and welcome. I'm Alexia Wolfe, Director of the Delaware Behavioral Health Consortium and SMI Social Determinants of Care Expert for SMI Advisor. I'm so pleased that you're joining us for today's SMI Advisor webinar, Addressing Social Needs and Social Determinants of Health for People Experiencing SMI. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Today's webinar has been designated for one AMA PRA Category 1 credit for Physicians, one Continuing Education credit for Psychologists, one Continuing Education credit for Social Workers. Credit for participating in today's webinar will be available until December 26, 2023. Slides from the presentation today are available to download in the webinar chat. Select the link to view. Captioning for today's presentation is available. Click Show Captions at the bottom of your screen to enable. Click the arrow and select View Full Transcript to open captions in a side window. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Now, I'd like to introduce you to the faculty for today's webinar, Dr. Shoma Saha. Shoma Saha, MDMS, a.k.a. Shoma Stout, has dedicated her career to improving health, well-being, and equity through the development of thriving people, organizations, and communities. She has worked as a primary care internist and pediatrician in the safety net and a global public health practitioner for over 20 years. Currently, Shoma serves as founder and executive lead of well-being and equity in the world. Shoma, I'll turn it over to you. Thank you so much, Alexia. It's such a pleasure to be with all of you today. I have no relationships or conflicts of interest related to the subject matter of this presentation. Today, my hope is that at the end of this presentation, you'll be able to build a working understanding of how mental health and social needs intersect together to worsen or improve health and life outcomes. I'm hoping that you'll be able to utilize a framework that's been released in the field together with CDC and ASTHO and We in the World called Pathways to Population Health Equity that helps you understand and assess how serious mental illness intersects with social needs and the social determinants of health, as well as the root causes that might be in play for a particular client. You might develop a population approach to patients with mental health and social and well-being issues. So, as we begin this work, I would like to always begin when I think about population health, for me, it still goes back to the stories of who is in the population, what were we talking about, and what does it look like and mean. As a primary care clinician, I had the privilege of caring for people often across three generations because I'm both an internist and a pediatrician. So, I'd like to introduce you today to Billie. This isn't, for obvious reasons, either Billie's real picture and it's not her name, but I had the pleasure of meeting Billie when she was about 15 and 16 and got to watch her for 16 to about 25. I also had the privilege of caring for Billie's parents, and what I learned about Billie is that by the time she was five in our suburb outside of Boston named Revere, which had become a place that had been once a thriving suburb that had had Italian and Irish immigrants that had built a whole community in a boardwalk, which had over the last a number of decades had fallen into from a place of prosperity to a place of poverty. And as it had done that, things had changed. And that meant that as opioid addiction set in, as this working class community began to have less and less hope, you began to hear stories where Billie, for example, grew up in a home where her parents who were addicted to opioids would give her Percocets by the time she was five when she had your infections. By the time she was 16, she was fighting, she was shooting up her dad because that was safer than watching him overdose multiple times. She had already watched him do it three times and had had to resuscitate him. And so shooting him up was an easier way or path for her. She finally broke free from the situation she was in when she was about 19. Now, Billie had underlying mental health issues, but had addiction as a strong corollary. And as she broke away, finally finding the courage to do that when she became pregnant at the age of 19, she found herself homeless with a serious mental illness and co-occurring addictions. And the first thing she did was get stabilized in terms of her housing. She got support and treatment with Suboxone and treatment to address the addiction and began working with a care team to address the underlying needs. And that combination of stabilizing, supporting, and then creating a journey of healing meant that by 25, Billie was a small business owner. She was able to support her child and retain that custody of her child and was free from substances and had her mental illness well controlled. And I think when we hear Billie's story, we hear why it's important to both understand how social needs intersects with serious mental illness and substance use in people's lives, but also to think about, as we think about the whole picture in a person's story, how we build a whole system, holistically understands the context of the story and is set up to be able to address it. You see in Revere, one in five people are addicted to a substance. In fact, in Billie's story, she just told me about times when a typical party in high school meant that there would be a bowl of pills and there'd be a spin the bottle game and kids would take a handful of pills. And depending on what you drew, that could be Tylenol or it could be Oxycontin. 76% of prisoners, people cycle in and out of prison. There's a school to prison pipeline in place that then leads people to sometimes getting help and sometimes experiencing even a lack of treatment within their walls and often a drop of treatment when people come out. And if we don't understand the entire system of both the social need that needs to be met, but the system that's producing that need, it's really hard to address it. I'm really proud to say that in Revere and our neighboring Everett, we were able to bring the whole community from police and fire to emergency rooms, to social needs providers, to community providers, to community health centers like ours who work on this problem together. And as we did that, we could actually begin to see a reduction in overdose in youth overdose and youth mortality as a result of addictions. But the even better story is actually seeing the story of over two thirds of kids in getting in treatment and adults in treatment, not only able through simple primary care interventions to be stabilized for their needs, but to have things like metrics, like connection to school and career connections to reconnection with family and children as the kinds of wellbeing outcomes that really matter to communities. So how might serious mental illness lead to a social need? Well, you've already heard some of this story. Of course, there's higher rates of school dropout, economic insecurity where someone might be able to work fewer hours and have fewer hours over the course of one's life and fewer years over the course of one's life. That of course means that there's less wealth. They may be able to earn less as a result of all of that because of how far they're able to go in their education. All of these are things that can be, of course, mitigated with the right supports, but that won't happen one person at a time if we don't build the systems of supports around them and make what is the kind of care that Billy was able to get, something that we were able to do at Cambridge Health Alliance was think about how we make that the norm rather than the exception. Of course, lack of access to mental health care that's affordable in the community, loss of social supports with marital instability, family connections, peers, and lack of access to housing are all things that come up. And all of this, of course, intersects with addiction and other root causes such as racism and economic inequality and other trauma. There's an excellent paper by Maggie Alagrias who was one of my colleagues at Cambridge Health Alliance that I would love to point you to in the resources for this webinar. You've heard me now talk about social needs and social determinants. And so for the purpose of this webinar, but also for your working knowledge of how people in public health think about this, downstream is where we're providing clinical care. And that's often where we're taking care of people's mental health needs or physical health needs, their substance abuse needs, and primarily is about medical interventions. Midstream is where we address people's individual social needs. So one person at a time, how can we help the Billy, for example, get connected? And so there are screening questionnaires that you can use, for example, like the PREPARE questionnaire that's often integrated into EMRs, that are evidence-based questionnaires that you can use. And so for this, having social workers, community health workers, community-based teams that can help both within mental health clinics and primary care clinics, as well as in the community, help to address an individual's social needs is really important. But upstream here is where we really think about the underlying community conditions, that school environment and social environment in Revere, what had happened in terms of jobs and hope in the community, and the system of laws and policies and regulations that puts people in prison and then often creates a revolving door between the community so that we pay a very steep price for people as a public to not meet their social needs and have them end up or their mental health needs and have prison rather than better mental health treatment and supports as the norm, especially given that mental health care can be prohibitively expensive if you don't build the systems around it. So how might social determinants are not about what one, an individual needs, they're about how the community is set up to be able to have either good social health or poor social health for the individual. It's a difference between whether a person lacks housing or whether the community has enough affordable housing to be able to, for someone who might have a mental health issue to be able to live and whether that housing is accessible to them. So how might social determinants drive health outcomes and how might serious mental illness relate to those social determinants? There are social factors like racism, adverse childhood experiences, discrimination and social exclusion based on race, ethnicity, gender, age or mental illness. These are just a few examples of how social determinants can relate to this. But health care inequity due to lack of access to care because of lack of parity and lack of insurance coverage is a major driver of often an inequity that a social factor that leads to an inequity in access. And I don't have to tell any of you about any of these things. Other things like exposure to violence in the criminal justice system also contribute. Economic factors such as in a neighborhood, the lack of resources for education, employment security, for neighborhood poverty of cumulative effects on an individual, the built environment factors like housing, pollution of the water, of the air, the water and the ground, depending on siting and climate change. All of these can have a substantial impact. So we all know about the Flint water crisis, but it turns out that that is that that high level of lead, as you know, is is not just about Flint, Michigan. That happens in communities that experience inequities all throughout the South. And that high lead level leads to increased rates of mental illness and potential violence and has been associated in a number of places. And so our environment and, of course, our genetics, but also how both of those work together in our bodies matters. And then our structural factors like cultural norms, systemic policies and laws and regulations that institutionalized disparities for populations such as black, indigenous, Hispanic, rural and other minority communities play a huge role. I think if there's one thing that I'd like you to take away today is that one, we need to diagnose the problem and the contributors well. A, we need to understand what's happening for a person in front of us and how we can have systems within our mental health clinics that our primary care clinics that help address people's mental, physical, social and spiritual well-being. But we also need to be the part of a team that's working in the community together with many others across the community or with policymakers to change the underlying social permanence of health in a community. And in case you had any doubts about any of this, I think many of you have seen this kind of map to the right. The story of the two kids to the left, this was, these are two actual kids. I'll call the one on the left Sean and the one on the right Thomas. These kids got their dads to take them to the barbershop to get their head shaved because they believed they could run pranks on their kindergarten teacher, that they were interchangeable, they were best friends and ready to prank their teacher. What we know though is that these two kids could grow up in this, be born in the same hospital, grow up just two miles apart and have between a 10 and 30 year gap in their life expectancy. What they'll die of is premature aging from chronic disease and poorly treated mental health outcomes or co-occurring disease. But that difference in life expectancy, and you can see that in the numbers from 69 to 85, just a few short miles away, or 69 to 81. This is in community after community all across the country. What we see is that you can see the genesis of this in both mental health issues and physical health issues really early in life. The left hand side is a map of economic hardship in Los Angeles County or poverty. The right hand side is childhood obesity. And if we were to fast forward that map, you'd see that was your rate of developing co-occurring depression and diabetes. And you'd see over in 20 years and another 10 years, those would become your high risk, high cost folks that all of our ACOs are trying to manage or your complex teams might be trying to manage. And then another 10 years, that'll show up as premature mortality. You can see these maps showing up. This is an opportunity atlas, which predicts the household income at age 35 for children of low-income parents. And what you see is maps that represent legacy of redlining and other policies and systems of marginalization. The fact that we lived and live in a deeply segregated nation shows up in the way in which our neighborhoods have the opportunity to either bathe our children and adults in toxic stress along their life, which then manifests over time in poor life outcomes and poor health outcomes. This is just an example of a kind of well-being survey that we were able to do in the last three years. As communities across the country responded to COVID, one thing our team knew from looking at all of the data was that COVID wasn't just an issue that related to physical health and a virus where immunizations were the only thing that people needed. What people needed in communities of color were experiencing disproportionate loss of family members and friends or losing access to jobs and job hours. If your income was less than $90,000, you were twice as likely to lose income as a result of the pandemic, for example. If you didn't have access to broadband, we knew that we were facing a mental health and economic crisis at the same time. So we began proactively saying, how can we use well-being as a way of finding where people are struggling and suffering and how to target proactively what people might need to address their social need? You'll see there's a simple question that I'm happy to share with you called Cantrell's Ladder, but you'll see that on the right-hand side, that outer limit, this happens to be a neighborhood, I believe, in Texas, which you begin to see is that the inner circle is the percent of people thriving, struggling, and suffering in nationally. And you can see that red high part is much higher of people suffering and suffering and struggling in this community. And that tells you that those are people, it turns out, where it's at much higher risk of deaths of despair. So by using evidence-based tools that have to do with understanding very quickly who's thriving, struggling and suffering and where they might have, why that might be. Is it their financial well-being? Is it their sense of purpose and direction in life? Does it have to do with their connection to loneliness? Depending on who the population is, these questions, people might answer these questions differently. But what we were able to do in the Communities Rise Together initiative, in the context of the pandemic, was use some simple evidence-based metrics to understand where that might be happening. We targeted communities that had high rates of place-based inequities. We understood why they might be experiencing those inequities and what might be going on and who might be in the context of the pandemic to have the cycle where their environmental stressors and their current stressors might, on top of a pre-existing likelihood of trauma, might lead them to much poorer mental health outcomes, much poorer social outcomes and much poorer physical health outcomes. We reintegrated the head with the body and as we began to do that, we could see that we could actually achieve far better outcomes and get more people vaccinated as well. So, our ability to think from a public health perspective so that when we respond to a pandemic or when we're doing long-term changes so that we can understand that things like generational and historic trauma, this dated ACEs pyramid from the CDC that really builds in the conditions of generational trauma, social conditions, and how that relates to adverse childhood events, which then leads to disrupted neurodevelopment that, of course, intersects with their genetic predisposition, connects with social, emotional, and leads to social, emotional, and cognitive impairment, adoption of higher risk health behaviors, and then eventually manifests in disease, disability, and social problems and premature death. I think as we're going along, we're beginning to understand the evidence base behind how things like generational trauma and those root causes and the history of segregation of neighborhoods leads to much poorer outcomes. A simpler way that we often depict this is to understand these root causes, these isms that are at the root of the tree, like underlying legacies and structures and policies and systems, racism and sexism, classism, and the way that they shape the configuration of our communities. For example, racism resulting in redlining, resulting in residential segregation, which means that those communities don't have everything they need and that there's been generational trauma and exclusion. And how that then shapes the way our communities are, that's from the roots to the trunk of the tree, it's what we call our underlying community conditions, whether a neighborhood has access to meaningful work and wealth, grocery stores, etc., or whether they have high present and generational levels of toxic stress and loss of hope, all the way to the social needs, which are the branches for the health outcomes that we see, which are people's individual health behaviors, illness, and life outcomes or mental and physical health outcomes. So the real question isn't just to understand this, it's what can we do about it? And so as we were mobilizing a response across over 500 communities, bringing together Black, Indigenous, Latinx, and other leaders, CDC approached us to ask, given everything we had learned in things like 100 Million Lives and in our early demonstrations in places like the state of Delaware, what could we do? And I think that what could we do is really about what will we choose to do with our power and our love. As Dr. Martin Luther King Jr. said, power without love is reckless and abusive, and love without power is sentimental and anemic. Power at its best is love implementing the demands of justice, and justice at its best is power correcting everything that stands against love. The first thing that I invite you all to think about is to know and lean into the possibility that you have power to change this. Because I don't know about you, but as a healthcare professional, this has been a hard time for us. So many of us may feel burned out or powerless in the face of everything that's going on. But I'm here to say, and I say this with communities all across the country that I have the privilege of walking with as they're creating real change, that you have enormous power to be able to do something as a clinician, as a nurse, as a social worker, a community health worker, an outreach worker, whoever you may be as a community resident, you have something that you could do about this. But we can't do it if we don't diagnose what's going on accurately or know how we can use our full power and privilege to create change. So when the CDC asked us to develop a model that everybody in public health could use, this is what we were able to develop together with communities across the country, adapting an existing framework for health equity that we had built in 100 Million Lives that had worked across healthcare, faith, and business. The Pathways to Population Health Equity framework and tools, which you can find if you go to publichealthequity.org, gives you practical tools to take action. It goes over the what. There's a really nice health equity primer if you look at the appendix. But more importantly, it has practical strategies that you can use to take action. I'm going to give you the CliffsNotes version today, because I want you to focus more of our conversation to focus on stories of how. So what Pathways to Population Health Equity says is that we need to think about people's physical and mental health and social and spiritual well-being. The left-hand side is thriving people. So as we think about people's mental, physical, and social and spiritual well-being over the life course, we can actually plan for the population's health in that way. And we can think about their mental and physical health and their social needs, including things like food, housing, but also things like loneliness and purpose and meaning, which is what we mean by spiritual well-being. We can think about those things together. On the right-hand side, it's about thriving places and thriving systems. So that first portfolio is physical and mental health for people. That second portfolio is social and spiritual well-being. Third portfolio is about addressing underlying community conditions. And the fourth portfolio, like whether there is food available or there is housing available in the community that anyone could access. And the root causes asks us to challenge why some communities and some groups of people might be marginalized and left out. What are systems of economic exclusion that might be in place and how can those be taken down? And so as we think about what it means, there is a reason this is drawn as an infinity loop. It's because these things are interconnected and action on any of these can help influence the others. But what's most important to know is that often we spend all of our efforts trying to address just one of these four portfolios, physical and mental health. But if we can't address social and or spiritual well-being, if we used more of our efforts to address underlying community conditions and root causes, we'd actually have less burnout and less that we needed to do for physical and mental health. And that on the flip side, if we can create a balanced strategy together, we have much more hope of being able to do better. So if the things that I want you to think about is thriving people, thriving places, and the thriving systems that address inequity, and that we need to have a balanced portfolio, just as like in retirement, you don't want to put all your eggs in one basket here. What we're looking for is balance. This model nicely aligns with, for example, downstream, midstream, upstream. And to that, we've added groundwater, courtesy of the Groundwater Institute, as a strategy of fostering community power and transforming inequitable policies and systems to address those root causes. So let's go into each one of these in some depth, physical and mental health. So one of the things that we say is to imagine what's happening over the life course, we actually need to stratify the population. So we often say that if you have persistent and severe mental illness, and that's unstable, if you pair that, people can have, as you all know, serious mental illness and be quite stable if they have the supports they need. In fact, I think the serious mental illness field has pioneered, post Olmstead, some of the most innovative strategies to stabilize people who are at highest risk. And I just want to applaud the example that you're showing the rest of the nation about how to do this well. When you think about group homes and other pieces, this is something you've already done and pioneered. When you think about who's in this top four to 5% highest risk, then, it's people with severe persistent mental illness, also have either high levels of social instability, and experience other structural inequities, maybe they're in a rural area and can without broadband and can't access mental health services, or maybe they are in a place that doesn't have sufficient addiction treatment supports, things like that. Addictions is like a ladder that takes you depending on its stability is in social needs, whether you're housed or not, takes you up and down this, the highest risk boxes up at the top, the medium or rising risk is people with active mental illness who have stable social circumstance, and everybody else sort of falls in the middle. So what could you do? So it Cambridge Health Alliance, one of the things we were able to do was build a step model of care and integrate social needs all the way through, was really helpful about addressing the social needs upfront, with the support of just a few community resource specialists integrated into primary care, for us, steps one through three, were often held in primary care. It meant that we often prevented people from needing to go to more. And then steps four to five was where we built mental health homes, especially for those at step five. And in their mental health homes, we were set up that physical health could be integrated there. And social needs were fully addressed through case managers there. And that idea of how you redesign a system so that you focus your efforts on those who really need it and support other non-traditional caregivers, whether it's in our case, we had both licensed and non-licensed care partners working together, supervised by a psychiatrist, integrated into the community team, and then for steps four and five, much more specialized levels of care, really gave us a way of thinking about how to do that. Today, though, I'm going to focus a little bit more on social and spiritual wellbeing. And here, we're so lucky to have Alexia Wolfe here, because she and her colleagues at DSAM really pioneered, at the time that I met this approach under the leadership of Elizabeth Romero, something called the START system of care, where they said, how do we redesign the entire system to address people's social needs? And that meant that they put peers who could screen for wellbeing and social needs wherever people might whether it's the emergency room, police officers, corrections, recovery programs, or whether a person was self-referring. And in that 24-7, 365 peer support, they created the ability to care for both refer people in the higher levels of care. They made sure that people got to levels of higher levels of care, not inpatient, but outpatient within 24 to 48 hours. And then they were able to say, how can we meet people's social needs along the way? And as they did that, they used a very simple tool called Cantrell's Ladder. Now, if you want to learn more about this tool, I encourage you to go to winmeasures.org and click on wellbeing. But this is a simple two-question screen that says, imagine a ladder where the bottom is your worst possible life, the top is your best. I'm paraphrasing here. Where would you say you are today? Where would you say you would be five years from now? It turns out that if you're four or below today, and you think life isn't going to get better, meaning you don't have hope that things are going to get better, you're suffering. And that usually translates your top 3.5% of your population. If you're seven or higher today, and you think things are only going to get better, you're struggling, you're thriving, you're going to be most likely fine. That's your top 45 to 50% of the population, and everybody else in the middle is struggling. Two simple questions, really easy to use, has been administered now over 3 million times by Gallup, has been in operation for over 30 years, but used in other sectors. It turns out that this relates to morbidity, mortality, cost, worker productivity, and deaths of despair. And so what DSAM did in the context of the pandemic, and what we did in Communities Rise Together, was pair this kind of simple ladder scale with additional questions that related to financial insecurity, which turns out to be a huge driver of why people are struggling and suffering, loneliness, mental health, and how people rate themselves, etc. And then we asked them what would most improve their well-being, and which of them was urgent. So by asking a very simple set of questions, and reaching out proactively to the people that we knew were under care, the Delaware Division of Substance Abuse and Mental Health were able to actually watch in real time as people's suffering increased in the early days of the pandemic, and as they got connected to, for example, a 12 steps groups virtually, or food, or other economic supports, they could actually watch suffering come down. That sounds nice, and it's certainly motivating. But what was even more powerful was watching that as the CDC analyzed their data at the end of 2020, that their overdose rates had only increased by 3.6%. Now, part of what they did was they saw what people, what else people were suffering from, and it turned out that what people needed for food. So they did creative things like start giving Narcan out at food banks. That's a kind of creative strategy where if we're thinking about social needs, and mental health, and substance use together, we can create an integrated strategy that meets people's needs. Delaware's overdose rates really only increased by 3.6% compared to the national average increase by 23%. And if you, they did a number of other really creative things like house people, create better diversion from police, from emergency rooms into treatment, and a range of other supports, including peer-to-peer supports for everyone. And I just share that because sometimes it can be easy to think about social needs and social determinants as just one person at a time. This is an example of how a whole system worked together in real time in the context of a pandemic to lean in to do what was needed for the whole person and trusted that that's what would be needed to improve people's mental health. Another example of doing that in a systemic way is the Pathways Community Hub model, which was first pioneered in Alaska and then the state of Ohio. And here, this is a system where everybody, all pairs, all connect and contract with a hub. The hub contracts with all the human serving providers and social service providers in a community. And assigns, as people are referred into the hub, that can be someone, the librarian referring someone in, a mental health clinician referring someone in, or a person referring themselves in. That person is assigned a care coordinator that then cares, looks at the whole family and addresses the social needs of the whole family. Because it turns out that if the mother is insecure, housing insecure, almost certainly the child is as well. And so, as they took that coordinated approach, they began starting, they began working with some of the highest risk women, women who are experiencing often serious mental health and addictions issues and were homeless and otherwise high risk and pregnant. So, as they did that, they saw that as they were able to holistically and proactively care for the person, they were actually able to reduce disparities in infant mortality. High risk mothers without the hub intervention turned out to be one and a half times more likely to deliver, have a baby needing special care nursery or NICU than if they got the hub intervention. And that means the difference between $5,000 a year spent in the life of that child to 55,000 if you did need special care or NICU. And so, I say this because sometimes in this case, doing the right thing, holistically caring for people's physical health needs, mental health needs, and social needs together is also the thing that most efficiently improves health outcomes and cost. But let's take a step back and look at some other strategies where states like Oregon, for example, and others are looking at this in terms of building resilience, in terms of building life skills, creating peer-to-peer supports, which creates living wage jobs, and teaching care partners solution-focused therapy. And as we do that, it's important to understand that there can be strategies that really help to take care of underlying community conditions and root causes. So that portfolio three and four are what we're going to talk about next. I'd like to introduce you to Dr. Ruby Gibson. She's at Freedom Lodge in Sioux City, South Dakota. And Dr. Gibson is an indigenous psychologist and indigenous practitioner who's pioneered something called somatic archaeology, which is about healing generational trauma and connecting people deeply, reconnecting them to their culture and roots. That kind of strategy of going deeper into the roots of what someone might be experiencing in generational trauma, along with what might be happening in their lives, is an example of something we can do for thinking holistically about people's social needs. And as you do that in the context of a peer group or community, you'll see that some of the pioneers of this are indigenous communities, like South Central Foundation Health System that built something called Beauty for Ashes and a Family Wellness Warriors Program. In this program, and we don't have time to look at the video today, but I included the link in your slides so you'd have the chance to look at it. This was a partnership with the tribal communities that said, what if we reclaimed, instead of being in a community that has a 75% risk of child abuse, domestic violence, and partner to partner, and other forms of violence and neglect, what if we could be a community that reclaimed who we were, which was where people, where the men used to be the protectors of the women and children, rather than those who were perpetrating violence. And as they did that, they knew that they had to bring the whole community together to tell story, to acknowledge and heal trauma in a community way. And as they came together and shared their stories with one another, and created the space for resilience, and paired that with outstanding primary care, integrated mental health, integrated traditional healing practices, they saw some pretty amazing outcomes with urgent care and ER utilization going down by 50%, hospital admissions going down by 53%, and you're seeing the entire risk, the set of outcomes. I will tell you, though, that this is easy to frame as coming out of a program, but it's not. If you know the NUCCA model of care, you know it's a holistic way of redesigning an entire care system based on a relationship. And I think that those are the kinds of things we underestimate power of as we do this work. Now, as we think about what that means and the implications of a health system that's truly designed to meet people's, the whole person, and it works with the community to create whole communities, we begin to really see the difference in what's called the vital conditions. What does it mean to have a health system or a community where people feel like they belong and have agency to create change? And then how do we create both the, address the social needs and the social determinants of whether someone needs housing and needs to be connected, or whether they need to have a community that has that? I'm going to share some examples of communities and places that have been able to address these upstream community conditions. Now, of course, I don't have to tell you how stigmatizing mental health and substance abuse can be. This is, of course, Philadelphia, and this is sponsored by APA, so you all know the work of Arthur Evans in Philadelphia and really the work of the entire system of care there. And many of you, if you've been to Philadelphia, have seen beautiful murals. One of the most powerful things that they did was to be able to bring people experiencing mental health and addictions issues together with community members to paint murals that reflected who they were. That broke down social boundaries. It helped people tell each other their story, and made them proximate to one another. And I think we underestimate the power of that kind of belonging and civic muscle until we begin to see that in the context of the pandemic, U.S. News and World Report stratified communities based on their level of civic capacity and community engagement with COVID outcomes. And it turns out that there is a direct inverse relationship between the more civic capacity and sense of agency and connection people had, the community, the less COVID cases they had. They actually worked together to help create safety. And root causes are another example of what can be addressed. So, root causes are, of course, things like racism, classism, colonialism. So, our ability to address past legacies in a way that acknowledges them and acknowledges the generational trauma that might come from them. And in Pine Ridge, South Dakota, that meant acknowledging the legacy of the boarding school movement there, and the thousands of people that had been lost, giving the opportunity of grieving and healing, and then beginning to say, how can we create and understand our narratives of othering and belonging and deservingness, and what might be needed to address those? How might we shift capital? The Department of Interior in the U.S. recently released a report about the boarding school movement and has now been moving funding to tribal communities as part of its efforts to address and rebuild wealth in these communities. And so, as we think about that, that's not something we have to wait for the federal government to do. It's something we all can be part of. The health system, Methodist Health Care Ministries in the state of Texas, has been thinking about how they could interrupt the cycle of generational trauma, what they could do if they could prevent people from entering the poverty pipeline through investments in education, how they could stabilize people through medical-legal partnerships, how they could think about family independence out of poverty, all of this while they're integrating mental health, building supports for people with addictions, and helping people to get better, and then what they could do for policy and systems change by taking their policy folks and turning them into not just folks advocating for better payment, which is, of course, you know, especially mental health needed, but also to advocate for things like housing for patients and community members, for things like digital inclusion and broadband. If you haven't seen it, and I know I've been going really quickly in this presentation today, I encourage you to read the Healing in the Nation report, which brings all of this together. What they suggest is that if we're going to really think about how we have excellence in mental health and well-being, we need to all work together to assure the vital community conditions everyone needs. We need to eliminate that barriers like stigma and cost and social isolation and lack of access. We need to think about coverage with affordability, comprehensiveness, and parity. Then we need to build that the treatment system begins not just with coverage, but also engagement and everybody in health systems and workplaces and communities and the judicial system and the education system working together with a focus on the populations that experience the greatest inequities and the places that experience the greatest inequities. And that to maintain these, if we do that, we'll be able to get improved outcomes, affordability, advanced integration, and the likelihood of better well-being and care. I've included some references and tools for you, but wanted to thank you so much for your time today. Thank you for such an interesting presentation, Shoma. And before we shift into Q&A, I want to take a moment and let you know that SMI Advisor is accessible from your mobile device. Next slide. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health reading scales, and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org backslash app. And we've had some wonderful questions come in during the chat, and one of them is just to clarify with the Pathways HUB model what HUB stands for. Oh, HUB just means hub, like a hub that brings things together. It's not an acronym. And then we have another question asking, what are some of the best person-centered tools and inventories to measure subjective well-being and phenomenological personality assessments, how individuals understand and interpret their care, and the systems and individuals providing it? Oh my goodness, that is such a great question. So what we've seen, so one of the things that We in the World does is facilitate the federal, non-federal process of through the Well-Being in the Nation Network. We were asked to do this by the National Committee on Vital and Health Statistics. So we've been looking at this question for the last eight years and seeing what really moves in communities. So those two, if you go to winmeasures.org, you'll see some beautiful examples of this. For example, those two Cantrell's Ladder questions are among the nine core questions that are recommended. Because what's lovely is they invite people to define well-being in the way that they define it, but gives different ways in which people can say where their life is. And as they read themselves, they can actually say, you can actually calculate the percent of people thriving, percent of people struggling, and the percent of people suffering based on just whether people feel that their life, where they feel their life is. It's also really powerful because often people have gotten used to our screens and they know to be afraid of our screens of suicidality, etc. But how someone feels about their life is surprisingly powerful in predicting who's at risk of deaths of despair, for example, and also who's struggling and suffering and might need a little extra support. By limiting our social needs screening to the people who are struggling and suffering, what's really powerful about that is it can help us focus and make sure we get to that for the people who are most in need. Excellent, thank you. We have a question asking where people can access the Pathways to Population Health Equity Guide? PublicHealthEquity.org. And where can the wellness survey be found? WinMeasures.org. Excellent. And as we have additional questions coming in, Shoma, let me ask you to elaborate on some techniques I've heard you share in the past. I know I've heard you speak about having medical trainees and residents accompany people that they serve in the community to better understand what people's day-to-day lives are like in terms of navigating these resources and how it's transformed the way that your organization thinks about the terms compliance and non-compliance. Could you share that with our audience? Yeah, I'd be delighted to, Alexia, and though I confess at this point we've gone far beyond medical students and trainees and just say everyone needs to do this because it is so powerful in seeing the bigger picture. And so one strategy is something called flow mapping where you see what's happening in people's day. And as people do that, whether they're just doing that within your walls, they see the most simple obvious reasons why people aren't doing what you think they should be doing and what you think the system is set up to be. In reality, as clinicians, we just never walk in the footsteps of our patients. When trainees did that at Cambridge Health Alliance, they discovered that the average time it took people to get to an appointment was 90 minutes. And then they would spend 90 minutes in our walls and then another 90 minutes getting back with the number of buses, etc. that they were taking. When they actually counted the number of hours the average Medicaid family was spending between themselves and their children and family members, often they were working 20 hours a week just navigating our systems. And so suddenly what we realized was it wasn't that people were not compliant with our systems, it's that our systems were set up to be inefficient with people's time and resources and energy. And the more we could bring those things together, just as that Pathways Hub does for social needs screening, but we applied that to everything, the more we could think that this was about reducing the work of being a patient to focus more on the work of healing and getting better, the more we could, people could actually do better. And similarly, the more that we can reduce the work of having to make that appointment or get that housing referral to actually get housing and food and things like that, the more that people could actually focus on getting healthier. And we have a great question from a participant asking what you would recommend as a first tangible step for moving from addressing midstream to upstream. Oh, that is such an excellent question. So the biggest thing I would say is if you're already midstream, then you may already be screening for social needs. Look at the existing, the needs that that are coming up over and over again and start by asking why. Why are so many people experiencing problems with say housing? That might have to do with the lack of affordable housing in the community. And so ask, then don't try to solve it yourself. Go say who's working on this already and ask how you might be able to help. It turns out that one of the most, if you look at the 100,000 Homes Campaign, one of the biggest things they had needed were clinicians at the table. They didn't need us to solve it. They needed us to figure out especially how to stabilize people with mental health and addictions in housing units that were permanent supportive housing. But they lacked mental health clinicians that could help fill that role. And so that's an example where just by reorganizing where we deliver care and how we deliver care, we can actually join with others in stabilizing what's needed in a community. We have a couple related questions asking if there are plans to reach out to the judicial community for integration into their systems and also share your thoughts on how this could be implemented in a correctional population. Well, Alexi, I think you know that that's already happening in many places, including in the state of Delaware. So one of the things that I think Issam did beautifully was look at where people were. So you actually said and realized that there was a revolving door between those who, especially for those at that tip of the triangle of highest risk, they were going between emergency rooms, police booking, social services, and jails. And so that no-wrong-door approach was all about that. So by connecting with the judicial system and finding ways to divert people into treatment, it meant that we didn't spend the money on jail cells and prisons, which are incredibly expensive, something like $50,000 to $70,000 a year, and instead could use that to fund treatment and supports. And then for those within a prison, it was actually about stratifying and working with the populations. And I think you have people doing that now within your DOC as somebody who is a former part of your agency. And as they've stratified and looked at their policies, what they realized was that they weren't getting treatment for addictions that was evidence-based to everyone. And so as you integrated mental health and substance use treatment within corrections, and as you plan for people's departure, starting six months before someone leaves the doors to A, reestablish relationships, to reestablish and make sure people have access to housing, access to jobs, access to, many of you have done insurance access, at least six months before, then you begin to create the conditions for people to come out and stay stabilized in the community rather than resorting to incarceration systems as a not best practice for providing mental health care. And one final question before we shift into housekeeping. One of the participants asked if you think mental illness has decreased since COVID rates have decreased. I wish I could say that was true, but that isn't our experience. I say that because we get real-time data across communities around the country because one thing we were able to do in the context of Communities Rise Together was create a data pipeline for communities could measure well-being and what was driving that. And in reality, for many people, the COVID crisis is over, but the trauma of the crisis or the economic insecurity that they've experienced isn't over. And that keeps people caught in a system where they're experiencing and are aware of the trauma, they're still recovering from the pandemic. If they're in a community that experiences historic inequities, whether from racism or income inequality, they've lost many family members and supports. So our communities are struggling and suffering in substantial amount, and they're among the most resilient to begin with. And so what that translates to is actually that it's a more timely moment now than ever to say, how can we work together, understanding that, work together in secondary prevention to prevent that next wave of deaths of despair or just incidents of despair. And it's, I think, a better time than ever before when more and more people realize how frail our systems are as we think about the loneliness of older adults and how, and that was then experienced by their adults. What does it look like to begin to think about a system where people are aging well? Thank you for that. And I will shift us into housekeeping with the next slide. If there are any topics covered in this webinar that you would like to discuss with colleagues in the mental health field, post a question or comment on SMI Advisors Discussion Board. This is an easy way to network and share ideas with other clinicians who participate in this webinar. If you have questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of SMI Advisors National Experts on SMI. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. It is a completely free and confidential resource. Next slide. SMI Advisor offers more evidence-based guidance on the social determinants of health, such as improving behavioral health services for individuals with SMI in rural and remote communities. This resource explores strategies and key lessons for developing, implementing, financing, and sustaining behavioral health services for individuals who have SMI and live in rural and remote communities. Access the webinar by clicking on the link in the chat or by downloading the slides. Next slide. And to claim credit for participating in today's webinar, you need to meet the requisite attendance threshold for your profession. After the webinar ends, please click Next to complete the program evaluation. The system then verifies your attendance for credit claim. This may take up to one hour and can vary based on local, regional, and national web traffic and usage of the Zoom platform. Next slide. Please join us next week on November 3rd. Dr. Megan Arrett presents Pharmacogenomics, Psychiatry, Is There a Role? Again, this free webinar will be November 3rd from 12 to 1 p.m. Eastern Time on Friday. Thank you for joining us. Until next time, take care.

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