Hello and welcome. I'm Shereen Khan, Vice President of Operations and Strategy at Thresholds, Illinois' oldest and largest provider of community mental health services, and I'm also a social work expert for SMI Advisor. I'm really pleased that you are joining us for today's SMI Advisor webinar, Digital Health Navigators, Implementing Technology for SMI. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one Continuing Education credit for psychologists, one Continuing Education credit for social workers, and credit for participating in today's webinar will be available until June 27, 2022. The slides from the presentation today are available in the handouts area, which is found in the lower portion of your control panel. You can select the link to download the PDF. And please, throughout the presentation, feel free to submit your questions by typing them into the question area, also found in the control panel in the lower portion. We will reserve 10 to 15 minutes at the end of the presentation for Q&A. And now, I'd like to introduce you to the faculty for today's webinar, Dr. John Torres. Dr. Torres is Director of the Digital Psychiatry Division in the Department of Psychiatry at Beth Israel Deaconess Medical Center, a Harvard Medical School-affiliated teaching hospital, where he also serves as a staff psychiatrist and assistant professor. He is active in investigating the potential of mobile mental health technologies for psychiatry and has published over 200 peer-reviewed articles and five book chapters on the topic. Dr. Torres is the SMI technology expert for SMI Advisor. And while he frequently moderates, we would like to tap into his expertise today. So thank you, Dr. Torres, so much for leading today's webinar, and I'll pass it over to you. Thank you so much, Shereen, for inviting me, and thank you all for attending. I have no disclosures that are relevant for this. So to jump in, I'll just start off our learning objectives, because I think covering this topic of digital navigators may be new to many of you, but I hope that we'll kind of learn how important it is and what we can do. So upon completing this activity, you're going to learn about what are the five core skills that a digital navigator can do and be able to identify how those can be relevant to your practice. You'll be able to evaluate your patient for needs around digital literacy and what type of resources you can help to ensure that they're able to connect, engage, and utilize technology, and even begin thinking of developing a job description and thinking about how digital navigators could fit into a role within your care organization. So this is an interesting talk because, again, digital navigators is a new concept, and we're going to build up to it. And how are we going to do that? We're going to talk about synchronous telehealth, which is, again, sometimes what we're doing now, video visits. And for those of you who are watching this not live after we've recorded it, that's asynchronous telehealth. It's something where we're not interacting live or going into detail. But we're going to talk about what's happening in synchronous telehealth for patients with serious mental illness. We're going to talk about what's happening in asynchronous telehealth for patients with serious mental illness. We're going to look at what some of the gaps are for each of those unmet needs, and we're going to talk about how digital navigators are new members of the care team that can be a solution to helping us both, again, synchronous telehealth, what we think of really classically as video visits, asynchronous telehealth. You can almost think of those as smartphone apps or self-guided things or guided computer programs around it. So we'll get to digital navigators, but we're going to build up and understand the need for this, and that will help us understand why the program exists. So if we take two views on the role of technology, especially the internet, in healthcare and especially mental health, I think we can take one perhaps slightly cartoonish flippant view, but then a more serious view. If we look at this cartoon, some of you may recognize in this Maslow's Hierarchy of Needs, where again, we usually say that people need food, shelter, warmth, and water to survive for basic psychological well-being, but again, the cartoon being, where does Wi-Fi and battery life fit into this? And again, I think if any of us have patients coming to the clinic these days, you certainly know patients are requesting Wi-Fi and battery. If you have patients in the emergency department that you deal with, you know that people always want Wi-Fi and battery, and certainly as you've done more telehealth visits, I think all of us have run into this issue that if people don't have Wi-Fi and battery, it's very hard to connect to them. If we look at a more serious lens of the exact same issue, and it is a serious issue, you can see this was a paper last year from NPJ Digital Medicine, and really thinking in digital inclusion as a social determinant of health. I think we talked a lot about social determinants of health. We certainly know at SMI if either of these matter, but if you look at this figure, right, think about all of the things that you may need digital inclusion, you need digital literacy, you need to use the internet or the phone to access. And if you think about just the way that the world is moving, the way things are going, it really is important, right, that our patients be able to have a high degree of digital inclusion or else you're going to be excluded, right? If we can imagine from healthcare, if you can't connect, and that's the one the focus is of what the digital health navigator role is. So you can see that question, right, but it's that box where it says healthcare system, there's wearable sensors, health coverage, telehealth, patient portals, health apps. So we're really going to be focusing on how the digital navigator can make sure that new services are equitable, open to everyone. But again, you can imagine education is moving online like this, different systems are. So I think what we're talking about here really is a social determinant of health, but our focus again will be on how it can help people at SMI access, utilize healthcare and use technology as part of their personal recovery. I think if you were to say, well, why do we need to be even talking about technology and smartphones and internet? And this was an interesting report from SAMHSA, it's about two years old now, but they were actually looking at this report at kind of what is the additional needed workforce to care for people at SMI or substance use disorder population. And if you look at these numbers, right, it's, there may be say 105 to 110 necessary psychiatrists, but this is not just a psychiatry issue, right? If you look at number of counselors needed, it's like 1.436 million social workers, almost 100,000, nurses, over half a million, peer specialists, million. So there's a huge shortage of workforce. I think all of us probably have experienced this recently in clinics we're running and practices that we're working with as we try to care for patients, there's really a huge workforce shortage. And I think we can all agree if we look at that total number, we're not going to train over 4 million people anytime soon. We can make important efforts to it and we need to, but I think that's why we really have to be looking at how can technology help us overcome this because these numbers are pretty sobering, right? When you see that many more people that we need, and again, we need all of them. It's not that we need psychiatrists, it's not just peer specialists, this is a total number to care for people with SMI. So I think that's where we can get an intrusive idea of how can technology help us fill this gap. And the core number that was technology is not going to replace anyone. No one's going to lose their job. There's 4.5 million people we need. So everyone's job is to care, we'll start out with that. But as we're talking about technology, I think we need to define two terms that will be very important in how digital navigators work. The first is, again, synchronous telehealth, which we alluded to, and the second is asynchronous telehealth. And synchronous telehealth is when you are doing something in real time with a patient. You're talking on a video chat with a patient in real time. You're calling them on the phone in real time. Asynchronous is a little bit different. It's where, again, they're doing something, but you see the cloud icon, their data gets stored in the cloud. Maybe you review it later. Maybe the navigator is doing something on their own. There's not actually a real time interaction happening. And you can imagine asynchronous has the advantage of it's a little bit more scalable, right? You can get everyone in your clinic access to a mental health app and they do exercises and then you can review their progress once a week and send out a message, right? You can actually treat a lot more people with synchronous. We can definitely treat more people. We can reduce geographic barriers. But I'm going to imagine there's only so many hours in a day that you can do video visits and you cannot do two video visits at once. Or if you can, we should talk in the Q&A because that's very impressive. But again, if we focus first on synchronous telehealth, which again is our way of saying video visits or phone calls, there is interesting data from NRI saying that, look, 100% of state mental health agencies surveyed really found kind of using telehealth and the flexibility around it from COVID to be beneficial. And no-shows went from 40% to just 10%. And again, it's pretty amazing to get 100% of state mental health agencies to agree on anything. So that just tells us how powerful this is. But you can also see that there's a couple cracks. It's not all perfect, these things in red, right? You can see that 61% of the agencies were noting that kind of, they weren't quite ready to do telehealth. Providers may have needed more equipment, there's more skills. And you can see this bottom one, there's this report that some patients had difficulty accessing telehealth. So again, we're excited about telehealth, synchronous telehealth, but we're a little bit worried about this bottom one, right? Who are these people that aren't connecting? Why are they not connecting? What are we doing? Even though everyone, we're excited that it seems to be working. And I think if we focus again, who are these people that aren't making it into care as much? So there was some initial work that came actually out of UCSF in San Francisco, and it looked at the proportion of visits for populations at risk for limited digital literacy. And it found that again, those people, when COVID initially began, who had less digital skills, weren't really making those synchronous telehealth appointments. They weren't making those video visits, they even have trouble making some of those phone calls. So these are the people that we first identified as people at risk of not being able to connect to synchronous telehealth, not having as much access to care. And you can see it was those people who were older, greater than 65, those people who did not speak English as a first language, and those people who were insured by Medicare and Medicaid. And again, this begins to give you a sense of, we need to be careful that we're not excluding people. And I think we could understand reasons why it may be hard for someone who's older to connect, but not always. Again, we'll talk about cases where sometimes young people have trouble connecting as well. Sometimes English speakers have trouble, sometimes people with private insurance, there's Medicare and Medicaid. But the point being is, it's not a perfect, perfect solution just because everyone can access synchronous telehealth. And this was interesting data that begins trying to look at how are we determining kind of who's favoring clinical visits and who's more comfortable with video visits. And this was a study that came out in, basically in June, 2022. And you can see that if we look at kind of panel A, where it's video visits versus clinic visits, if you see this for patients who are under age 18, they kind of are neutral, they're kind of on the fence. But if you look at where people get a little bit older, 45 to 64 in panel A, they kind of want more clinic visits and greater than 65 is more clinic. If we look at difference in terms of sex, you can see it's not greatly different. What's interesting is we begin to look at the race and ethnicity, where again, it's looking at the preference compared to white as a control group. Patients who identified as black in this research were 1.62, more likely to prefer video, Hispanic was 0.92, so less, Asian was 1.26 or more, and others, they defined it was there. If you look at the socioeconomic status of a neighborhood, it was people from a lower SES were more likely to prefer a clinic. And again, there we see English speaking, right? People who prefer English are more likely to use it. And the right one is telephone, there's not as much of a difference, but you can already see, right, that there's different ways of who's going to be more likely to want or show up at a digital visit, a video visit versus in-clinic visit. And we're again, seeing different information based on people's age, based on, well, not really sex as much, but certainly race we have to take into account and neighborhood. But again, keep in mind, we're looking at the next slide, these numbers are, most are less than two, right? So we see again, the largest number there was around 1.62 for race under black, but there is some very interesting data from the same paper. And we'll start to bonus, I said, prior experience with video visit in the last year was associated preferring telemedicine or video visit relevant at 11. So you can see that basically if people had done a video visit before, it would be 11 on this scale of favoring video visits again. So the point being, we have to, and we will show that how we have to take into account people's individual preferences. But if we want to go for the highest yield factor to help more people connect to video visits or prefer them or to want them, we're going to get a, basically a relative risk ratio of 11, which again is going to be up to almost 10 times higher these other ones. So we can't ignore anything here, but we have to realize how important it is that people have prior experience, that they have help getting that set up for that first visit. What's also interesting, this report, and I think it'll be interesting discussion if anyone has any comments is, it was noticing that mobile devices, smartphones are becoming increasingly the device that people are using for video visits, especially among vulnerable groups who may not have access to a computer. And we'll look at some data that vulnerable groups, including patients likely with SMI are more likely to have a smartphone that they use to connect to the internet, to do video, to do anything we do on a computer email than a computer itself. And again, I think we have to think about that as something we may not always recognize. We may think that, well, if I do video visits via the computer, everyone else should do video visits with a computer, but it may be worth checking and seeing kind of how your patients are connecting. I can say certainly most of the folks I see with schizophrenia are connecting via their smartphone. So again, I think it's just, we're beginning to build the case that synchronous telehealth doesn't always work for all patients. Some people are being excluded, but we know that one of the strongest predictors of getting onto telehealth is prior experience using it before. So that's something that we really have to be thinking about how we can strengthen how that we can increase. But I think we also know synchronous telehealth video visits, there's challenges right on both sides for everyone. And I think this is a picture that's a generic of a clinician, a patient. I think some of you may be part of practices that, you know, other colleagues, you may work with other treaters and telehealth hasn't been exactly simple for people. And as we know, there's been some resistance to adoption. Some clinicians we'll talk about also want to go back to it. There's a need for new additional skills that you have to have. There are some clinical limitations to what you can do on telehealth that's harder to do physical exams. If we're working with people with clozapine, we're working with people with antipsychotics, we're trying to understand movement disorders. We can still do many of the exams, but sometimes it's certainly not as easy to do it. So again, we're not saying synchronous telehealth is always great, but I think we also have to think about for patients who look on the right that there can be a lot of logistical barriers. Again, even finding a private place to do these visits. A lot of my patients, at least, are still doing visits in their parked cars, not moving cars that would present some safety issues. But I think helping patients, again, especially if they're using their phones, do they have access? As all of you have probably seen, different people have different quality of their phone, of their camera, of their microphone, of places that they can do it. I think some of us have also seen certain engagement is beginning to not be as high with synchronous telehealth visits for some of our patients. At the beginning of COVID, I think most of us saw, as we saw from NRI data, no-shows quickly went down. It seems like no-shows are, again, probably on the rise a little bit again. I think people have got used to video visits, they're missing them, there's not as much a routine in getting to it. So it's not perfect in some sense. And I think there are service limitations that we have to think about too for some of our patients. And again, especially around community integration, around how we can engage and work with our patients. So again, we like video visits, they're going to be here to stay with us for a long time, but we really do have to think about them, not only that they can connect more patients, but we have to be thinking about what are some of these barriers, again, both for clinicians, both for patients. And again, these are what we're making the digital navigator here to solve. So we want the digital navigator to be a new member of the care team that's going to help us both on the clinical side, and it's going to also help us both on the patient side of looking at these. And clearly, I think we all know that there's not going to be one panacea, one role cannot fix every issue. But again, these are things that we have to think about. And I'll say again, we're not here to say telehealth is bad, we're excited by it. We like it, but we just have to understand what's not ideal, we're going to build a new role to help around it. In terms of justifying why perhaps a smart focus on smartphones is so important. This was interesting data from Medicare beneficiaries. And you can see the idea was in the left column to look at who is without, keywords without a desktop or laptop computer with high speed internet. And the middle column is who is without a smartphone with a data plan for wireless internet. And you can see that it's roughly about 40% of each. Again, this data really is from 2018, because it's a 2020 paper, and it takes two years to get the Medicare data out. But if you look again, age under 64, so let's say we're trying to reach a patient who's a Medicare beneficiary, they're under 64, there's a 35%, 35.2% chance that they're not going to have a smartphone data plan. And there's a 46.8% chance, right, that they're not going to have a computer. So already, even four years ago, we're much more likely to reach people via their smartphone for appointments, especially if they're under age 64. If you look at the bottom, where it's looking at race and ethnicity, you can see again that these differences are still present. If we look at, again, what they call non-Hispanic Black, it was 47.9% of people in the data set were without a smartphone with a data plan, but it was 56% without a desktop or computer. If we look at the bottom row, right, for Hispanic, it was 40% without a smartphone. And again, it was 51.8% without a desktop or laptop computer. So again, the point being, it may be important to focus on smartphones because if overall there's kind of equal access to both of them, we're likely to reach a lot of patients via smartphone that have SMI. And I think we also then have to look at what's actually happening in synchronous health, even though it is mainly happening via smartphones. This was data from California early in COVID, and on the left is kind of primary care and on panel B is behavioral health. But what you can see is actually a lot of the initial synchronous telehealth visits that were happening, right? If you look at that kind of audio, which is in black, you can see audio goes up and video is kind of that brownish color. I'm sometimes slightly colorblind, but I'm gonna call that a brownish color. But the point you can see is there were a heck of a lot more audio visits and phone calls, right? And that is synchronous telehealth. We're happy about that. But there really wasn't as much of an increase that you can see kind of in video visits, where again, a lot of what was driving the increase in telehealth was audio. And again, this is data from a safety net organization in California. So again, this is patients that are more likely to be SMI. We're not looking at the general population. But I think it's important to recognize that even though we did have this big rise, right? 63% of visits were via telephone and 13.9 or via video. So we may actually not be getting synchronous telehealth, even to work as we think it is, right? We're doing a lot of phone calls. And when we kind of look at the evidence, is a phone call visit as effective as a video visit? It's a little bit of a harder question. We have very good data from experts in the field and years of experience that video visits can be just as effective as the in-person visit. But again, telephone, it's a little bit, we know less about telephone-only visits, right? We haven't really built practice on telephone-only visits. I think most of us would say doing a new intake via telephone is pretty hard, or at least it is for me. Doing a follow-up by telephone is okay. But again, I think we just have to be wondering why are we seeing, again, such a low uptake of a video right here of 13.9? It's almost, right, five times less with it. So again, we like synchronous telehealth. We want patients to access care. We have pretty good indication to federal government to, again, continue reimbursement for synchronous telehealth for video visits, even after the federal government declares an end to the COVID emergency. So it's not going away, but again, we're getting this kind of lingering sense that maybe we're not reaching all of our SMI patients, or maybe some people are not able to really connect on video is how we want them to do. And there's kind of emerging polls coming out. And again, it's hard to get national data. All of us know it takes usually two years to get the full data set, so we may learn it later. But there's emerging evidence that people who are connected to care were continuing to get care during COVID, but we weren't really reaching a lot of new people around telehealth. And some data, again, showing that people with SMI were having higher rates, actually, of missing some of their appointments. We said overall, again, appointments were down. But we're looking at patients, again, with depression, with bipolar, schizophrenia, with SMI, there's some kind of emerging concern that are we reaching all of the people that we want to be reaching? And this was actually rather new data that came out from data in the Veterans Administration. And you can see it says adjusted odds of patient visits occurring mostly via phone, video, or in person during the COVID pandemic. And what's nice is they actually break out for schizophrenia, and we can see actually, right, that patients with schizophrenia, and if we kind of go to the middle where it has 0.36 of a star, but we can see that patients with schizophrenia are basically less likely, this number is 0.36, it's less than one, likely to be using video visits, right, they're actually the group that has kind of the lowest odds of kind of selecting a video visit. And that's, again, not great, but we're saying why are patients with schizophrenia having these lower rates with it? You can see that it's also a little bit lower for hospitalized patients, I mean, for substance abuse patients, for people who have psych hospitalization, it's also lower too, but that kind of 0.36 for schizophrenia is a pretty concerning number, right, that it just shows you, right, that we're less likely to be having our patients do video visits. And again, it's not happening in depressive disorders, you can see above that's 1.1, right, they're more likely, bipolar's a little bit less likely, 0.89, but again, that 0.36 is, again, really something that we have to say what are we actually doing with video visits or synchronous telehealth, I guess we could just more telephone visits, who are we reaching and are we actually, again, inadvertently perhaps excluding our patients with schizophrenia? So again, if any of you are interested in details, the citation is there, but that's some of the newest data we have that came out basically around Christmas, so a couple months ago on it. I think, again, we've talked about synchronous telehealth in kind of real time, we also have to think about asynchronous, and again, asynchronous we're gonna consider to be kind of more self-help-based programs and more self-guided programs, this could be kind of internet-based CBT, many of us have heard of insomnia CBT programs that can help patients right around sleeping, or again, mental health apps, which we know there's so many of them. And I think the reason we're gonna hear more about asynchronous telehealth, especially for SMI, is it goes back to that SAMHSA data we had that said, look, we're short 4.5 million providers. Again, even if we could all do synchronous visits, and let's say even the synchronous visits did connect everyone with schizophrenia, everyone could connect equally, it still is not gonna fill the gap of 4.5 million people, so we're gonna have to use some of these kind of self-help and internet-based programs to help fill the gap in care, so I think we do have to care about asynchronous, especially in serious mental illness. So that really brings up the question of, what do we know about asynchronous? And again, there's many different tools that we can be using, but I think smartphones are really, again, because of apps, because there's CBT programs, people can access on them, it really is kind of the primary device that we're doing asynchronous telehealth for. And if any of you have probably looked at any social media ads, sometimes bus stop ads, even TV ads now, there's infinite ads, it feels like, for kind of these asynchronous tools or these internet CBT programs and apps. We've estimated that there perhaps are 10,000 or more of them available today, it's hard to keep count of them. If you just type in apps for schizophrenia, apps for depression, apps for bipolar, you'll get a large amount of them. And I think one trend that we've seen during COVID is it's actually become one of the hottest new investment areas for Silicon Valley. And it's unclear if that's a good or bad thing for the field, we're not here to comment on that, but there's certainly a lot of venture capital money flowing into these things of what they are. But I think we just have to be aware that our patients are being exposed to these and seeing these things, no matter what. And I imagine we can also put in a Q&A, some of us may have favorite apps that we like, we may have good anecdotes of patients using them. So in these asynchronous tools can certainly be very powerful in serious mental illness. We've actually covered in prior webinars in SMI Advisor, a lot of work on asynchronous or apps for mental illness, for serious mental illness. So I'm just putting some screenshots of prior ones that we've done. Because if it's a new world you're hearing about, there's a lot of interesting stuff happening there. So I think one thing that always comes up when we talk about smartphones and schizophrenia is sometimes people go, do patients with schizophrenia own smartphones? They wanna use technology. I think we just have to banish that as almost a stigmatizing question. People with schizophrenia or people bipolar are people. If you live in the year 2022, you most likely have a smartphone. So this is data from December of 2021, looking at ownership of smartphone. And you can see that smartphone ownership is pretty darn high in people who have psychotic related disorders. And again, it's interesting, what are people using the smartphones for? You can see it's to help depression, to help with anxiety, to help with voices, to help maintain mental health, to help others mental health concerns and crisis helpline. So again, I think people with psychotic disorders, people serious mental illness are using smartphones already. They're looking for things that anyone else would be looking for. They have depression and anxiety as well. And these apps offer to help with it. So it's something, again, if you'd be surprised... If you think your patients aren't using them, it's probably worth asking the thing, hey, have you tried any mental health apps? How are you thinking of them? Because you'd likely be surprised how many of your patients go, well, yes, I'm interested in trying these apps or yes, I perhaps try these apps. But I think there are, as we talked about, there's some barriers to synchronous telehealth, right? We began to get some indication that maybe we're not connecting as many patients with schizophrenia to video visits as we think we are. There may be some barriers to kind of using smartphones for patients with serious mental illness. And this is actually very old data that was done by our team in 2018. But if we look at the left panel, I didn't put a ledger here, but the question was really asking in two clinics. One was the state clinic I work in, which sees mainly people with serious mental illness. And the private clinic in gray is our university clinic that generally sees people with private insurance and more anxiety spectrum, anxiety depression. But we basically asked in the left, what is the number one barrier that you have to using an app? And if we see for the state patients, the number one barrier was actually setting up the technology, right? That it was that patients with SMI said, well, I'm not sure how to download an app. I'm not sure how to get an iTunes account. I'm not sure how to find storage on my phone to do it. If you look at what the number one barrier was in the kind of university clinic on the left, it was privacy. It wasn't that patients with SMI were, privacy was a number two barrier for them as well. So privacy is an important barrier, but you can see where there's a big difference in setup, right, where patients with SMI are going, hey, the barrier for me is kind of helping me get started, helping me use this. And again, this was, you can believe we're at such a time before COVID, this was an issue then. And I think we'll see that that issue hasn't really gone away, just because we're more reliant on technology five years later, doesn't really mean that we've made efforts to help people with kind of helping set up and get it working. And again, the privacy concerns are still important. We're not saying accuracy concerns or cost are not important, but you can see, again, that setup result on the left of kind of, that's what patients were worried about is kind of so important to figure on the right, for B is actually kind of saying, are the same things benefits, do you want them? So, but it's just keeping that setup in mind. And that kind of proved this issue hasn't gone away. This was a study from January of last year, it was UK based, and they looked at 249 patients with SMI, which they defined here as schizophrenia bipolar disorder. And they noticed that about 88% owned a digital device and probably smartphone ownership in countries like the US, Canada, UK is probably around 85 to 90% of the general population. So again, people with psychosis, schizophrenia bipolar, of course they own smartphones, but this study is interesting. It found that again, patients actually lacked foundational skills, 42%. And again, it was generally, it wasn't always the youngest patients but maybe patients were a little bit older, but it's that patients have these devices, but again, 42% that you can kind of look at there were kind of lacking some of the skills that you need to really thrive. Again, perhaps this again, telehealth, use apps, use services. You can see I cannot update or change my password and prompt to do so. I cannot change the settings of my dice to make it easier to use. These are worrisome things, right? Because if you can't do these things, it's gonna be a lot harder to connect to any healthcare services, right? Be it a portal, be it a video visit, be it downloading an app. So again, I think we have to recognize that there's many SMI patients I've worked with who have taught me so much about technology and they've been absolute wizards at it. But there are other patients who again, may silently kind of be struggling. They might even know to ask these questions, right? Because no one in the healthcare team is saying often, how are you using technology? Do you need help setting up? Can we talk to you about what Wi-Fi is and how you use it? So again, it's an important thing that we probably have to learn. I think we also gonna have to recognize too, right? That these issues of using technology, especially kind of smartphones and apps and care, it's not just patients of SMI that may be having some concerns as we saw about kind of setting it up. Some concerns around kind of digital literacy we saw here. But this was again, we're looking at older data to show this problem has been here for a while. This was a focus group of 20 clinicians in the UK who treat SMI. And they were worried about using apps and care because again, they were worried there's a digital divide. Some patients may not have the skills to use it. They were worried that they as the clinician didn't actually know how to support using the app, right? They felt a little bit uncomfortable talking about apps. They're worried about the negative impact on them if they're kind of using an app. And they were basically worried that with technology replaced them, they wanted to enhance care. So clinicians also kind of have some concerns about integrating these type of technologies into care that we have to respect, right? It's not just that we're saying patients of SMI need help, it's clinicians have valid concerns as well around this. But if we go back again to patients and how they're actually using these apps today for SMI, again, it's actually very hard to get engagement data from an app. But if you go onto the iTunes store and look at the app, you may see how many stars it has, how many downloads, but do you actually know how long a patient actually uses it for? Like do people use it for five minutes and give up? Do they use it for a year? So the only time I've ever seen that we've got data from an app for schizophrenia was actually this paper we did in 2017. But the company actually agreed to let us get anonymized user data on who engaged with the app. And this is an app that's actually still available on the iTunes and Android store. If you type in schizophrenia, it's called I think Schizophrenia Health Storylines, you'll still find it. But what we're able to show, because again, we're interested even when apps weren't as popular five years ago, what are people with schizophrenia doing or using on a free app that's on Apple, Android, and iTunes store? And this is a graph. It's a little bit hard to read, but see the first one says medication feature. It says number of users. So you can see about 225 people at first dot logged into the app once. But again, to track a medication, you probably want to track it for at least 30 days, maybe up to 100 days, three months. You can see across all of the US and over a year of data, we looked at only 50 people tracked a medication basically for 100 days. If you look at mood tracking in the middle, you can see that was even less, right? It was almost approaching like five to 10 people were actually tracking their mood for more than three months and for symptom tracking was very low as well. So you can imagine there's probably a reason that companies don't love to share data like this. It doesn't look brilliant on them. But the point is that if we're just handing apps to our patients with SMI, this may actually be what we're getting from a national rollout of an app, right? We may actually be impacting in reaching less people than we think. I mean, these engagement numbers are pretty darn low. Again, for something that's free and available. And it's again, the app is actually, it's been built with people with lived experience that they've tried hard. It just shows you that giving people an app that's kind of self-help based for SMI may not be perfect. And I think we have to be clear that just because we have SMI specific data here, this is not specific to serious mental illness. This was 2019 data looking at very popular apps on iTunes and Android store. The apps for broad mental health problems, mindfulness, happiness, all apps. And you can see right that engagement defined as kind of does someone open the app after you've downloaded it. It's pretty low, right? Overall, what we can see is by day 10, right? Day 10, there's only about 10% of people are actually still using an app. What's encouraging on the right is you can see the peer support apps are actually doing a little bit better, right? You say what mental health apps are most engaging, the peer support apps. Again, they're not bucking the trend, but they're doing a heck of a lot better than say a breathing app, which is kind of losing a lot of people very quickly. But again, it is nice. We actually do have some SMI evidence that kind of shows us that we have to be careful with asynchronous telehealth apps because we just give them to folks. This is what we're gonna get. And clearly something like this is not going to really help with care. It may help for 10 days, but generally we wanna help people for more than 10 days. So if we kind of think about, again, so we've talked about synchronous telehealth at work. We're not sure we're connecting everyone. Asynchronous telehealth apps are exciting because we could reach a lot more patients. We're a little bit worried that patients may not have, are worried about the skills of getting the apps on their phone and that engagement is not really high. So begin to think about what are some solutions that we can be doing to kind of fix this? And again, how does the digital navigator fit into this role? And if we can step back and look at some data from right before COVID, again, we get it. So this was kind of looking at reasons that someone would not be doing a video visit before COVID. You can see that regardless of age, they have income here. They define race as black or other, and they define gender as men and women. The number one reason, right, was my doctor doesn't offer it. But if we say that my doctor doesn't offer it, it's gone. Your doctor does offer it. Look what the number two reason is, right? And this was across all of health. It wasn't just serious mental illness, but it was, there was this group, right? It was up to 20% for I don't know how. Based on income, it was I don't know how. Based again, race is how they defined it there. It was I don't know how. And gender, I don't know how. And gender, I don't know how. So we begin to see that digital literacy was a barrier before. Again, we may not have recognized it. Again, so few clinicians, not just doctors, it's everyone, was not offering video visits that we weren't really kind of as focused on this lack of digital literacy for these people that don't know how. But we can see it. This has kind of rapidly emerged into the number one barrier, right? Because again, now we all are offering these video visits. We will keep doing it. So I think what we've hopefully seen, right, is clinicians need some help. We've talked about in doing this. There's workflow issues. It's not simple to do. Clinicians have a little bit more help with technology. Patients need some degree of help in getting this worked. Synchronous telehealth is working, but we're not reaching everyone. Asynchronous telehealth, these apps would be critical for increasing the access to care and SMI, are really failing our patients today, right? We're not seeing that many apps for SMI. Again, from the data we have, they're just not able to kind of keep people doing it. So this kind of led us on a path towards digital navigators. And the first part was really thinking about digital literacy for patients with schizophrenia. So we had a program called DOORS, or Digital Opportunities for Outcomes Recovery Service. And this was really a patient-facing program where we would go to a mental health clubhouse each week, which is, I think most of us may know what a clubhouse is. In some ways, it's kind of related to, it's a place where people can go get services, community support, employment. And they're certainly popular on the East Coast, at least. But you can see we'd kind of do different skills. And this was the photo week. So we teach about how to use the camera, both to build a virtual hope box, to take pictures that are medications, and to learn different digital skills. And I think a program like DOORS, we kind of quickly learned, was actually very effective for people with psychosis, because it let them use their smartphone not only, say, to connect to healthcare services, but to just do things that you want to do in daily life, to check the weather, to go on the internet, to apply for a job, to listen to music that you would want to do. And as we began to kind of, when COVID happened, we clearly began to realize that we needed to move a program like DOORS online to begin to do teaching like that. But again, we also know it's hard to teach people in some ways only online of digital literacy. But we began to realize it can't just be our team that's offering groups like this. We need to kind of have a scalable way to help support digital literacy. So again, we like DOORS, we still run it. It's an effective program. But what if it wasn't a scalable solution? We talked about, we also began to realize that clinical teams need help too. It's not just we want to be able to support our patients with serious mental illness. As we said before, clinical teams are in some ways struggling of how they can use technology. And I think two important points here is one, we know that most burnout is very common now. There's probably more reasons to be burnt out in some ways than there aren't. But I think one factor that may be driving a lot of burnout in healthcare is certainly forcing healthcare professionals with low interaction of digital technologies to kind of be using technologies that they don't understand, they don't want to do. So we start telling all of the clinicians that you work with, you now have to use smartphone apps and you have to be supporting more types of technology use and care. It may end up kind of driving people towards burnout. And what you can see here is a report that we actually did with the Australian government thinking of kind of what is the new national digital health framework look like. And you can see that what was interesting is the Australian government was beginning to say, hey, it's important that we have, again, programs and systems in place that can really work on digital literacy and make sure that people are able to connect and use tools. If we're thinking about what kind of the next version of digital health looks like for Australia, maybe we really need to focus on digital literacy. And you can see this is where the role of the digital navigator begins to emerge, right? That we need someone that can begin, if I go back a slide, supporting patients, helping make sure they can do the basic things on their phone, they can learn these fundamental skills. Also in part, right, helping clinical teams use the technology, helping to support it. And this is, again, is the core of what a digital navigator can do. So we've defined at least three central roles to it. The digital navigator can kind of help in that sea of all those apps, which ones you may wanna use, may not wanna use. They can kind of work with the client to kind of say, hey, I can help the client find apps that may be appropriate to use. They can also then help the patient or client with technology set up and troubleshooting, right? They can say, you don't have to spend all your clinical time working to download the app, fix the password on iTunes, help them connect to the internet, clear up storage. It's that you can basically say, hey, I would like you to help get this patient up and running on this. And a digital navigator can also help the clinical team and the patient by previewing data, summarizing it, giving encouragement to the patient to keep using it, and then helping the clinician understand what was the use of the app, what was happening. So the analogy in kind of medical field may be there's a radiology technician for radiology, there's a pathology tech for pathologists, right? So it may be, as we're saying, as we're realizing we need to do a better job in synchronous telehealth and video visits to connect patients with SMI, we need to do a way better job making apps and asynchronous telehealth work for our patients with SMI. Maybe the solution, right, is not going to be artificial intelligence or machine learning. It's going to be, can we have a new role like a digital navigator that really helps facilitate the integration and the use of technology for patients and for clinicians and kind of serves as that kind of bridge that will help people learn those skills and work together towards it. So we've actually outlined what digital navigator training would be. And you may say, well, who would be a good digital navigator? Who would this role be great for? It could be in some way someone's first job in healthcare. It could be in some ways what a research assistant could do. It could be a volunteer who goes through training. It could be a front desk administrative person who learns these skills. It could be a clinician who becomes a super user. But in essence, in the five modules of digital navigator training, the first two, or the first one is core smartphone skills, kind of like that door is digital literacy. How do you help people with Wi-Fi, with calls, with text messaging, with internet, with photos, with notes, with clocks, with health apps, connecting to telehealth. The second one is basic technology troubleshooting, the second column, right? And that's important because all of us know technology is pretty frustrating when it stops working. And the good news is there's probably about 10 common things that happen. So digital navigator training is really designed to help kind of make sure that a digital navigator knows those core smartphone skills, but then can help someone troubleshoot around them. Module three is designed around app evaluation. The idea being, can you help people pick smartphone apps that may be useful or appropriate for them? Most of these apps are not medical devices or wellness devices, so it's almost like the digital navigator helping pick a wellness device, but helping them make informed decisions, picking apps that could be useful. The fourth module is around clinical terminology and data, because some people being a digital navigator, this could be their first healthcare role, helping them understand what clinical red flags are, what HIPAA is, what privacy is, and then how to interpret data, how to look at a graph of a patient. And the last module is engagement, how to keep people using those apps. We saw those kind of pretty disappointing engagement curves with smartphone apps. What are things that digital navigators can do to check in to make sure that a patient is using an app and staying engaged? So you can see across these five modules, of course, smartphone skills, basic technology, troubleshooting, app evaluation, clinical terminology and data, engagement techniques, we really are able to kind of equip digital navigators to go through this training with a lot of resources to help both patients and to really both help clinicians and clinical teams going. What's interesting about the digital navigator training is different teams have actually begun to uptake it in different ways. This is a picture from the Greater Manchester Mental Health Trust, GMMH, in the UK. And you can see they kind of adapted to five sessions of digital navigator training to be a little bit customized to what they need to do in the UK. I always laugh if you look on the right, they have fire extinguisher safety training. I don't know how that fits into digital navigator training. Maybe if the smartphone catches on fire, the digital navigator can use a fire extinguisher. But again, the point being, there's some flexibility in what you can do and how you would customize it to your organization. But I think the core principles make a lot of sense in what we wanna be offering for it. And again, the fact that it can be uptaken in the UK is very powerful. This is the screenshot that we took after the webinar with Henry Ford Medical System. And they actually worked with us to hire a digital navigator because they basically have a new online CBT program and they wanted to increase engagement uptake of their new online CBT program. Again, this is more asynchronous telehealth, right? And you can see the job description was to provide individual or small group assistance of patients to be technical support with login usage, navigation of apps, coaching introductory digital skills in order to become effective users, perform a variety of administrative and analytical tasks and dashboard monitoring related to digital care to assist in a quality and compassionate providing, manage the registry. So it was exciting right on this webinar to hear kind of Henry Ford Medical System talking about in part how they kind of customize the role to support this new asynchronous telehealth version that they were working with. So again, we're getting different examples, right? We're seeing one from the UK, we're seeing one from the Detroit region of how it can work. The way that we're using it at my hospital, Beth Israel Deaconess Medical Center or BIDMC is we're doing traditional face-to-face therapy, which now is on a computer. So synchronous telehealth, right? Then you can see we have the digital navigator that they put in the infographic for us. And then what you're seeing, right, is we're using the apps, we're doing asynchronous telehealth. So in some ways we're using a digital navigator to do something called hybrid care. It's not completely synchronous, it's not always care is done kind of both via video, but care is done kind of via the smartphone app often. So in some ways you can have the Henry Ford system where it's supporting asynchronous telehealth and this we're supporting hybrid care where we're kind of mixing a little bit of asynchronous with synchronous. And again, there's no right or wrong way to mix it and do it. I think it's exciting the different ways you can do it. So you're seeing in part that the digital navigator training that we're offering and the role kind of is really a way to bridge health technology with unmet mental health needs, right? So we have a lot of health technology because we have too many apps, we have a lot of programs, we have a lot of different ways, we have a lot of EHRs, but how can we kind of bridge those two together? So the goals again, digital navigator training is to support anyone to use their own smartphone recovery, help anyone navigate and find and use apps and help with engagement and benefit from technology. So those first two modules are again, how do you support someone, get them connected and troubleshoot, help them find an apps, module three and four and five, increase their engagement and benefit from technology. So again, in terms of what the digital navigator is doing and they're learning in the first two modules of the training, right? They're basically helping offer tech 101 to patients who may need it, to clinicians who may need it. They're offering, they're serving as tech support. They're able to kind of do digital literacy training like indoors. They can also be hosting something like office hours. They can help anyone use apps or there's many different ways to find and use apps. There's the AP app evaluation model. When our team runs it, we're using mind apps to website we've developed our own apps but then the third part, right? Is they're helping to increase engagement from technology by checking in with patients, by discussing data, by summarizing parts with clinicians. So again, it's a diverse role, but I think if you kind of look at all three of them, it really covers a lot of different spectrums and ways that you may wanna use technology. So I think the part that I'm most excited about is with SMI advisor, where we're taking all of the parts that we talked about today, all the individual trainings, all the information that we've learned and really putting us into a new online interactive training that you'll be able to take yourself, you'll be able to refer your staff to, you can refer your peers to your patients and we're pretty far along in making this digital navigator training. As you can see, it'll have skill-based practice, it'll go through all of the modules and it'll be something right that you can basically, we'll have a database of digital navigators that they can talk to each other, find support in it. So I think we're really gonna centralize the role in this exciting new interactive program that you can kind of use as a basis to get started. So if anyone's listening and wants to be an early site for kind of testing this newest way that we're gonna deliver digital navigator training, you should let us know in the comments now, you can reach out to us, but we really have made good progress and it's gonna be a very interactive program, it's gonna have a lot of skills-based things that you're learning and doing. And we'll even actually be demoing it at the APA annual meeting. So Shereen Khan, who's doing this in partnership with me, we'll have a session that looks at it and kind of has an early preview of what the system looks like. So there's lots of references, as you saw, this is an active area around it. So we'll look at the bibliography, but with that, I'll say thank you all for listening. Thank you, John, for such an interesting presentation. Right before we shift into the Q&A, which will probably be just one Q, I wanna take a moment and let you know that SMI Advisor is accessible from your mobile device. So you can use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. So download the app now at smiadvisor.org slash app. I'll join you on camera, we did get a few really good questions. But if we're not able to get to your question today, I'll tell you at the very end how you can submit a consult that you can get an answer from John or somebody like John. So a big question is, I think somebody is understanding how this would be helpful. But John, if you were to take this like organizational leadership, how would you explain the need for the role of the Digital Health Navigator? How would you sell it? Yeah, so I think you would say there's two things. The Digital Health Navigator is gonna help you increase access to care for your patients, because it's gonna increase the rate that people show up to video visits synchronous. It's also gonna increase your utilization of apps and asynchronous. So you're going to increase access to care through both forms of telehealth immediately. I think the other thing that you're gonna do is you're gonna increase quality of care, right? You're gonna have patients actually again, accessing more services, using more programs, actually engaging with the most innovative parts of digital health. So classically SMI has been last on the kind of innovation train, right? We don't get a lot of new medications, we don't get a lot of new treatments, we don't get a lot of new programs. But what we're seeing is again, we could get our patients with SMI connected to these really powerful things, right? And again, we all know there's exciting apps that can help with people being more active, they can help with different CBT. So I think I'd say we're gonna increase access to care, we're gonna increase quality of care and with that kind of comes higher utilization of existing resources. Somebody's asking about when the Digital Health Navigator training will be available and I can answer that. So I can try to get one more expert question at John. So we are aiming to be able to start piloting it over the summer. We wanna run it with a few smaller like sites and then it'll be largely available, I would say in early fall. So that's our goal. So just so you know, thanks for asking that. The last question I just wanna try to squeeze in John is how do you differentiate an IT person from the DHN? What's the difference? What can the DHN do that an IT person does not do? Yeah, so I think an IT person, right? Isn't really, I guess they're designed for perhaps troubleshooting technology. So maybe they could do module two of troubleshooting, but they're really not designed for the help of engagement, right? And I think all of us know one of the biggest challenges of all healthcare, especially SMIs, help people engage with care. So they're not really there to help patients find an app that may kind of match their needs, not there to help a patient actually continue to use the app, they're not there to interpret data with the patient. And I think as many of us know, right, it's not, it really is all about forming a therapeutic bond, understanding what a patient needs and kind of working as a team. And again, tech support really runs more on tickets, right? They're like, they're going, can you connect to Wi-Fi? You go, yes. But so I think the DHN training goes a little bit deeper of trying to think about what does this person need to survive, start to thrive, right? It's the IT is kind of going what you need to close out the ticket. But I think there is a little bit of overlap. You could say that a DHN role for the clinician, it is more like IT support around using apps and kind of getting people connected. In some ways, it would hopefully be IT support has a better understanding of the clinical needs and realities on the clinician side. On the patient side, it's probably more about helping build some type of therapeutic alliance, helping build a relationship, helping understand what people need for technology for. Great, thank you. So that's all we have time for today. But if you do have follow-up questions about this or any topic related to evidence-based care for SMI, our clinical experts are now available for online consultations. So any mental health clinician can submit a question and receive a response from one of our SMI experts. Consultations are free and confidential. On behalf of SMI Advisor, I'd like to invite you to learn more about the APA's 2022 annual meeting. The in-person conference takes place May 21st through 25th in New Orleans, and the virtual meeting takes place June 7th through 10th. During the live conference, clinical experts from SMI Advisor are leading a variety of sessions on how to improve care for individuals who have SMI. Topics for these sessions include the basics on how to use Clozapine, digital navigators, again, as John mentioned, and making technology work, and how to improve physical health in patients who have SMI and more. I encourage you to take a moment now and browse the agenda at psychiatry.org slash annual meeting. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. And please join us on May 6th, 2022 as Dr. Kurt Cousins presents utilization of Clozapine to treat schizophrenia and serious mental illness in transitional age youth. Again, this free webinar will be May 6th, 2022 from 12 to one Eastern time. Thank you so much for joining us and thank you to Dr. Torres. And until next time, take care.

SMI Advisor webinar

Digital Health Navigators

Implementing Technology for SMI

mental health care

Digital Health Navigators role

smartphone apps

technology troubleshooting

app evaluation

clinical terminology and data

engagement techniques