So, our first question comes in from a viewer, who writes, in the person-centered care model, what do you do if the values of the patient and the identified family member are different? So I guess this is really a question about competing priorities, and what's your advice to clinicians in that framework? Ken or Terry? I'm going to start with take a deep breath, because this is a not uncommon clinical situation. So it may be that the family appreciates the condition more than the individual does, or the individual, either through lack of insight or anesthesia, does not appreciate that they may have a vulnerability. So this is, of course, a tremendous clinical challenge, but I think the idea is to engage work with people, search for the purple in the Venn diagram, overlapping perceptions of things that they can agree upon. That sleep might be a problem would be a great example of something that people would agree upon. It would be great if I could get back to school. Harder conversations are the parents believe the person has a cytotic illness, the person does not believe that. I tend to focus on that over time. When a first meeting, it reveals that there's a lot of conflict in this perception. My goal is to create the second and third conversation, because it is only through active engagement, you know, that you're going to have a chance to see if you can get the narratives to align. Terry, do you want to add to my answer? I can't think of a thing to add. I think you said it beautifully. It's about keeping people, keeping them coming in and thinking about where they are and letting them know you're hearing both sides and finding the road in between. Well, I think your answer leads well into our next question, which just came in from a webinar participant who asks, how do you engage Latinx individuals with SMI in treatment? I guess here, if you were to add in kind of a cultural dimension, how does that change your approach? Yeah, it's a really good question. I think the first thing, at the Massachusetts Mental Health Center, we had a service devoted to the Hispanic Latino population. We had clinicians who were from different countries in Latin America. They had a coherent team and culture. We had a doctor who worked with that team. I think that having a workforce that looks like the individuals and understands the culture from the inside out. We had a clinician from Guatemala, a clinician from Colombia, a clinician from the Dominican Republic. I think it was just such a natural way that we worked together well. That's often difficult to pull off, but I think the leadership, now we're into the medical director and the clinical director of the service, if you can make a priority to understand the demographics of the places that you're living in and working in. At the Massachusetts Mental Health Center, we had a large Latino Latinx population. There was a reason we developed that entire service. I appreciate that's not always easy to do, but I think the fact that they had each other and weren't simply the one clinician who had this cultural expertise promoted a multi-decade longevity of the individuals who work for the team. When I go back to do a consult at MassMental, the same individuals are still there. They've been supporting each other as well as the individuals. The only thing I would add is that it's never underestimate the value of how your facility is interacting with other healthcare providers in your area. Because again, we know that the more individuals, especially from diverse cultures, but just in general, the more individuals can see the mental health or the mental illness services as part of overall healthcare, the less stigma there seems to be attached and the more engaging the service can be. Thinking of shifting gears just a little bit here, we talked about some of the evidence-based models in the United States, coordinated specialty care, assisted outpatient treatment. And I'm wondering if you could comment a little bit about resource utilization and even in shared decision-making. Are these models that work in all resource-level environments or how do you think about some of the NAMI programs or some of these other models in terms of resources that might be available within a particular clinical setting? So I'm going to answer the question having been the state medical director and the commissioner of mental health. It takes commitment to fund programs like assertive community treatment. It takes financial commitment to keep these programs going. And when there are budget shortfalls, which happens all the time in the public mental health system, there's a great tendency to either close inpatient units, close hospitals or close assertive community treatment because on paper, these programs look expensive. If you attend to the fact that they're keeping 100 people who are quite vulnerable out of the hospital in large measures, they're promoting recovery, they have better employment outcomes. The idea is if the leadership can advocate for continuing these programs, even during recessions, right, that's the biggest challenge that I see nationally. Now peer programs are typically less expensive. NAMI programs are free. Family groups and wellness recovery action plan are pretty accessible across the country. But I think coordinated specialty care faces financial challenges as well. This is a SAMHSA grant through the state mental health block grant, which 49 out of 50 states picked up. And that's really important to think about the sustainability. So the idea of billing MassHealth, being able to bill private insurance, CMS working on a code that people could bill for the six months of early psychosis is going to be really important for the longevity of the program. So I mean, I feel like coordinated specialty care is one of the greatest things that's happened in the last decade. The National Institute of Mental Health, Robert Heinzen, SAMHSA, and the advocacy community, including NAMI, can really feel good about the fact that we've gone from virtually no programs across the country, except for a few in Oregon a decade ago, to a national network of these programs. But I do worry about their long-term funding capacity because block grants have a way of changing over time with shifting budgetary priorities. And finding ways to bill for these is going to be a long-term challenge. So I took that question in a direction based on my experience of working in and conducting systems of care. I don't know if that was where you wanted me to go. Perhaps you could ask it differently and Terry could give a better answer if I didn't direct it in the right way. I think that's a great answer, Ken, and I think it speaks to the complexity of the work we do.

person-centered care

engaging patients and families

shared goals

Latinx individuals

diverse workforce