Hello and welcome. Thank you for joining the Third National Conference on Advancing Early Psychosis Care in the United States, presented by SMI Advisor. We are pleased to present today's session, Can We Create Sustainability of Coordinated Specialty Care? Hi, this is Dr. Ken Duckworth and I'll be beginning this conversation. I'll be joined by my friend and colleague, Dr. Christine Crawford, who's the Associate Medical Director of the National Alliance on Mental Illness. Between Christine and myself, we're going to try to talk about the coordinated specialty care model and the reason it needs to be sustained and how it can help to address inequities and the discrimination that African Americans and other people of color have experienced. I'm going to start by introducing myself. I have the best job in American mental health, in my opinion, as the Chief Medical Officer for NAMI. I'm very grateful for that role because I get to spend time with people who have lived experience of mental health conditions in their families and they're in continuous process of engaging and supporting each other and advocating for better services for people. That's a part-time job and I also have a part-time job as the Senior Medical Director for Behavioral Health at Blue Cross Blue Shield of Massachusetts. I've done a lot of work with my colleagues at Blue Cross to liberalize mental health benefits and I'm working the problem on trying to figure out how to get coordinated specialty care funded as a private benefit, but I'm going to need a little more help. It turns out that some of these things are more or less light switches that I can switch and some are a little more complicated. By way of background, I'm an adult and child and adolescent psychiatrist. I teach a little bit at the BU School of Public Health and at Harvard University Medical School. I've been a board member of the American Association of Community Psychiatrists and I've been the Deputy Commissioner and Acting Commissioner of the Massachusetts Department of Mental Health. I've been very fortunate to lead a number of systems of care in different ways. I've also served as a doctor on an assertive community treatment team in Lawrence, Massachusetts. I did that for about three years with the kind of creative community model of providing people care in the community as opposed to a hospital. One of my core interests is in more creative ways to approach services. I'll be talking about the sustainability piece of this equation first and then Dr. Crawford will be talking about the inequities and needs to address that second. Let's go to the next slide, please. My colleague, Dr. Christine Crawford, I'm going to allow her to introduce herself, but let me just tell you she is this remarkable young woman that I met when I gave a talk at the Mass General Hospital Child Psychiatry Residency. I offered to meet with anybody who wanted to talk about their career over a cup of coffee and she took me up on it. If somebody who's senior to you and has gray hair offers to look after you, I would encourage you to consider it because Christine is now actively working with me at the National Alliance on Mental Illness and I am incredibly grateful for that. Christine is a teacher and a compassionate caregiver and just a lovely human being. Christine, do you want to introduce yourself more formally? Absolutely. Thank you so much for that introduction. You really have been instrumental in my career in focusing on psychiatry, especially for those who are quite vulnerable. I'm the Associate Director of Psychiatry Medical Student Education over at Boston University School of Medicine, where I also serve as an assistant professor there. As Dr. Dutworth had already mentioned, I have an active role with NAMI and I was recently appointed as the Associate Medical Director for the National Alliance on Mental Illness. I did my training over at Massachusetts General Hospital and McLean Hospital, which I focus on adult psychiatry as well as child and adolescent psychiatry. I got my master's in public health over at Boston University School of Public Health. I do a lot of work in the community working at a community health center in Boston called Codman Square Health Center, as well as I see children in our child and adolescent psychiatry outpatient clinic over at Boston Medical Center. I've done a lot of work in the community working with various organizations such as the Boys and Girls Club and NAACP, and also have done some writing in the field of exploring various mental health disparities, especially social cultural issues that are affecting communities of color. I'm really happy to be able to have this opportunity to address some of the issues having to do with inequities and racism and how that can factor into us developing and thinking about ways to create sustainable coordinated care models. With that, next slide. So I have no financial relationships with commercial interests or conflicts of interest to report. I should mention that NAMI was just awarded a four-star on Charity Navigator. If you're interested in learning more about NAMI, you can look at NAMI.org, but our finances are actually quite transparent, and individual donations have become a dominant force for funding the National Alliance on Mental Illness. Christine? I also do not have any disclosures to report, no conflicts of interest, no financial relationships, and commercial interests. All right, next slide, please. So we're going to have you see if you can get a good handle on describing the history of the growth of coordinated specialty care and the future need for licensing or certification. I'm going to summarize other models that offer day rate payment, that is to say they're not paid by the hour like an individual psychotherapy session, the so-called 90834, 90837. Those are not things that we're looking to fund if you're actually trying to fund this in a sustainable way. And for my learning objectives, we're going to describe the elements of private pay services that foster third-party payment. So for my half of the talk, these are the three things I want you to focus on and take away. And with any luck, I'll convey that information to you. All right, next slide, please. So can we create sustainability of coordinated specialty care? That's the big question to me. I've done nine years at a health plan, a progressive health plan. We've done a lot of very remarkable things, which I'm going to tell you about. But I want to start with the first construct, that we're not France, we're not Sweden, we're not the National Health Service of England. Had I become the director of the National Health Service of England, I could have worked with other people in the money spending actuarial product idea and basically said we need to pay for coordinated specialty care. And they would have resisted or approved of it, and I would have worn them down over time. And then the National Health Service would pay for this benefit, because this is a better way to provide care to people with early psychosis. You know, coordinated specialty care has a strong evidence base and treats people with more of a strength focus, prevents people from getting on disability so quickly as it's engaged in goal setting for school and work. And so I think I could get this thing funded, or you could get it funded, if you had that job in the equivalent of England, France, or Sweden. But in America, we do things a little bit differently, as you might know. America, your health insurance is tied to your employment. And apparently after multiple battles around the Affordable Care Act, it's pretty clear that Americans kind of want it that way. So we don't have a Medicare for all. We have Medicare for people who are 65 and older, right? So we have one set of benefits across America for people 65 or older or who are disabled through Medicare. So that's not really spot on for the advancing early psychosis question, because advancing early psychosis implies, you know, this is going to be happening to people in their teens and their 20s. And as you know, three quarters of all mental health vulnerabilities begin before age 25. And most people are now on their parents' insurance if they can be. So understanding private health insurance has actually become a very important issue. One of the things I learned in my part-time role at Blue Cross Blue Shield of Massachusetts is that employers set a lot of benefits. So if you work for Stanford University, Stanford is probably setting your co-pays for the medications you take. They're probably informing the co-pay you're paying for Narcan to reverse the overdose of your cousin. They're probably deciding what they pay for teletherapy. Do they pay for 100 percent? Do they have teletherapy as a benefit? One of the great lessons I have is if you look at American health care, the little businesses, this would be Bob's Auto, are typically fully insured. They write a check to the health plan and the health plan decides on their benefit package. So that's easy for me because I can then advocate for those individuals to get service A, B, and C. The large companies, not Bob's Auto, but rather Ford Motor Company, they're so big they say, you know, we're going to take our own risk. We're going to self-insure for our tens of thousands of employees. The reason that happens is if two people at Bob's Discount Auto need a bone marrow transplant and they're paying for it, Bob's Auto will go under. Ford Motor Company has plenty of resources, not as many as they used to when I was a boy growing up in Detroit, but still they're doing fine in terms of resources. They can handle more risk. They then get to decide what the benefits are for their employees. I want to emphasize that Medicaid is also a patchwork. So Blue Cross of Massachusetts happens to be a progressive health plan on mental health and MassHealth here in Massachusetts happens to be pretty fabulous insurance if you have a mental health vulnerability. But not all state Medicades are created equal. Not all of them have the same benefit structure. So one of the things I want to say to you, and I say this with full knowledge that I didn't know this, which is hilarious now that I am working at a health plan part-time, I didn't understand that your health plan benefits are something that you not only are a policy taker, but through collective action, through your union, through your colleagues, through other enlightened people, you can give input to the people who are controlling your benefits. So I used to think that open enrollment was a chance to figure out which health plan would best cover my kid's asthma. I had a very narrow understanding of the health plan. I now understand that health plans are part of the public health fabric of mental health care and that you have to convince your HR leaders who are deciding upon which health plans to use, some are better than others, and which benefits to cover. That's a big takeaway. I want to emphasize it's a national pastime to beat up on health plans and I see how you get there, but it's the businesses behind the health plans, especially the large businesses, that are making decisions about the benefits and in some cases the payment structure. I just want you to remember that because if you're like, why doesn't Stanford University or Vanderbilt or Bob's Discount Mental Health Plan cover the thing that I want, which is coordinated specialty care for my patients, you're going to have to advocate for that. It may not just happen. All right, let's go to the next page, please. Next slide. So I have traveled in these waters. It does really make a difference if good people take these jobs. So another friend of mine who I met at the same class at Mass General Hospital is now my counterpart at a major other health plan and he and I confer on ways that we can improve services for people with mental health and substance use disorder vulnerabilities. That's important. So if you can, consider taking a job in this field because you'll be able to impact millions of people indirectly. I mentioned the self-insured versus fully insured. Again, the self-insured is Bob's Discount Auto, a small number of employees. Ford Motor Company, big company, they can fully insured and select their own benefits. So one of the things you should know is which are you in. So if you have a tiny practice, you're probably self-insured. You're buying the benefits that a given health plan will set up for you. If you're fully insured, you can make decisions on your own. I can't emphasize enough how much mental health parity has made a difference in this equation. Anytime you can find a medical analog to a mental health concern, that is a way to get a health plan to pay for something. I'll give you one example. After the final interim rule of the Mental Health Parity Act was filed in 2014, I conferred with my medical and surgical colleagues at Blue Cross and learned that nobody had a call to health plan for a prior authorization number to admit their patient for a cardiac event or for an orthopedic problem. No physician's assistant had to come and see how fractured the femur was before they were allowed to go into the hospital. And no physician's assistant had to evaluate the work of the cardiologist in the emergency room to make sure this was in fact a sick patient. So mental health parity led me to make the change that nobody in a mental health crisis or an addiction crisis should have any challenge from a health plan of any kind to the point where you don't even have to call to get an authorization number. You just send your patient and just as on the medical surgical side of the house, the first two days are covered. This is one of dozens of examples, but it's the first one I was able to work on that illustrated the power of mental health parity. Mental health parity is a federal law. The attorney generals are extremely interested in making sure that while the mental health system is fragmented and chaotic, it is at least fundamentally not rooted in a discriminatory structure. And so if you're having questions about mental health parity, Google your local attorney general and mental health parity, and you'll find that many attorneys generals of many states have had settlements with health care plans to address mental health parity concerns. Mental health parity is your friend. Mental health parity is improving care. It's not perfect. I see this as an ongoing process of making a difference that will be solved case by case and decision by decision. Next slide, please. All right. So I just wanted to emphasize if you were to ever take a job in the public health of mental health through a health plan, here's the kind of thing that you can do. We had a for-profit carve out at Blue Cross Blue Shield of Massachusetts. We decided to let them go and to run it ourselves. We then did something that they were not doing, which is that any provider with an independent license could join our network. So there's no, our network is full. There's no, we have enough practitioners. There's none of that. If you have a license and you want to provide services to our members, go right ahead. We removed the prior auth from emergency room to hospital in 2014. I already mentioned that one. As the opiate disorder crisis became more acute in Massachusetts, we made a decision to remove the copay and the deductible for methadone in 2015. This resulted in substantial increases in the use of methadone, which saves lives. Prior to that, and this is again the kind of thing that you might not have been able to do if you had an outsourced behavioral health team, those people had a so-called medical benefit. Methadone was a medical benefit and they were paying a copay of perhaps $25 every single day. If you've known any people who are addicted to heroin or opiates, you could imagine that a $25 a day copay for a service that you need every single day, 365 days a year, plus a deductible was going to be prohibited. And so that was something that because I was inside of an in-source team, we were able to problem solve that. I'm proud of that one because the use is up about 800% since we made the change and it has not broken the bank. In fact, more people are getting care and relative to all the other expenditures that a health plan makes. This is a small contribution to the expenditures. For the first time after the codes were changed in psychotherapy, Blue Cross added the 60-minute psychotherapy code in 2015 for the first time. This was because there's an analogous code in medical care. And remember with parity, if you do something on the medical surgical side of the house, you've got to do it on the mental health addiction side of the house. Again, fabulous lever. I made up the Narcan toolkit and we eliminated the copay for Narcan in 2017. I was visiting my brother in Philadelphia and I read in the Philadelphia Inquirer that they had trained the librarians in the Philadelphia library to reverse overdoses and there were interviews with 60-year-old women who had been librarians their whole life who had made a decision to become public health in the community experts. You might remember that I worked on an assertive community treatment team. I really like community mental health and so I came back to Blue Cross and I'm like, hey guys, let's give away Narcan and let's eliminate the copay. So the Narcan toolkit was a little kind of makeup kit size thing with two doses, how to recognize an overdose, and we gave it to organizations like the Carpenters Union, like a construction company, like the town of Brockton, which has a very high overdose death rate. And what we found was we trained a lot of people in the administration of this. One of the towns we worked with gave it to all their lifeguards and all their public officials. So we've had several overdose reversals that we knew about. Mostly what we were trying to do is highlight the idea to demedicalize the administration of Narcan, that in fact you can recognize when someone is overdosed. You can hurt no one with Narcan. You're not going to make anybody dependent. No trouble will come to you. In Massachusetts, there's a good Samaritan law. If you're in good faith trying to help a person who has overdosed, no legal harm can come to you. The legal department got a little fatigued of my efforts to give away thousands of doses of Narcan through my DEA number, and so we weren't able to scale the toolkit, although we generated a lot of love, publicity, and awareness. But by eliminating the copay for Narcan, I learned from the pharmaceutical company that we had eliminated the problem of pharmaceutical abandonment. This sounds like something Winnicott would be interested in from a psychoanalytic point of view for vulnerable young children. I didn't know this term. Pharmacologic abandonment is you go to CVS to pick up Narcan so if your brother overdoses, you can reverse it, and your copay is 50 bucks, and you're like, nah, I'm good. That's pharmaceutical abandonment. So not as bad as what Winnicott was thinking, undoubtedly, but we were able to fix that. And by fixing that, more people picked up their Narcan. And again, all these things cost a little money, but if you work for a health plan that has the right values, you can get stuff done. For psychotherapy in 2017, we did something that will cause clinicians to still spontaneously high-five me when they run into me. You don't get this a lot as working for a health plan, that's all I can say, but we get rid of all the paperwork. You don't have to ask us anything. See your patient, see him up to twice a week, send us a bill, that's it. You don't have to ask anything, you don't have to ask for more sessions. You don't have to say, my patient's really sick, I wanna keep seeing them. You're the independently licensed clinician, you understand what you've got in front of you, send us a bill, we'll pay for this. It won't surprise you that more clinicians joined our network after we eliminated their hassle. And it won't surprise you that our utilization, more human beings getting help has gone up substantially. We decided to pay teletherapy at 100% post the COVID emergency. So after the emergency is over, and this will end someday, we're still gonna pay for the service at 100% to practitioners. We're also gonna pay for phone sessions, which is a little more radical. Teletherapy has a very strong evidence-based, everybody knows that teletherapy is considered as effective to in-person. It might lose a little interpersonal magic, but a lot of people, not everyone, find that driving to a session, paying for parking, and dealing with the hassle isn't actually worth it. They just assume, see their clinician. One of the things we've learned is that virtually no one misses their appointments. If they do, they reschedule them quickly and easily. And the clinicians have to give up those five minutes when they get to read The New Yorker. That's over. People show up on time, just like they do for their work. So it's very interesting. Now, the phone sessions was a great triumph in my little opinion, because that has very little evidence-based. But what we learned, and this is gonna tie into Dr. Crawford's talk, some people do not have access to the internet. Some people do not have a three-bedroom apartment that they can go and speak privately. In fact, some people don't have the internet at all, and some people are living in very close quarters. So the idea that you could have a phone session while taking a walk is an example of something that we did because of the equity equation. It was not based on science. This was a decision we made to do the right thing. So it's gonna be after the COVID emergency. So what this does is it says psychotherapy is psychotherapy, whether you do it in person, through a video screen, or on the phone. We're paying for the clinician's time. We're not hassling the clinician for paperwork. Take care of your patients. Go, live long, help people, right? This is how the health plan has gotten. I wanna emphasize this is not all Blue Crosses. So I've gotten calls from people about another Blue Cross plan that shall remain nameless. They're setting their own benefits. All I got is Massachusetts. It seems like a big job until you realize that we're kind of a dinky state. And it's humbling when you realize that what we've done is a success for about three million people, but people in analogous jobs to mine will need to do the equivalent thing for other states. We incented collaborative care. Collaborative care, as you all know, is the only actual evidence-based idea of integrating mental health and medical care. This is done by the AIM Center at the University of Washington. They have job descriptions for what the case manager should do. And the radical idea is psychiatrists don't see the patients. And people are like, what? They don't see the patients. What they do is they make the primary care doctor better at seeing the patients and supporting and working with the case manager who makes sure that all 5,000 people get a PHQ-9 and that somebody with a 17 gets a follow-up call. And nobody falls through the crack. So unlike the individual care model that we have been trained to in psychiatry, which I value and believe in, this is a very public health approach. How do we take care of the mental health risks of 5,000 people? We're doing that when the alternative quality contracts or ACOs come up for renewal. We're gonna write them bigger checks if they actually do this model. Collaborative care model, very well established. The AIM Center, University of Washington, check it out. I think because mental health demand is so high, we're gonna have trouble meeting that demand with individual sessions. We're gonna have to think more creatively. Child psychiatry rates, we increased them by 50% in 2020 for anybody who's willing to say they'll take our patients. So this is an experiment to say, all right, so the market for child psychiatry is completely out of control. What if we got close to meeting the market and again, gave them no hassle and paid promptly? We're gonna find out. So those are a good example of the endeavor that I've been involved in at the day job. Next slide. So what about coordinated specialty care? I mean, for gosh sake, I got rid of all the paperwork. We got rid of the copay for methadone and Narcan. I mean, we've got child psychiatry rates up 50%. Why can't a guy like me or a woman like me just make this change? And here's what I want you to know. At our health plan, I'll use a Boston example. You're spending Dunkin' Donuts money. For those of you in California, I don't think Dunkin' Donuts is really out there. But if you lived in Seattle, you're spending Starbucks money. And if you live in Los Angeles, you're spending Miramax's money. Try to speak your own individual language, right? You're living in Detroit, it's Ford Motor Company. The health plan is spending other people's money. It turns out I'm quite good at spending other people's money, but you have to really represent to them what you're spending it on. So a great example is peer recovery coaches for addiction. I've been advocating to cover for peer recovery coaches, but I want the peer recovery coaches to go through a certification process so that Dunkin' Donuts, Starbucks, or Miramax knows what they're getting. They wanna know that a person has been in recovery for a long period of time, has taken an exam, will follow ethical principles, and has a license or certification that they could lose were they to misbehave or breach the trust placed in them. So this is just like your board of registration in medicine, social work, or psychology. You have an independent license. You should be proud of it. You've earned it, and you can help a lot of people with it. But you may know colleagues who have lost that privilege or have had that privilege suspended. And the reason for that is you need to know what Dunkin' Donuts is paying for. So this is my challenge with coordinated specialty care. Next slide. So if you wanna get something paid for, you have to have clarity of purpose. You have to know what you're getting. You have to have mental health parity in the back of your mind. Is there an analogous thing in early detection of diabetes? The answer is no. There's not an integrated multidisciplinary team that is out there trying to find cases of hypertension, diabetes, or stomach cancer. So the mental health parity argument is not the best argument because there's no early detection multidisciplinary team. Remember, coordinated specialty care is multidisciplinary, is taking a look at high-risk patients, and is trying to engage them in a strength-based approach to care. So one of the things you have clarity of purpose, I want to get this paid for. People who have early psychosis with traditional health plans get inpatient care paid for, their therapy visit paid for, and their psychiatry visit paid for. We all know that the families need psychoeducation and support. We all know that learning from your peers is powerful and may be the best predictor of how people do. We all know that supported employment and supported education is essential for people to regain an identity and to participate in an activity that gives them some sense of meaning. So you look at mental health parity, it's not going to be there. Mental health parity has given me many levers to make a dent. I don't see it here, but if you learn about an early detection or screening program for any illness, you should pay attention to that because that's going to be your mental health parity lever. Employer demand is fascinating to me. Five years ago, no employer wanted to talk about mental health. I would try to invite myself on sales calls and they would say, no Ken, we're trying to cut down. I'm like, hey guys, I have a new shirt, I have clean tie. Mental health is really important. We have a national suicide and overdose crisis. You really might want to think about leveraging our strength in mental health. About three years ago, what happened is my email box started to fill up with people saying, company A wants better mental health services for their employees. Company B is really concerned about the risk of suicide and there are people that are doing repetitive drone work. Company C is really concerned about opiate addiction in a field that has a lot of injuries and people don't get paid if they don't come to work. So we want you to come. So the employers are demanding access to mental health and addiction care, but they're not sophisticated enough to know that coordinated specialty care is a thing, right? This is very important. So employer demand on mental health and addiction is high instead of low, but it's not high for this service yet. Individuals and families can also demand it and this is where your local NAMI comes in. NAMI has 650 chapters across America. So there's a NAMI in Louisville, there's a NAMI in Topeka, there's a NAMI everywhere. In fact, coordinated specialty care at last count had just under 300 programs available on every state in America with the exception of Arkansas. And so if you live in Little Rock, have a conversation with your local NAMI. There's absolutely no reason you can't have coordinated specialty care in Arkansas. So NAMI helped to create these just under 300 programs by testifying and advocating in Congress for a block grant to go through SAMHSA to the states. And the states through the block grant are encouraged strongly to use it for early psychosis programming that meets the coordinated specialty care specs. So NAMI helped create these programs. My worry is that it's gonna require sustainable private funding because a subset of people who show up to the early psychosis program that I have volunteered at are walking around with private insurance because they're on their parents' insurance. And all they get paid for is individual psychotherapy, psychiatric time, and hospital care or partial hospital care. Ideally, you want it to be cost neutral or better and actuaries will work to figure that out. I can tell you these patients are expensive, but I don't think that's the fundamental driver here. I think the fundamental driver here is that there isn't a CPT code with exact specs of what is covered, staffing, et cetera. And there isn't a licensure or certification process so that I can say to Dunkin' Donuts, we're adding coordinated specialty care to our portfolio just like we added the 17 methadone clinics. There's a medical director who's support certified in addiction. There's X number of staff. There's X number of nurses. There's X number of people. The idea is you have to know what the thing is until you can pay for it. And you actually can't pay for things that you can't say what's in it. So my challenge to the group, the PepNet, the early psychosis group, who I have tremendous respect and affection for is to figure out how to produce a licensure or certification so that people like me in the progressive wing of the health plan want to do this. We can say you're spending X thousands of dollars a month and what you're getting is this thing for the few number of patients that will actually require it. This also helps when a coordinated specialty program loses their doctor and two of their therapists, they actually can't call themselves a coordinated specialty care program. And therefore you wouldn't be spending Dunkin' Donuts money on it. Next slide, please. Dr. Crawford is gonna take over and talk about, well, I'm gonna let Dr. Crawford tell you about it. We'll come back for questions at the end. We'll just have one or two questions that we'll take up at the very end. Christine, why don't you take it away? Thank you so much, Ken. And thank you so much for providing that framework in terms of providing us with a larger context as that all the work that's taken place behind the scenes regarding coverage for a coordinated specialty care and also outlining the integral role that NAMI has played in this process in terms of advocacy. You know, a lot of you already know this, but there are tremendous set of benefits to coordinated specialty care for individuals who are living with mental illness. However, there are certain segments of the population that have experienced a number of barriers to accessing such care. And a lot of it has to do with the existing inequities that are in place and the health disparities that are in place within the mental health field. And so, given what's been going on with the pandemic, there's a need for everyone to have access and easier access to mental health services, just given the rise in psychiatric conditions that have been a direct result of this pandemic. But today, what I'm going to focus on are some of the inequities that exists within the mental health field that are experienced by the black community that will actually be further exacerbated by the COVID-19 pandemic. And I hope that by talking about this one particular segment of the population, it will further illustrate the importance of sustainable coordinated care for all communities, but particularly keeping the black community in mind, just given how they've been impacted by this pandemic. Next slide, please. So what I like to do is just provide a little bit of background information about black mental health. What we do know to be true is that black Americans are 20% more likely to experience psychological distress when compared to the general population. And so, although prevalence rates for various mental health conditions are similar across the races, we do notice that there is a significant difference in terms of mental health care utilization rates. We know that looking at this figure over on the right, which was provided by SAMHSA, that looks at mental health service utilization among individuals who are living with severe mental illness between 2008 to 2012. And you can see as indicated down below, we have it separated by race in terms of whites, blacks, and Hispanics. And you could see that across the board, the white population tends to utilize various forms of psychiatric care at higher rates than communities of color. And we see that particularly when it comes to the use of medication, any mental health service use, and also when it comes to outpatient services. But what's interesting to note and what we'll talk about a little bit more so later on is when it comes to inpatient utilization rates, we do see that higher among black people who are living with severe mental illness. The other thing too, that's important to know, Ken had mentioned that there's a significant issue with suicide in our country. But what we've noticed more recently is that when it comes to black children, especially children under the age of 13, we've actually seen an increase in suicide rates within that demographic. So we do know that pre-COVID, there were a number of issues in terms of mental health utilization rates, the amount of distress that black people are experiencing when they experience psychological distress and suicide. We have noticed that there are trends that suggest that there are some issues within that community that need to be addressed. Next slide, please. Now, knowing that some of those issues were in existence pre-COVID, it's important to talk about some of the changes that have occurred during this pandemic. And it's also helpful to have a better understanding about why is it that black people have been so tremendously impacted by this pandemic. Now, kind of starting off with some factors that might've contributed to the increased burden of COVID-19 within the black community. What we do know to be true is that 20%, only 20% of black workers have the ability to work from home. And we know that there's over-representation in jobs that are considered to be essential. Working in the grocery store, working as a personal care assistant. There are a number of individuals who are working jobs, which increases their likelihood of being exposed to the virus. And this could be secondary to a number of barriers, but what we do know is that there are some longstanding inequities when it comes to being able to access certain jobs, due to job discrimination, which I'll touch upon a little bit later on. The other thing as well, is that we know that within the black community, individuals are more likely to live in these multi-generational households in which you have a young kid who's probably going to school with grandma who's elderly with a number of medical conditions that increases their likelihood of experiencing pretty significant morbidity from this virus. And so we do see that there's an increased rate of transmission among family members. Not only are they living in these multi-generational households, but due to various reasons, particularly around residential segregation and making it such that black people tend to live in more dense metro areas, again, has made it more likely that the virus can be transmitted within some of those communities. And we know that this pandemic has a tremendous impact financially on a number of communities. One thing that's important to highlight is that black Americans are almost two times as likely to live in counties that have the highest risk of severe public health and economic disruption from the pandemic. So not only are folks paying the price financially right now, but may continue to pay the price long after this virus and this pandemic has ended. Next slide, please. Now, you can imagine having significant worries and anxiety about contracting this virus or someone in your family contracting the virus and the impact that it will have medically, physically, emotionally, as well as financially. But the one thing that is important to know, and there's been lots of data to support this, has to do with the tremendous toll and the trauma that's associated with all the lives that have been lost from this virus. And this is data that was collected earlier on in the pandemic, going back to April, in which there were a lot of reports that black communities, communities of color, were significantly impacted by the number of deaths within the black community. So for example, here, as you can see in this figure, the blue line, the blue bar indicates the percentage of black people who live in a given state. And the gray bars represent the percentage of COVID-19 related deaths that are represented by black people. And we see back in April in a state such as Mississippi, in which the black population is about 35, 40% of the state's population. However, they represented nearly 70% of all COVID related deaths, right? And so there are a number of black families who have been tremendously impacted by this virus, have lost lives of family members, friends. And you can imagine the trauma and the emotional toll that that has had on the black community as they continue to kind of navigate throughout this pandemic. Next slide, please. Now, one probably wonders why is it that the black community and communities of color in general have been so disproportionately impacted by this virus? Why is it that some of the factors that I talked about in terms of the increased burden of COVID-19 exists within the black community? And a lot of it has to do with the fact that in our country, we've had these inequities within healthcare that have been unmasked by this pandemic. And those inequities have been driven by racism, systemic racism, structural racism. I like to show this figure that you see on your screen here and it represents an iceberg, right? And it's so easy for us to recognize and identify the overt forms of racism, which is just the tip of the iceberg. Those overt forms of racism are things like hate crimes, poor treatment, the one bad apple who said the wrong thing to a person of color, said, made an inappropriate comment. You know, and most people can easily identify, okay, that clearly is an example of racism. But what I argue is what is far more dangerous and what has allowed it such that these inequities continue to exist to this day in terms of unfair treatment and unbalanced availability of resources, it's kind of what lies beneath this waterline here. And that's the rest of the iceberg. And the rest of the iceberg is comprised of the structural piece, the structural racism is comprised of implicit biases and attitudes. Those are the things that are difficult to observe. Those are the things that are often overlooked. And those are the reasons why we see these inequities continue to exist because it's difficult to recognize what is beneath the water surface in terms of the implicit attitudes and the structural racism. Next slide, please. So how does that all come together? Now, this figure represents how it's this ongoing cycle in terms of structural racism and how it is that we continue to see it in a variety of different systems, including the mental health system, the criminal justice system, and how it just has been perpetuated over the years. So let's just start off with history, policies, and practices that have been in place. Now, we know that there's been a longstanding history of discrimination against black people when it comes to jobs, when it comes to hiring. We also know that there are a number of policies that have made it such that we see a large number of black people who are in the criminal justice system. And based on the history in terms of certain practices, such as redlining, segregation, residential segregation had occurred. We also know that there's been longstanding issues with voter suppression over the years. Despite policies that were enacted, we still see the day-to-day practices in which voter oppression continues to this day, especially within black communities. And because of the history, the policies, and practices that have been in place, we see the outcomes of that. And what we see are these inequitable outcomes and these disparities in terms of seeing the fact that black people experience 20% more psychological distress. We see that black people are in the criminal justice system at much higher rates when compared to other races. And we see disparities within education as well, in terms of the dropout rates, et cetera. And what that ends up doing is that it primes people within our society to make these associations with black people. They'll make the association that, well, black people, there must be something about being black that makes it such that their health is so poor, or it makes it such that they live in these poor communities. And they make these assumptions, these associations about black people, and that helps to reinforce some of the biases, some of the unconscious attitudes that they may have towards black people. And these things are being reinforced by what they see out in the community, when they drive through a black community, or things that are reinforced by what they read or see in the media. And these things just continue to fuel each other such that we're in a position in which we've had all these inequities that have been in existence, that again, have been unmasked by the COVID-19 pandemic, although they've been lying underneath the surface, beneath the surface this entire time. Next slide, please. The other thing is, I talked about the trauma that's been associated with all the lives that have been lost from this pandemic. There's also the worries, the anxieties about contracting the illness and what impact that will have physically, emotionally, and financially. But in addition to all of the things that have come to be because of this pandemic, we also had this national reckoning around race and social justice within this country that created further stress or exacerbated the underlying stress that was going on because of the pandemic. And I like to show this picture because this is a young girl who is living during a time in which people in her community, in her family, are being devastated by this virus. Her life has been turned upside down. She's no longer in regular contact with peers. She is doing school over Zoom, using virtual means to attend school. And then on top of that, especially in the summertime, when we had a lot of those Black Lives Matter protests, all she's hearing is that there are a number of people within our country who are against this phrase of Black Lives Matter, right? And just seeing all the violence that occurred and the protests and just all the tension that was displayed on TV having to do with that movement, the Black Lives Movement, you can imagine how confusing and stressful of a time that was and continues to be for a lot of Black people, especially our young Black people. And the reality is for our young Black children and just children in general, they didn't go onto the Black Lives Matter website to read the mission statement or what have you. All they know are the words. And all they know is that there are people who are against that phrase. And it also is incredibly confusing because it makes them wonder, well, why is it that the lives of people who look like me and my family don't matter? Why is it that? So we can imagine what toll that will have emotionally and psychologically on our young people as well as our adults as well. Next slide. And so hearing about how Black lives don't matter or people are against it or hearing these various reports in the media about Black people being treated unfairly or discriminated when they're out and about, or even when they're in a hotel lobby mining their business and someone accuses them of stealing a cell phone or if they're out in Central America or if they're out in Central Park and someone threatens to call the police for no objective reason at all, it can send this message to young people that there's something bad about being Black. And that can result in a process known as internalized racism in which individuals can actually accept the negative stereotypes that are posed on their group by the dominant culture. And we've known that that's been associated with having a lower self-esteem, lower sense of self-worth, can lead to hatred towards themselves as well as their own racial group. And we know that experiencing these feelings can be incredibly challenging and difficult and can also further exacerbate kind of underlying psychological issues that they may be experiencing. So you can imagine that during this period of time that more individuals might've experienced an internalized racism, which would have increased the likelihood of developing such conditions as depression and anxiety. Next slide. The other thing to think about, and this is for us to keep in mind about how important it is during this period of time for everyone to have access to coordinated specialty care, to have access to good quality care because of all of these things that I'm talking about and the trauma. We not only see the impact of this pandemic and current state of affairs, the impact that we see on adults, but also on kids. And kids who may not be experiencing trauma directly, but there is a process known as vicarious trauma that we know has also played a negative role in terms of some social, emotional difficulties that young people may be experiencing during this period of time. So vicarious trauma is being exposed to traumatic events that occur to other people. So it's not just family and friends, but it can be strangers. So hearing about trauma, traumatic incidents to other people of color that they've heard about on the media can have the same impact on children. And the reason why we see this in kids is because for kids, especially our younger kids, they tend to imagine themselves in the role of that person or that individual who was actually the target of the traumatic incident. And we've seen that this has been associated with lower psychological wellbeing, increased anxiety, the sense of sadness, as well as a heightened sense of danger and vulnerability. And there's been studies that have also demonstrated in the past that individuals who experience racial discrimination are known to, that's been associated with seeing depressive symptoms in some of their children as well. And so this, the trauma that's going on right now, the emotional toll that's happening to adults is being experienced and felt by our young people as well. Next slide. And so I've talked about all of these different factors that have kind of exacerbated the psychological and emotional wellbeing of the black community during this pandemic and the ever growing need for access to good quality mental health care. Now, this figure further demonstrates that, further illustrates that point. As you could see here, and this was a figure that was taken from the Washington Post earlier on in the summer. And we have seen that over the course of the year, rates of anxiety and depression have nearly tripled for black people and for Latinos. You can see that from between the months of January, June, 2019, anxiety affected 8% in terms of 8% of folks who were screened for anxiety symptoms screened positive. But during the period of time from May 28th to June 2nd of 2020, which was kind of the height of the first wave, around the time of all the protests, we see that anxiety symptoms went up to 34% in blacks. And same thing was seen when it came to depressive symptoms. From January to June, 8% of blacks, and then from January, from May 28th to June 2nd of this year, went up to 30%. So we know that black Americans are certainly shouldering the heaviest burden emotionally and physically from this pandemic. Next slide, please. So I know that this conference is focused on individuals who are living with severe mental illness, but what we do know to be true is that underlying mood symptoms, anxiety, depression, stress, can exacerbate some psychotic symptoms that are experienced by individuals who are living with severe mental illness. And I think it's important to note that there were a number of preexisting disparities in mental health care for minorities who are living with SMI. I showed earlier on from that SAMHSA figure about how inpatient rates were higher among black people when compared to whites and Latinos. And there's been studies that have, there's been data to suggest that black people with SMI utilize inpatient services at higher rates than whites. And also there was a study that was done that demonstrated that among Medicaid beneficiaries, blacks received lower quality of care based on a number of indicators. There's also been some barriers to care for those who are living with SMI during the pandemic that have been worsened by the current pandemic. And you can imagine that with all the changes that have been in place because of social distancing practices, because of the ability to not go out and seek out community supports in the same way, that there have been exacerbation of psychotic symptoms in the context of just ongoing psychosocial stressors that are related to the limited social contacts that people have now with family, friends, as well as with their healthcare providers. So just having these limited supports and feeling less connected with others has made it such that folks can experience worsening of their psychotic symptoms during this time. And the beauty of coordinated specialty care is that there's a number of people who are involved in providing the care to the individual to support them and to ensure that they're able to remain in the community and live a productive and meaningful life with all of these supports. But you can imagine that, especially during the beginning phases of the pandemic, it was difficult for people to access such services. And Ken had alluded to this earlier on about how amazing for some people telehealth is, telepsychiatry is. But if you don't have access to cell phone, and there have been a number of practices that have been in place such that certain cell phone companies require a credit score to do credit checks prior to signing up for a phone contract or living in particular communities in which there isn't adequate digital infrastructure that's available to be able to readily access the web and to be able to log on to Zoom has further impacted people's ability to remain engaged in care with their providers of what's being referred to as the digital divide and not having access to critical sources of technology. Next slide, please. So even though it's been great what's been going on with telemedicine, and I'm so encouraged by what Ken has been doing over at Blue Cross Blue Shield in Massachusetts in terms of ensuring that access to telemedicine will be available post pandemic to its members, but we need to make sure that everyone has access to the resources available in terms of the technology in order to be able to access mental health services. And we need to ensure that companies besides just Ken's at Blue Cross, that all insurance companies consider a push for permanent change when it comes to coverage for telemedicine with the hope that if we can increase access as well as increase access to the actual tools that are needed, that we can be able to meet the tremendous psychiatric needs of communities of color, especially during this time and post pandemic. And also, I think it's really important, I hope that this talk will help to place this in all of your minds about how important it is to be mindful of the unique impact that the COVID-19 pandemic and the race related trauma has had on the current presentation of symptoms that a lot of our patients may be experiencing. And then also the importance of advocacy. I know that I'm focusing my talk on the black community, but there are a number of people in the population who just need better access to care, but I hope that by highlighting some of the unique challenges within the black community, that individuals will feel more empowered to advocate for the necessary resources within that community. Next slide. So I hope that this talk provides some more insight about coordinated specialty care, all the things that have kind of gone into it based on what Ken has discussed and hopefully talking about the uniqueness, the unique challenges of the black community will help shed some light on this. So thank you very much and I'll turn it over to Ken. Yeah, this is Ken. One question is where can I find my local NAMI group? NAMI programs are free and I highly encourage you to connect locally. It's all available at www.nami.org, which has become a major site for where people are finding mental health resources. You also wanna get information about mental health conditions and read our award-winning blog of people who've had first person experience. It's all right there. We cite all the studies we identify and you can click on them and take a look at them. So I think people like the NAMI website and the more mental health practitioners who know about NAMI, know about our programs, the better off we will all be. Thank you for your attention and both Christine and I hope you have a great day.

Sustainability of Coordinated Specialty Care

National Conference on Advancing Early Psychosis Care

SMI Advisor

Dr. Ken Duckworth

Dr. Christine Crawford

Coordinated Specialty Care Model

Health Disparities

African Americans

Mental Health Parity

COVID-19 Pandemic

Telemedicine