Yale Psychiatry Grand Rounds: April 30, 2021

April 30, 2021

Information

"Addressing the Nation's Behavioral Health Pandemic: The Need for a Population Health Perspective"

Arthur Evans, Jr., PhD, Chief Executive Officer and Executive Vice President, American Psychological Association

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00:00Everyone today, today's ground red rounds,
00:03which is jointly sponsored by the Division
00:05of Prevention and Community Research,
00:07the psychology section and the Diversity,
00:10Equity and Inclusion Committee.
00:11It's my pleasure to introduce
00:13our speaker Doctor Ever,
00:15Arthur C Evans Junior,
00:17who's the Chief Executive Officer of
00:19the American Psychological Association,
00:21the leading scientific.
00:24Professional organization representing
00:25psychology in the United States with
00:28nearly 100 and 22,000 researchers,
00:30educators, clinicians,
00:31consultants and students as members.
00:34APPA promotes and disseminates
00:36psychological knowledge to benefit
00:37society and improve lives.
00:39A mission consistent with
00:41Doctor Evans's life work.
00:43Doctor Evans is a clinical
00:46and community psychologist,
00:47a policy maker and healthcare innovator.
00:50Who previously served in public
00:52policy positions in Philadelphia as
00:54Commissioner of the Department of
00:56Behavioral Health and Intellectual
00:58Disability Services and in Connecticut,
01:00where he served as Deputy Commissioner
01:02of the Department of Mental
01:04Health and Addiction Services.
01:05In both positions,
01:06he left the transformation of their
01:09respective behavioral health systems
01:10and their approach to serving a
01:12wide range of individuals with
01:14complex needs over his tenure.
01:16The money each agency saved was reinvested
01:19into improving and expanding services.
01:21And employing innovative
01:22strategies to reach more people.
01:25Doctor Evans has always been
01:27an unconventional leader,
01:29employing science research,
01:30community activism,
01:31spirituality,
01:32traditional clinical care
01:33policy and cross systems,
01:35collaborations to change the status quo,
01:38and behavioral health to improve lives.
01:42Doctor Evans is held faculty
01:44appointments in our Department
01:46at the University of Pennsylvania
01:48School of Medicine and is an author
01:50of over 50 peer reviewed articles
01:53and numerous chapters reviews,
01:54editorials.
01:55He has received national and
01:57international recognition for his work,
01:58including the American Medical Association's
02:00top Government Service Award in Healthcare,
02:03the Lisa Mohair Tortoise Award
02:05from Faces and Voices of Recovery.
02:07The Visionary Leadership Award from
02:10the National Council of Behavioral
02:12Health and was named an advocate
02:13for action by the White House,
02:15is office of National Drug Control policy.
02:19A major emphasis of his career has been
02:21equity and social justice and need to serve.
02:24Multiple has received multiple awards
02:26named for the Reverend Doctor Martin Luther
02:29King Junior for his work in this area.
02:32Doctor Evans holds a doctorate in
02:33clinical Community psychology from
02:35the University of Maryland Masters
02:37degree in experimental psychology
02:38from Florida Atlantic University,
02:40where he also completed his
02:41undergraduate work and in his
02:43alumnus of our departments,
02:45doctoral Psychology Training Program,
02:46where he completed his internship in
02:48clinical and Community psychology.
02:50I'm pleased to have him join us
02:52today to speak to us about addressing
02:55the nation's behavioral health,
02:56the need for a population health perspective.
03:00Arthur
03:09I think you're on mute. Yeah,
03:10thank you. Sorry I I was trying to do
03:13screen share an on you at the same time.
03:15There was a little much so then we just
03:18have to get you into the slide show mode.
03:20OK, can you see my screen?
03:22I could see it but I can
03:24see all of your slides.
03:26OK sure yeah OK good.
03:28There were perfect, alright,
03:29so you have sound and you have
03:31visual so thank you very much Jack.
03:34I'm really happy to be here.
03:36I wish I could be there in person.
03:38For those of you don't know me.
03:40I know one question that is on your mind and
03:43let me just dispense of that real quickly.
03:46It's not Sally's or Pepees,
03:48it's modern and it's the clam pizza.
03:50One of the things one of the many
03:53things that I miss about being in
03:55New Haven where I was for many years
03:58so I don't have any disclosures.
04:00What I want to talk about
04:03today is population health,
04:05but I couldn't do this in this talk
04:08without paying homage to Tom Kirk,
04:11who you all know it was.
04:14Commissioner Ann passed away last year.
04:17Tom was one of the kindest people
04:20I have ever met, an with greatly,
04:23greatly influenced me and my career.
04:26My thinking, and you'll see vestiges of.
04:29Tom,
04:30throughout my talk and you'll
04:32see his influence on my career
04:34and how I've approached my work.
04:36Now.
04:36One thing that I do want to
04:39point out about Tom's impact.
04:41It was not only on in Connecticut,
04:43but it was really,
04:45nationally and internationally because
04:47he was the first commissioner in the
04:49country to adopt recovery as a frame for
04:52how we thought about and delivered services.
04:54And many people were talking about it.
04:57More and more program level,
04:59but understood that you have
05:01to change systems.
05:02In order to really have the
05:04impact on people's lives,
05:05and that's something that has stuck with me.
05:09Today we're facing multiple pandemics,
05:11and it's really a perfect storm when we
05:14think about the impact on our mental health.
05:18First of all, we started with a pandemic,
05:21which we know had significant.
05:24Impact on our mental health.
05:26The fear,
05:27the anxiety.
05:27If you remember in the very beginning
05:30there was a lot of uncertainty,
05:32but we do a stress in America survey
05:35each year and we saw for the first
05:37time after doing the survey for over
05:40a decade of the stress levels in
05:42America go up appreciatively right
05:44at the beginning of the pandemic.
05:46But then after the pandemic started,
05:48we discovered that we had these inequities
05:50and that there were certain communities,
05:53communities of color that were
05:54being disproportionately impacted.
05:56And so the impact on those communities,
05:58the increased loss and grief that
06:01those communities were facing in
06:03addition to the anxiety caused
06:05by being at greater risk than
06:07the rest of the population.
06:09Added to that that psychological
06:11distress that people were experiencing
06:14and then on top of that we had then the
06:16economic downturn,
06:18where millions of people lost their jobs.
06:20People lost their businesses,
06:22and we know from decades
06:24of research that that.
06:26Those kinds of economic stressors have
06:29an impact on suicide rates and an
06:32mental health rates and then on top of that,
06:35during the summer we started to have
06:38these incidents related to racial
06:41justice and what our stress in America
06:43survey shows is that those incidents not
06:46only affect people of those communities,
06:49but they have an impact on the broader
06:52population and then we had a very tumultuous,
06:56very tumultuous.
06:57Political environment culminating in
06:59January 6 with the attacks on the capital,
07:02which again was another set of stresses
07:05that we were able to document so we
07:08really have this perfect storm of a lot
07:11of issues and these layers have created
07:14a really unique set of circumstances.
07:17It's showing up in the data,
07:20so I've mentioned are stress
07:22and stress in America survey,
07:24which shows that 80% of Americans
07:26are saying that they are experiencing
07:29significant stress from the pandemic is
07:32showing up in our Health 6 and 10 people
07:36are reporting undesired weight changes,
07:38either gaining too much weight or
07:40losing weight that is undesired.
07:42And in fact the the weight changes
07:45were on average, about £60.00 for.
07:48I'm sorry, £29 for those who who.
07:54Gain weight and actually it was close to
07:57£60.00 for about 10% of the population,
08:00so some really massive weight gain
08:02for some individuals are the the
08:04medium was about 15 pounds of added
08:07weight that was not desired.
08:09Racine it in terms of sleep disturbances,
08:12people filling that they're not getting
08:14enough sleep or or too much sleep.
08:17We're seeing it in terms of increased
08:20alcohol use to manage one stress,
08:22and we're seeing it in.
08:24Symptomatology the rate of
08:26mental health symptoms,
08:28anxiety,
08:28and depression in particular is
08:31about three to four times what
08:34it was before the pandemic.
08:36We've seen increased overdoses.
08:39An increases in intimate partner violence.
08:43But we also have to put this
08:45in the context of how what was
08:48happening before the pandemic,
08:49and it suffice it to say that.
08:53Are milk behavioral health systems in
08:55the country were not really keeping
08:57up with the needs of the population
09:00and we had some some significant
09:03challenges like retention programs.
09:04Most of you know that the modal out
09:07number of outpatient sessions is 1.
09:10Most people come,
09:11they leave and we know that if
09:14you're not in treatment for a
09:17sufficient time that we're not going
09:20to get the outcomes that we need.
09:23That we have challenges around
09:25engagement of people having the
09:27right amount of treatment in
09:29transitioning from levels of care from
09:32between different levels of care.
09:34So.
09:36We have this perfect storm of
09:38issues that have created a really
09:41significant challenge for our country
09:42when I was growing up in Florida.
09:45As a little boy,
09:46we used to have these really
09:48intense thunderstorms.
09:50Lightning the Sky would get
09:52dark and and these intense
09:54rains and then you know a couple of
09:57hours later you would come out and the
10:00the the family dried up pretty much
10:02all the rain and if you very large
10:05building you couldn't even tell that.
10:07Sometimes if you had gone through
10:10this particular rainstorm.
10:11But then we also had tornadoes and
10:15hurricanes, and when you came outside,
10:19the world had changed.
10:22What worries me is that.
10:25I think many people in our population
10:27think that we have gone through a
10:30rainstorm when what we've really
10:32gone through is a hurricane,
10:33and our lives are going to change forever,
10:36but we certainly know that in the short term,
10:39over the next three to five years that
10:42we're going to be dealing with the
10:45results of chronic stress for over a year,
10:47and all of the things that I've
10:50laid out for quite some time so.
10:53No, the whole point of my talk
10:55is this is that we can no longer
10:57afford to do the same things and
11:00expect different results.
11:01I believe we have to change our
11:03paradigm not only because of the
11:06longstanding issues that we've had
11:07in our in our service systems,
11:10but because of this collective
11:12trauma that we've gone through as
11:15a nation in the long term.
11:16Impact that that's not going to have,
11:19and so I want to propose that
11:21our field needs to really adopt
11:24A population health framework.
11:25And I'm going to explain what that means
11:28and why I think it's so important for our.
11:32Our field.
11:33But if I'm going to ask you to
11:35adopt A new paradigm,
11:37at least I will start with what is
11:39the current paradigm.
11:40And this is what I think the the
11:42current paradigm is for our field.
11:46I I refer to it as a black box paradigm.
11:49This is the mental model that most
11:52of us who are trained in the field
11:55have and that is that we create a
11:58black box that could be a clinic.
12:00It could be doctor's office,
12:02it could be a hospital and the way the
12:05paradigm works is this people get sick.
12:08They come to us.
12:10We figure out what's wrong with him.
12:13We diagnose them.
12:14We treat what's wrong and
12:15we discharge them as you.
12:17Well people, that's a basic paradigm.
12:19So now if I were with you many people,
12:22many of you know that I am a Baptist,
12:26and when when I present I have to talk and I
12:29expect you to talk back and the first world.
12:33That's a little harder.
12:34So I'm going to tell you what you
12:38would have said if I were there.
12:40What you would say if I asked
12:42you to critique this paradigm,
12:44he would say,
12:45well, first of all,
12:46it doesn't really line up with the
12:48science of what we know about how
12:51mental health and addictions work.
12:52This is an acute care model for
12:54what we know are chronic conditions.
12:57You would probably say, well,
12:58you know many people never come to treatment,
13:01and so.
13:01This passive model of waiting
13:03for people to come to us actually
13:05doesn't work for a lot of people.
13:08We know that half the people who
13:09have a mental health diagnosis are
13:11never going to come to treatment,
13:13and 90% of those with a substance use
13:15problem or not going to treatment.
13:17So most of the people with behavioral
13:20health conditions in New Haven and
13:21every year the other place in the
13:23country are not coming to this black box.
13:25You would point out that when people leave,
13:28they're not well,
13:29and one of the challenges we
13:31have in our field is that.
13:32There is a Cliff.
13:34Often when people leave treatment
13:35and people don't get the
13:37immediate support that they need,
13:38the long term support that they often need.
13:41You would point out that it is a
13:43box and that that metaphor works
13:44well for what happens in many
13:46treatment programs because one of
13:48the things that we require people
13:50to do is to go to the right box.
13:53So if you have a core occurring
13:55condition and you go to a substance
13:57use box or a mental health box and
14:00that particular box doesn't have
14:01the expertise to deal with your.
14:03Problem sometimes we put the
14:05onus on the person.
14:07One of the things I started to do
14:09when I was when I was still doing
14:12active clinical work is to watch
14:15my language and not use language
14:17like recalcitrant or the person
14:19isn't ready or all of those kinds
14:22of that kind of language,
14:24because that's putting the honest
14:26on the person as opposed to us
14:29looking at are we meeting the needs?
14:31Have we modified our program in such a way?
14:34To respond to the unique needs
14:37of individuals,
14:37well, we could spend another 20 or
14:4030 minutes critiquing this metaphor
14:42and all of the reasons why this
14:44mental model doesn't work for mental
14:47health and substance use conditions.
14:49But I want to point out one thing
14:51that I think is the biggest challenge
14:54is it constrains our thinking
14:56because the focus is on treatment.
14:58If you ever watch.
15:01Television the talking heads
15:03from our field who come on.
15:05And you know,
15:06after some tragedy or something
15:08and they're talking about
15:09the need for mental health.
15:11What almost invariably people will
15:14say is we need more treatment.
15:17That's the solution if we get
15:19more people into treatment will
15:21solve this problem of untreated
15:23mental health issues and so forth,
15:25and I have spent my entire career
15:27over 30 years now believing in trying
15:30to get funding for treatments deal.
15:32Believe in treatment,
15:33but I want to suggest to you that
15:36treatment alone is not going to address
15:39the magnitude of the problems that we have.
15:42The 80% of the population that
15:44is saying I'm stressed and it's
15:46starting to affect my life.
15:48Or the people who are untreated
15:50and are not coming into treatment.
15:52And so I want to start to make a case
15:55for a different way of different
15:57paradigm than that black box model that
16:00we are most of us are trained under.
16:04So here is one way to look at the population.
16:07If you look at the population about 25%
16:10of the population has a mental illness.
16:13About 5% have a severe mental illness.
16:15We spend most of our money on that top 5%,
16:19about 80% and about 20% sold.
16:218020 rule here and about 20% on
16:23the 80% of people who don't have
16:26a severe mental illness.
16:27But we we miss or we don't spend any
16:31resources or very little resources on this.
16:345% of the population that doesn't
16:36have a diagnosis as mental health
16:38professionals we know that mental
16:40health is more on a continuum
16:43as opposed to a binary.
16:45Either we have a mental health couns or
16:47not and that we're moving up and down
16:51that continuum over the course of our lives.
16:54And some of us crossed that
16:56that that diagnostic threshold.
16:58Some of us are in recovery ourselves.
17:01But the problem with this paradigm?
17:04Is that many of the people who are
17:07in the 75% will be in the 25% some
17:11other point that in the future.
17:13But because we've ignored them and
17:16we've not tried to do any kind of
17:19early intervention,
17:20many of those people access
17:22treatment much later in the process.
17:24And when it's much more difficult
17:27to treat folks,
17:28let me give you another problem
17:31that our field has.
17:32Many of you know that that.
17:35Healthcare itself only accounts for
17:36about 10% of the variance in our
17:39health status that other things,
17:40particularly behaviors,
17:41have a much greater impact on where
17:44we live has a much greater impact.
17:46Robert Wood Johnson says.
17:47You know,
17:48our zip code is a much better
17:50predictor of our
17:51health status than our genetic code.
17:53Context matters are behaviors matter,
17:55and they matter.
17:56And when it comes to our health,
17:59much more than health care,
18:00but this year, we're going to spend
18:03about 3 1/2 trillion with a T.
18:05On healthcare and the question
18:07is that if that only accounts for
18:0910% of the variance in our health,
18:12what are we doing about
18:14those other areas that?
18:15That we know impact on health.
18:17The impact on our behavioral health.
18:19And I want to suggest to you that
18:22that there are things that we can
18:24do outside of health care that
18:26can have a profound impact on
18:28people's behavioral health status.
18:30Now we talk about a lot of those
18:32as social determinants and we
18:34know that many of these things can
18:37have a major impact and I'll give
18:40A at least a couple of examples
18:42of that in the presentation.
18:44Now, at this point,
18:45I would probably say to you are you
18:48with me and I can't see your face,
18:51but if you could just virtually nod.
18:53If you're still with me,
18:55I would appreciate that.
18:56I need a little bit of feedback here.
18:59Alright, so so.
19:00So what I've made the case,
19:02so I hope I've made the case that we
19:04have significant problems and we have
19:06a paradigm that is not equipped to
19:08deal with the magnitude of the problem.
19:11The complexity of the problem,
19:12and the known issues that we have with
19:14the way we've dealt with these issues.
19:16So I'm going to offer a different way,
19:19and this is what I mean by a
19:21population health approach.
19:23If you took that same population
19:24and you divide it into three
19:26people who are diagnosed,
19:28that's at 25% that we talked about earlier.
19:30But we also know in our communities
19:32there are people who may not have
19:34crossed that diagnostic threshold,
19:36but they're at greater risk.
19:37And if we spend a little
19:39time in about 10 minutes,
19:41we could identify most of the people
19:43in our communities who are at greater
19:45risk for having mental health challenges.
19:47And the question for us is what?
19:49What are we going to do about that?
19:52And then?
19:53There are people who are relatively healthy,
19:55so despite everything that
19:57I've I've talked about,
19:58there are still people who are doing
20:01quite well in our communities,
20:03so our strategies would look like this for.
20:07People who are in that top part of the
20:10paradigm, the pyramid it would be.
20:12How do we create effective and
20:14efficient clinical Care now?
20:15I think this is really important
20:18because when ever people talk about.
20:20Population health or using public
20:22health strategies in mental health,
20:24they hear that as we're going to
20:26turn away from our traditional
20:28work and now we're going to focus
20:31on the broader population,
20:33nothing could be further from the truth.
20:35Hospitals are a an important part
20:38of a public health system.
20:40Treatment is an important part
20:41of a public health or population
20:43health approach to mental health.
20:46And if we're going to have a really
20:49good population health approach.
20:51We have to make sure that treatment is
20:53as effective and efficient as possible,
20:55but we also should be and this is where we
20:58start to expand beyond the black box, right?
21:01And we're starting to get out of our
21:04four walls and starting to look at well.
21:07Who are those people in our community
21:09and how can we either mitigate risks,
21:11lower the risk that people are actually
21:14going to develop a problem, or a minimally?
21:16We are intervening at the earliest point.
21:19That's our goals for that group.
21:21And then.
21:21For people who are relatively healthy,
21:23it's how do we help keep people healthy?
21:27And for me this is in my work.
21:30In Philadelphia is probably one of the
21:32most interesting and exciting things,
21:34because it's something that our
21:35field has not done historically is to
21:38look at how we keep people healthy.
21:40We do that on the physical health side.
21:43We talk about exercise,
21:44we talk about wearing a safety belt
21:46where we talk about things to avoid so
21:49that we decrease our risk for cancer.
21:51We actually know quite a bit about the coral.
21:54It's of good psychological health.
21:56The question is.
21:57As a field,
21:58how are we helping to educate
22:00the public about that?
22:02So as many people as possible can
22:06stay psychologically healthy?
22:07So what I'm going to do at this point?
22:11The rest of my presentation is what I've
22:13tried to do is make a conceptual argument,
22:16but what I want to do is to give
22:19you a concrete examples of how
22:21we can actually do this,
22:23and I'm going to pull very heavily
22:25from my work and Philadelphia prior
22:27to me going to a PA where I was
22:30Commissioner essentially a single
22:32payer behavioral health care system,
22:34whereas Commissioner my Department had
22:36Medicaid dollars to state and local.
22:38Grant dollars children and adults,
22:41substance use mental health.
22:44So that's sort of the whole range
22:47of services,
22:48and so I'm going to pull different
22:50examples just to illustrate how
22:52we can as a field implement a
22:55population health approach.
22:57So let's start at the top of the
22:59pyramid and talk about effective
23:01and efficient clinical care.
23:06So most of you know that that we have a
23:08gap between what we know from the science
23:11and what is widely practiced in the field,
23:14and one of the things that we tried
23:16to do in the Philadelphia system is
23:19to close that gap so that we had as
23:22much of our system operating and using
23:24evidence based treatment approaches.
23:26These are just some of the
23:28initiatives that we use,
23:29and I'm going to take one of them
23:31and sort of illustrate why it's
23:33important for us if we're trying to.
23:36Improve clinical care to be very
23:39systematic about implementing
23:41evidence based treatment strategies
23:43and so one of the people we work
23:46with was Aaron Beck and trying to
23:48get CBT throughout our mental health
23:51and or behavioral health system.
23:53And so we were implementing
23:56in all kinds of settings and.
23:59Substance use in children settings,
24:01outpatient, inpatient,
24:01and one of the challenges,
24:03and I should say this 'cause I know
24:05there are a lot of people who are
24:07probably listening is very interested in.
24:09Ebp's aren't thinking around
24:14EBP implementation.
24:16Transition and transform overtime
24:17in the very beginning we were very
24:20focused on training clinicians
24:21and then we figured out that,
24:23you know, training clinicians.
24:24It's not where it's at.
24:26We really need to think about how we build
24:28capacity at the organizational level.
24:30And then we evolved to really what we
24:32need to be thinking about is how do
24:35we create an evidence based treatment
24:37system and so over time would happen
24:39is we started to ask the question,
24:41not how do we get more EVP's
24:43out into the system,
24:45but how do we use EVP's to address
24:47the challenges that we're having?
24:49In the system and so that sort of
24:52frame that frame that change in that
24:55framework actually really was quite useful.
24:58And here's an example.
25:00So we had a service called extended
25:02Acute Inpatient Program 00 hospital
25:05based programs for people who did
25:08not get better after a traditional
25:11impatience day and so historically
25:13those people would have gone to state
25:16hospitals or when those beds closed,
25:19we built those.
25:20Services I was long term longer
25:22term beds in the community,
25:24but what happened?
25:25Overtime was the length of stay
25:27started to go up.
25:29To the point where we had some
25:31people that were in inpatient
25:33units for six months up to a year,
25:36sometimes more than a year.
25:38And you can imagine that's not
25:40good for anyone,
25:42particularly people who have
25:43very serious mental illnesses.
25:45So we did, was we use a mill.
25:48You approach using recovery
25:50oriented cognitive therapy.
25:52Train everyone on the unit,
25:54including the people who
25:56brought out the food.
25:57The lease on the concepts,
26:00and here are some of the results
26:02that we got by doing that.
26:05We cut the length of stay in half.
26:09We reduce the salt,
26:10we reduce restraints and seclusion.
26:12We reduce the need for I am medication.
26:16We reduce.
26:17Well we increased the
26:18number of people moving
26:20out of that very high.
26:22$700.00 a day service. Into the community,
26:25and it was simply by using what the
26:29science says around one of the best
26:33approaches to treating people want
26:35to share with you another strategy.
26:39Using financial levers just go
26:41through this one pretty quickly.
26:43This is a you could look at the
26:46numbers on the left side there.
26:48Those are actually hospitals.
26:50This is sort of sample data.
26:54Going across, going across the
26:57columns are things that we measured
27:01providers on and what we did was to.
27:06Measure providers you know
27:07they get a green, red,
27:09yellow took the top performing providers,
27:11paid them a performance payment
27:13if they met certain criteria.
27:15Now what was interesting about this
27:18is that hospitals we've been saying
27:20to hospitals for years that we need
27:22you to improve your continuity of
27:24care rates and essentially what
27:26they said back to us as well.
27:29You know,
27:30we really can't do anything about that.
27:32That's the outpatient system.
27:34Our role is to treat.
27:36You know the cute illness and
27:38then to discharge.
27:39And it's really up to the
27:41outpatient system to pick people up.
27:43Well,
27:43interesting thing happens when we
27:45started to pay for performance.
27:47So the first year we did it and
27:49because we paid providers based
27:51on their their volume and their
27:53and their revenue,
27:54some of the providers are top performers.
27:56Actually got hundreds of thousands
27:59of dollars in performance payments
28:01in the first year.
28:02Well,
28:03the provider who was at the
28:04bottom of the distribution,
28:06obviously doing performance payment
28:08comes into us and you know,
28:10says you know well,
28:12what can I do around improving
28:14continuity of care.
28:15So we shared with him some of
28:17the things that some of the other
28:20providers were doing really interesting.
28:22Thing was at the very next year
28:25that same provider was at the
28:27top of the distribution and so
28:29this notion that people couldn't
28:31do couldn't make these changes.
28:34Actually change it pretty quickly.
28:36Once we introduced financial
28:38incentives and let me just show
28:41you a few other levels of care.
28:43This is the dropout rate.
28:45So for ASD or autism spectrum disorder,
28:48these are services for children
28:50had 2/3 of people of the children
28:53in those services dropping out
28:55after two sessions or fewer.
29:00We introduce pay for performance and
29:02you can see the dramatic decrease,
29:05so improving retention rates.
29:06This is the transfer rate from
29:08residential programs to inpatient
29:10program programs for children,
29:12and so we're trying to do is get
29:16those providers to do a better
29:18job of managing those children
29:20and not just referring them out.
29:23And you can see what happens once you
29:27introduce financial incentives or this.
29:29Other data that shows.
29:32Contact of targeted case management
29:35services for people in patient.
29:38So another strategy for
29:41improving clinical care.
29:46We also have to make sure that we're
29:49not only using evidence based practices,
29:52but we also need to individualize and
29:55have strategies for those things that
29:58we know have are related to outcomes.
30:01So what you're looking at here is
30:04penetration data and penetration data
30:06is simply the proportion of people who
30:10are in a an insurance program who are
30:13accessing the behavioral health benefit.
30:15So if you have Blue Cross Blue shield,
30:18typically 3 to 5% of people who
30:21have Blue Cross Blue shield will.
30:24Access to behavioral health benefit
30:25well in the Medicaid program,
30:27it's actually pretty high,
30:28so like 20% and you could see
30:30that it was improving overtime for
30:32both children and adults.
30:34But if you disaggregate that data,
30:36you get a very different picture.
30:39What you see is that for
30:41whites and Hispanics,
30:42pretty high penetration
30:43for African Americans,
30:44half of that and for Asians half of that.
30:48So disaggregating the data on
30:50based on things that we know affect
30:52outcomes is extremely important.
30:54Then the question is, well,
30:56what do you do about that?
30:58In this case,
31:00some researchers at University of
31:01Pennsylvania, I mean Rothbart and her.
31:04Colleagues.
31:05Did the interesting thing,
31:07but they did what you see here is a map
31:10of Philadelphia an explain this real quickly.
31:13What she did was she did a Geo mapping
31:15and she mapped the utilization
31:17rates were African Americans that
31:19where providers were an essentially
31:21what this data told us was that.
31:23In the areas where we had high
31:26concentrations of African Americans,
31:28we had low utilization rates
31:29and what explained that?
31:31Or one of the things that explained that,
31:33was that we also had fewer providers.
31:36Given the density of people that
31:38we had in those communities.
31:40So the solution here was to then
31:42do RFP's in those particular
31:43areas where where we had a higher
31:46concentrations of African Americans
31:48low utilization and I point that out
31:50because a lot of times when we're
31:53thinking about how do we help.
31:55Communities of color or routes
31:56that were not being well served.
31:58We talk a lot about cultural competency,
32:01but sometimes it issues are at the
32:03systems level and the only way we're
32:05going to know how to address those issues
32:08is to have that systems level data.
32:10Now we did in fact require that those
32:12providers be culturally competent,
32:14but cultural competence in the absence
32:16of dealing with the structural issue
32:18was not going to get us there.
32:23So those are examples
32:24from a real life system,
32:26but at a PA we are adopting this
32:28population health approach as well,
32:29and so as I go through,
32:31I just want to share with you a couple of
32:34examples of things that we're doing at a PA.
32:37One of the major things that we're doing is.
32:41Especially during the pandemic,
32:43is really looking at the issue of
32:45Tele Health and making sure that
32:47we are that Tele health services
32:48are available to people because
32:50we know that that will make a huge
32:53difference in people's access to care.
32:57So what about risk? So if.
33:00Tomorrow we gave you the keys to the
33:02mental health system and said look,
33:03we want you to implement a.
33:05A population approach?
33:06How would you think about the
33:08at risk communities or at risk
33:10individuals in the community?
33:11So I think there are two
33:13ways that we think about it.
33:15I think about it.
33:16One is what are things
33:18that put people at risk?
33:20And are there groups
33:21that are at greater risk?
33:23And so one of the things
33:25that we know puts people at
33:27risk is experiencing trauma,
33:28particularly childhood trauma.
33:29So most of you probably
33:31familiar with the Aces studies,
33:32and so one of the things that we did well,
33:36this is a map of Philadelphia.
33:37What you see here are evidence based
33:40treatment programs throughout the
33:42system that we built up over a few years.
33:45So after a federal grant,
33:47what we did was we started to
33:49screen children for traumatic stress
33:51in pediatric settings in either
33:54pediatric primary care settings
33:56or even mental health settings
33:58and what we found is about 30% of
34:01those kids in Philadelphia were
34:04screening positively for traumatic
34:06stress and once we identify them
34:08we were able to refer them to.
34:11These are men in space.
34:12Treatment programs is probably one
34:14of the most important things that I
34:17felt that we did in my tenure because.
34:19Those of you particularly work
34:21in substance use programs,
34:22but mental health programs as well
34:24know that that there are a lot of
34:26people that were treating in late
34:28adulthood who had experienced early
34:30childhood trauma that was never identified.
34:32Many of those individuals
34:33develop substance use problems.
34:35They don't develop other problems.
34:36It really changes their life trajectory.
34:38And so if we can be systematic and
34:40identifying those children early
34:42on and getting them connected
34:43to the services that they need,
34:45it can make a big difference in their lives.
34:48Another strategy we started to think
34:50about trauma from a public health
34:52standpoint from not just thinking about it.
34:54As something where we treated an
34:57individual but more like a contagion
34:59that was in a community and that we
35:01needed to have Community level interventions.
35:04So one of the strategies that we
35:06employed was just making sure that
35:08whenever there was a traumatic
35:10event in the community,
35:12we sent people in the community
35:14who were trained in psychological
35:15first aid to provide support to help
35:18educate people about what a normal
35:21trauma response was and to give
35:23people resources so that if they.
35:25Started to experience difficulties
35:27that they could get connected to
35:29care earlier and that work actually
35:31transitioned over time and it
35:33moved from professionals.
35:35Quote unquote going into communities
35:37doing that work to training people
35:39in those communities themselves to
35:41be peer to provide peer support to
35:44their other neighbors when these
35:46events happen.
35:47And so in the city after every major
35:50kind of traumatic event where there
35:52was a shooting in a community, or.
35:56Building collapse or whatever it
35:58was there was almost
36:00always a behavioral health response to that.
36:04So that that is.
36:07A something that happens to people
36:09that puts them at greater risk.
36:12Homelessness is an example of a social
36:16determinant that can have a profound
36:19impact on people's mental health so.
36:23One of the strategies that we
36:25employed was using multiple pathways
36:28off of the street that was really
36:30grounded in this notion that the
36:33best way to help people who are
36:35homeless is to give them a house or
36:39to provide housing for them and so.
36:43In a partnership that was set
36:45up by the Mayor of Philadelphia,
36:48then Michael Nutter,
36:50he negotiated about 200 Section
36:528 vouchers and So what we did
36:55is we leverage Medicaid dollars
36:57by providing services.
37:01Compare that with housing dollars to
37:03provide housing for individuals who
37:05are living on the streets and not just
37:08people who are living on the streets,
37:10but people who were who
37:12were chronically homeless.
37:13That means that they have been living on
37:16the Street seven, 10-15 years sometimes.
37:19Most people in most communities
37:21give up on these individuals.
37:24But a really interesting thing
37:25happens when you change the approach,
37:27because what we have been doing is the black
37:30box model of let's get people into treatment.
37:33Let's stabilize them and then
37:35we can if we stabilize them.
37:37Perhaps they can get a job
37:38and they can get housing.
37:40That was the model that we were
37:43using that was a failure.
37:44It helped some people,
37:46but for most people it didn't work.
37:49Interesting thing happens when you
37:51can go to someone and say look,
37:53we're using a housing first model.
37:55For example,
37:56we can get you directly into housing.
37:59Will you go?
38:00Many more people were able to many more
38:03people agreed to go into housing support
38:05of those people with mobile services.
38:08But we also created other pathways because
38:11that pathway doesn't necessarily work
38:13for people who have chronic longstanding
38:15substance use programs with problems,
38:17and so for them we created a different
38:20pathway which relied on long term
38:23residential care up to a year.
38:25I remember when we ran a managed care
38:28program and when I said to our staff.
38:31We're going to authorize people for
38:33up to a year in residential care.
38:35I saw a lot I rolling.
38:37I was like what is he talking about is like,
38:40yeah,
38:40well,
38:40we know from the research that the
38:42longer people stay in these programs,
38:44the better shot that they have.
38:46And for people who've been living
38:48on streets for a very long time,
38:50that was very important.
38:51Turns out that most people
38:53didn't need that long,
38:54but just the psychological stress
38:56that we removed from people
38:57within people told us this.
38:59It was like, OK,
39:00I'm in a place I can get better before I.
39:03Move out well at any rate,
39:05what we're able to do is to
39:07get people into housing 89%.
39:09When we looked a year later,
39:12we're still in housing,
39:13but let me show you a little
39:15bit of the cost data.
39:17This shows you the first, really.
39:21Light blue bar. Over here I'm just
39:23going to take one of the pathways.
39:26These are different pathways.
39:27You can see the different costs based on
39:30the clinical presentation of the individuals.
39:32This is a harm reduction
39:34strategy that we use.
39:35You can see that two years before the person
39:39was house they were causing about $85 a day.
39:42Then as we engage people you can
39:45see the costs start to go up.
39:47But look what happens the
39:49year that the person's house.
39:51$18.00 a day.
39:52So we ended up saving literally
39:54millions of dollars.
39:55People were able to get into
39:57housing and be successful.
39:59The streets of Philadelphia
40:00were better because,
40:01you know, we were able to
40:03get people off the streets.
40:05It is a win win and it was simply by
40:08understanding that treatment alone,
40:10even though many of the people who are
40:13homeless have mental health issues,
40:15was not going to get us there.
40:17We had to deal with the social determinant
40:20of housing and when we do that.
40:22We can get pretty dramatic effects.
40:25One other example,
40:26this is about the population.
40:28I've talked about things that
40:30make put people at risk,
40:32but sometimes we have populations
40:34that are at risk and one of the
40:37roots is men and boys of color.
40:40And so we understood this group
40:42will know that that many of the men
40:45of color are disproportionately
40:47have behavioral health challenges,
40:49or disproportionately incarcerated.
40:50They just personally end up in hospital.
40:53Urgency Department as opposed to treatment,
40:55and so we we decided we were going
40:58to try to change the change that
41:01dynamic and one of the ways we
41:03wanted to do that is it sort of
41:06change the narrative around mental
41:08health for men and boys of color.
41:10These are Asian American,
41:12Latin X and African American.
41:14And here's just one example of that.
41:16Using storytelling as a strategy
41:18with this group,
41:19we put out a call to ask men if they
41:23would be willing to tell their story.
41:27And we use different language.
41:28We didn't talk about mental health,
41:31we didn't talk about psychopathology.
41:33What we talked about is your
41:35stories around mental strength.
41:37And we talked about psychological well
41:39being and psychological health and not
41:42sure that people were going to do it.
41:44Actually,
41:45men from all kinds of backgrounds
41:47ended up volunteering to do this.
41:50We coached them from that.
41:51We were mental health people.
41:53We we partnered with a.
41:56Storytelling organization First
41:57person arts in Philadelphia.
41:59We got a popular,
42:00uh well known person from the city.
42:03The person up here at the top is a.
42:08Actor from a program called Empire is
42:11actually from Philadelphia and so we got,
42:14you know,
42:15celebrities to have a little star power.
42:18Interesting thing happens,
42:19so we have these storytelling events.
42:21These men from different cultural
42:23backgrounds telling stories,
42:25their stories of psychological health.
42:27First time we do it,
42:29we get about 300 the Phillip division.
42:32So it's 300 people come out
42:34Friday night and we always have
42:36a top back where people have an
42:40opportunity to talk to the audience.
42:42About what they heard or the
42:44audience to talk to that to the
42:47presenters about what they heard.
42:49The first time we do it with 300 people,
42:526 next time we do it 600 people.
42:55The next time we do it,
42:571000 people and what started to
42:59happen is many of these individuals
43:01and there were other events,
43:03but the what started to happen
43:05is that we started to change the
43:08narrative around mental health and
43:10mental Wellness for men of color
43:12an so that we could get people
43:14one more activated around their
43:16own mental health but
43:18also seeking out help when they.
43:20Needed it similarly for people.
43:22This something that we're
43:24doing at a PA which is too.
43:28Create tools for frontline health
43:31care workers to help them manage their
43:35stress envivo on during their shift.
43:38It's based on psychological science and
43:42what we essentially done is to say.
43:45Here's an exercise that you
43:47can do to manage your stress.
43:49Here's the science behind why it works,
43:52and it's another strategy to try to reduce
43:55risk of people developing other problems.
43:58OK, so homestretch,
43:59let me just give you the last group here.
44:02Keeping people healthy and thinking about how
44:05do we work with communities who are healthy.
44:08So one of the strategies that we're actually
44:11doing at Appa is working with leaders,
44:14CEOs, and.
44:15Political leaders,
44:16and the reason that we're doing that
44:18is that as a leader, if you're a CEO,
44:21if you're a school Superintendent,
44:23if you're a teacher.
44:25The way you conduct your work and the
44:28way you do your work and create a
44:31toxic environment or it can create an
44:35environment that's more psychologically
44:37healthy and so one of our strategies
44:40is to help leaders understand the
44:42coral it's of environments that
44:45create psychological health.
44:46In fact,
44:47we have a program called psychological,
44:49psychologically healthy workplaces,
44:51and it's based on the science around
44:54what we know about what actually.
44:57You know the environments that
44:59actually create psychologically
45:00healthy work environments?
45:02Interesting thing is that.
45:04That CEOs get that this pandemic has had
45:07a big impact on them on their workforce,
45:11and they're actually paying a
45:13lot of attention to it.
45:15So it's another strategy where we,
45:17as mental health professionals,
45:19can have an impact on larger groups of
45:22people simply by helping leaders in
45:25those other systems and organizations
45:27understand how their role can
45:29promote people's mental health.
45:31Another strategy is just to go
45:33out into community,
45:34so getting out of the black box,
45:36going into communities,
45:38doing community screenings when we when
45:40we first started doing this we started.
45:43Going to train stations,
45:44libraries and people said, you know,
45:46look people are never going to
45:48go up to a table in Philadelphia.
45:51That's about mental health and
45:53talk to someone,
45:54let alone do a screening.
45:55Turns out that actually people do an.
45:58In fact, people are wanting that
46:00they will come up and they'll say,
46:02well, you know, I've been,
46:04you know, feeling pretty depressed.
46:06Or you know my husband or my
46:08daughter is having problems.
46:10How can I get help and almost?
46:12Every time that we did this,
46:14there was at least one person who
46:16came up to the table who was suicidal.
46:19I always wonder what would have
46:21happened if we weren't there that day,
46:24and what happens every day?
46:25Because we're in our black box when
46:28the problems and the challenges
46:29are are in our communities.
46:31I have a belief that inherent
46:33in every community is wisdom to
46:35solve its own problems.
46:37These are members of the Burmese
46:38and Bhutanese communities in
46:40Philadelphia. Very small immigrant
46:41community and it's easy to.
46:43Miss these folks, but if you go to
46:46these communities who often have
46:48significant mental health challenges
46:50and you expect them that they're going
46:53to come to our traditional treatment
46:55approaches or treatment systems,
46:57that doesn't work.
46:58It's an unrealistic expectation,
47:00but if you go to them and
47:03you ask those communities,
47:05what are the challenges that they're facing,
47:07and what did they believe the solutions
47:10are they those communities can help.
47:13Designed the interventions that
47:15their communities need and in the
47:17case of the Burmese and Bhutanese
47:19communities they said look,
47:20let's create rather than asking our
47:22people to go to traditional programs.
47:25Let's take a mental health professional,
47:27embed them in the places where
47:29our people are already going.
47:31In this case a storefront program
47:33where people are going for
47:35English as second language.
47:36That kind of thing and that mental
47:39health professionals either help people
47:41within that context or they help to
47:43connect them to a culturally competent.
47:46Provider,
47:46that's a solution that.
47:49He never would have come up with,
47:51but because we were going to
47:53listen to bring our resources,
47:55our expertise and marry that with the
47:57knowledge and wisdom from the community,
47:59we were able to get a solution
48:01that reach many more people.
48:03And so here's my last example.
48:05This is this is a mural.
48:07If you ever been to Philadelphia,
48:09will see murals all over the city.
48:11This is taken from about a mile
48:14away so it gives you a sense of
48:16the size of some of these murals.
48:19Which are actually painted by the community,
48:22the city's mural arts program.
48:25Goes into communities.
48:27They engage people around a topic
48:29and then the community comes up
48:32with the concept and they actually
48:34paint the mural well.
48:36When I first heard this,
48:38I got really excited because we
48:41were struggling with this idea
48:43about how do we engage people?
48:46How do we engage people around
48:49issues around mental health an?
48:52And so I asked,
48:53if you know,
48:55could we partner around some mental
48:57health topics and we actually started
49:00a collaboration that actually is
49:02still going on today and some of
49:05the topics that we started to engage
49:08communities around where issues
49:10like recovery and trauma is one
49:14of the first ones that children's
49:16trauma or in the Latin X community.
49:19Talking about immigration and the
49:21impact and the struggles that
49:23communities have around immigration,
49:25this is one on suicide over 1000
49:28people worked on this mural and if
49:30you could look over to the right
49:33you can see these portraits so many
49:36of the people were family members
49:38of people who died by suicide.
49:41Some of them were were people who
49:43were survived suicide survivors.
49:45These portraits are people who
49:47died by suicide. It was a way of.
49:50People who came together to talk
49:53about their experiences honoring
49:55their family members and friends
49:57who died by by suicide.
49:59And, you know,
50:00one of the things that happens with
50:03suicide is that many of the families you
50:07know pretty isolated because of that.
50:10People don't talk about it is
50:12openly and so over the course of
50:15over a year there were series of
50:18workshops around suicide and suicide.
50:21Prevention and people coming
50:22up with this this concept.
50:24There were a lot of firefighters who
50:26had had probably about five or six
50:29firefighters who died by suicide,
50:30and you know the previous couple of
50:33years and a lot of them participated so.
50:36Just another example,
50:37and this is one last example.
50:39This particular one is in a methadone clinic,
50:42and because the community and the
50:44methadone clinic worked together
50:46on this mural, it actually changed
50:48the dynamic between that provider,
50:50an the community and I always said,
50:52you know,
50:53if we were to go into community and say hi,
50:56I'm doctor Evans,
50:57I'm here from the mental health Department.
51:00Would like to talk to you about
51:02suicide or have a community meeting.
51:04You know we get like.
51:06Three people and two of them
51:08would be related to me,
51:10but you know,
51:11when you can use the resources that
51:13are already in the community and make
51:15those connections that can make a big
51:18difference in our ability to reach people.
51:20And I just want to say and give
51:22a public shout out to Jack teams
51:24who evaluated this and this.
51:26This program and essentially found
51:28that even for people who were not
51:30directly working on these murals,
51:32it had an impact in the community.
51:34So thanks to Jack for demonstrating
51:36that we were on the right track with.
51:39This work?
51:39So that's what I mean by population health.
51:42So what I hope I've done is to share with
51:45you conceptually why I think it's important,
51:48but also to demonstrate that it can be done.
51:51But we can reach people
51:53that were not reaching.
51:54We can make a difference in the
51:56outcomes that people can get.
51:58We can.
51:58We can make a difference in the lives
52:01of children and people that frankly
52:03a lot of our society has given up on.
52:06But it's going to take us being willing
52:09to push out of our black boxes into.
52:11Innovate and to frankly take some risks.
52:14So about now people will say,
52:16well,
52:16you know how do we pay for all of this and.
52:22The first thing my first response is
52:25how we think is free and just as we have
52:28a mental model and we're training on
52:30mental model to think that people should
52:32come to us and we should treat them,
52:35we can have a different model that that
52:37is about how we can take our expertise
52:40and use that expertise in all kinds of
52:43settings in all kinds of different ways.
52:45But we also know that there is a
52:47paradigm shift in how Healthcare
52:49is going to be financed,
52:51and while now we have a fee for service.
52:54Paradigm which generating more revenue
52:56means just doing more services,
52:59independent of the outcomes that people get.
53:02Increasingly,
53:02our healthcare system is moving
53:05to a pay for performance or a a
53:09performance based way of financing.
53:11In particular putting healthcare
53:13systems at financial risk.
53:15Where where you know provide assistance
53:18will be given a pot of money.
53:21A population of people and.
53:24When that happens,
53:25it changes the financial incentives.
53:27Now there is a very strong incentive to
53:30provide effective and efficient care.
53:33There's a very strong incentive
53:35to reduce risk and to intervene
53:37at the earliest possible moment.
53:39There's a very strong financial
53:41incentive to keep people healthy,
53:43and so over time we're going to see
53:46as accountable care organizations,
53:48health homes,
53:50those kinds of alternative payment
53:52arrangements start to emerge.
53:55There will be a very strong
53:57financial incentive to do this.
53:59Going to end with just a
54:02couple of words about.
54:04Implications obviously for our field,
54:06we have to start thinking about
54:08how we work further upstream,
54:10how we address social determinants.
54:12We need to have more research in this area.
54:15We need to be training our our
54:17folks around how to pay attention
54:20to social determinants.
54:21We don't have to solve all of these problems,
54:24but we have to include them in
54:27our conceptualizations of how
54:29we work with people.
54:30We have to partner with other people who can
54:33help us address some of those determinants.
54:36But if we don't think about them,
54:37we're not we're going to miss that.
54:41We have to look at how we
54:43help keep people healthy.
54:45I'd like to see more research on the
54:48recovery process an and helping us
54:50to better understand strategies that
54:52we can employ to keep people healthy.
54:55So the point is that I think we have
54:58a lot of room here to change our
55:01system and I want to end with this.
55:04You know,
55:05yell is one of the Premier academic
55:07medical centers in the country,
55:09right in the world.
55:11For that matter,
55:12and if we're going to make these
55:15kind of changes,
55:16it's going to take the yells of the world,
55:19helping to do do that.
55:21The picture you're looking at is
55:23what the people who were doing the
55:25first recovery walk in Philadelphia.
55:27They had about 150 people,
55:29and these people understood that that
55:31we needed to change the paradigm if
55:34we're going to make a difference in
55:36people's lives, and so they were
55:38trying to put a face on recovery, Anne.
55:43And to change the paradigm so that
55:45people wouldn't be ashamed of being
55:48in recovery that same walk today
55:51looks like this like 26,000 people
55:53that come and all kinds of people,
55:56not just people in recovery.
55:58These early pioneers were really
56:00important in helping to shape and
56:03change the paradigm and the way I
56:05see are moved to population health.
56:08It really is about a movement.
56:11It was really clear to us.
56:13As we got into the later stages
56:15of this work that that it was more
56:18than just changing our thinking,
56:20it was really changing how we relate
56:23it to the community and bringing
56:25the community into how we work.
56:31A huge difference in a lot of people's lives,
56:34and I think that as a field we can
56:36keep pushing the envelope to do that.
56:39So with that, I'm going to say thank you
56:41and we'll see what questions folks have.
56:47Thank you so much Arthur.
56:49Just a really. Inspiring talk that
56:53you gave every time I I hear you,
56:57I learn something more and inspired
56:59by you so there's opportunities
57:01for folks to ask questions either
57:04directly or through the chat.
57:06Be happy to monitor that and and pass that
57:09along and so as you develop questions,
57:13I have one I can get you started
57:15with with Arthur is so you're
57:18talking about a change effort,
57:21a significant change effort.
57:22And you need both people that are staff
57:26and partners and allies to help do it.
57:29But then you're also going
57:31to encounter individuals.
57:33Systems that resist it.
57:34What have been some of your
57:36strategies to deal with both of those?
57:39Those
57:40dynamics? That is such a great question
57:42and is reason why I always in my talks
57:45about talking about a movement when you
57:47know one of the strategies we employed
57:49was to engage the faith community.
57:51We had these really large conferences
57:53and one day one of the members
57:56of the was actually a clergy.
57:58He stood up and said,
57:59you know, Doctor Evans,
58:00you all were trying to change the system,
58:03but what you really did was you.
58:05You created a movement and I was
58:08like that really crystallized for
58:09me because there was a point at
58:12which it was clear that we were
58:14no longer driving the train that
58:16there had been enough change in
58:18the community that people were.
58:22Working differently and
58:23approaching issues differently,
58:25we had nothing to do with.
58:28And I wish I had known that before because
58:31I would have been much more intentional
58:33about trying to build the choir.
58:35We now we we actually did that because like
58:37the first picture I showed you is just
58:40a few people who kind of believe in this.
58:42I mean, I'll tell you,
58:44I'll tell you this story.
58:45When I when I went to Philadelphia,
58:48they really didn't trust me right?
58:49Because, you know,
58:50at the time I I was working for a.
58:53Republican governor and a really
58:57heavily Democratic state.
58:59The city can be pretty parochial,
59:01and you know they're like you know what's
59:03this yell stuff you know and you know
59:06Republican Connecticut would you know?
59:07Would you know?
59:08And there was a lot of this.
59:10You know, folding of the arms
59:12when I was talking about recovery.
59:14And you know some of these new
59:16ideas and so there was a really.
59:18But there was a really small
59:20group of people who were really
59:22committed to these ideas.
59:23They were already ahead of me right
59:25there ahead of where I was thinking,
59:27like really pushing,
59:28and that group just grew and grew.
59:30And grew in one of the reasons
59:33that it grew was because.
59:35It was about giving voice to people who
59:37hadn't had voice before it was about.
59:40We did a lot of work around peers,
59:42an empowering people to, you know,
59:44we really took to heart that idea
59:47of nothing about us.
59:48Without us, you know.
59:49So we engaged communities.
59:50So at some point it was less about
59:53us trying to change and more
59:55about people in the Community,
59:57saying this is what we want.
59:58This is what we need and they were
01:00:01driving and they were saying to
01:00:03the providers you need to make.
01:00:05These changes,
01:00:06so I think it's about thinking
01:00:08differently about it.
01:00:08How do we engage people?
01:00:10How do we give people voice?
01:00:12How do we empower people?
01:00:13And yeah,
01:00:14we there are technical things and
01:00:16I showed some of the technical
01:00:18things that we did,
01:00:19but I think what really changed was
01:00:21people who would lived experience
01:00:23who just said we got to do this and
01:00:26they put the pressure on a lot of
01:00:28people who were resistant in the beginning.
01:00:32We thank you. Other
01:00:34questions for Doctor Evans.
01:00:42Hi, could you say more about
01:00:44the work that you've done with
01:00:46the believe it was CEOs and
01:00:48organizations and how they help them?
01:00:50Think about organizations and
01:00:52health promoting environments?
01:00:55Yeah, we we got a PA where
01:00:58we actually spend quite a bit
01:01:01of time talking to leaders,
01:01:04mayors, working with National
01:01:07Governors Association or.
01:01:09School superintendents,
01:01:10through the PTA, and so forth,
01:01:12and what we're trying to do is to
01:01:14help educate them about the role
01:01:16that they can play in creating
01:01:20psychologically healthy workplaces.
01:01:21In fact, we can send folks if you're
01:01:24interested in that that we can send
01:01:26you some information about that.
01:01:28But there are five domains that
01:01:30we look at that we know are
01:01:32related to healthy workplace.
01:01:34We actually give award each year.
01:01:36We didn't do it last year during
01:01:38the pandemic, but you know,
01:01:40corporations like Marriott and
01:01:42other corporations like that have
01:01:44received that award because they.
01:01:46Done, I've been very intentional
01:01:48in those five domet domains
01:01:50in helping their work places,
01:01:53so one of the domains,
01:01:55for example,
01:01:56is employee engagement as an example and so.
01:02:01We think that that's a really important
01:02:04thing that we can do as a mental
01:02:07health field to help individuals.
01:02:08We don't have to necessarily
01:02:10just provide direct services.
01:02:12We can also help those organizations
01:02:14change their organizational climate.
01:02:18Thank you bye bye. I'd love to see more of
01:02:21that. Thank you. OK, I think does
01:02:24everyone have access to the chat?
01:02:27Yes. I have a colleague on who
01:02:32might be able to get into the chat.
01:02:35A link to the the psychologically
01:02:38healthy workplace work.
01:02:41Great will look for that.
01:02:45Other questions comments.
01:02:58Great talk. Really enjoyed it, thank you.
01:03:03Good, thank you.
01:03:08I have another question.
01:03:10I'll just jump in again.
01:03:12Can you say more about what
01:03:14AP is doing around racism?
01:03:16I know I read a lot in terms
01:03:19of reports and studies,
01:03:20and if you could
01:03:22just kind of give an overview of maybe
01:03:25some of the things that
01:03:27you're doing or finding.
01:03:28I think that would be really helpful.
01:03:31Sure, so right after George Floyd's death,
01:03:34we made a real long term commitment to
01:03:37addressing issues of race and racism.
01:03:40We have a multi pronged commitment.
01:03:42First of all, Appa has been involved
01:03:45in these areas for quite a bit of time,
01:03:48but one of the things that we noted
01:03:52is that what happens is we have these.
01:03:56Incidents the public pays a lot
01:03:58of attention to these issues.
01:03:59They go away out of the news media.
01:04:02It's kind of quiet.
01:04:03Then another incident happens and
01:04:05we pay attention and then sort of
01:04:07this up and down and we decided
01:04:10after George Floyd's death that.
01:04:12This is a real systemic issue for
01:04:14our nation and that we needed to
01:04:16make a long term sustained have
01:04:18a long term sustained effort,
01:04:20and so we've done a couple of
01:04:22things in the aftermath of that.
01:04:25One is that we put together a a group to
01:04:28look at the psychological science around.
01:04:32Policing and whether there are
01:04:34things that we know and things
01:04:37that we can recommend that will
01:04:40reduce the likelihood that.
01:04:45Police will use a kind of force
01:04:48and violence that they're using
01:04:50with African Americans, men,
01:04:53and in particular the one group
01:04:56so that that group is ongoing.
01:04:59There's an initiative around HealthEquity.
01:05:02We're looking at again,
01:05:04a long term strategy around.
01:05:06First developing recommendations around
01:05:09things we can do as a field to improve
01:05:14HealthEquity and then to work with
01:05:16a partner with other organizations.
01:05:18To do that.
01:05:19We're also taking a look at ourselves
01:05:21because one of the things that
01:05:24we've heard consistently from
01:05:25communities of color is that our field
01:05:28psychology has contributed to some
01:05:30of the things that we we've seen.
01:05:33You know where they were talking about.
01:05:36Some of the eugenics movement we
01:05:38actually have people who were a
01:05:40PA presidents who were part of
01:05:42the eugenics movement, so.
01:05:44We we're we're not.
01:05:47We're also culpable as an organization,
01:05:50and so one of the things we are doing
01:05:53is taking a systematic look at our role.
01:05:56Our field's role in
01:05:58perpetuating racist ideas,
01:05:59and we're going to be engaging in a process
01:06:03to not only to identify that to make amends,
01:06:06but then to to really take
01:06:08on some of those issues.
01:06:11And we,
01:06:11you know,
01:06:12we suspect that that's going
01:06:14to mean that we're looking at
01:06:16issues like pipeline issues and.
01:06:18Who's coming into the field?
01:06:20We're going to be looking at research.
01:06:22Who are the people who are?
01:06:23Who are the editors of journals were
01:06:26already starting to look at that?
01:06:28And how do we diversify our field,
01:06:32and in particular those kinds
01:06:34of positions so that we have a
01:06:38field that is not only anti racist
01:06:41but also one that really?
01:06:44Incorporates the diversity of of our nation,
01:06:47and so it's pretty exciting the
01:06:49the to see the level of support we
01:06:52right after George Floyd's death
01:06:54have been the previous president.
01:06:56I have been doing town halls with
01:06:59our membership an right after
01:07:01George Floyd's death.
01:07:02We did a town Hall and the platform that we
01:07:06were using cannot hold all of the people.
01:07:09I mean,
01:07:10people really across the spectrum.
01:07:12From researchers and clinicians just.
01:07:14Across the field really felt strongly
01:07:16that this is something that we needed
01:07:18to take on as a as an organization.
01:07:22Thank you. I know Alyssa thank you
01:07:26very much for posting in the check the.
01:07:30Psychologically healthy workplace
01:07:32awards link so people can can follow
01:07:35up on an other thing that's mentioned.
01:07:37There's a question in the chat that can read.
01:07:41There's been talk about moving away
01:07:43from fee for service for decades,
01:07:45but yet it persists in part due to the lobby
01:07:48of hospitals and professional organizations.
01:07:51What makes you optimistic about future
01:07:53changes toward more population based focus?
01:07:56Well, I think I think it's going to be
01:08:00hard because as the question indicates
01:08:02that there are a lot of forces that
01:08:06want to maintain the status quo.
01:08:09The problem is if you look
01:08:11at health care inflation,
01:08:13it's been running about twice the
01:08:15inflation in the general economy,
01:08:17and it's been doing that for
01:08:20for a few decades now.
01:08:22So what's happening is that
01:08:24a greater and greater part.
01:08:26Of our GDP is being taken up
01:08:29by the healthcare dollar.
01:08:31It puts our our industries at a disadvantage.
01:08:34If you take a car, for example,
01:08:37and you look at the costs of producing
01:08:40a car in the US in the same,
01:08:43the cost of producing the same
01:08:45car in a foreign country of big
01:08:48chunk of the cost for a car in
01:08:51the US is related to healthcare
01:08:53unrelated to the actual vehicle.
01:08:57At some point we're going to reach a
01:09:00point where it's going to be untenable
01:09:03for us to continue to finance healthcare
01:09:06the way we have historically done that.
01:09:10Whether that will happen in
01:09:12the next five years.
01:09:14Next 10 years, whatever,
01:09:15that's that's a question I.
01:09:17I'm hoping that it happens sooner.
01:09:20I mean, we've already seen some.
01:09:23Some examples of that
01:09:24accountable care organizations,
01:09:25and you know,
01:09:26if you follow that research that you
01:09:28know that that's been a mixed bag,
01:09:30so maybe that's not the right model,
01:09:32but but I do think that the financial
01:09:35pressures on our health care system
01:09:37at some point is going to really
01:09:39force us to to make a change.
01:09:41And and I think when it happens,
01:09:43it's going to happen like managed care.
01:09:45So those of you who are around
01:09:47in the 90s when managed cares
01:09:49just started to emerge,
01:09:50especially when it started to
01:09:52move into the public sector.
01:09:54If you recall that those changes
01:09:56happen pretty quickly over a
01:09:58pretty short period of time, so.
01:10:01We'll see, I'm hopeful that that will happen,
01:10:04but but even if it doesn't,
01:10:06I think that systems have more
01:10:08of an ability to work in this
01:10:10way than they probably realize.
01:10:12You know, we were able to do that,
01:10:15and in Philadelphia,
01:10:17I think that most systems
01:10:18have some ability to do that.
01:10:21I do think that the.
01:10:23The medicalization that is making
01:10:25moving more and more of the public
01:10:28dollar into Medicaid is a problem
01:10:31because it is a fee for service.
01:10:33Treatment oriented service and I know why.
01:10:38Service systems do that,
01:10:40but what it does do is that it.
01:10:43It gives commissioners systems
01:10:45administrators less flexibility to
01:10:47do the kinds of things that we often
01:10:50need to do to reach reach people.
01:10:55Great, well thank you so much Doctor
01:10:58Evans for speaking with us today
01:11:01and really gives us a lot of food
01:11:04for thought for next steps around
01:11:07behavioral health systems so I know
01:11:09some some students will be joining you
01:11:12briefly for a follow up afterwards,
01:11:15but I want to thank you again
01:11:18for coming and say farewell.
01:11:21Well, thank you. It's good.
01:11:22I wish I could be there in person.
01:11:25I spent 16 years and you haven and I
01:11:28have very fond memories and it's great.
01:11:30See I see a lot of old friends
01:11:33Deborah and other people on here and
01:11:35sambol I saw but a bunch of folks so
01:11:38it's good to see all of you, Ann.
01:11:41I hope after this pandemic I get
01:11:43a chance to come down and just
01:11:45hang out with with folks.
01:11:47And thanks John for inviting me
01:11:50as well and Jack for having me.
01:11:52It's an exciting time and I hope
01:11:55I again I get to see you all
01:11:57in person sometime soon.