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Learning From Each Other: Reimagining the Role of ...
Presentation and Q&A
Presentation and Q&A
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Hello and welcome. I'm Dr. Rob Kotez, Director of the Clinical and Research Program for Psychosis at Grady Health System and an Associate Professor at Emory University School of Medicine. I'm so pleased that you're joining us for today's SMI Advisor webinar, Learning from Each Other, Understanding the Role of Medication in Crisis Care. 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 that 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 one Nursing Continuing Professional Development Psychopharmacology Contact Hour. Credit for participating in today's webinar will be available until 9-1-22. Slides from the presentation today are available in the handouts area found at the lower portion of your control panel. Select the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them into the question area found at the lower portion of your control panel. We'll reserve about 10-15 minutes at the end of the presentation for Q&A. Now I'd like to introduce you to the faculty for today's webinar, Dr. Charles Browning, Dr. Pat Deegan, Lisa St. George, and Dr. Sosamolo Shoyenka. Lisa St. George, MSW CPRP CPSS, currently serves as the Vice President for Peer Support and Empowerment at R.I. International. Her work with R.I. spans 22 years, during which time she has provided executive leadership and program development of R.I. International's peer support workforce and programs. She's the principal author of R.I. International's Peer Employment Training, which has trained over 15,000 peer support workers nationally and internationally. In addition, she has written over 100 training tools, articles, publications, and presentations that are focused on peer support recovery, inpatient psychiatric care, and crisis services. Dr. Sosamolo Shoyenka is the Chief Medical Officer for the Department of Behavioral Health and Intellectual Disability Services in Philadelphia, Pennsylvania. In this role, Dr. Shoyenka leverages health system policy and process improvement strategies to ensure optimal population health for approximately 1.6 million Philadelphians. As Chief Medical Officer, Dr. Shoyenka led the redesign of Philadelphia's crisis system in preparation for the implementation of 988. Dr. Shoyenka is a co-developer of the SMART tool, which facilitates self-directed anti-racism work within organizations. Dr. Pat Deegan is the founder of Pat Deegan and Associates, a company run by and for people in recovery that focuses on empowering mental health service users in their own recovery and providing peer supporters and clinicians with the know-how to support people in their recovery journey. Dr. Deegan has numerous peer-reviewed publications and has held a number of academic appointments and has carried a message of hope and recovery to audiences around the world. And finally, Dr. Charles Browning is the Chief Medical Officer of AHRAI International and Medical Director of Behavioral Health Link. He has devoted his career to improving the systems and care experience for our mental health needs. He has held leadership positions in public and private systems of care, including crisis systems care, assertive community treatment teams, rural community behavioral health companies, and opioid treatment programs. So, I'm so glad that you all are here. Thank you so much. We have no disclosures of interest or conflicts of interest that are related to the subject matter of this talk. The learning objectives for today. So, at the conclusion of this activity, participants will be able to describe how a power differential between staff and individuals receiving service may impact care in crisis settings, list two ways how the use of medication and crisis care can be informed by the perspective of lived experience, and finally, interpret how the self-modification of anti-racism tool or the SMART tool may be applied in crisis settings to address disparities in care. All right. So, to provide a little bit more context, with the national implementation of 988, there's a real opportunity to think about how we provide care for individuals who are in crisis. Today, we will be considering the role of medication from a number of different perspectives. Several of us had a chance to begin this conversation on a recent 988 Crisis Jam call. And today, we're going to continue that discussion through a roundtable format. So, throughout the rest of the discussion, I'm going to be referring to all the panelists by their first names. And we can, I think, go ahead and stop the slide share. Great. Thank you. So, Chuck, I'd like to start things with you. So, can you give us a little bit of an overview? Can you share your perspective on how to conceptualize medicine in crisis care, maybe the why's, the what's, and the how's? And then we'll open it up to the group. Sure, Rob. Thanks. I'm so excited to be with this group, again, to be able to talk about this subject and more in depth. So, I'm going to set the table very similar to what we did in the Crisis Jam in talking about the why's, what's, and how's of medication. And again, it comes from my lens as a prescriber in that role, but also looking at the whole system approach, which I'm excited about the fact that we're going to be able to talk about that. So, why do we need medication? For one, they're an important tool. It's one of many tools we use in crisis care, but it's definitely not the only tool. So, medications, they can be helpful as a way to be able to help say yes to everyone coming to your facility in crisis. They can oftentimes be best practice in some situations where they offer better care with either relief or symptom improvement or harm reduction, especially when combined with other crisis care therapeutic tools that are available that we use. The people that we serve presenting to our crisis facilities, just to give a perspective of thinking about who are these medications for, they can often present with a range of challenges that are the reason that they're at our crisis facility. It could be things like suicidality, sleep problems, depression, mania, psychosis, trauma, substance use, and other concerns. And sometimes folks may be coming in to voluntarily seeking help, saying I need help, or help brought in by an outpatient team that they're working with, or their family members, or loved ones, but sometimes they come in on an involuntary basis against their will. And in some cases, guests and people that we're serving in our facilities may have such severe agitation from things that they're dealing with that in the moment, they may be at imminent risk of self-harm or harm to others. And that imminent harm, though, may be related to mental health challenges, could be substance use effects like intoxication or withdrawal affecting the way that their brain is working, could be medical causes and other issues. But without medications as a part of an available tool to use, sometimes those people may not be able to be served appropriately in a crisis care setting. And so oftentimes we'll hear crisis facilities say, this person is too dangerous, too violent, too medically sick, or things like that, and becomes a reason not to have access to care. So it becomes a really important, just one of many tools that you have to be able to have in your infrastructure and know how to use them correctly. But also one other aspect of why for medicines is a lot of our guests and people that we serve show up and may need help with certain medical problems that they're dealing with. And they may not be emergent medical problems, but it may impact our ability to serve them safely while they're there. So you have to be able to have meds, be able to help with medical issues that people often present with, blood pressure, diabetes, skin infections, things like that. So the what, Rob, is like, what medications do you need in this facility? So you don't have to have typically the full armament that you might have like in a hospital emergency department setting. But if you're thinking about medication as a tool, you need meds that are available that are ready for mental health needs that we mentioned above. So being able to support some of those different concerns. So for example, in substance use, for best practice, you may need meds for withdrawal management, for comfort, or there may be symptoms of withdrawal from some substances that could be dangerous medically, like alcohol and benzodiazepines. And if you don't have the appropriate medication infrastructure in place, it's hard to serve those people safely without having to send them to an emergency room or a hospital, therefore, again, creating delays and or barriers to access and care. So in best practices, in crisis care, going back to substance use, you know, being able to have medications that you can use for medication assisted therapy for opioid use can be really important. So if someone comes in to our facility who's struggling with suicidality, for example, but they're also on 120 milligrams of methadone, if you don't have the ability to continue that methadone while they're there, you can't just stop that suddenly, it can be very dangerous and uncomfortable for that person. So again, if you have access, you need to have the infrastructure to be able to continue that. And a new thing that's happening across emergency rooms all over the country, and now kind of trickling into the use in crisis receiving centers is the use of being able to do inductions with buprenorphine for people, since that's a best practice for approaching opioid use disorder. And then finally, you need some basic medicines on your formulary to be able to manage some of these medical things that we talked about, like blood pressure, medications, certain medications for diabetes, certain basic antibiotics, and so forth. One last medication that I always bring up that's super important, but it's often overlooked is nicotine replacement. Most facilities are non-smoking, and it's such an important comfort measure, but also makes a big difference in supporting people, because especially if they don't want to be there, or even if they want to be there, that can be a big barrier if they are used to smoking and can't going through nicotine, which can be very uncomfortable. So you need to have that in mind. And then finally, the how, and that's how we use these medicines. And so we're going to really get into the details of this, I think, in our panel discussion, but I'm going to just offer some big overarching categories. One is, I think the most important, one of the most important things is collaboration. And that's working with two shared experts, the provider being the expert in medication knowledge and education, and then the person that you're seeing and working with being the expert on themselves, and what works for them or not. And being able to have a collaborative, shared decision-making process. I have the privilege at RI of working with so many amazing teammates and friends with lived experience, who have actually been persons served in crisis themselves. And I really value the learning from their experiences and sharing their experiences of seeing a psychiatric provider when they were in crisis. And one of the things that you just can't understate if you're a provider, understanding sometimes the power dynamic that's there when you're working with someone who's in crisis. And so oftentimes, the people you're serving, they may not feel as empowered to talk about their concerns related to medications and truly be a partner in their care. So we have a saying at our place where I work to help really hone in on this concept of collaboration. It's called do with, not do to, because it's so easy in crisis to get busy and to rush through wanting to work with all of the numbers of people that you may have to serve. But what you really need to be able to do is have a collaborative, engaging, supportive relationship that works together with them to say, here's what do you want to get from medication? Here's some of the things you need to know about these medications. Here's side effects. A big important question, do I take this forever or not? And so those are all dynamics that are really important in collaboration. A recovery-oriented approach that includes, again, keeping that role of medication as just a tool for that crisis situation, but an understanding there's so many other holistic factors that can be an important part of someone's improvement. So if your crisis service only involves developing a psychiatric diagnosis and then picking the medication to prescribe for that, your clinical outcomes are likely to suffer if you don't look at the whole person-centered, recovery-oriented approach at that. Another really important thing as you talked about, Rob, and we're developing our crisis systems in 988 is the importance of inclusion. And so having an inclusive approach as we develop crisis guidelines for medications, it needs to embrace the voice from lived experience, families, IDD, BIPOC, other communities that haven't often been as included in the discussion and in the dialogue and the design of systems as we create them. We know that happened historically in 9-1-1, and we have an opportunity now in our crisis system to really embrace looking at that. And so I'm excited about Dr. Sriyanka talking about the SMART tool and some of the ways that it can be used to help us in our systems to organize as an organization to look and assess how we're looking at racial bias and how it may affect diagnosing and prescribing practices. And then finally, any of these things that we design in our system need to have this concept that we're constantly developing and managing the system when it's related to medication to embrace continuous quality improvement so that we're collecting data and evaluating this just like it's been done for cardiac care, for care for strokes in emergency medical situations, that we're able to have systems in place so that we can evaluate and do more research about what works to help with different issues and concerns that happen in crisis care, what makes the most sense, what becomes a new approach to understand, you know, appropriate evidence-based and best practices that we can share, develop, and continue to hone across the country as we, you know, lean into this more. So those are my big picture approaches. I'm still looking forward to the in-depth panel discussion. Thank you so much, Chuck. A lot of things really stood out to me there. You know, I think the entire idea of doing with, not doing to, is a way that I think we all really like to sort of think about this, having two experts in the room, really thinking about things holistically, not just from a mental health standpoint, but also from a physical health standpoint, and really taking, you know, a person's entire, you know, all the needs into account. I guess I want to come back to this continuous quality improvement part in a little bit, I think, in our panel discussion, but I guess I would like to open it up to the panel and see if people have other thoughts or reflections about what you just said, Chuck. Well, as a person who's experienced crisis care, you know, what was so important the last time that I went for care, which was quite a while ago, but it was so different than experiences I had before because there was a discussion about what worked for me, what has helped me in the past, and there was an understanding that I, in fact, knew something about what might help me the most, and that I was listened to. And it sounds extraordinary, but that hadn't always been my experience in the past. And so, as the person who's taking the medication, who knows what it feels like, and who knows what's worked for me in the past and what hasn't, and really believing that so we don't have to go through all those meds again, was really, really helpful to me, because, you know, there's been times in the past where I would say that I wasn't, no one thought that I knew or understood, or even sometimes I felt like there might have been a thought that I wasn't actually truthful about what I had taken before, as if I would avoid certain medications because I just didn't want to take them, and that's never been the case for me. And, in fact, in my work, I've met very, very few people, if any. I don't really remember any who absolutely refused to take a medication, any kind of medication. All they want is to be part of the decision-making process and for the physicians to listen to them when they describe side effects and to take that seriously, because I think not being told about possible side effects can be really devastating to people, because I remember having one side effect. I couldn't, I never would have connected it to the medication, and I just really went for some months thinking something was really, really wrong with me, and it was actually a side effect, but I hadn't been told about it, and I hadn't, you know, sometimes understanding the tiny little writing on the papers at that time before the internet was really difficult, so, yeah. That collaboration. Well, I'll jump in and say that I appreciated the overview, Chuck, that you did about all the different kinds of medication, from nicotine replacement to, you know, the full medical, full medical range of medications, because as a person with my own lived experience of recovery after having been diagnosed with schizophrenia as a teenager, what comes to my mind immediately, frankly, when I think about crisis situations and medications is getting snowed on, you know, what in the olden days we call tranquilizing medications, and I think that this is a real issue that we need to talk about openly, and I don't think that that trend of over-medicating people in crisis situations is gone, and when I think about over-medicating people in crisis situations, I think you have to be a very kind of special individual to want to work in crisis situations. People are coming in at points of incredible vulnerability and in situations where they're experiencing perhaps anguish or ecstasy or, I mean, people just all over the place, and we're only human as people who are working in those settings, and what happens is that one of the, I think we don't speak enough about the fact that, let's call it tranquilizing medications, medications that can snow us and sedate us and put us under, put us into kind of a chemical hibernation, also have a vicarious effect on the staff, so when I'm present to somebody who is very vulnerable and very perhaps excited, and in many ways I may feel threatened by that, and sometimes it's possible to, in medicating this other person, I vicariously calm down as well, right, and so it's an understandable, a human reaction to want to contain and manage and control that situation, and psychiatric, certain psychiatric meds can extend our power to do that, and I think that in order to do medication well in crisis situations, there's a real focus on supporting and training that workforce so that they are able to monitor their own levels of, you know, anxiety and arousal in working with folks who are stressed and stressful, and I think that talking openly about that vicarious tranquilization and the temptation to manage, to over-medicate, as opposed to using medications, as you mentioned, Chuck, as a tool that extend and empower me to manage my own situation, that I think is an important distinction, right, and so I think the strategies that are being talked about, two experts in the room, really amping up our ability to listen to a person who is having these experiences during time of critical need, I think is the key to then making medications a more cooperative venture where the emphasis is on how this drug can empower me to move through this life situation. I also think there's this tendency to really, really, as Pat says, you know, like dose people at really high doses to make everything go away. And then it takes a really long time to crank down those medications. And I actually wish it would be the other way where we see at what level a medication is affected before we just throw a ton of medication in like Pat says. I think that is a huge risk when people are in a crisis setting for all the reasons that she mentioned. But as a person who's experienced that, it takes you out of your life. It causes you not to be able to be a participant in your life to the extent that you want to. I mean, I couldn't even drive for a long time because it wasn't safe for me. And that's not okay. And it evidently wouldn't need to be that way because at this point, I'm on a very low dose of every medication that I'm on, and I'm fine. And so it tells me that we can start at lower doses and titrate up rather than having to wait a long time and sometimes months or years to titrate down. And that can begin in a crisis situation. And to add to that in a way, I think, you know, meds shouldn't be disabling. They should empower and enable me to extend, you know, and move toward that life I want. And I think the other thing that's critical in crisis care is to recognize that medicine is not just a pharmaceutical. Medicine can be what I do. And once we can get our head around that, I call it personal medicine. So there are pharmaceutical medicines that are an option for me, but also personal medicines, the things that I can do to manage distressing voices, the things I can do to manage anxiety or challenges in these areas. And so I can't imagine, for instance, having a crisis setting without a good set of workout equipment in it and being able to, we know that exercise is a powerful antidepressant and really has a very large effect size when it comes to all sorts of wonderful outcomes. And so I think during crisis periods, it's a wonderful time to be able to learn this important message, medicine can also be what you do. And here are some amazing ways to manage impulses for self-injury, for instance, right? Self-inflicted harm. And what a place to learn, right? And people are still sort of present in those situations of crisis and can learn the skills at those time. And what a great way to sort of wed the work of peer supporters in crisis setting with the work of the psychiatric care staff in those settings and make them very synergistic. No, I'm hearing a lot of, thank you for sharing your perspectives, Lisa and Pat. What I'm hearing a lot of, or some of what I'm hearing is that we really need to rethink how we design crisis services. I think just the physical plants, oftentimes I think really require additional thoughts to permit some of what you're talking about, Pat, which is creating space for non-pharmacological interventions, exercise, calming rooms that don't tend to lead to the use of coercive treatment. I certainly think that's an idea that I think our field needs to embrace. We call that a trauma-informed space. It's a trauma-informed space. It's creating a space to actually design to help be comforting, not trigger particular expectations of harm or unenjoyable experiences and make it warm and welcoming and calm and using all of those senses in the way that you design it. So I think that's really one of many important factors as well as the things that you do beside medications. Pat, I want to specifically speak to the comment you made about the importance of not over prescribing or over using medications. When Rob and I talked about this on the Crisis Jam, we actually went into specific categories and we spoke about early psychosis. One of the things that we typically see there is a lot of times people use too high doses for people who are just presenting the first time with some symptoms of that and that the general guidelines now are much more about lowering the dose when using that. In a similar mode, the classic traditional, and I still see it being used across the country, is certain types of medications for agitation. Not being necessarily with the current best practices on what can be used that is less sedating, let someone be a partner in their care a lot sooner so that even in a case where they're voluntarily or in an emergency situation or receiving meds against their will, the types of medications that you use in either of those situations can make a big difference in someone getting immediate relief but then still not being sedated so that they can participate and work in their care. So even in those really challenging situations that we don't want to ever happen, using the current best practices that are out there, and there's some really good guidelines established through the American Association of Emergency Psychiatry called Project Beta that did analysis of multiple different types of medications and gives you a workflow based on whether you're seeing someone going through withdrawal from alcohol versus intoxication with a stimulant like methamphetamine or cocaine and the different types of approaches they can take, but they all work on that principle of trying to partner with the person first for voluntary medication if needed and using medications at the right doses that decrease the chance that that person can't be a shared decision maker with you. But unfortunately, like you said, Pat, it just doesn't happen universally even now. So it's part of our system is to work towards educating and promoting that, that it's done across the country. I think the other elephant is in the room for us when we talk about emergency or acute crisis care with folks and crisis stabilization. As a white clinician, I have to be incredibly conscious of implicit racial bias because it is a fact that Black men of color will more likely be diagnosed in most situations with schizophrenia and underdiagnosed depression. I know we know this, but we can't say it enough that folks of color are going to be more likely to be involuntarily committed and coercively given medications and will spend more time in restraints and seclusion and medication against my will. So I'm always interested in the question, we understand these systemic inequities in terms of how we approach the work, but how do we operationalize dealing with the reality of crisis, which is like now, now, now we got to, you know, beyond this. And so those biases have a, you know, a right opportunity to express themselves. And I think the data supports that in fact, they do. And that we, how do we think about, you know, I guess what I struggle with a lot is how do we think about the chasm between understanding some of the inequities that lead to some of the results we see in the data with the immediacy of this individual, not a population, this individual. That was a tough one. I don't know if anyone wants to say something about that. You threw it right over home plate for us to talk about the smart tool, because it incorporates a lot of the, a way to operationalize looking at that, Pat. Thank you, Pat and Chuck. Yeah, I think this is a perfect timing to discuss the smart tool. You're right. The data is pretty clear and convincing. When you look at population data across all types of treatment settings, all levels of care in any health system, the consistent finding is that persons of color, other minoritized groups tend to experience coercive treatment to a larger extent. That is certainly true for things like AOT. That is also true for things like restraints, use of restraints, as you said, Pat, and whether that's chemical or physical restraints. That's also true for who gets sent to higher levels of care, like acute inpatient, like a residential treatment for children. It's also true for, I think, episodes that result in injury to persons that are seeking treatment. There's no one answer to this. A lot of this obviously boils down to personal, let's put it this way, discretion when you really take a step back and look at what happens. Discretionary decision-making is necessary in these situations. There's no one-size-fits-all, but that very ability to make decisions on a discretionary basis is what tends to drive disparity. I'll share a quick story to this point. Early in COVID, about March, April, May of 2020, there was a push to empty the jails in Philadelphia. We have a team that tracks data on who gets released, who gets incarcerated, and so on. The data actually showed that persons with SMI tend to stay longer than persons without SMI in jail. Of that population with SMI, persons of color tend to stay even longer. Well, our team in Philadelphia decided to was involved in creating a transitional housing for persons being released to support them in their transition to the community. With the very best of intentions, a look at the data within a couple of months of setting that program up showed that there was disparity in who had access to that service. If you looked at percentage of persons of color versus white persons who were in prison and eligible for that program, persons of color tended to not get that service at the same rate. This was entirely due in large part to just the way things work. That's just the system. Then what happened was, obviously, that finding then allowed our team to be very intentional about matching individuals that needed that service or qualified for that service to the service. In psychodynamic speak, that would be making what is unconscious conscious. That speaks to a lot of what I think has to be done to eliminate bias. Now, we all have this awareness, I think, especially now with the conversations that have happened in the last couple of years, but making it operational in our own work is a different thing. That idea of measurement, measuring processes and their downstream effects is what informed the SMART tool. A lot of organizations who are horrified by the idea that they could be perpetrating structural racism nevertheless continue to do so, simply because it's kind of the way the system runs. The SMART tool was created to help organizations to conduct self-directed anti-racism work. It's essentially a 25-item questionnaire that's organized into five domains. Those domains reflect what is found in the literature. They include hiring, retention, promotion, and discipline. It also includes clinical care, which is what we're talking about here today. It also includes workplace culture, community advocacy, and I'll come back, I'll talk about those in just a minute, as well as population level outcomes. I'll just say this very quickly. The literature is really clear on who gets hired and who gets promoted. If you look at the academic literature in academia, well, women and minorities tend to be underrepresented in terms of promotion to the highest levels of organizations. The same is true in the business world. Six percent of top managers, CEOs, if you will, are only six percent of minorities. That's obviously not reflective of the larger population. We've already spoken about clinical care, the over-diagnosis of schizophrenia, for example, the overuse of coercive treatment, for example. In terms of culture, the culture of the organization is just the way we do things. Are we free to talk about racism? If a colleague experiences a microaggression, which is ubiquitous, are they free to talk about it? If they do talk about it, do they get punished? Do they get ostracized? Do they become persona non grata in the organization? Does it affect their chances of promotional or advancement? Do they then become a troublemaker? Or conversely, does the organization have processes to create listening spaces so that people can candidly have these conversations and actually have things acted upon? Then in terms of community advocacy, it really reflects the role of community psychiatry within the broader society, the broader systems of care. For example, we know the public mental health systems and persons within those systems often encounter law enforcement. They often require services, social services, housing, income assistance, and so on, that really are integral to their recovery. We also know that if we take a look at population outcomes, we know that our population, and I'm talking about persons with SMI in particular, tend to die much earlier than their counterparts and are, again, overrepresented in things like incarceration, low graduation rates, and so on. Now, the SMART tool allows an organization to basically, because these conversations, let's face it, are very difficult, people get uncomfortable. They feel like it's very easy to feel like fingers are being pointed at a person rather than being pointed at a process or a system. And so the SMART tool allows an organization to basically assess itself. So let's talk about, let's bring this down to crisis services in a couple of different ways, or three different examples here. The first would be, and I'm just sort of giving these as examples, what would it look like for a specific crisis response center, psyche D if you will, to take a look back at its own data and look at the past one year of who got restrained in the ED. And even if we really wanted to drill even further down, look at, well, are there disparities in who ended up being injected, who ended up in physical restraints? And if you really wanted to get very specific, you could even drill that down to the individual provider or team who made that decision. That sort of scorecarding is pretty powerful, particularly if it's benchmarked against other teams in really shaping behavior. If you think about it, that's sort of what exams are. And certainly as a physician, I've taken a lot of those. Another example would be taking a look at who gets disciplined within the, I mean, this is maybe a little outside of the medication realm, but are we able to talk about incidents of maybe suboptimal interactions between staff and clients, where people get called names or people get treated in ways that are really not recovery oriented? And is there the avenue to do that within that? Is there a process and a system to address that within the system? And so on. I'll stop there. That's, I think, a broad overview of the SMART tool and how it can be used in crisis settings. There's a lot more that we can talk about, obviously. I think talking about the restraint is an important part of this and the medication used during restraint and things like that. And as a person who experienced that, who also has a trauma history, it was devastating. And the reasons were, I mean, I didn't raise a hand to staff. There was nothing about me that was dangerous at all. And still, I was restrained because I didn't know I had to move 10 feet over as soon as someone told you to do that when you're in a crisis setting. And that really, we think people know what's expected of them because they have a mental illness in a setting like that. People don't. And helping people to understand what happens when they arrive in a crisis setting, but to restrain people as a punishment. And I think this is, I hope and I pray that this is stopping, but that's what it was for me. And injecting me with a medication that knocked me out was really, really unhelpful. It wasn't at all therapeutic. And it was something, another thing that I had to recover from and still recover from because it is one of the traumas that plays again in my mind a lot. And so I think looking at that is a really important part of, as we're approaching this reconfiguration of how we look at services for people. And instead of taking them to jail, taking them for medical care in a psychiatric emergency center, we have the opportunity to rethink all of the processes that have gone around emergency care for people with psychiatric illness for hundreds of years, actually. And can we shift the way that we're looking? And especially with vulnerable populations who are just really at such higher risk. And I think if we don't address that, all of the changes that are potentially able to happen will be set back so much by coercive practices. And so going back to kind of summarize all three of what I've heard when Pat first asked about how the operational loss and tying it back into the medication prescribing aspect of being in crisis care, I look at some basic principles that I think can serve us all well in your organization of how to look at doing that in these ideal ways that we're talking about we should all be doing in our crisis design, but it's not necessarily happening everywhere. And so the first thing would be that we have voice and the right culture and leadership in the folks who are designing the workflows and the systems and the things that we do that incorporates and co-design workflows and processes that minimize the chance of creating those dynamic tasks. And then when those things are designed, having the right trainings in place that help educate people, what is the right way to do that? And then actually putting that training into knowledge, not just knowledge, but actually doing. And so what ways are you using as an organization to track that your staff has retained and understands that information, and then it's practicing it day by day. And then that ties into what Sosa Molo was talking about is having the tools to look at the data and measure, are you really in place, the responses that you're hoping that you have? How are you doing with engagement feelings? Are you measuring people that you're serving feel engaged and cared for? And comparing that in demographic groups, looking at seclusion and restraint data, looking at what meds you choose for different forced meds for different groups. Who gets access to offering of best practices of like MAT? Is there a racial bias in offering suboxone induction to someone of color versus not? Those kinds of things. And then having people within the system who own looking at that data on a regular basis and doing quality improvement, continuous quality improvement based on that. I think having all those things in place, it's simple and it makes sense that it's simple, but it's not easy or else it would be done all over the place. And so it's putting those types of workflows in place I think are important. And like I said, as we do this more and more and share that data and share what's working and not working in a learning community type atmosphere and in papers and in research, I just can't imagine that it won't continue to do what we've done in emergency medical care for emergency behavioral health care. Let me just underscore something you said there, Chuck, which I think is so important and so powerful. It's the idea of normalizing quality improvement. It's the idea of baking that concept into processes and systems, as opposed to it being this thing that sits off in the corner and it's the responsibility of chief quality officer. I think there you make a good point that absolutely has to be designated persons or a team that's responsible for that. But the idea that we will never really arrive, that we will, as an organization, we're constantly striving to improve and to back that into the conversation around disparity, whether that's based on ethnicity or other factors. The idea of normalizing that, the conversations around that as well. The idea that it's going to take a very long time to change many of these processes and systems and that using a tool like SMART to continuously engage in this effort is the way forward to help organizations reach that equity goal. One of the things I really love about the SMART tool, Susan Molo, is that I think that it provides this incredible framework for how systems can look at a lot of these questions, but also then there's a lot of room for innovations about how people can actually go about making these changes to help to, you know, I think address these disparities. Because you can't just, you know, look on PubMed and find the answer to actually how to do this. Individuals need to think about it for themselves and develop these new processes. And so I think that the tool is innovative, not only in terms of just sort of looking at what happens, but then also what we'll learn from addressing these changes. Absolutely. And I think it's a great way to address these changes. Absolutely. And I'll just say a quick word to your point about how the SMART tool should be used. So basically, the recommended strategy is that an organization that decides to use a SMART tool, create a work group, essentially, that's drawn from, that has representation from all levels of leadership and service across the organization preferably with a multiplicity of training backgrounds, career stage, and identities. Because that by itself, you know, and obviously this would include persons with lived experience. And the idea behind that is that, you know, I as a provider see what I see, but my colleagues who may be working on the frontline may see things very differently. And that one perspective is not necessarily better than the other. And having multiple perspectives enables us to reach better decisions, see better, more clearly and reach better decisions. So forming the work group in that ways is strongly recommended. The second step would be for that group to then select an area or select all the five domains and apply the tool to the organization. Now, one of the, I think, key aspects of the SMART tool is that I think actually facilitates changes, the requirement to score, to reach a consensus around scoring. So an item, a five-point Likert scale on an item that has a five, that can be scored on a five-point Likert scale for example, hiring, you know, how well are we doing with hiring? Are there disparities in hiring? Well, again, the requirement to reach a consensus score will provoke, tends to provoke very robust conversations. And then based on those conversations, the organization can decide on an action plan, which can then be revisited periodically at six months or at a year to re-score or revisit that particular item or topic. So that's the recommended process. In our organization and other organizations that have applied the SMART tool, they found exactly that happened, that there was robust conversation. And also, I think the recognition that this is work that takes commitment for over the long term, as opposed to things like, we're going to train our way out of this, we're going to change the language you use and so on. So there's something I, so we had a number of questions, you know, when we were setting up this round table discussion, and I think we've gotten through the first question. So what I would like to do for the frontline clinicians who are, you know, a part of this webinar, who are listening in, we've been talking a lot about ways that we can address the entire system. But what I want to do real, just briefly, is sort of get some thoughts about that dyad between the person who is, you know, offering a medication and the person who is on the other side, who's, you know, who's about to take a medication potentially. And I'm wondering if there's any strategies or tips or thoughts from the panel about how we should be presenting, you know, medication to individuals in a way that minimizes coercive practices. I think this is great for Pat. Well, I think that because of the pattern imbalance in the room, so we may agree there are two experts in the room in order to find the treatment that's right for me, me as a psychiatric care provider, and me as an individual need to share the decision about how to move forward in terms of medications, including the idea that medication can be what I do, not just what I take, finding that right balance. I believe that in order to begin to equalize the power differential in the room is that people need to prepare to participate in having a very different kind of conversation with a psychiatric care provider. And that's where I think the entire peer workforce can play a very, very special role. My view is that there is no time in today's healthcare system to wait in waiting rooms. There is no time to wait. We got to get prepared to participate in what may well be a very, very short, but critically important meeting that's upcoming. And I think my work for a very long time is focused on how to mobilize the peer workforce in order to support people in getting prepared to have that very different kind of conversation and to participate in shared decision making. And so I call my approach medication empowerment. How do we support people in thinking through the challenges they may be experiencing in using psychiatric medications in their lives very often, particularly in sort of post-crisis stabilization? A lot of things that lead people into having really acute challenges, crises, is that they've abruptly just gone off meds with absolutely no support. We see that frequently. And there's just sort of a mentality of, oh, we got to get them back on the meds and we just got to go and re-medicate and out you go again. And it does lead to a revolving door and to high recidivism and to unnecessary crises. What if we took the approach of saying, well, let's help to mobilize the peer support workforce and sensitize the psychiatric care workforce to understand that using meds is a process that occurs over time and that there are many challenges on what I call this journey to use meds optimally to support me in getting the life I want, to support me in getting my recovery. And that imagine, if you will, a peer workforce that's empowered with specific tools to help people in a very guided process discover what are the challenges that I'm experiencing. I'm not motivated to use meds. I wonder what I'm like without medication. I prefer getting high on my drugs to using your drugs. You know, I'm not crazy and I don't need meds. Imagine a guided process of helping people before they actually meet with a psychiatric care provider begin to explore and articulate the challenges they may be experiencing and to be able to bring that right into the consultation in a crisis setting. And let's deal with it from the beginning. And I think we can deal with these issues right from the beginning as opposed to just repeating the same old, same old recidivism because that goes nowhere fast. So that's it in a nutshell, medication empowerment, that's what we've been working on and what we do. I love that, Pat. And then I would also add to that, that on the provider, prescriber end, we need to continue to lean into understanding and promoting some of the, what we call in our peer power practices, but there are these things of being, you know, training a provider or prescriber how to be collaborative, how to be recovery oriented, how to focus on strengths and the whole person rather than just their diagnosis or what's wrong in their crisis. And so if we attack that from both ends, think about the synergy of that. And so giving, Lisa is in charge of designing and training for not just our peer staff, but for how all of our staff can take those approaches and use those in specific examples of things in crisis training for what we do. And so I think it's a really important element as it's not, I don't remember getting a lot of training of that in my residency and in med school, some, but not in a day-by-day walk of how to do it every day. And so I think we can really build that up in our systems from all angles to support that shared decision-making. Just having seen Pat's tool, you know, as a person who has been on this medication journey for almost all my life, it is such a comforting tool. It is a pleasant tool and it is a safe feeling tool that promotes discussion in a really, I don't know, it's just a really wonderful way. And it's, you know, it's been my experience over the years, just helping people talk about side effects is such an important part of understanding why they don't want to take medication or what's happening about the medication. And it's not always the question that's asked. And one of the things that Pat's tool does is allow that to happen. And I just want to, if I might, we had a tool that we worked with for a long time, and part of it was practicing talking to your doctor. So it had a little, you know, you role play talking with your doctor and the students really liked to do that. And it helped them prepare. And it wasn't nearly as sophisticated as what Pat has, but just the smallest things. And so if we help people to understand they can have a voice, and if we help our providers learn to listen to their voice, you know, we'll make such a difference. And if I could just add, one of the most important ways that people can use their voice, even in their worst moments, is through an advanced directive. And in having an advanced directive that you've made when you're feeling good, and you know, it's been my experience over the years that people are very thoughtful when they make those advanced directives. They are very well aware of what goes on for them. And for instance, I didn't have anyone ever who was making those with me that ever said, and you have to realize I did this with many, many people, that, you know, they're wanting to change the person who's their spokesperson, you know, in the middle of a crisis. People know that that's not the optimal time to change who their representative is. And they're very, very aware of those kinds of things. And I think, you know, what was one of the most difficult parts for me was when people would take that advanced directive, and, you know, go to the hospital with it, and nobody would pay attention to it. And so this has to change. Also, we have to, you know, every time I go in for, you know, any kind of procedure that takes me anywhere near, you know, anesthesia or anything, I am asked, do I have an advanced directive, you know, but we don't do that in behavioral health care. And it's such an important part of people's empowerment and feelings of safety that they've prepared, and they know who's going to support them, and they know the kinds of, you know, they've written down the medications that have worked for them in the past and the ones that haven't, and they've laid out this process that is important to them. And so we need to take those things seriously and not dismiss them. And I hope that we're moving in that direction and beginning to trust in people's wisdom. They have a deep, deep wisdom. I don't see people who are reckless about their health care, you know, mental health care is health care. I don't see people a lot who are reckless. And I work in the same population as everybody else does. I don't work with different people who don't have as challenging of symptoms. I work with the population of people who are diagnosed with serious mental illness. And they, you know, I hear these stories from not just the United States, but lots of places around the world where people's voices is disregarded. And I think it's starting to change. I'm really hopeful that it's starting to change. But I really think that this is an area that we need to look at is respecting people's advanced directives. I'll get off my soapbox. I really like the idea of systematizing the use of advanced directives. I think it would be such a key intervention in our system in Philadelphia as part of our crisis system redesign. Now, Pennsylvania has had implemented advanced directives on a scale many years ago, around 2015. But we've certainly revisited that idea in our family. We know our family advisory work group has done a lot of work and has made recommendations on how we can do that. So I could not agree with you more. And just a plug for SMI Advisor has a free download app for iOS and Android. It's a wonderful thing. Well, thank you so much, everybody. This was a really, really, really wonderful discussion. Very, very rich. Chuck, Pat, Lisa, Sosamulu, really, really wonderful. Over here are some references that people can take a look at from even some of our panelists over here. If we could go to the next slide. And thank you. Unfortunately, we're not going to have time for audience Q&A today. But I did want to mention that SMI Advisor is available on your mobile device. And you can actually access the PAT app as well. So you can use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions to our team of SMI. So thank you so much for joining us today. Experts, you can download at smiadvisor.org app. And if you have more questions about this that we didn't cover, feel free to post a comment or a question on the SMI Advisor webinar roundtable topics discussion board. This is an easy way to network and share ideas with other clinicians who participated in this webinar. And if you have questions about this webinar or any other topic related to evidence based care for SMI, you can get an answer within one business day from one of our SMI Advisor's national experts. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who experience SMI. It is completely free and confidential. SMI Advisor is just one of the many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the mental health addiction and prevention TTCs as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health to the opioid epidemic. So, 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 finally, please join us next week on July 7th as Dr. Batt presents chronic pain and serious mental illness, an approach to diagnosis and management. And again, this free webinar will be on July 7th from 3 to 4 p.m. on Thursday. And thanks so much for everyone for joining us. A big thank you to our panel. This has been great and until next time, take care. you
Video Summary
The video is a webinar titled "Learning from Each Other: Understanding the Role of Medication in Crisis Care." It is part of the SMI Advisor initiative, which aims to help clinicians implement evidence-based care for individuals with serious mental illness. The webinar is hosted by Dr. Rob Kotez and features a panel of experts, including Dr. Charles Browning, Dr. Pat Deegan, Lisa St. George, and Dr. Sosamolo Shoyanka. They discuss the importance of collaboration and shared decision-making when it comes to medication in crisis care. The panel emphasizes the need for providers to listen to and respect the perspective of individuals receiving care, and for individuals to be empowered and prepared to participate in their own care. They also discuss the use of advanced directives as a tool to support autonomy in shared decision-making. The panel acknowledges disparities and biases in crisis care, particularly related to race and ethnicity, and highlight the SMART tool as a resource for organizations to conduct self-directed anti-racism work. The panel also touches on the importance of continuous quality improvement and measuring outcomes to address disparities in care. Overall, the webinar provides insights and strategies for clinicians to improve their approach to medication in crisis care.
Keywords
Medication in Crisis Care
SMI Advisor initiative
Evidence-based care
Collaboration
Shared decision-making
Advanced directives
Disparities in care
Race and ethnicity
SMART tool
Continuous quality improvement
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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