our policy process set up operational procedures that actually work for these people we aren't there in parity I praise parity and parity is wonderful but we need to get it implemented so it actually is true so you can say you have the parity protection and in fact if something happens to you it actually works for you and that doesn't happen so I think there's a slip between the cup and the lip here a little bit in terms of our ability to actually do that financing I want to say a word about financing of training so this isn't the first time we visited this issue so in the early 2000s we actually developed a strategic plan for human resources for behavioral health care and it was done by CSAT and CMHS Matie Chalk and I were involved in that and we had that plan in hand by about 2005 we then said well we need to build political support for this plan so we wanted to convene a very large meeting 500-600 people of the leaders in the field to buy into the plan modify it whatever I left the government at the end of 2005 so the meeting was held in 2006 and we went to the meeting we did that there was a second step the second step was to set up a center on human resources in behavioral health care that would allow entities that are doing interesting work I mentioned the Kaiser Permanente work this morning on measurement-based care learn how Kaiser's doing measurement-based care so it can be moved somewhere else that step never center became a website the third step was a $300 million training program we have not done clinical training in behavioral health since 1994 last year where there was any federal funding was in 1994 it was $3 million so it went from $3 million in 1950 to $117 million in 1972 to $3 million in 1994 to zero it used to be when I would go out and give talks I could always ask a group how many of you had a clinical training grant first from NIMH and then later from SAMHSA there would always be people the leadership in the field all had training the administrator of SAMHSA had a clinical training grant at an earlier age now there's next to no one we haven't had any leadership training in the field since 1981 so I think there's a huge agenda here it's a financial agenda for us but it's tied into the policy agenda and being able to move the policy agenda on the hill I was wondering before I get to Dawn Bradley if you'd be willing to comment on that and the value of generalized training versus mentoring an ongoing supervision within the organization where CARE is delivered I have two comments actually it's a piggyback on what Ron has said we were in the Under Secretary's office this is circa 2005 and said we want to embark on this unprecedented initiative to disseminate and implement a variety which ultimately came 16 evidence-based psychological treatments the VA even though it's its own payer it's a payer, provider, policymaker all in one Under Secretary rightly said well okay but what's the business case for this and we made, I'll be honest with you, inferential arguments we said that to the extent that you can invest on the front end in a protocol of evidence-based treatment bring people up to a appropriate dose of treatment which they typically don't receive and have it be evidence-based then there will be cost and savings offset on the back end but that was an inferential argument there weren't cost offset data or service offset data at the time directly speaking to evidence-based psychological treatments I will say now and I think this could be used as some type of ammunition perhaps when talking with various policy makers on the Hill or otherwise we actually now have some of those very cost offset and service offset data and that's what the business leaders, the policy makers will need to see ultimately that in the end of the day this front end investment in training and so forth is going to yield some back end savings or benefit from a financial perspective because mental health care is a business in many respects whether you're non-profit or for-profit some of those studies actually came from VA after implementing those treatments Kaiser Permanente to his credit just did a study published this year in the northwest region of Kaiser Permanente demonstrating that CBT yielded significant, very significant cost reductions when they followed those patients that received CBT over time so we have those data now that we didn't have even just maybe a few years ago the other thing I want to say is don't engage in training please don't do training if it's a one-time event this is what Linda was getting at save your money unless you just want to and most of you know this but others don't necessarily know this you want to promote knowledge and awareness great but will practice change will behaviors change in the therapy room no so you really need to invest in a process that includes that ongoing consultation and support we actually found in doing that within Kaiser Permanente not only did that improve specific skills in CBT and bring there was a few therapists that baseline to every single therapist achieve competency at the end of this consultation process they also their general therapy skills were significantly improved their satisfaction was significantly improved and it was used as a recruitment incentive by the region so I would say that we need to use our resources wisely we need to be aware of the cost and service that are there and engage in processes that are going to move the needle that was the point I was getting at and I just want to add something to that which is the organizations that are behavioral health specialty organizations working with people often who are insured by Medicaid get whatever fee that state sets in their Medicaid program it is not cost-based the way hospitals are and FQHCs are which has been a big policy initiative around something called certified community behavioral health centers and this morning they just put out an array of grants to a range of organizations a second you know really set of grants the problem with grants are is that many of the things that would discuss this morning including in the community are funded by grants I had heart bypass surgery almost one year ago I didn't have to find a place that had a grant to get it I could have gotten it and I would have gotten the same treatment I got it at Columbia if I was at USC it would have been the same it is standardized but it's also ongoing covered by insurance so I was going to ask Dawn about your experience with parity in New Mexico and is that part of your purview and what are you seeing are you seeing more availability of treatment because we had this law passed ten years ago so that's not something that is in the New Mexico Department of Health it is something though we do have to be familiar with what are the laws that influence the services that all the agencies are providing and so do we see an increase in access to services yes and in covered services yes I think people who are familiar with New Mexico know that we have had some issues with the behavioral health infrastructure and so I think it's taken several years to recover and so it's hard to say with the long term impact is at this point because I think it's really been over the last probably two to three years that we've really started to see the system recover and more services and providers put in place to kind of address the gap that existed when our kind of system had a crisis a few years ago can we move to the workforce itself Ron mentioned baby boomers you know it's obviously a group I'm very fond of but we are not the future matter of fact many of you will hope that we just get out of the way so but we do have a workforce that's primarily millennials now certainly I do we have about 130 staff at the National Council primarily millennials and they are different and they are smart and they're bringing us into the digital age but they want to be engaged and have a say in a way that certainly I didn't when I started out I kept my head down and worked hard and thought that's how I'd get ahead my staff really wants to be involved in all our decision making it's very different are any of you seeing that and can we keep up with the for profit world that is offering the kind of perks that we have to struggle to do like fruit every day available really things like a sabbatical after three years if you want to keep somebody who stays longer and retain them these are things people are getting where they go to work we barely give them a laptop so what are you seeing in terms of are preparing for what is now our workforce versus thinking they're going to act like we did anybody start by commenting on that so yes we have a lot of millennials but I think the millennials we have in behavioral health are what I'm going to call churning so they come in they don't have a very good salary they and the concept of working is very different now than what it was 30 years ago the concept of working now is you go one place you're there a couple of years you take your 401k you go to the next place then you go to the next place and so on that type of a model of working doesn't fit well with somebody being mentored into higher roles in an organization and so we need to think about whether we have the right incentives or not for that group I teach a lot of millennials millennials have a lot of the same values of baby boomers they have social justice values they want to see the right thing done but they have a different concept of work baby boomers volunteered for everything so you know I'm in many boards and all these kind of things millennials don't volunteer they have a different concept of that and we need to respect their concept of that generation group if we're going to be able to engage them I agree with you we also don't have the right incentives they are smart they are very smart they are very smart and I would say we even need to get to people before the millennials we need to get to people when they're in high school and engage them in having interest in working in behavioral health in the rural areas to give you a few statistics so 85% of the counties in the US have either inadequate or no behavioral health services and 63% of the counties don't have a psychiatrist now if you're going to do anything about that you're not going to take somebody from New York or DC or LA and move them out to Elma Key County Iowa that simply is not going to happen but you do have a chance of doing recruiting of people from Elma Key the time they're in high school work with them through college they will be very likely to go back there we haven't implemented some of these basic tools that the science shows us and research shows us that actually works here so I think we have a huge agenda with millennials can I ask go ahead Dawn please I would just add that we definitely are seeing that with state government and public health in particular we know the average age of a US public health worker is about and we have done in New Mexico specifically we've conducted several workforce surveys and one of the things that comes out of that is wanting more flexibility wanting to be able to work from home I think anybody who works for the government knows that you don't really get to work from home there's a much greater degree of accountability of course and so I think that the state government workforce in particular is going to have to adapt in order to accommodate the changes in the way that millennials in particular are targeted to them how are they able to care for their families how are they able to pursue continuing education and do we have a system in place that supports that and also supports our interest as a government in getting certain activities done we almost have a PR problem in health care I think you know for so many years we focused on what's wrong with health care in this country that what we see is many young people and I think Ron is right who have very strong values around social justice want to be in health care but what they choose is policy rather than practice so we're having a pipeline problem not in the MPH's and in policy but in the practice side because we also I think keep adding layers of expectations and oversight and every good idea we have you know when I was in New York and I went to state government at the higher level from actually direct service and running a hospital I said to my staff this is fun we just make stuff up and people have to do it I think practitioners feel that pressure that we're sitting around coming up with solutions and it's layer upon layer in terms of what they have to do to get through the day Bradley comments about young people I actually think there's a big opportunity here there's a big opportunity we have from the perspective of the younger generation of providers and I'll give you a case example of this in just a moment is actually very interested typically very engaged to deliver treatments that work right so they typically know what evidence based treatment is they want to deliver it a case example of this is in VA we realize as part of this transformation initiative to move VA to an evidence based recovery oriented system of care there was a need to hire a large number of staff and we had veterans coming back from Iraq and Afghanistan are starting to come back at this time circa 2005 to 2006 when this began ultimately VA went on to hire about 7,000 mental health providers in the ensuing years and we actually found in many respects that facilitated this transformation process because the younger generation providers they know what evidence based treatment is they're more likely to have had at least some exposure toward in graduate school although another topic we haven't talked about is the need to really change the curriculum within graduate training programs which typically is not practice oriented or focused on competent delivery of evidence based treatment that's next year's forum and I would add to next year's forum that we have a concentration on financing in graduate education so social work school you have to understand how things are financed today and I don't think they're doing that at all I don't think that's in the curriculum at all so I actually think and know from the experience of VA that we have a motivated, engaged younger generation of providers that if we can position them well can really help to transform mental health care we don't need to preach them I think they get it they're used to evidence based practice models from their own personal experiences and we hear it all the time and they've probably heard it at some level in graduate school in ways that maybe earlier generations have not and I think we also need to provide leadership opportunities we need to really empower them to help lead this process everyone should be a leader but especially the younger generation of providers coming in their leadership will also be an important part of sustainability I think I couldn't agree with you more I have one more question and then we're going to open it up to the audience and it's also about the kind of world we live in today so where an Amazon is right I expect I'll order something tonight when I get home to New York tomorrow it will be there right we don't deliver care that way actually we're starting to do it on the physical medicine side every corner has an urgent care center that I can go into if I have a sore throat on Saturday or Sunday or this evening when it comes to mental health services we are still stuck often in a nine to five which absolutely doesn't work kids and families and Monday through Friday what are people's thoughts about the delivery of care both because we have the technology and what you're doing in that area in your world but also because it's what people expect and they also expect intermittent care we have a notion in mental health that people are going to come for the next you know ten months every Wednesday and we wind up with lots of no shows and lots of capacity that's going on filled we've had a same day access initiative now for eight years to get organizations to completely have you know care on demand walk in are all of you dealing with kind of this changing environment and where do you see that fitting into attracting a workforce and keeping it so quick comment so we have the problem that we're trying to address in the counties of a huge number of people in the county jails have behavioral health problems so tonight there'll be seven hundred and thirty thousand people in the county jails fifty percent of them will have a substance use condition twenty five percent will have a mental health condition and another ten percent an emerging group will have intellectual and developmental disabilities so eighty five percent of the people in the jails tonight have these problems so this is what what can we do about that well there's a kind of a clinical response how do I get these people out of jail into care but there's a public health response how do I prevent them from going to jail in the first place and we're working on the public health response with what we call ergy divergy center so ergy divergy center and ergy divergy center in a community where it's open all the time anybody can come there are no appointments you can come your family member can bring you the police can bring you there appear can bring you there and whatever actions needed with you is taken if you need to come there and sleep you can come there and sleep if you need to come there and take a shower you can come and take a shower if you need to come to talk to a consular you can talk to a consular so the care is wrapped around the person but it's short term care and the goal is to do whatever is needed with that person to divert them from the trajectory of being picked up by the police and going on to jail if you have no alternative the police will take you to jail and in that I think we're having some success there's a wonderful center in San Antonio there's another one of these new centers out near Portland that has been developed and I actually have a PowerPoint of a presentation on that center and we figured out a way that we can get Medicaid to pay for that et cetera et cetera so we're trying to respond to a real problem with a different solution than the nine to five office model and I think in the future it's going to be more taking care to people where they are rather than expecting them to come to where you are basically and technology will help and Dawn are you trying to do this and do you have any technological solutions yeah so we also I think that very similar goal with our crisis triage centers is the idea of outpatient or short term residential treatment for acute situations and same kind of concept communities can identify what services are most appropriate for that facility and they can be accessed at any time we're also seeing facilities everywhere not just in New Mexico who are co-locating emergency departments in urgent care clinics we're looking at utilization reports to say what hours do we need to have for urgent care so that we can continue to appropriately refer people out of care so we're looking at telehealth so our office of school and adolescent health for example helps to facilitate telehealth services for behavioral health needs for adolescents as an example and so we didn't really talk about project echo but we also use the project echo telehealth model for a variety of things including for opioid use disorder as a way to provide training and also for case management services for people in rural areas so we can make sure that people or need assistance with a particularly difficult case have that available to them in their local community without having to travel to one of our three metro areas. Questions? I have plenty but you must have some. Good. With active body works so I was just wondering there's an application that's called talk space which is a new thing where you can actually sign up and have pay a $79 a month fee to have a licensed therapist so you can actually be completely detached from your therapist and they're on call 24 hours a day so I would like to know how it is that the industry within itself is kind of transitioning into something like that. So go ahead. I was actually going to make that exact point and also provide some caution there so first of all I think there's no wrong door and there's no single door so we have to have different doors whether it's integrated care whether it's same day access and mental health facilities but the private sector has caught on and I think we're going to see some real disruption here disruptive innovation is going to spread in this era we're going to see more of these mobile apps they're going to proliferate but right now it's happening separate to a large extent from the mental health care behavioral health care workforce and sector and that's concerning for a variety of reasons but these apps that have been developed you're not completely attached to your therapist you're not getting the level of care that you typically would with your traditional mental health provider or what not there are some real restrictions on exactly how much face time you get exactly what the content is of the actual communication and there's no regulation really about around that and for some of these reasons they don't call it psychotherapy they don't call it treatment it's mostly called coaching so I think there's potentially a place for that private sector though is going to expand and proliferate that and push the boundaries as much as they can so I think there may very well be a place there it's probably in the early intervention side ideally of the care continuum if you will but we need to make sure that we're working together so that this continuum is joined and that there's partnership because the private sector has figured this out or they're figuring it out and they're going to exploit it so I would go beyond the private sector it is the private sector but I want to point out it is mostly venture and private equity that is investing in these and they have a particular model of investment they buy something they buy more of the same they put it all together and in about five years they resell or go public usually resell to another private equity company and they own things like Talkspace Michael Phelps you know he has all kinds of big ads talking about how he's used it there's another company Seven Cups that the county LA County is actually going to use as their front door to get people into care there'll be a handoff, handoffs are always complex so we'll see how it goes I'm on the board of Seven Cups but I'm very cautious about the same things you've put out there but I think those are the big disruptors the only reason we don't see private equity and venture capital in traditional community based services is there is no margin if you look at hospitals private psych hospitals if you look at addiction residential treatment if you look at methadone clinics they are all owned now by private equity because the margins are good so that's not something we spent a lot of time with here but I think it's something we've got to think about forming really the business of behavioral health and I think it's a reflection of our success we've made talking about mental health and addiction acceptable we've up the demand we just finished the survey with the comb veterans network it was very clear the younger you are the more comfortable you are talking about your issues and the more you want to find care and so we've created this demand and where this demand business moves in and it's the issue of do we want business to run health care and that's a different discussion but a discussion next I actually asked him to let me jump in line my name is Kevin Detner and I'm the founder and CEO of Henry health and we are a mobile app that provides self care support and mental health services to black men we are very close to securing our lead investor and we'll launch our product here in the Washington DC area in just a few weeks but I wanted to speak to your point because I have a public health background and the company was born out of my own period of depression and so we are trying very hard to not quote provide therapeutic conversations which is what our competitors do we're trying very hard to provide real therapy but I will just say on the policy side that there are some very significant barriers to providing teletherapy legally and this is where when we talk about the policy conversation that we could actually use some help here and this is also the reason why our competitors provide quote therapeutic conversations as opposed to real therapy because of the jurisdictional laws so I do think that whether you all like it or not we're here and we're disrupting how people treat how people access mental health services I have been inundated with people demanding when is your product coming and I just wanted to put that out there for you but I also invite feedback to my comments thank you. We're very involved with the DEA around the regulation which is very cumbersome of delivering telehealth particularly prescribing by psychiatrists across state lines absolutely that's our challenge I just wanted to add and even to the earlier point is just the importance of looking at interstate licensure compacts and regulations that allow for reciprocity that's one thing that on the state government side that we are responsible for doing and it's one way that we can facilitate practice especially in rural and frontier states like New Mexico or even anywhere in your state where you have communities that just don't have access to providers we're not bringing them in and so I know that's one of the challenges through looking at opportunities for interstate compacts there aren't that many out there but there are a few that could help facilitate these types of services proliferating more. That's a great workable to do and I love workable to do is where you actually can move an agenda so let's talk about that yes please. My name is Lindsay Haagel I'm a baby boomer and I have four millennial children and every panel has been outstanding. I question and I know you can't go over everything in one day but I guess a plea that you'll keep families and in that implementation and training piece because they're the ones that need to know what you're doing so that you can continue it when it's home and also help us define the spectrum of mental illness. We have a lot of children see it in other people and we all have to support each other so I think those to the families and the children really need the training and I know you're digging for fire hose here but again thank you but keep the families in the picture. I couldn't agree with you more I started my career as a family therapist and for many years we lost our way to what we call HIPAA sometimes in order not to have to work with families and do the kind of education they need and deserve. Ultimately you are the caregiver I might think I am but you're the one who lives every day with the issue so I'm glad you made that point thank you. Hi I'm Lee Taylor Penn from the National Governors Association and I had two questions one for Dawn I'd love to hear more about the behavioral health investment zones and then also I do a lot of work in the rural health space and states that are working on getting more providers in rural areas and trying to figure out how to get care there do you know of any innovative programs or states that are doing a lot of great work in the rural health and behavioral health space for anyone? Do you want to talk about the zones a little bit? Yes so in 2016 the New Mexico legislature supported the establishment and funding of the behavioral health zones in two counties in particular one of those counties is Riba County and it has roughly three times the death rate from overdose than the entire rest of the state and so that's really significant and so we looked at an opportunity to give to empower communities really to identify what their needs are and so our behavioral health services division has been leading an initiative to help establish these investment zones and help guide the counties and how that does give me an opportunity to bring in one of the things that states can leverage that is an important task is strategic planning and state health improvement planning and so we are currently updating our state health improvement plan many state health departments and even county and local health departments that are accredited have to do these and as part of that one of our priorities are related to reducing overdose death reducing alcohol related morbidity mortality for example we can't do that alone and so we engage our behavioral health services division to say how can you help support these priorities and so one of theirs is related to that is related to behavioral health investment zones we also have a treat first program that we've been piloting that really gets at an earlier point about how do we get people the care they need and then reduce no-shows subsequently so we're keeping people in the system so that's kind of some of the work that we're doing right now in New Mexico there are several states that are involved in updating their state rural health improvement plans we're doing that in New Mexico with the hospital association the rural hospital association primary care association lots of different partners and we're looking at what community identified needs were and incorporating those into our state health improvement plan and I will point out that one of the things I think is a good opportunity for states to collaborate on is hospital community benefits investments and how they can better align with state health improvement plans that state health agencies are required to do I think that in many cases right now that's a real missed opportunity but it's a way that we can align services, behavioral health services in particular because we know that everybody's putting resources toward this and everybody has ideas and they're not all necessarily coming together yes please so my name is Jonathan Duff, I'm a psychologist by training but I work in the policy sector now and I have a lot of thoughts on reimbursement because I think we've mentioned it several times today but I think financially we disincentivize people coming in to the behavioral health workforce I mean you mentioned how the next generation coming up is very intelligent if you crunch the numbers graduate training is very expensive and yet we're not paying behavioral health providers even for the very same things that someone with medical training might be doing so I'm particularly curious about your thoughts on Medicare scheduling because it seems like a lot of that happens behind closed doors and it doesn't seem that behavioral health as sort of a sector really has a seat at that table scheduling in Medicare is a very complex process I have learned actually about how those rates are set but I think you raise something very important and what we see instead is stealing from Peter to pay Paul so for the nonprofits their staff goes on to work for the VA or for FQHCs rather than the specialty sector because they can't pay at all so our contribution to that is this certified community behavioral health center where like FQHCs and some hospitals you can build salaries into your rate if you can't build salaries into your rate it will the specialty sector in the public specialty sector will have to disappear in fact but I think the demand we're seeing for mental health services will result in higher salaries it will take some time but we're beginning to see some of that psychiatric salaries have clearly gone up over the last five years and I think others will follow because of the tremendous demand but go ahead Dawn I'd like to add kind of an alternative consideration is looking at other workforce incentives as part of our rural state health planning process we're looking at what incentives exist one example of that is a rural health care practitioner tax credit right now in New Mexico that does not include behavioral practitioners outside of clinical psychologists and so we're looking at can we add other practitioner types to that law the other thing that I would suggest that we could look at that isn't going to give anybody more money necessarily but we're going to look at other practices that might facilitate people coming into your state so if you have a military spouse for example if you have someone who's licensed them as an emergency medical emergency medical personnel teachers so what are we doing to help facilitate you bringing your family to a state so even if you're not private industry does right yeah and so we look at the same thing in state government and say what can we put in place that kind of gives the same kind of edge that's great Ron we're in on policy here so in Medicare for primary care physicians the system is going to go through a huge transition in January and the rate is going to be standardized to be I believe $93 for a primary care visit no matter what happens or how long it is this is creating HAVAC in the primary care area we need to have opinions about these things and we need to act nationally on these issues when we know that this is going to be a disaster 75% of all behavioral healthcare occurs in a primary care office these days what will happen if that would fall to 35% as a result of some of these changes so we're implicated in this change that primary care is undergoing and Medicare is a huge payer we're going to have 100 million elderly people by 2060 how are we going to handle the 15 or 20 million people of those 100 million who have behavioral health problems as we close I want to go back to the theme of the community role in all of this and the continuum of distressed people are under from anxiety and depression that perhaps is situational all the way to the most serious mental illnesses does everybody need treatment and is the public having a hard time discerning who does and who doesn't and how they can really help each other in communities anybody have any thoughts about that so I would say no not everybody in the continuum needs what we call formal treatment and treatment can have a much broader concept in the community so we mentioned family supports we mentioned peer supports we mentioned social supports that people have they play a huge role in this the churches play a huge role in this and so on so I think we need to do a better job of differentiating that and I know from the work that was done historically on epidemiology so you know when we did the first national epidemiological study where we have a diagnosable mental illness we were not sophisticated enough to realize that if we went to the hill with that number 25% we would overwhelm the people on the hill even the people who wanted to help us would say my god I can't get my hands around this mammoth problem that you're bringing me so unless we break this problem down into smaller pieces we aren't going to be able to move the agenda and so I think the continuum about is an absolutely critical continuum here you know we've trained not we but local instructors have trained about a million and a half people in mental health first aid and I think that enormous demand is because people do want to understand mental illnesses they want to know well what in the world is depression and is it the same thing as schizophrenia but they also 14,000 of those people have become instructors because they want to help people in their community and there got to be more ways like that we can tap into it and certainly I'm refocused on the clergy in a way I wasn't before today to be honest with you and the power they have to help in so many cases anybody else I think just the whole idea of right sizing the intervention whatever the intervention is I think we have a lot of work to do we collectively it's not only the behavioral health community it's other communities as well but doing a better job of right sizing and trying to get to people earlier than we typically get to them you know there's been interesting enough I'm seeing coming across my computer screen lots of state efforts now in promoting social connectedness because there's been a proliferation of research around the power of social connectedness I think we'll see more of that so that's hopefully you know all the way to the left on this continuum but really focusing more within the treatment community further to the right but across the entire spectrum in right sizing and really trying to get to people earlier in the continuum we're done thank you


The other thing is that having a platform from teachers to talk in a safe space, because we need that too. We really need, because we do deal with a lot of trauma, whether it's like our own trauma or just trauma through the child and their families and what they're going through and the workload that we go through, that it would be great for teachers to be able to sit way more often and just acknowledge each other. Teachers are incredibly creative. They're ingenuity and their willingness to do whatever it takes. You put us in a group and allow us to bring that power of yes. I think we could go, I don't know where we could go, I think the sky's the limit, quite frankly. And that was the other important part, is that power of yes.


I'm here to bring the Sunday Supplement, basically speaking about everyone's 3-1 loss against Man City. These are usually just a look back at the game once the dust has settled and all the kind of rawness from the game has gone. A look back over the teams but replays and stuff like that. So a more calmer I suppose approach to looking at games after they've been played. Going off with the line-up was pretty much what we were expecting, defence midfielders again. But we're playing Man City so we were going to have to be defensive anyway but we went with Pickford and Goal, James calling back captain in the side after sitting out the game against Sheffield Wednesday for a Sidibe and then me, Nett and Keaton in centre half position and look at Deane on the left hand side as usual, I think the backfoy pretty much picks itself these days anyway at least. Then you had Morgan Schnoerland and Fabian Delph in midfield and then just ahead of them you had Guilfee Sigurdsson and then you had Theo Walcott, Richard Addison and Dominic Avalon as our front three I suppose. And yeah I mean early doors, we were expected to be dominated by Man City, I was not looking forward to this game to be perfectly honest, I was not looking forward to it whatsoever but you know early doors they get in behind, Kevin De Bruyne in their ball in and Conduggan hits the crossbar and the alarm bells were ringing at that point then obviously Theo Walcott went off as well quite early on, Alex Oboby came on for him on the left hand side but Richard Addison on the right then but I mean I was expecting City to dominate us and you know we were doing okay, we weren't doing amazing but we were doing okay, they were dominating the ball, their tempo was quite high and they got their goal with De Bruyne put in a fabulous ball for Gabriel Jesus and it was a great header by him and something in which we're kind of lacking from a striker at the moment albeit Dominic Avalon did get a goal but it comes out in a sec but I mean at that point when they score how many is it gonna be but to our credit like our players they put it up to Man City and they could have just went into the shell and you know heads down like they did against Sheffield you know but they went at Man City and they really put it, they showed what you need to do against Man City basically the only thing is we're not clinical enough but as I say James Coleman will feel aggrieved that he didn't get the goal because obviously Dominic Cavett-Leon stole it I mean if I was Cavett-Leon I would have done the same team but I'd be fuming if I was James Coleman but either way everything got the goal, the equalizer and we were really dominant at that point like I wasn't as worried as I suppose I had been previously but we were coming into our own and I suppose that showed of a large part of the game like people were moaning afterwards saying oh you know we felt like it's a chance wasted and so yeah City had a very very good side like up there with some of the best teams I've ever seen in the Premier League playing like and even when they're missing players they're still unbelievable. I know they had a bit of a makeshift back for but still you know they're clever as well, Pep has them well drilled and you know we held on to like well not held on but we kept them at bay for you know a large portion of the game and I think that's something that needs to be admired. Okay we didn't get the result we wanted but you know after last week's performance I think we shall much more to try and get into the game. I thought all over the park we looked really well and as I shamed Coleman was fantastic throughout the game and Dominic Cavett-Leon I suppose in and around the box he's looking very well, Rich Ellison was very good, Talwabi was fairly average, well I wasn't supposed to be but he came on that early that you know I wouldn't really be looking at as a sub being subbed the way they made it out on the telly but like I'm looking at our team like we show character we show that like we're not gonna lie down and let them come out. We had chances as well don't forget and ultimately they get their goal with the Amare's free kick the second goal and a lot of people put blame on Jordan Pickford but I was watching it again on goals on Sunday and you know Chris Camaro made a good point this way that you know they had Delph in between I think it's Fernandinho and Automendy and just before they take the free kick he actually looked if you go back on watch it he actually Automendy says to Fernandinho let's split there so Delph is actually the one that's blocking Pickford's view and once this pass Delph, Pickford can only see it down and you can imagine the pace that that's coming out like a top elite level player hitting that ball okay people would say that's on the side and stuff like that but I think people were being very overcritical and especially Gary Neville he seems to have some sort of agenda against Jordan Pickford but I'm not saying that Jordan Pickford you know in any way you know doesn't deserve criticism he does but I just thought it was very harsh to just blame him solely on the goal it was a really good free kick in my opinion people probably disagree in the comments but I don't like I was looking at it and I'm not a goalkeeper I've never played in goals but far from where I was looking it looked like it was just it was destined to be a goal and that's that right into the side net and like and sometimes you just got to put your hands up and say it was a top quality goal or there's no disagree that's totally fine that's that's your opinion and you're entitled to it you look at their players and they've just got so many good players they were bringing Aguero off the bench then they were bringing on Bernardo Silva and stuff like that but then obviously they got the Turgo Raheem Sterling and at that point look we just look tired and you know so you just dominate dominate dominate dominate and they mentally break down teams you know and after Sterling's goal then you look at you know and shame is called and the chance he had to whip it across but he hesitated in the box and then was obviously the early meaner chance of something like that so we had our chances too it was just I suppose not clinical enough again as I say Moise King came on still doesn't look like he's up to the task right now as I said before he needs to get on them weights and step put himself about I do think things will change from once he gets a goal I think he's just lacking that one goal I think I think Silva did the right thing by playing Cavalilandome and I was delighted to see Dom get his fourth goal in three games really was because he gets so much stick because he doesn't score goals and I think people want to see him do well I think all fans want to see him do well but it's just he's not scoring enough and he's leaving himself out into criticism because he's not scoring he's not converting the chances you know maybe he'll say that the service isn't good enough but again looking all over the park I suppose I thought we done we thought we done moderately well we weren't amazing but it was a much better performance than last week and I think we can take positives out of a gun for but next week against Burnley it's most win and we need to we need to get the win and you know might be time for Moise King to get his first goal in that game I do believe that we are far better than Burnley I'll disrespect them but I look around our team and I know we might be missing a couple players Gomez and that and I think he really makes us tick when he's on it we seem to always be on it look at Dean had a very poor performance for his performance actually everybody his standards rather and I love him he's probably my favorite player at the moment but he's the last couple games he just hasn't been he hasn't been at it and I don't know whether that's because Bernard's been taking over the team or what but he's just doesn't look the same player he was and the back end of last year and kind of a couple of games early in the season but hopefully he can rediscover that form and hopefully we can get back to that win and I just wanted to briefly touch over the pick for a thing where people are saying he's laughing about where he nearly made a mistake I don't think he was I think he was kind of in shock when I was looking back at it he didn't really look like he was laughing he was just look like he was like oh my god I nearly fucked up there that's that's what I thought it looked like I don't think he was laughing and smiling the way Gary never made out you know and I do believe that there's some sort of agenda against Pickford because he's England's goalkeeper that if he makes a mistake it's ten times worse than Hugo Loris or someone like that who makes mistakes all the time and a lot more mistakes I think than Pickford but look that's been my Sunday supplement let me know your thoughts in the comments and do you think we'll be burning next week and carry this momentum on and if you want more videos from me especially if you're Irish or your followers football check out Irish football fan TV my YouTube channel and then follow us on Instagram Twitter Facebook a lot and thanks very much for watching don't forget to like this video and don't forget to subscribe to toffeeTV if you haven't already thanks very much guys I'll speak to you all soon all the best