Hello and welcome. I'm Amy Cohen, a member of the Clinical Expert Team with SMI Advisor and an Associate Research Professor in UCLA's Department of Psychiatry and Biobehavioral Science. I am pleased that you are joining us for today's webinar, Chronic Physical Health Management for Individuals with Serious Mental Illness, Integrated Care, Evaluation, and Interventions. 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. Now I'd like to introduce you to the faculty for today's webinar, Dr. Lisa Rosano. Dr. Lisa Rosano is an Associate Professor of Psychiatry at the University of Illinois at Chicago, where she is Deputy Director for the Department of Psychiatry's Center on Mental Health Services Research and Policy. In addition to her academic appointments, she is Director of Research at Thresholds. For nearly 30 years, Dr. Rosano has conducted research related to individuals with psychiatric disabilities, chronic health conditions, and community-based services dedicated to improving the health, wellness, and community participation of people with serious mental illness. She is an elected member of the American Psychological Association's Task Force on Serious Mental Illness and Serious Emotional Disturbance, and serves as the Task Force Chair-Elect. Lisa, thank you for leading today's webinar. Thank you very much, Amy, for that gracious introduction, and we should probably go ahead and get started. I just want to say there are no relationships or other conflicts of interest related to this presentation, but as many do, we would like to thank the University of Illinois at Chicago for their support, Thresholds, and our government project funders from the National Institute on Disability, Independent Living, and Rehabilitation Research of the Administration for Community Living, the Substance Abuse and Mental Health Services Administration Center on Mental Health Services, and data that I'm going to speak of today comes from three grants, two rehabilitation research and training centers, and one disability and rehabilitation research program. I came up with three learning objectives for today's presentation, really to give us an overview of some of the physical health interventions that we have been working on at the Center with our collaborators that have moved the needle on some of the health conditions for people with serious mental illness, talk a little bit what about the ongoing needs we still have, and then talk about an area that we've been exploring not only at UIC, but also in our partnership with community mental health providers like Thresholds to really hone in on what health literacy and health functional literacy is related to this population. So the place where I usually start this conversation is with data that we received in a report around 2006 from the National Association of State Mental Health Program Directors, often referred to as NASHPD, regarding the morbidity and the mortality among people with serious mental illness, and where we often start is the Parks report of 2006, which stated that on average, there are 25 years' life lost for people with serious mental illness compared to individuals in the general population. And to give you some scale on that, the average lifespan of an American woman is about 77.5 years old, I believe, according to the CDC. So if you subtract 25 years from that, when a woman on average with a serious mental illness is looking at 50 to 55 years old as being a critical time, not only for her health in general by aging, but also by the progression and the effects of potentially chronic health conditions. When you control for things like accidental death or violence or suicide, which is often attributed to serious mental illness and its symptoms, 60% of these deaths and the driving of these years' life loss is actually related to preventable and largely treatable medical conditions, and we'll talk about what some of those are. In addition, we find that aside from affecting the lifespan of people with serious mental illness, these medical issues are usually more progressed in people with SMI compared to the general population. So if you were to take a 55-year-old white woman and match her to a 55-year-old white woman living with schizophrenia, and both of those individuals experienced diabetes, the probability is that the symptoms and the progression of diabetes and its consequential illnesses would actually be further along in the person with serious mental illness compared to the person without it. There are a lot of social justice factors, most of them listed in Healthy People 2020, that would affect this. And socioeconomic status is probably one of the most driving forces in those health disparities. But you also get things like age, race, geographic location. The symptoms of mental illness themselves can have some effect on physical health. A lot of research around the inflammation that we see related to depressive symptoms, for example, can affect immune functioning and vulnerability to other illnesses in that way. So when we look at people with serious mental illness, all of those factors really come into play. The health disparities that we have been tracking in the population really come along into these big six areas. I'm sure it is not a review for most of our listeners that diabetes is probably one of the most invasive chronic health conditions, but it's also followed by cardiovascular diseases and its effects, which are primarily diseases of aging, but also affected by management of diabetes in terms of circulation and heart health. And certainly reflected also in number five, the respiratory conditions contribute to cardiovascular disease. Nonviral liver diseases like cirrhosis that can often be more pervasive in this population, not only due to lifestyle factors, but also a higher probability of use of alcohol could contribute to that. Early screening and early detection of these nonviral liver diseases is not as common as you would think. And so oftentimes you see many of these things progressing to early stage or even mid-stage liver cancers. Real diseases are common, often attributed not only again to lifestyle and nutritional factors, some individual factors, but then also untreated hypertension, also again related to cardiovascular illness. Respiratory conditions would be the other area that I think most people are keenly aware of the impact of lifestyle and behavioral factors on people with serious mental illness, chronic obstructive pulmonary disorders, all of the consequences of smoking. And I believe an article was published in 2000, I think three years ago, maybe 2016, that showed that people with schizophrenia particularly are three and a half times more likely to die of a respiratory-related complication or condition than people in the general population. By some estimates, people with schizophrenia smoke about 300 times the rate of the general population. And then the last area is infectious diseases, primarily HIV, the viral hepatitis and tuberculosis. My own research has been mostly in people with co-occurring HIV and mental illnesses. And many of the things that we've done in community mental health have been able to be adapted and applied to people with HIV. And likewise, the HIV community has really been informative in some areas such as medication adherence, aspect of prevention, that have really informed community mental health work in terms of people having multiple medication regimens. That is something like a psychotropic drug as well as taking multiple medications for their physical health and wellness. So the other thing that we like to talk about is how we got to this place. And not only in terms of creating some of these health disparities and differences, but also what we can do about them and what our role is. And so clearly there are individual factors for people with serious mental illness. What do they know about their mental health? What do they know about their physical health conditions? This is one of the reasons we pursued an investigation of the actual health literacy of the population. Some individuals are not as motivated for treatment obviously as others. And then some of the factors that make people a little reticent to join psychiatric services, whether they're institutionally based or whether they might be community based. The clinical factors associated with the treatment of mental illnesses themselves are related to this. Obviously some of the metabolic syndromes that people experience as a relationship to certain kinds of medication use, gaining weight, waist circumference, BMI, all related to the growing rates and the invasion of diabetes in the population. And then we get to whether providers and systems are really equipped to deal with this. And I think all of the providers obviously on this webinar are interested in some of these health models and how we can move forward in not only knowing about these disparities, but actually doing something about them. And then whether the systems are really going to support that. And I think while we overall have more of a call for integrated care between primary care and mental health services, we still have some barriers to overcome in terms of access and coverage. And I will say a little bit more about that as we move through the webinar. So the place I'd like to start now is really talking about some evidence informed health interventions that not only affect wellness overall, but they specifically look at some of the issues that affect people with serious mental illness and are specifically designed to affect recovery and physical wellness for people with a psychiatric condition. The ones that I'll talk about primarily are health fairs and screenings. We're here at the University of Illinois. We've done a series of studies about that. That's more survey research. And then in the ones that follow, wellness recovery action planning for wellness, nutrition exercise wellness for recovery or NUAR, and then the whole health action management or WHAM, we've done randomized control trials here at the center on those types of models. And I have some very encouraging outcome data to talk about in terms of their ability to be used with the target population of people with serious mental illness. So the one thing I'd like to say is that all of our tools at the center are driven by our federal grant portfolio. And so I would invite you to come over to our management tools online. We have some policy focused things. We have some science focused things. Everything at the center is downloadable for free and available for people to use. And we encourage you to not only use it in your programs, but certainly provide it to your workforce in terms of giving them additional things to take out into their work with clients and individuals. So the first place that I would start was with health fair and screenings. You can see here a screenshot of our health fair manual, which was developed not only in terms of evidence based practices for health screening events, but we also collaborated with the collaborative support programs of New Jersey, which is led by a woman named Dr. Peggy Swarbrick, who worked with us in terms of developing this tool. And we put it into a survey research project with more than 450 individuals in recovery. And we found some really, really telling things. This can be a great way for people to start the conversation about health and wellness in some particular areas. It's an excellent strategy for people to identify what the clients in their programs might know about health. What we did is we had 10 different stations at our health events, and people would kind of flow through them free form, and they would stop, for example, and do their BMI. And in addition to getting feedback about their BMI, they would actually talk to an individual, oftentimes a trained peer specialist, about what BMI means, strategies to promote healthy eating vis-a-vis a healthier weight, and to give them some real factual information about things. The other thing that we noticed was that it created a little mindfulness of people, or that cue to action in a more traditional health beliefs kind of framework, where many people knew, for example, that they might be overweight, but they had no idea of how maybe far overweight they had become and that their health risks were advancing to some degree based on their obesity. And so it, again, brought people into a state of mindfulness that we thought was useful. The other thing that a health fair can do for you or do for a program is to not only identify people who need to be referred for screening, like if your A1C, for example, tests in a prediabetic or even diabetic range, but you've never been told formally that you have a diagnosis of diabetes, that's an excellent opportunity to set up a referral and work with that individual to get a full, more medically-oriented workup. The other thing it tells you is if a person has been told formally that they have a diagnosis of an illness like diabetes or hypertension, if their values at the health screening are out of range, it's a good cue to us as providers that they're not necessarily managing their health very well. So it would be an opportunity to introduce medication adherence or review symptomatology, go back to some meal planning. And so there's a lot of opportunities to do this, and it can be much lower impact than doing a big survey. Clients often really, really enjoy it. I would strongly encourage you, if you do decide to do this type of program, to consider working with peer support programs in your local area, because the peers can be really compelling. Oftentimes, they themselves are not just living with a mental health issue that makes them peers to the participants, but they themselves may have diabetes or hypertension, and that really helps people feel like they're not the only ones who are dealing with these combined comorbidities. Another tool that we've used is Wellness Recovery Action Planning, which is designed primarily for prevention and other kinds of processes. Those of you who have been to the Copeland Center, for example, or Advocates for Human Potential now have a strong role in sustaining WRAP and using WRAP. You know that it has been used in multiple countries to address many different conditions. There's been WRAP for HIV, WRAP for diabetes, but the original components of WRAP are really something that you see across all of the adapted or the unique disease type of use or application of WRAP. One of the things that's most important is to help people identify not only what their state of wellness is currently, but to really become mindful about the types of things that might distinguish them and their health when their health is starting to decline. On the traditional or the initial WRAP for mental health, a person would look at something like their prodromal symptoms. They might talk about what I look like when I'm well, what I look like when I'm declining. They might identify triggers, not only for their trauma experiences, but things that they know trigger not necessarily health-positive behaviors. Usually the example I would give there is emotional eating. That would be something that people would do. Once they work through those things, then they flip, if you will, to the proactive activities of building a wellness toolbox. What are the things, for example, that they want to use as wellness tools? They do crisis planning. How do I want to be treated in a crisis? Many people talk about elements that they would want in an advance directive. Many people have never heard of a psychiatric advance directive. That's an opportunity to discuss whether it's available in their local area, what it might look like, how they might want that to be handled. The other place that this is really helpful in terms of the toolbox and the crisis planning is if a person is taking medications for a physical health issue, many of them will put in their crisis plan for not only their psychiatric medications to be collected if for some reason they go into the hospital, but they might also say, I want you to bring all my medications. Instead of the medical team having to figure out if I have a medical illness or me skipping a dosage of a medication that I really need for chronic health condition, all of those medications can come with me and my history in physical, if you will, as a patient is much more complete when that happens. This application in terms of WRAP for wellness has been extended to specifically how to plan for diabetes, specifically how to plan for HIV. WRAP is something that you can do in multiple formats. Here when we do research in the RCTs, we usually will do an eight to 10 session group intervention of WRAP, but people, again, have adapted WRAP to be much more intensive three-day planning versus other kinds of planning. Again, these materials are available both at our center as well as through the Copeland Center and AHP, or Advocates for Human Potential. Nutrition, Exercise, and Wellness for Recovery, or NUAR, is a weight loss program that was developed here at the center. We worked with an occupational therapist. If there's any OTs out listening today, I just want to compliment your discipline, not only for hanging in there with us at mental health, but also for bringing some very practical tools that oftentimes people really recognize as necessary and supportive for people with physical disabilities, but they don't necessarily often recognize them for people with psychiatric disabilities, and so we found that even going into an individual's apartment and looking at their living space and helping them put their living space into a little better structure and flow can have an enormous effect on people in recovery, and thus their overall sense of well-being in their home. What NUAR seeks to do is to actually provide concrete information about meal planning, about intentionality for eating and exercise, and to help people build up capacity in two different ways. One is that it meets for 90 minutes a week with a group format that uses a lot of peer support and motivational interviewing, things of that nature, and then the other thing that it does is it allows some meetings if you want to offer them one-on-one, so people could come into a NUAR group and all have the intention to be losing weight. One person might have the intention to do that because they're interested in better management of diabetes, while another person might be interested in doing that because they want to lower their cholesterol and avoid taking a medication or potentially heart disease, hypertension, any of those, and so it uses different sessions. One of the things that you can see here is an example session from NUAR would be to actually read with a person a food label and talk with them about portions and portion control and serving size. Most of us, to some degree, often take for granted that everyone understands how to read a food label and what are their target types of things that they might be looking for, so in the case of a person with diabetes, you might be looking at sugar, you might be looking at fats that convert to sugar, any of these types of things in the food label. For a person with high cholesterol, you would definitely be wanting them to read the label and be looking and be monitoring their fats. You could argue the same thing for sodium for a hypertensive diet if you suggested someone they should be reducing sodium or going to something like a DASH diet, and so these very concrete steps are things that help people understand the impact of eating and what their kind of target label activities should be focused on. I can tell you from another research project that we did that included use of something like food labels, when we did an exercise where we talked about the amount of sugar that's in soda and other canned and commercial beverages, it was very compelling for one of the group participants, and when she became self-aware of the amount of sugar and started reading food labels on the beverages that she was using, she started to reduce the use of those beverages and therefore her sugar intake, and within the 10 weeks of the intervention period for that particular group, this client lost upwards of 12 to 15 pounds just by cutting out things like Pepsi and Mountain Dew and really sugary beverages, and one of the things that she commented about in discussing her success was how happy she was that something as small as changing a beverage could have such a big impact on her weight and that she thought weight loss was not for her, she would not be successful, it would be really hard to lose weight, and so just by changing to things that didn't have so much sugar, she realized that you could recognize and implement some very simple things that could have a really large benefit. Whole Health Action Management has been a randomized control trial that we've been working on for the last year and a half. We're getting into some preliminary data, and WHAM is a little different from NEWAR in that it's not exclusively focused on nutrition and exercise for wellness. And it really makes use of some of the techniques of illness management recovery, such as goal setting, making weekly action plans. And like others, it's a somewhat hybrid intervention where people go to group sessions, but then they also receive weekly one-on-one peer support sessions where they can talk a little more individually about the things that they want to focus on. WHAM has been a very successful intervention. You can visit two places to find workforce training, for example, in something like WHAM. You can go to our center and actually get the research version of the WHAM intervention that we use, which includes a structured, modulized intervention manual. There's a podcast on the value of WHAM, if that's something, again, that deciders at your programs or other people less familiar want to become more educated about the benefits of WHAM. And then an actual how-to training to walk you through facilitating that. You also can contact the National Council on Behavioral Health Care. They offer WHAM training. And at this year's past event, they had a two-day WHAM training. And so there's a relationship there if people in the workforce are interested. But WHAM does, like most of these other interventions, focus on things that people have to take some action. One of the things that really distinguishes it is we use what we call an impact goal, which looks a little bit like a SMART goal. But it's been revised to have a specific focus on what health would be. So the improving health quality makes it a little bit unique. And the idea that the goal has to be positively stated. And so that's another factor, I think, in the WHAM impact goal that sets it apart a little bit from a traditional SMART goal. So for the positively stated, rather than having people say, I want to lose 20 pounds, I want to quit smoking, we work with them using motivational interviewing, peer support, and other types of activities to add health-promoting behaviors. So you can see on the right there are some examples of how you might frame a WHAM goal. So if somebody wanted to work on their exercise or respiratory health, rather than potentially saying quitting smoking, you might have them focus on trying to jog and adding the exercise in. And then naturalistically, it's possible that the smoking would reduce because it's hard to smoke and jog, as far as I know. So they would be trying to promote their health by adding the healthy behavior and not only trying to promote health by reducing the negative behavior with more or less success. Eating more healthy fruits and adding more healthy things into your diet, rather than just taking away the things that you like. So again, we really, really focus on people to put those goals into a positive framework. And then we work with them to ensure that this is a goal that can be attained. So in a WHAM meeting, really, if a person came in and said they wanted to lose 50 pounds, even if they wanted to and probably medically needed to lose the 50 pounds, it's not really something that they could achieve in seven days. And so the analogy that I often use is it's really hard to move boulders. And so we put a little WHAM dynamite under that boulder and we break it up into gravel. And gravel is much easier to move in smaller amounts. And so instead of focusing on the 50 pounds, we focus on can you spend the next seven days focusing on eating seven servings of vegetables, trying to do 20 jumping jacks three times a day, working on adding the health-promoting behavior so that over time you will build up a habit for those health-promoting behaviors and you will see some short-term success. Many of the goals that people in recovery are focusing on are long-term, lifelong health changes. And without promoting that initial short-term success and recognizing that, it's really, really hard to continue to build these health-promoting behaviors, at least from what we found in our research studies. So we also, as I mentioned, extend motivational interviewing into the WHAM framework by actually using motivational interviewing for a number of reasons. And here are the primary reasons that it's such an effective form of contingency management is that people have ideas about what they want to do. Usually, it not only includes making a decision to do something positive, but it also puts you in a position of identifying some of the negative behaviors or negative activities that you do. So it promotes this kind of dual mindfulness of what am I doing that's health-negative, but at the same time, what can I do and how can I frame it to become more health-positive and have those promoted behaviors. And really, this shouldn't surprise any of us because the foundational models for these cognitive behavioral interventions, particularly in mental illness, have behavioral components, but the cognitive components are the things that sometimes we really have difficulty with. Ideally, we're helping clients to manage symptoms in schizophrenia or other illnesses that might have cognitive components. And without some of those cognitive management strategies, a lot of the behavioral components encounter those boulders that we talked about. And so you'll see these in mostly your illness management and recovery, in some of your self-directed care, in WAM, in all of these health models, and really helping people work between both the symptoms and the techniques that we know are useful. Obviously, I've talked a little bit about motivational interviewing, but the other place that you really see some important cognitive and behavioral intervention components are in the ingredients of peer support, which we have found, again, to be invaluable in promoting health and developing and sustaining health-promoting behaviors, and then also looking at some trauma-informed services and practices. One of the places where, for example, I can tell you that trauma-informed work and being mindful of the impact on trauma, not just in terms of health from maybe a traditional adverse childhood experience kind of perspective. We know that people with four or more ACEs are more vulnerable to physical illness, more vulnerable to substance use, more vulnerable to mental illnesses, and the consequences of lifestyle factors for all of those areas. One of the things that I found in working with a trauma survivor in a community mental health center was she didn't want to go to any gynecological services. So as almost a 60-year-old woman, she couldn't remember the last time that she'd had a pelvic exam or a pap smear, and she was pretty certain she had never in her life had a mammogram, at least not one that she'd known about. Some of this was driven by the fact that she was a trauma survivor, and because of the sexual assault she had endured, she was very resistant to go to a gynecological exam, and it was something that we had to really work on with her. But the truth was, even though she wasn't necessarily in current danger of a health risk, she wasn't following up on what would be the recommended screening and preventative care that would have distinguished a woman her age, at least in terms of mammography and gynecological screening. And so think about the ways that some of those long-term consequences of trauma can present themselves even in people who don't necessarily have a lot of immediate needs, but they're also maybe very quietly affecting their hidden needs. Other barriers that we see and we apply, I like to say, like most Americans, is denial. People with mental illness are not the only community that is struggling with obesity and heart disease and all these other kinds of illnesses that we see. We try to frame for our community mental health programs that these are health risks for the entire community, and we're trying to implement our health promotion activities in line with some community health activities, not only to make people with disabilities feel included, but to also then recognize the ways that strategies for prevention might really need to be unique for people with serious mental illness. So that's something that we've worked a lot on. Obviously, treatment of mental health, reduction of symptoms, as I mentioned, helping repair concentration and ability to take in some of this technical health information, things like feeling of invulnerability, we saw a lot of that in our work with people with HIV in terms of them feeling like they could control, for example, when they might infect a person through sex versus not. And then, again, of course, understanding these long-term consequences of health risks, but also understanding the long-term consequences of aging, because many of these illnesses, particularly the cardiac illnesses, the respiratory illnesses, some of the others, are things that we become more vulnerable to simply because we're getting older, even if we exercise and we eat right and we try to take steps to take care of ourselves. So that's led us to a large grant that we're working on here at the Center and other academic centers that's funded by NIDILRR that is centered at thresholds. And it's a five-year longitudinal program. It's got some interconnected projects that I'll briefly talk to you about. Here are the three project areas that we're working on, and we've made a lot of headway in projects one and two. We're about to start project three, which is about sexual health and wellness. So our first study is actually conducting a longitudinal study of medical wellness and treatment and medication adherence in people. So instead of going and doing something like our survey health fair, where we really only had contact with people for one event or even a chart review or two time points, we're studying the level of medical management and medical values in people every six months over a two-year period. And we're mapping those medical and behavioral values along with their use of medical emergency department care, other types of mental health services to see if there were any, you know, relationships between these things and also identify for the clients, thresholds that's called our client-based members, what members experience in terms of long-term management for their physical health illnesses. The other thing that we're doing in project two is trying to promote some health literacy, not only in our client and member base, but also in our workforce providers. Because when we look at the workforce of a community agency like thresholds, and I suspect it's true of many community mental health agencies throughout the country, the workforce is not all people who went to medical or nursing school or who have a real foundational knowledge in components of medical illness. But we have, in fact, invited them to become managers of medical illness. You know, the majority of the case managers that I work with are people from social work, occupational therapy, counseling. Those are people who'd say, I don't know much about managing diabetes. I didn't go to med school. And so it's often hard for them to work with their clients about, you know, prevention, better management, interpreting what their test or lab results are. And so we're trying to bring that sensibility to that workforce in the essence of having more integrated care, not only on the medical primary care side, knowing more about mental illness, but our mental health workforce, knowing a little bit more about primary care and health without actually having to go to medical school to get it. And so basically our foundational group of people is about 15,000 service recipients at the agency. You can see the demographics here. Probably, depending on your location, would not surprise a lot of you in terms of, you know, what we are learning. We have a slightly older population. Two-thirds of the people are really, again, we're approaching it from they're in an age group of individuals who need to talk about aging, not just primary prevention, but prevention due to aging. And then you can see we do have a lot of individuals who experience schizophrenia, bipolar illness, and major depressive disorders. What's very interesting is that at least half of this group would be individuals who would report a GED or high school graduation. But one of the things that we've learned is while that average education might be 12 years and the lower end might be around eighth grade, we have the average reading level of clients at our agency is about sixth grade. The lowest that we have encountered, and unfortunately I have to report we're encountering more of it, is people who can speak and functionally have a conversation about things, but their reading level is about second grade when you hand them something that is about colonoscopy prep. There's jargon. There's medical terms. There's things that even at a sixth grade reading level could be really complicated. And so we're identifying that there's not only a lot of functional issues, but that people probably aren't really told a lot of factual information about what their medical illnesses are. So what I've been asking case managers are, okay, so if your client with schizophrenia who's 24 or between 24 and 30 now becomes newly diagnosed as an individual living with diabetes, what type of diabetes education has this person been provided that they can understand that's in context of their treatment of their mental illness and the fact that now they might be doing dual regimen type of treatment. Management. So what we found just in terms of our initial data is that we used NHANES to look at co-occurring illnesses that had a formal diagnosis. You can see that there on the first column. The number of individuals who reported being in medical treatment, which is what we characterized as having a formal diagnosis and receiving and using a prescription medication for the treatment of that comorbidity. And then we screened them for their medical values on that day. And so while we find that about 72% report having COPD or asthma or some other respiratory condition, 60% of them are still smoking. And of those, the level of nicotine addiction is pretty high, which means they're using a pretty high volume of cigarettes. At least I think 12 to 15 cigarettes on average. Half of our samples so far has been formally diagnosed with hypertension. The majority of them are in medical treatment for that. And we find that still nearly half of them are screening into a prehypertensive state. And then you can see some of the others. Diabetes has been one where, again, a lot of people are diagnosed. Most of them are in treatment, but many of them are still showing a fairly elevated A1C. And so this is giving us the sense that while people know about their illness and they're in treatment, the management of those illnesses might not be as effective. And we want to address that both from an individual and a provider and a systems perspective. And then in yellow there, you can see we have some blood pressure readings and just the average across the sample that we have so far. So our health education for non-medical providers has begun. And as you can see, if you go to CDC.gov and you recommend to a person to read the CDC's description of something like diabetes, that's usually going to be up there at about an eighth grade reading level. We've been using a lot of these materials from other healthcare providers like CDC so that they have an anchor point to go to, at least as providers, and there's some consistency in terms of the information that they get from at least an overview about what does it look like to have this illness or what should we monitor in terms of indicators for this illness. With our Health Literacy Center, we are developing now a series of online tools and courses. And so the first course that we have in this library will be going up in the next couple of weeks started with World Health Day because the theme of World Health Day in this particular year is about integrated primary care. And so we wanted to set the tone of integration of this healthcare and the psychiatric care and how invaluable it is. We've also been developing tools every month for the mental health workforce that are aimed not only from a I didn't go to medical school or nursing school type of perspective, but it gives case managers an ability to talk to more medical providers with a little more authority and a little more information. And I put the colorectal screening cancer up because obviously many of us are turning 50 or we've become 50. And I don't know about the rest of you, but many of us have probably been getting a lot of information from our docs about you're 50, you need to do the prep, you need to do the invasive, embarrassing colonoscopy. Everybody needs it at 50. It's like this longstanding preventative screening milestone that we all hear about when we turn 50. And then, you know, there's some other risk factors, whether you have a history, certain populations that might be an elevated risk. What we didn't anticipate was finding out here on the backside that in many cases, Medicaid is not going to cover your colonoscopy. And in fact, on average, people who are having their healthcare funded by Medicaid are probably not getting their colonoscopies for on average about 15 years after. And so they've already advanced and have the potential to have cancers in this area. And so we're finding out and working with providers to figure out what is and isn't covered in some of these payment systems because of the core support that many people with serious mental illness have on Medicaid, because we don't want to start referring or asking clinicians to make referrals into areas where clients won't be able to get care or have success. And so we're uncovering this, not only in some areas like colonoscopy, but we're uncovering them in a lot of other different kinds of areas. In this final tool, you can see here we're trying to have people talk again about, say, alcohol, using the cage, less again about diagnosis or scoring, but as a way to have some questions where you can start a conversation and then use your techniques of motivational interviewing to keep that conversation going. And on the other side, we put some common medications that people use for treatment of mental illness and the risks of drinking alcohols along with them. We launched these tools in concert with Colon Cancer Screening Month, Alcohol Awareness Month, we did a hypertension course like the World Health Day course for National Hypertension Awareness, so that we try to promote this community health sensibility when the world is promoting this community health sensibility. We're going to continue to do this for another two years with a map schedule of some of the things that we would do to align ourselves with National Diabetes Awareness, the Great American Smokeout, and some of those more traditional types of things. So our success in these areas has been primarily in identifying not only gaps, but ways that we can invite a more comprehensive workforce to come in and be part of this conversation. All of the randomized control trials have not only showed a little bit of patient activation, improvements in self-rated abilities for health practices, knowledge to some degree about these things, but we still find, at least in our research so far at threshold, that we have more work to do. And so I would invite all of our listeners to think about the ways that we can implement new programs, the way we can use tools, motivational interviewing, things of that nature, to actually drill into these health behaviors and then move on to what may be a real niche for us, which is helping people understand the nature of aging, the screenings that are normative for them, and that all of these health and wellness protective factors really should be something that's a lifelong commitment to health and not wait until you're in an age group where something's appropriate for you or recommended for you. And then from, I think, a policy perspective, we really need to look at the impact of poverty, the coverage that people have, and whether or not those public entitlements are allowing them to keep up with the prevention milestones that we all know are evidence-based and medically informed for the general population. Thank you so much for listening. Here's my contact information, and I guess we will go to the questions. Thank you.

Dr. Lisa Rosano

chronic physical health conditions

serious mental illness

integrated care

evidence-based interventions

health literacy

barriers to effective physical health management

trauma-informed care