Hello and welcome. I'm Dr. Amy Cohen, Program Director for SMI Advisor and a clinical psychologist. I am pleased that you're joining us for today's SMI Advisor webinar, Depression-Related Mobile Apps for Self-Management in Underserved Integrated Primary Care Population. 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'm happy to introduce you to the faculty for today's webinar, Dr. Margaret Emerson. Dr. Margaret Emerson is an assistant professor and an ANCC board-certified advanced practice psychiatric nurse practitioner. She has worked both in and out of state as a nurse practitioner since 2011. Dr. Emerson specializes in the delivery of integrated care. She completed integrated and collaborative care training and has served as a consultant, advisor, and presenter related to her integrated work. She was one of the first psychiatric nurse practitioners to serve as an integrated psychiatric consultant in a local primary care clinic. She joined the University of Nebraska Medical Center College of Nursing as an assistant professor in 2018. And in 2019, she was appointed the Director of Workforce Development for Advanced Practice Providers with the UNMC Department of Psychiatry. Dr. Emerson, thank you for leading today's webinar. Hello, thank you, Dr. Cohen, and thank you for welcoming me to present this content. So just to start off with, I do not have any relationships with any commercial interests or conflicts of interest to report. So a broad overview for learning objectives for this presentation are really to include being able to identify strategies for selecting appropriate self-management technology tools for the use in primary care. In addition to discussing the provider and patient as well as clinical staff perspectives relevant to depression-related apps, and specifically, my hope is to really address the use of these tools in the integrated primary care setting and targeting the self-management for the underserved and how we can promote the self-management for those folks. So just a broad outline for the presentation, I'm going to cover three of the different studies that we conducted that really are sort of the basis for the information that I'm going to be providing for you today. And then also, I'm going to be looking at some of the future directions based off of the information that we have collected. So looking at self-management as well as the perspective from the patients, providers, and clinical staff, and then moving into directions that I see mobile apps being used in integrated care at this point. So just a background here. So with major depressive disorder, we know that 17.7 million U.S. adults have the criteria for this in the past year. And depression really is characterized by this depressed mood, which is often accompanied by other symptoms such as lack of interest, fatigue, feelings of worthlessness, impaired thinking, psychomotor agitation or retardation, sleep disruption, thoughts of being better off dead, and or suicide. And we know it's one of the leading causes of disability worldwide, affecting approximately one in 10 U.S. adults. And with the shortage of psychiatric providers that we have and some of the stigma associated with mental illness, a large amount of the cases are being banished in the primary care clinics. And in fact, when we look at the prevalence rates for depression diagnosis in the primary care clinics, it ranges anywhere from 24.2% to 56.7%. So beyond looking at just depression as a disorder that we're going to be focusing on, we also want to look at the underserved population and those that experience health disparities because individuals that can experience additional factors associated with their underserved dynamics, which can also affect the rates of depression even further. So this is a slide where it's a graph that represents really that inverse relationship between income and depression. So we know that individuals that are living below the federal poverty limit have 15.8% of depression rates in comparison to those that are about 3.5% of those individuals who are at 400% of the federal poverty level. Additional disparities that we know with regards to depression treatment and mental health are that of the 17.7 million adults that are meeting that criteria for major depressive disorder, only 64.8% of them actually reported receiving treatment. And then we look at different racial differences, 30% of African American and Hispanic adults with any mental illness have received treatment in comparison to 43.3% of the overall US population. And there are further disparities with individuals with lower education with the odds of receiving treatment declining in women or remaining stable and not improving in men from the years of 2005 to 2014. So speaking broadly, we know that there are challenges in receiving care for serious mental illness in particular for depression that include things like access to care, wait times for patients, transportation from non-urban areas to urban providers, and just the co-management of medical and psychiatric disorders. And so my experience really as the psychiatric consultant in these integrated environments is seeing the differences between traditional practices in comparison to my integrated setting where in the traditional practice, I would have wait times up to six months. And then the longer, I think we all know that the longer that it takes to see a patient, the increase of chance that we have for the no-show rates. And so not having primary care and psychiatric care aligned can really result in not being able to achieve some of the outcomes that I think we're all targeting or hoping to achieve. And so in response to some of the challenges that you see in primary care, you have this allocation of delivery models that include collaborative and integrated models that are really meant to support the efforts and sort of after realizing that a lot of these patients are being managed in the primary care setting, how can we really facilitate excellent care? And so in working in this environment, it was very clear to me that there are benefits and this has been widely distributed in the literature that there are benefits of primary care for depression that include just this timely engagement of evidence-based medication treatments. We can provide the initiation and effective psychotherapies for patients that are really brief and time limited, but really based on the literature and evidence that we have. And then there's also an opportunity for patients to really receive that close follow-up with behavioral healthcare providers on treatment adherence, as well as the approach really is about outcome accountability. However, despite the fact that we have these delivery models that are quite effective in care, there are some limitations that don't really address some of the folks that are in that underserved population. And so challenges that I see on a regular basis are individuals that really struggle with being able to attend their appointments. And this can be just due to common things like a lack of access to transportation or the bus route, not getting to our clinic location with a direct access where they have to take multiple schedules. I think also now we're seeing inflexible work schedules and with people being worried about retaining their jobs and all the different dynamics that go into the stress that the coronavirus has had, that we're seeing inflexible work schedules make it difficult for them to attend appointments. And then also just some of the tangible things that patients experience of just a range for childcare to be able to arrange for that, and then also subsequently attend appointments. Other factors that impede us are limited or no health insurance. So in 2019, 9.5% of the US population had no insurance, which is roughly 30 million people. And the underserved populations make up a substantial portion of these 30 million individuals, creating another barrier to being able to receive care. And difficulties in reaching patients via phone for care management is another factor affecting their care, as well as just maintaining treatment related to costs. So having an understanding of all these different dynamics that underpin integrated care and management of depression, we really have to be creative and innovative in how we address this because offering face-to-face traditional care is not going to be a tangible way to address some of these things. And so the question really lends itself, what are our options? How do we manage this? I think what you see now is a push for the utilization of technology. And in a way, having the coronavirus sort of force us to get used to using technology has been an advantage because we had to really look at how we can safely deliver the management of psychiatric services in a virtual format. And our idea prior to the coronavirus really was looking at addressing some of these challenges that exist in integrated care through the leveraging of technology. And so incorporating technology really can increase access for care and really put some of that access within the community. And opportunities using technology can provide reminders for appointments or assistance with medication support, can also offer the opportunity to foster some self-reliance in the development of self-management skills, as well as be a low resource option for individuals that are struggling financially, and also provide a way to promote self-management within the community, which, you know, technology, broadly speaking, sounds great, just to say, you know, technology is a good resource and we can really make this happen, but we do have to understand that there are different dynamics that underpin our feasibility in doing so. So broadly speaking, looking at smartphone ownership, we know that 81% of Americans own a smartphone, and over two-thirds of adults are willing to use their smartphones to help manage their health. And the mobile apps can be used for people to manage their depression symptoms, and the availability of depression-related apps is rapidly developing. In fact, in 2017, approximately 325,000 health-related apps were available, 10,000 of which were mental health-related apps available in the digital healthcare marketplace. So as a clinician, one of the things that we also have to consider is, in order to use technology in the underserved, it's important for us to understand the populations that we're treating. And so when we're asking patients to use mobile apps to self-manage their depression outside of the clinic setting, what are we really asking them to do? What is this concept of self-management? So again, self-management really is this way of promoting patient independence and asking patients to be an active participant in the management of their own care. And technology can promote that self-management and enable the components of activation, such as being able to acquire skills, education building, as well as engagement in desired behaviors. However, we have to make sure that what we're trying to do with the self-management is really tailored towards the resources that are available or determine if it's going to be feasible. So with our population, it was important for us to look at, did they have smartphone capabilities and ownership and data plans really to support that usage? So with underserved, I think the concerns with socioeconomic status, are these actual feasible devices and tools that we could leverage to enable them to self-manage? And then also looking at self-management interest factors. So we may have this great idea to put on the table of them being able to use a mobile app, but do they have any interest in doing this? Do they have experience in using mobile apps for health improvement? Do they have, is there reasons that would help us better understand their need for downloading a health-related app? And what is important regarding apps versus what may be not be as prioritized for them? So is learning to use the app easy, is that an important feature for them? And then also just that willingness to use a particular app and their data plans on those apps to promote self-management. And if they have an interest, particularly related to depression and how those apps can really facilitate that. And then beyond this, the other factors that play into self-management, I think in particular for integrated environments are looking at the aspects of patient activation and health literacy. So we think about patient activation. This is really, it's comprised of the patient's knowledge, skills, and competence and their ability to manage their own health. So essentially self-management. And the patient activation measure is a 13-item measure that we use that has excellent reliability and validity. But what it does is it allows you to categorize the individuals into one of four levels of activation, where level one is low activation, suggesting that a person doesn't really have yet the understanding of their role in their own healthcare. Level two is that the person has some knowledge, but they largely believe that their health is still out of their control. Level three indicates that a person has key facts and is beginning to engage in a positive health behaviors. And level four is that the person is proactive and has adopted many health-related behaviors. So you can see when you look at a population and you start divvying out, you know, which level they're at, the importance of us understanding that because we can tailor their self-management needs as well as the resources that they may need to promote their self-management outside of the clinic setting. And then anytime you're looking at the need for educational opportunities for some of these tools, it's important to explore the health literacy component because the underserved population, we know that socioeconomic status, age, race, cognition, and educationals all contribute to a person's health literacy. And when we're asking patients to be involved in informed decision-making and take actions that are really designed to improve their health, it's essential that the tools and resources that we have are able to actually be understandable so that they can best support them and enable them to use the technology that we're asking them to utilize outside of the clinic setting. So when we first started kind of looking at options of identifying mobile apps in use for our particular setting, so there's a population of apps that unfortunately kind of what we found is that there aren't any requirements for developers to demonstrate or to publish data on the effectiveness and efficacy of apps before they put products onto the market. So you have a fair amount now of various app screening models and evaluation tools that have been published by researchers and professional organizations, yet the utilization of these tools is really not standardized or mandated in clinical practice. I think part of that is because we don't necessarily have the time in clinical practice to devote to some of the demands that can come with utilizing these tools. And so there is a bit of a learning curve depending on your tech savviness. The other part is really plays into some of that confidence and again, this not mandating the process for standardizing these tools makes people a little bit leery if they're going to sort of see using mobile apps as a prescriptive option for them. And so at the time of the work that we did, we didn't have some of the tools that are available now. So I'm going to kind of walk you through the steps that we took and to discuss some of the challenges that we encountered because there are some lessons to be learned in just the process and the opportunities that we had to sort of learn as we went. And I just want to make sure that you know that as I'm describing the steps and process that we use to identify and explore apps for our population, the material is not really an indication of endorsement of any one particular app or tool, but I thought it was important to really contain the information here because it helps provide the context pertaining to the tools and apps that were explored. Because again, I think what will be highlighted through this is that you need to understand the population that you're working with in order to really tailor some of the needs and the apps to be suitable to that population and to the providers. So we started our search thinking we're all researchers and so we are going to go to the literature and find what are the best apps for depression and we will just start there and it'll just be lovely. And we learned very quickly that there are tons of challenges to incorporating apps just from the literature alone because as we all know, research tends to lag behind and especially when we're talking about technology. And the apps that we identified early on were not readily available for us and so we ended up I think it was the lapse of time was about four months before when we identified them when we went to go use them and many of them were no longer accessible in the same way, which really speaks to that potential turnover. So getting accustomed to maybe one or two apps has its disadvantages if people are not invested in maintaining those apps or if there's not money to support the use of them. So it does make a difference in getting comfortable with more than one app. And then the other thing that we found is that these with our organization, there are just a lot of compliance and privacy related concerns when you start to talk about using mobile apps in practice. And so you could come up with this great mobile app, but if it doesn't align with the organizational requirements, it does make it difficult to actually incorporate into practice, especially when you're looking at incorporating the data that you collect from the apps into the electronic health record or vice versa. So these are all things that are, I would say, just precursors to really understanding what you want to have in an app. And I think having app evaluation resources that I'll talk about a little bit later can help you sort of be informed about that process. So because we had some pitfalls in our first search, we decided we're going to revamp things and sort of address finding apps the way that patients typically do. And so we researched how do apps really get identified by patients and kind of thinking that a provider is probably going to have patients come in and ask, what do you think about this app? And what are the steps to use accordingly? And what we found are that patients and providers that are looking for apps typically are not going to search for more than 10 apps on any one particular topic, and that they're going to identify apps through internet searches like the top 10 lists and Google stores or Apple stores, as well as identifying apps within other apps themselves. And so we decided to complete a second search using those same strategies. And we had a team of three researchers, and we were all given the same instructions of search for up to 10 apps and use the same steps that a patient would use. And then we'll come together and decide what we come up with. And what was interesting for us is that we had a list of 30 apps, but actually just based off our search strategies, we ended up resulting in only 16 apps because we had so many that overlapped. But given all our experiences, we also realized that we each had different strengths and weaknesses in terms of individual team members as well related to mobile technology. So some of us may have been a little bit more tech savvy in certain areas, but not others. So what we decided to do is to really level the playing field and seek out additional resources. And so we had a gal here at the UNMC that is a research IT specialist. And what we did is we said, here's this list of 16 apps that we have. And we'd like you to just to take a deeper dive and tease out anything that maybe we didn't think about or things that details that you think would be important for us to be aware of. And so what she did is she looked at with each of the apps, what are the main areas of app promotion? What are options for in-app purchases? When were the apps last updated? What's the size, the number of installs? What permissions are you giving when you're using this app? Number of reviews and star ratings. And these are all things that now, when you look at some of the frameworks and evaluation tools, they do talk about the necessity to look at some of these items that she had identified. And so we certainly didn't think it would be feasible for us to present 16 different apps to patients and providers. So we needed to take another level of sort of narrowing down the apps. And so what we did is we met and determined the minimum criteria sort of deemed by acceptable by all of us, including what the IT specialist had come up with. And so we decided is that there had to be a minimum number of reviews of a thousand that we had minimum of four out of five stars on either Android or Apple app stores. That the app had been updated within the last six months and that there was evidence of some expertise or research involved that really pertained to depression management. And someone's explored this at a little bit deeper level so that there were psychologists or psychiatric providers that have really been at least involved in the process of development. And then we also looked at with our behavioral health providers working in the integrated setting, what are the things that they think would really be beneficial for their standard of care? What are features that would be helpful for them? And so things like skill modules, CBT techniques, are those embedded in the apps? And that's another approach that we use to narrow down the list. And so once we had the list of seven apps, we went ahead and evaluated them with tools that we were informed of were available. And we picked more than one just because again, I think the complexity of when we started doing this was there just was not a ton of information out there. And we were dealing with depression related apps. So we wanted to use the APA app evaluation form, which at the time was an online site where you could fill out this form. And you would just submit it to the APA with potential feedback. And so I will go through that a little bit more in depth on the next slide. And then the other one was the mobile app rating scale. And so we'll talk about both of those tools, but we thought it was important to have a couple different lenses, just again, because there can be some variability in how you can explore these apps. And so with the APA evaluation form, it's at the time it looked at, what's the app name? What is the release date? And it would give you options for each of the four categories of safety and privacy, evidence, ease of use and interoperability. It would give you options of no concerns, some concerns and major concerns, either each of the categories that had questions prompted with it. Sort of the downfalls with that, it's somewhat subjective in nature. And so that we had two members of our teams complete the forms. However, it's based off of sort of your tech savviness and what you can really navigate with those forms and what you can see within the apps themselves. And there's no static score. But some of the benefits for using more than one tool is that it explored some of the components that the MARS didn't really get to. And it lets you get into the apps in a way that maybe you wouldn't otherwise if you just downloaded it and just kind of waited to see when it would be useful for you. So the mobile app rating scale is a tool that involves looking at the engagement features of mobile apps. So it's a multi-dimensional measure and it looks at the aesthetics, the functionality, information quality, and then the overall subjective quality. And it has been used quite a bit, has some internal consistency and integrator reliability. And also it's a good indicator for app quality, both from a clinician and patient perspective. It's pretty easy to use. The thing is that you do have online training that you have to complete the authors of the, or the developers of the tool recommend that you complete the online training. And then after that, it's a bit easier to complete the tool, but really it doesn't take, it's not too time consuming to complete it, but the MARS has been used to evaluate apps and studies seeking to increase self-management, which was another reason why we thought it was important for us to utilize another tool. So once we identified our apps and then we went ahead and evaluated them, we wanted to make sure that what we had was appropriate for our population. So again, going back to serving the underserved and the primary care integrated settings, we work with the behavioral health providers and said, here's our list of apps, what features and what are the things that you think would be a deal breaker for some of these patients? And anytime there was a cost associated with the app use, especially for a feature that would be very beneficial for them, that was sort of a major thing that said, we aren't going to be able to use that app. So I don't think without us doing those tools that it would have been as clearly easy to identify some of the features that we wanted to have without delving into these app related evaluations, because it's not until you start using these apps that you really see what you can and can't do without paying for the service. So for us, when you think about engagement and different things that pertain to people's sort of sustainability of apps, if cost starts to get to be an issue, then that's really going to disperse use. And so that was one of the things that narrowed out some of the apps for us. So once we had our apps narrowed down, we did start to get further information from individual patients. And our criteria were that we had two integrated clinics, and the patients were 19 years of age or older, and they had to have a previous or current diagnosis of depression in their medical record. We did a convenient sampling method, and we actively had the behavioral health provider who was really in charge of making sure that the patients who needed mental health needs were addressed in some way during those clinic days. And she and our graduate assistants would work with recruitment. And what we would do is look at recruiting them in that setting, and then getting information about how to proceed with next steps for the focus groups. And so what we learned from the initial sort of clinic differences that the behavioral health providers, although they are both integrated clinics, they were very, the demographics, they said it was important for us to capture that because that could play into some of the things that we would need to know later in terms of self-management. So what we collected for baseline information were again, the details regarding smartphone ownership, use and data, the self-management interest factors, and then as well as your patient activation health literacy. And then once we completed the baseline data information, we also asked the participants if they'd wanna participate in a focus group, which we wanted to hold individually, and not individually, but in a group setting in the clinic, but then coronavirus happened. And so we ended up having to switch and do everything virtually. So we did have virtual focus groups for the patients that they had an interest. So we would take down their information, then contact them when we were ready to hold a virtual focus group. And so here are some of the results in terms of demographics, there were clear differences between the two clinics. And there was a higher percentage of males at the Midtown Clinic with younger patients at the Fontenelle more African-American patients at the Fontenelle Clinic and more Hispanic patients at the Midtown Clinic. In terms of employment, approximately only 29% of patients were employed at the Midtown versus 44 at Fontenelle and disabled and unemployed patients made up about 51.2% at Midtown and 41% at Fontenelle. And so there's other details on here, but I just think for intense purpose, highlighting some of the major differences can be valuable. In terms of health literacy percentages, almost 30% and 23% of the clinics of the patients reported sometimes to always needing help with reading materials. And so I think this really speaks to the importance of understanding the information for the development of educational needs. So for seeking to incorporate technology into these environments, we need to understand that the materials that we make have to be suitable for their needs and already indicating that, a fair amount of the population was struggling with some of the materials being provided and those conversations with the healthcare providers really warrants a need for us to address that if we're gonna seek to really empower them to self-manage their depression. When it came to smartphone ownership, so despite the fact that these folks were struggling financially a lot of times, the smartphone ownership was quite high and with the majority of them having unlimited data plans suggesting that it would be feasible for us to incorporate an intervention like this. The smartphone use for health information, there were about 58.2% that had used a smartphone for health information purposes at the Midtown Clinic and then 77.3% at the Fontenelle Clinic. There was also an overwhelming willingness to use the data that they had for depression management with an average, well, 76.5% at Midtown and 86.4% at Fontenelle. And then there was a belief that an app can help in symptom management was also high at 66.3% at Midtown and 72.7%. So all the things that I think that you would really wanna know is there, do they have the phones, do they have plans to support this as well as do they have an interest or willingness to use their plans for something like this and do they actually have a belief that this could work? Those are all things that we thought would be important to be aware of, but as you start to read the literature regarding engagement strategies and promotion of mobile app use and sustainability, those really are key features of really determining does somebody have an interest because that will play into the sustainability of their use of the mobile app over time. This is another just graphical representation of some additional data that we collected. One of the things that I thought was just interesting that most users were Android users at over 62%. However, there was enough of a distribution that I think it's important to identify with apps if you're gonna identify apps that are applicable to a variety of patients to really make sure that those apps are available both in the Google and Apple stores because that way you're not just seeking or targeting one particular type of phone user. So additional data here. So a limited number of patients were currently using a health app with only 34% or less. It was very important to the patients that the app was easy to use at 80% and only 7% or less had used an app recommended by a healthcare provider. So this was one thing that really sort of lends itself to understanding that despite the fact that there were patients that were interested in using a mobile app, they weren't getting recommendations from their primary care providers to use anything to facilitate treatment. And again, that majority were willing to use their data and believe that it could be helpful in depression self-management. So we look at activation levels. Regardless of activation levels, there was anywhere from 12.8 to 38.5% indicated difficulties with reading material. And overall, 43.9% of patients measured at a level three of activation, indicating that they have some key facts and are beginning to engage in positive health behaviors. So essentially a good candidate for self-management. 20.7% at the level four, meaning they're currently proactive and have adopted many positive health behaviors. So those are folks at those level three and level four, there's a clear percentage of the population that could benefit and probably are well-equipped to really start utilizing mobile apps for self-management. Whereas the individuals that are scoring in the one and twos are gonna require quite a bit more support in terms of gaining that confidence and sort of empowering them to be managers of their own care. And so there are just some differences there and nuances in understanding how you can apply that. There was a statistically significant association between health literacy and patient activation levels with individuals with higher health literacy tended to have higher levels of patient activation. So understanding literacy and activation levels can really help to promote interventions and tailor them to the needs when looking at mobile apps. So the other thing that we had the focus groups do are UMARs, which UMARs is a user version of the mobile app rating scale. So important to note that it was, this was something that we ended up doing virtually again. And during the focus groups, we had the patients complete this UMARs. And this is a reliable tool that can assist developers and researchers in assessing the quality of the mental health app. It consists of a 20 item measure, including four objective quality subscales. And the patients ended up identifying WISA and Youper as two that had the higher scores when they looked at the apps individually. But when we looked more broadly with some of the semi-structured interviews that were applicable, that only a few of the participants had ever used mobile mental health apps before, and no one was currently using something. But if you had ever used any sort of health tracking app at all, most of the patients and participants said they would be willing to try out an app if their provider recommended it, which is very congruent with the literature out there now. Really, if providers are recommending apps that can promote use. Additionally, if there are ways that you can incorporate the data that they are collecting and make it meaningful and valuable, that's a significant way to promote someone's engagement with the use as well. So these are all things that are consistent with what we're seeing in the literature now too, that if you find ways to personalize and provide value for someone's app use, that you're more likely to see them engage in that. And so we were looking to understand those facets a bit more. The other thing that we identified is that we had a library of apps that they were looking at, but everyone found at least one app of the three, because we reviewed three in each focus group, that they would be interested in trying on their own. And so that was important to note that there wasn't one predominant one, although they had scales that were rated and they had a hierarchy that way, but when they actually played with the apps, there wasn't one that stood out among all of them to say this is the app that we would use. Suggesting that, again, there's layers of engagement and the aesthetics and some of the features that go into these MARS and eMARS that it's important to be aware of so you can look at how to best support patients and then also personalize their features that are desirable for them. So now that we had looked at the patient perspectives, we also wanted to look at the provider and clinical staff perspectives. And so we did focus groups of those folks as well. And some of the providers had used mental health related apps, but only a few were currently using one. Typically these were related to mindfulness or meditation. Only one provider had ever recommended a mental health app to one of the patients. They identified patient barrier issues to phone issues. They had concerns that maybe there were limited data plans or prepaid cell phones, so they wouldn't be able to use those things. They also had concerns about patients having difficulties with utilizing technology, which then they felt like could potentially cause additional strain on them. And time was one of the most often mentioned barriers for them to support mobile app use because there were some concerns about being able to support their technology in a way that wouldn't impede their care, but trying to find how to incorporate that information into their electronic health record or incorporate that data into their treatment seemed to be a daunting task for them. A majority of them really emphasize the importance of education and awareness, that they want to be able to support patients in using this type of technology, but they had some learning and education gaps in their knowledge to do so. And that they really felt like there should be a person available to help with that tech support for the patients. And again, making it a positive experience for them, as well as being able to leverage the data that they would be collecting. So some of the general study implications that we found from all our results is that there isn't one app that meets the criteria for a patient or provider or clinical staff. There really are multiple app options. And the thing that plays into that most are, what are the educational needs for patients and providers, as well as how can we promote the engagement and really personalize the mobile app to benefit a patient's care? And by being able to personalize the technology, it really looks at, what is the patient interested in pursuing? How can we align those with the goals, especially in integrated care where that focus is really patient centered? How can, what app features are really gonna promote that? And what can we work with on the patient to support their technology use? If they're in a level one activation, they're not really seeing how they can progress to being management of their own care. What are the foundational things that we need to promote there? In comparison to someone who is really at a level four and they're ready to go out there and they're already demonstrating health promoting behaviors, and they are probably well equipped to download the app and start doing those things. But what if they run into tech issues? How do we support that? So we know that uniform application of one app probably doesn't work. Having a library of app potentially is a good way to address that, or being comfortable using more than one app. So patients have different features that they're desiring that you feel comfortable doing that. And in order to do that, I think we really have to look at providing education to providers to enhance that comfort level. And so things like app evaluation methodology that I'll talk to you about, there's a few tools there and some resources at the end of this lecture I can speak to that really help, I think, promote that comfort level for individuals. So we think about educational materials, especially with our population, making sure that patient activation and health literacy are ways to really tailor the needs to the individual. The underserved experience some significant barriers to access to care and some other dynamics that can affect their depression treatment. But what we found is that they have the devices, they have the interest, and they also want to use these tools. And we can support that if we are able to empower our clinicians and behavioral health providers to support that tech and also include that data to make it meaningful for the patients. And so the mobile apps can provide a feasible way to address those barriers, but we have to make sure that we're always looking at ways to engage users and providers as an important feature. Otherwise, the application is probably not gonna be sustained and work. And the one size fits all doesn't work for mobile apps. And so again, being comfortable with multiple options and promoting that comfort level. Because we know that mobile technology can be very useful. But I think to this point, embedding it in an integrated system where you can leverage that team and accountable care, where people are looking at data actively, pursuing those things and evaluating outcomes is a way where you can really reinforce the opportunity there. But you have to train folks to be able to do that, to serve in that role. And so I'm gonna talk about a couple of ways that you can facilitate that. So this is just an example of a dashboard digital platform, basically where you can take information that is actively input to the mobile app. And then also, it provides a way to collect some of the passive data. So that's information that comes from the sensors on the phone that can be used to incorporate the data in a meaningful way. And this is some of the stuff that's being explored in the literature now where you can, the behavioral health provider and the patient can use this platform to review some of the information that the patient has inputted, as well as link that to some of the passive data. So if a patient is exploring their patient activity patterns and social engagements through the data that's collected passively, and then we can correlate this to their change in active data entry. So let's say they've had a depressed mood, and you identify that maybe they were not as active around that timeframe. It sort of helps puts the whole picture together, versus oftentimes we're really reliant on the patient to recall the details of some of these things by their own account. And sometimes that's not possible. So this helps paint a picture with a little bit more detail and tangible information. We think about training. One of the other things is there are digital navigation training curriculums that are available. And this is for integrated care. We see the behavioral health provider as really being the person that will receive the digital navigation training, because they are the person that's sort of that mainstay of working between the primary care provider, the patients, as well as the psychiatric consultant. And so they have the ability to support the PCPs and the patients in a way that is unlike anybody else on that team. So if we can provide them with a basic understanding of how to use a smartphone, how to evaluate the apps and make sure that they understand the different functionality, and then really train them on how to engage the patient so that there's a process for them to really, create that value for the patients. It's a way to bridge that gap and improve that comfort level and provide that support that's necessary in those environments. So I'm gonna review just a few of the resources that have become available for app evaluation. These include the, it's the APA evaluation model screener, the mHealth app usability questionnaire, as well as the One Mind Cyber Guide. So the screener here has eight questions, and this came from the app advisory panel. And what it does is so for busy clinicians, this is an option for you to just kind of run through on an app and say, what are the main, very important key things that it would be helpful to roll in or roll out for an app? And if you sort of, it's like a sort of a pass fail if you ask these questions. Some of them are, has the app been updated within the last 180 days? Is there an apparent privacy policy? If you start to see that no, no, no to these questions, it's sort of a way to say this may not be a good app to incorporate into practice. And if you wanna take a deeper dive into the evaluation process, you can also do the full APA questionnaire framework, which has approximately 37 questions. And that looks at access, background, privacy and security, clinical foundation, usability, and then data integration. So that was developed by the APA advisory panel, all the questions there, and it really goes into a deep dive. But I do encourage people to look at that if they're really seeking to incorporate apps, because I can tell you having done this, my understanding of apps and all the different functionality is far different than when I first started doing this work. And I am a little leery of downloading certain apps just because there's an informed process that I think I now go through before I start putting stuff on my phone. Another tool that is the mHealth app usability questionnaire. And this was a survey questionnaire that was designed specifically to look at mobile health apps with end users in mind. It's 18 items and it asks questions like if the patient liked the app, if the app helped them manage their health effectively, and if they liked the interface of the app. They do have four versions that are directed at patients and providers. And then two, a couple of the versions look at mHealth apps and standalone or interactive interventions. And then one additional resource is the One Mind Cyber Guide, which is a non-for-profit project that houses some digital materials pertaining to apps and digital health resources. This is just a screenshot of one of the apps that they reviewed, but Burbyhurst look at research supporting the technology and the credibility of some of those things. They look at user experience related to the app and then as well as transparency. So looking at the privacy policy and key pieces that are available. So these are just resources that if you're seeking to employ apps that are available free of use and just can kind of help inform you. So just in closing, technology really continues to advance and mobile apps obviously are becoming readily available. And I think we can really facilitate our ability to self-manage or help patients self-manage outside of these traditional settings. And it's just a matter of finding the best way to engage them in this. And so the underserved with serious mental illness, such as depression, really experience a need to have ways to be innovative and being able to provide them for treatment. And mobile apps have a mechanism to really support these barriers. So I really suggest getting to know the needs of your patients, providers, and staff, so that you're able to facilitate this ability and develop materials that will be in accordance with their needs. And I think that will really help identify how mobile apps can best serve your patient population. So I appreciate you listening to everything and having this opportunity to present this information. Thank you so much for that presentation, Dr. Emerson. A lot of what you talked about today is right in line with what we're doing at SMI Advisor. So Margaret, I wanted to talk to you a little bit about the app navigator role. That's something we're thinking and working on at SMI Advisor as well. And I think has become even more relevant as we've had our clients do more tele-mental health, tele-psychiatry, where we're really using a lot of tech in this time of COVID, in addition to the self-management. When you think about that app navigator, do you see that as a role that's both supporting the client and your colleagues? Who are trying to look for things for their clients? Talk to me a little bit about where you see them sort of facing. Do they face both groups or one group? Well, I think in alignment with really integrated care that behavioral health provider really, in my mind, has the digital navigator training that's able to be both facing, for the provider side of it as well as the patient side of it. So supporting the patient's use of the app, but then also helping the primary care and psychiatric providers look at that data integration from that platform to be able to say, this is the information that we're gathering both from active and passive data so that they can really be informed. And we can start to, with the wearables that are existing, you can really get a lot of that physical related data that can play into and shape a lot of the stuff that we're trying to address both mentally and physically. So I think sort of sky's the limit there. I think the other consideration is there's a ton of data. And so how do you make sense of all that data? So you have to make it user-friendly and equip those digital navigators to not be intimidated by the amount of data that exists. But when I think about the navigators also, I think it's important to have a shared decision-making process where they're not just being prescriptive, but they're really working with patients, which is in alignment with that integrated model of what's your priorities of treatment? How do we make this care central to you? And how can we leverage technology to support what your goals are and make sure that we provide that value by having the PCPs and the psychiatric consultants take into consideration the data that they're actively using in that app. Right. Yeah, I really like that framing of it around the individual's recovery goals, maybe short and long-term and thinking about how technology can help them reach those goals, either in part or wholly. So I really like that framing of it. And I think you're right. We recently talked to two digital navigators in the field and they really talked about the fact that there was as many questions from colleagues in the clinic as there were from clients. That a lot of people were like, what do you know? What could be helpful? Which one would you recommend? What are a couple you would recommend? So we are hearing that as well. I wanted to also bring up another idea, which was we recently had a webinar about wearables. And I really liked this idea from a speaker about almost having like a small library where you could sort of check out some wearables, to think about before a client like got a Fitbit or considered anything like that. And it made me think a lot about trying out an app for a while and thinking with a client about, is this meeting your needs? Is it too complex? Is it too simple? Do you have your digital navigator or your clinicians check in with them after a while of using the app? So we're working on a study right now where we actually are having them follow up and see is that feature that we kind of narrowed down or that app engagement process, the goals that we set, is that meeting your needs? And if not, then looking at what are other functionalities within that app that would be suitable? Because it's not until someone, I think, goes home with these things that they really see what works for them and what doesn't. And being flexible, this is why I think it's important to just not have one app in mind. That flexibility allows for us to recognize that as we learn and get more comfortable, that we can, we're probably gonna have different needs and changes and wanna have options for apps. And so I think the idea of being able to check something out like a wearable would be awesome. There are some people that would completely love that. There are other people that may just not love that their wearable goes off when you're telling them that they are not exercising or beating their rings. So, yeah. It reminds me of, I love my Kindle because I can download book samples that are free. And if I read the first 20 pages and I don't like it, I don't have to buy it. And I feel like his idea of having a small library of a few wearables that people could check out for their client to try for two, three weeks. I just really thought it was a great idea. So I just, I wanted to bring that up. As you were talking about apps for self-management of depression, I couldn't help thinking about the challenge of not only getting someone to use an app to self-monitor, but someone who's depressed to begin to self-monitor. And I'm wondering, of course there's lots of research on the benefits of behavioral self-activation and stuff, but it is hard. It is hard to get them interested and to get them to stick with it. So can you talk a little bit about engagement strategies that you use? So I think it, again, it goes back to that idea of what's the priority for the patient and then also tailoring to what they really need in the moment. So somebody that's really struggling with getting out of bed, maybe it's them looking at, so some of the great engagement features can be reading like a mindfulness opportunity or like an inspirational quote. Maybe it's just something very simple, just to kind of get used to incorporating an app into their care and then building on those things. So it's like anything, you have to establish that behavior and then start to maximize your ability to sort of build on that. And I think, going back to when you were talking about the watches and the ability to have a, try it out, I think with apps too, like having a library of apps is something that we've kind of, we've discussed, but when you start looking at that, you're looking at a repertoire of apps that you have to look at organizational and HIPAA compliance and everything. There's just tons of layers that get involved with that. So that's sort of, I think an impediment to using these things in clinical practice, because it makes sense to us practically. And I think that's the goal, but there are some things that make it difficult for us to actually make it happen, especially when you're seeking to do it in a way that has all that patient data coming back and forth. Right. Well, I mean, that's why I love the idea of the digital navigator, because it's sort of like one person takes responsibility and begins to have some institutional knowledge about what apps works with the population in that area. What kinds of apps data do these kinds of clinicians like to receive? And they sort of become this in-house expert on apps. And I think it's too much of a burden, I think, to ask our providers to be the encyclopedia of these things. There's so much that they're doing these days that to have someone sort of own that, and especially someone who's sort of jazzed up about it, somebody who's like, yeah, I really like this kind of stuff. And I like to follow tech magazines and to think about these kinds of things and to be the promoter of these. Just really is a great addition to the team. And I think others are relieved to have somebody else who's excited about it. Right. And I definitely think having that excitement is important. And I think being able to really sell the idea of for folks that struggle getting to appointments, this is a way that we can really engage you in your care. And you don't have to worry about getting childcare or trying to get transportation to come see me, but it's not wasted time. If you're engaging in this, I will, when I do see you, I will use that information and we will shape your plan and your treatment and we will be able to really make things better for you. So yeah, it just, there's a lot of opportunities there and that excitement really can be instilled, but there has to be buy-in and how do you create that meaning for those folks? And in my mind, if finances right now, especially are contributing to our ability to see these folks. And if there's a way for us to really sell this idea that they can get help and not have to come to the appointment directly. I mean, by all means, that's a, I did not get into this for the money, and so I mean, that's just a good way to approach it. Right. Let me ask you about the digital health navigators or digital navigators that you've had. You said that they're the behavioral health expert in that. We've been thinking about, would this also be a good role for, for example, a peer support specialist? Do you have a strong feeling that the individual who does this needs to have clinical training? I think for our purposes, just because of being an integrated care, it's helpful. And that's just that environment because that's the one that everybody goes to. So equipping them with the skills makes the most sense, but I certainly don't think that they have to have clinical expertise. They certainly think that you can have digital navigation training where it improves patient's comfort level or anyone's comfort level with using technology and looking at apps more intently. I mean, that's really that curriculum. So I think it could be anyone, but I think for integrated care, for us, it made sense to make sure that it was somebody that was a stakeholder in that team that really had a vested interest in incorporating that data and being accountable for that data. Mm-hmm. Have you had, you know, the other thing we've wondered about is, do you have any data or any just sense of if the digital navigator spends more time with clients based on age or diagnosis? You know, for example, would you find that the younger clients catch on easier and engage longer and the older ones are more reticent or would you find that people who have had, you know, illness for longer periods versus first episode, any anecdotal data around the time spent by the digital health navigator? Well, I think from our focus groups, I mean, I think we went into this information thinking that like the older folks were going to be less likely to wanna use an app or be less, you know, tech savvy, but there was no sort of predominant feature that says, you know, this particular age group really struggled. And so I think that speaks to the phenomenon that the providers and the patients and the digital navigators all, you know, until they get that basic training, all are gonna have a different sort of skillset. And there isn't one type of person that's gonna walk through your door. You can just say, okay, this person's gonna need X, Y, and Z skillset or knowledge development before they can kind of use an app. So I think we kind of just had that preconceived notion that we would have to provide much more support for those folks. And that was absolutely not the case. Some of them were, you know, kind of going off and exploring the apps a little bit more intently without us, you know, needing any prompting from us. So I think that that was one thing that we noticed. The more that we can equip people with that digital navigation training and then evaluate some of those aspects, I think the better we'll be able to answer some of those questions. Because there may be different strategies that you'll wanna use depending on the patient presentation. Right, right. Well, I hope that as SMI advisor begins to do more around digital navigation, that we can connect with you again and maybe, you know, pull some of our ideas and see if together we can answer some of these questions about variables that may impact the training of the digital health navigator and the carrying out of the job. I would look forward to it. I mean, I love this work and any opportunity we have to help improve the patient care to me is a priority. So thank you so much for the opportunity.

mobile apps

self-management

depression

underserved populations

integrated primary care

access to care

evaluation

patient activation

privacy concerns

app engagement