Hello and welcome. I'm Amy Cohen, Program Director for SMI Advisor and a clinical psychologist. I am pleased that you're joining us for today's SMI Advisor webinar, Practical Tools for Behavioral Health Staff Supporting the Medical Care of People with Serious Mental Illness. 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 and has also been approved for one CE credit for psychologists. Credit for participating in today's webinar will be available until July 15, 2020. Please note that the time frame to claim credit for this event is shortened due to our transition to a new learning portal later this month. Again, credit will not be available after July 15. Please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the lower portion of your control panel. We'll 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 Kern. Dr. Kern serves as a clinical professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington. His work focuses on training and implementation of the collaborative care model. And as well, he has led a number of initiatives to address the medical needs of people with serious mental illness. Dr. Kern, thank you for leading today's webinar. Thank you very much, Amy. I'm pleased to be here. Proceeding through the boilerplate, I have no relationships or conflicts of interest related to this subject matter of this presentation. They teach me at the AEM Center that every teaching activity needs learning objectives. Here they are for today. We're going to be talking about a very granular approach to helping people who actually do the on-the-ground work of supporting people with serious mental illness in terms of their medical health. And so what we're going to do today is hopefully differentiate the team's role, the mental health team's role to monitor, support, and intervene with medical conditions, not to treat them per se. We'll describe the specific role of behavior health case manager in supporting medical health of people with SMI. We'll talk about where you get good information and how, because you can't remember everything. And we'll talk about some learning and job support tools that actually exist and others that could be created to support your efforts to help clients be healthier. And now, a poll. Okie dokie. So I'm hoping you can see this as well. About 44% of the folks on this call are case managers, which I think is just awesome. I do a number of these kinds of talks and often I get everybody's boss. So I'm thrilled to see that folks actually doing the work are on the call. So let's move ahead. And the rest of you are welcome also. Everybody has a role to play on the team. We'll be focusing today with the case manager. That's the person with the most direct contact with the client and the most opportunities to encourage and support health-enhancing activities. So who does the face-to-face support of medical care for our SMI clients? Is it care managers, care navigators, peers? I think all of those are people who inhabit the same space in different programs. Certainly nurses and nurse care managers do as well. I think that folks doing the case manager, case navigator, peer are the folks that probably we're obligated to offer the most support for, most of the grindstone part of this to do. The question you may have been wondering about is how can I be useful supporting physical health when I'm not a medical person? But in fact, the relationship with the case manager is maybe the most important tool the team has to work with. This is from Joe Parks, who many of you may know, was the director of the Missouri Health Home Projects and now is the medical director of the National Council. But he says all meaningful behavioral change occurs in the context of a personal relationship. And I think this is so profound that I usually repeat it twice during each presentation that I do. This makes a huge difference. Behavioral change is hard. Getting people to take better care of their health is challenging. And the personal relationship is the strongest tool we have. It's always interesting to me that in our field, we wander away from this truth and to technology and to procedures and programs. And then in the end, you come back to the relationship, which shouldn't be surprising. We should know better. But it's still important and the most important thing. And so what we'll be talking about the rest of the time is leveraging that and giving you some tools to leverage it with. Now, why are we going to all this trouble? Well, this should be familiar, sadly, by now. This is data reflecting the life expectancy or shortened life expectancy or the increased mortality of people with symptoms of serious mental illness. It's still short. It's been quoted to be 25 years shorter than the life expectancy of the average person. And this is in multiple versions of this in multiple countries. And we've been, I certainly have been actively working on this for over 10 years. But we've made little headway. The decreased life expectancy has not improved much at all. And the actual implementation of team-based efforts like the ones we're working on has been rather rare. We persist. Nevertheless, we persist. Now, this is a gory looking slide to have us focus on the issue of cardiovascular disease. Why cardiovascular disease? The primary target of our work in trying to address the increased mortality of our clients with serious mental illness has to be the kinds of diseases that are actually killing people. And this, it turns out, is what it is. Cardiovascular disease is a condition where a plaque containing cholesterol sticks to the arteries and builds up and blocks them and can eventually cause a heart attack. If arteries to your heart gets blocked off or stroke, if the arteries to your brain get blocked off. And this is the number one health condition that's killing folks with serious mental illness. So what I'm going to talk about today in terms of common medical conditions aren't just random medical conditions and aren't everything that can go wrong with a person. And you will notice that it's a short list, but it's because these are the most common and most addressable conditions that predispose to cardiovascular disease. And if we can address those, we can address this problem and hopefully keep people from dying of heart attack and stroke, which is what it is that's killing our clients. For the most part. So now what we're going to do first is we're going to learn about a few crucial conditions that we're trying to impact with our integration team. Now, why do we do this in behavioral health? Why not just hand this off to our very able colleagues in the primary care side? The reason is that our clients represent a very high risk population for premature death. And the extra support that we can add in addition to their standard medical care to facilitate their standard medical care can make a difference in their survival. Nobody else is going to do this. No one's going to take this primary responsibility for the primary care world. Our clientele is a niche. For us, it's our whole business. And so because we want people to still be around for us to assist with the recovery, this has become our responsibility. And this is now really considered to be part of the work of a of a state-of-the-art mental health facility. So the question is, are you going to know everything there is to know about, say, cardiovascular disease? And the answer is no. The knowledge base is massive and you couldn't possibly know everything. And I don't expect to know everything. How much should you expect to know? A nice rule of thumb. I did not invent this. This comes from the primary care folks at University of California, San Francisco. Rule of thumb is expect to know about as much as if you had the condition yourself. So if you're working with somebody with diabetes, which is common as dirt amongst folks with serious mental illness, you should expect to know about as much as you had the condition, diabetes yourself. So where do people go to get information? Well, here they go to the internet. And clients are going to talk to you about their health and share ideas about how they view it. Sometimes they'll be misinformed in ways they're concerning. With access to the internet, there's constant exposure to a lot of nonsense. It's difficult to distinguish from useful information. Now this website, this particular website is a great example. I was actually looking for some information not long ago, and I was making a list of medications for blood pressure. And I had forgotten, because I have a little squishy gray brain, I had forgotten the word amlodipine, which is common blood pressure medicine. And I, for the life of me, couldn't pull it up. And so I go online and looking for a list of medications to jog my memory. And I come across this, and I scroll through this high blood pressure medicine site. And I'm thinking, hey, this looks pretty good. This might even be something I can recommend for my staff. And then I look at it a little more closely. And I see that scattered amongst the fairly good information, for example, about how I should take amlodipine. There's these ads that get stuck in the middle of this by the Google or whoever is putting the ads in here. And they're related to blood pressure, because it's a blood pressure page. But when you look closely, you see Harvard Health publications. You think, oh, this must be bona fide. This must be genuine. But then you have these other things, blood pressure medicines to avoid. And it turns out that this is a snake oil. This is absolutely positively the kind of thing you would want people to avoid. But it's all mixed in together with what you think would be good information. So it's tricky, even if you're using your nonsense detector, to find information that you can trust. And so this is a, how can you tell what's reliable? This is so easy. So what we usually do, what we do with my staff is list a small number of reliable sources of information. So of course, if you're working with medical providers and you have them at hand, you can ask them. The internet, of course, with caution. And so this is a short list of sites that we look at as being reliably accurate and dependable. And these are the places where I would look for information. And so I would strongly, strongly, strongly recommend, if you're trying to give good information to folks, you limit yourself to these sites or the sites that are similar. And in general, if you read something on the internet, I would say, never make a clinical decision based on that without checking with your. So one of the things I did for my folks was to make short guidelines or short reference tools or job aids, as we call them, about commonly encountered health conditions that our folks encounter that we're trying to impact with our work. So there's one for hypertension, there's one for diabetes, there's one for hyperlipidemia or elevated cholesterol. And they're meant to be brief. They're meant to be used as a reference tool. This is what they look like. And they're a page and a half or so, and they're meant to be kept around in case you need some reliable information. You don't feel like going somewhere else to look it up. So this is a summary of the first one, of the high blood pressure one. Elevated blood pressure or hypertension, it's the same thing. Hypertension, of course, doesn't mean I'm tense, super tense, really tense. It means my blood pressure is high. And that refers to elevated pressure in blood vessels. And this is one of the things that increases the risk of death by stroke or heart attack by assisting in that process where the arteries get all gunked up. How do you treat it? You treat it with medication, health behavior change, keep the weight lower. That's good. If they exercise, that's good. If they don't smoke, that's really, really good. And limiting alcohol. This is the bottom line. This is the short version of hypertension. And so if you're talking with your clients, you're hearing from your clients, you're involved in the care of somebody, these are the anchors, the anchor knowledge of what you really need to know. And this is a little table. It's included in the handout of what's a normal and what's an abnormal and what's an elevated. Because who remembers these things? It's nice to be able to look it up. Similarly, diabetes mellitus or diabetes is what you normally hear people say. Diabetes mellitus is a specific term. And this is where people's blood sugar is elevated. People say they have sugar. That's what we're talking about. This is a medical condition where the blood sugar is elevated and it can cause a ton of trouble. This is maybe the most important condition that people with serious mental illness have that impacts their health. It does all these things, damages eyes, kidneys, blood vessels. It's usually related to overweight. There's been an epidemic of diabetes in the US in the last 20 years. It's related to people being heavier. This is treated with dietary management, medications, including what are called oral hypoglycemics, medicines like metformin or sometimes insulin. These are folks who have to check their sugar regularly. And this is just part of their life. So if you're working with somebody with diabetes, and if you're a case manager and you're working in mental health, you are working with people with diabetes. I would venture to say, depending on where you were at, at least a third of your patients probably have it at some level. And so the question is, you know these things, if people are talking about their diabetes, these are, again, the touch points. How else can you be helpful to a client? You can encourage them. Diabetes is a frustrating and chronic condition. It's often associated with depression and folks who are depressed take worse care of their diabetes and have significantly worse problems. So it's really helping them stay in the game, helping them be encouraged, helping them take good care of themselves can be really important. And one of the things that you can do is model healthy eating and support their efforts in physical activity because it makes a difference. Finally, our last common condition is hyperlipidemia or high elevated cholesterol. And cholesterol is stuff that's normally in your body. It doesn't just come from food that you eat. Vegetarians, even though cholesterol comes from anything that's animal, vegetarians have cholesterol. It's just part of what's in your body, lots of it. But if the amount in your bloodstream is too high, this can be, again, related to cardiovascular disease. And so this is something that's measured with a blood test. It's something that's very successfully treated with medication. Maybe the most responsive of all these conditions to medication and to weight reduction. So these are the big three. These are the big three conditions you can hear about over and over and over and over and over. You get familiar with those, you know a lot. You can make a big difference. Now, we're not expecting that you're going to become a medical professional. It's not your job to diagnose these. I've worked with a number of case managers who are terrified that their patient will go or their client will go untreated because they've failed to identify the signs of the illness. If somebody really has diabetes who's being managed, this will turn up. Patients who are being prescribed the psychiatric medication should be getting screening labs anyway that will detect the disease, these diseases. And so the role of the case manager begins after the diagnosis. So if a client shares information with you that you think your team doesn't know about, then you want to let them know. They happen to mention that they used to be treated for this or that, or they're having some kinds of symptoms. There's no law against letting somebody know. But again, you shouldn't feel responsible to make this diagnosis or empowered. So what can we do about all of this? These are the things that will actually move the needle on people's mortality. Smoking is probably a number one, and this is, of course, modifiable. Smoking cessation is a thing that works. We'll talk more about that. Obesity is a modifiable risk factor, not easily modifiable, as everybody knows. Lack of exercise is a modifiable risk factor. Untreated medical illness, so what we just got done talking about, hypertension, diabetes, hyperlipidemia, if those things are treated, they can make a difference. If they're not treated, they're a risk factor. And then one of the things that can happen in people with serious mental illness is they're prescribed a psychotic medication that can cause very significant weight gain. Probably everybody knows someone who has had, has been treated with a medication like Ceprexa, for example, or Clozapine, or Seroquel, that's associated with very significant, many, many dozens upon weight gain. And that's something that we can usually find a way to work around. I'm going to talk a little more about that. So what you want to know, you say we're presented with this situation, oh my goodness, people are dying so young, and it's absolutely true. And they're dying of these diseases, which sound formidable, which they are. And so what are we going to do? How are we going to help them? We're going to help them in modifying things that can really be modified to make a difference. So what do we do? What do we do? Us case managers, what do we do? These are our angles, health, behavior change, and supporting medical care. That's the big two for us. So supporting medical care to start with. What does the case manager do? I know I'm probably speaking to the choir, and you guys know what you do, but arranging appointments, making, keeping, using, building relationships. Remember, all meaningful behavioral change occurs in the context of a personal relationship. And so building relationships with clients, with their caregivers, and we're going to talk a little bit about building relationships with the medical side, primary care providers, which is something that you can really do, you can really modify and get better at and more skillful, and that can make a huge difference. Healthy living, encouraging healthy living, reminding folks about what's good for a person, encouraging, and frequent touches. One of the things that makes a huge difference between the contact of, for example, a primary care provider with our clientele in our context is that we have many, many more. Someone may see their primary care provider a couple times a year, and if you're a case manager in an intensive program, you'll see them dozens and dozens of times a year, and each one of those is an opportunity to support healthier living, support change, to be encouraging. And so that's a huge advantage in some ways in the movement of this supportive role to the behavioral side because we have so many more opportunities and in some ways have a more personal relationship. Other things you have to do is just navigating the medical system, which is forbidding for anybody. I don't care who you are. Navigating the medical system is a challenge, and for our folks, many of whom have problems with executive functioning and planning and memory and persistence, a lot of support is required. And so just to interact and interpret, like it's a foreign language, which it is, and to advocate for your clientele. As you know, probably when you're getting medical care or assisting somebody with medical care, there's advocacy involved. The system does not run smoothly and flawlessly, and if you need something, you often have to advocate. And so getting comfortable can help you do your job better. So again, we talked about what do we do? In order to address these risk factors, we support medical care. And then we also support health behavior change. Supporting health behavior change is an investment in the long term. Some of the other things that happen on the medical side can make a difference rather quickly. Well, strategic medication change can make a difference relatively fast. But health behavior change is a process, as everybody knows, who's ever tried to change their behavior. Really changing behavior that has to do with weight, with what you eat. It's really hard, especially if it's in opposition to what your body wants to do and what your caveman evolved body wants to do is pack on the weight for a rainy day. And so you're really, you're really pedaling upstream. And yet these are the bodies we have. When you're encouraging somebody to make change, it's best to start slow. It's best to just do something together where you can, like I say here, get an early win. You want it when you're trying to encourage people to adopt new behavior. But you want to do something that's the smallest, meaningful change. Because you're just really practicing changing more than you are changing this person's whole medical situation. You want to practice the activity of changing first. And so you do a little simplest possible behavior change. So you don't say, let's go run a marathon. You say, let's maybe stand up from the couch and walk up to the porch. And that's our goal. Maybe we can make it out to the sidewalk. You get an early win. This is what getting that early win and getting that positive, affective experience is the thing that builds the likelihood that the person is going to actually repeat this behavior. And with the anticipation that there will be another pleasant experience. So getting an early win, doing the simplest possible thing, and then making healthy behavior easy. This is what is called a nudge. And the idea is you try and make doing the right thing, the default thing, the thing that's in your way. So you put the pills next to you. If you know you're going to brush your teeth, if they're that far along, you put the pills by the toothbrush. If you know you want to get up and go for a walk in the morning, you put the shoes by the bedside so you don't have to go find them. But you put healthy behavior in the way. And that's how it goes. So you need to be really patient with three steps forward and two steps back, because that's how it is for all of us. And this is how it will go. And three steps forward and two steps back is still a step forward. So even without being an expert in health behavior change, you can do the simple thing, make changes as effortless as possible, and think of what you can do to practice changing so that you get early wins. Now, of course, this leverages your relationship with patients, which we already talked about twice. And so you want to preserve that. You want to use it, but not use it too hard. Here's an example of this. This is the brain and the heart. They're friends. And the brain is very worried about the heart. They want the heart to be healthy. He's always giving him advice that he doesn't really want. And he says, you know, there's new research in the heart disease, it says. And the heart says, let me stop you there. You're making me choose between you and pizza. It's going to be pizza. So, at some point, you may be talking about pizza, but you don't want to make the patient choose between you and pizza. You want to be a little more subtle than that. Sometimes you'll judge this incorrectly. You're not always going to be right. If you never ask them, if you never talk to them about pizza, you never get anywhere. And sometimes you do too much. And then somebody might get upset. You do better next time. You have lots of chances. You don't beat yourself up if you don't do it right every time. If you don't try and move forward, if you don't nudge a little bit, you never get anywhere. All right. So, I am a huge fan of what we call job aids or pocket tools. And I have sent out with the materials, this particular pocket tool, which is one that we developed to support a client's interaction with primary care. On one side, there's a checklist of things that you can do for calling primary care. And the other side, there's a checklist for a visit. And the idea about this is that dealing with primary care is its own skill. They have their own language, and they have their own expectations about what will happen when you call and interact with them. And so, the better prepared you are, the better. So, the idea here is that these are used to get yourself organized and make sure you're all prepared for all the things that are going to happen for a call. As you know, when you call, it all goes fast. And you don't have the ID number, and you don't have the schedule time, and you don't have the relevant information, and the whole thing just goes to hell. So, you don't want that to happen. You want to be prepared. You want to be skillful. And you want to help your client develop the skill of interacting effectively with their primary care client. So, this is what it looks like. So, this one, this is the easy one. This is just skills for calling primary care. And there's a list of things you do before the call. You get yourself organized, what you're going to talk about. You've got relevant information. You've got the ID numbers. You've got the insurance card. You've got the case numbers. You've got prescriptions. You've got something to write on. And there's some instructions and some suggestions for what you do when you're calling. Always talk to the staff by name. If you can, you cultivate a relationship with a person at a primary care organization. So, they're your person. They're your guy. They're the one you go to when you're there. And you try and give the reason for the call briefly, pithily, in two sentences or less. And then you write down what you did. So, it all sounds perfectly straightforward, and it is perfectly straightforward. But just go and try and remember it all under the pressure of everything else you have to do. It's nice to have reminders. And this grows out of the whole interest in checklists that was written about in Atul Gawande's book, The Checklist Manifesto. And this is a way, these simple checklists are ways of making sure you do the important things. And these have been shown, for example, to make a huge difference when used by surgical teams, So, you operate on the correct leg, or you make sure you prep the right number of sponges. Things that seem obvious, of course, you don't want to do that. But having a checklist, it turns out, makes a big difference. This is the other side. This is supporting an office visit. So, going is more complicated than calling. So, there's more checks. So, there's things you do before, you know, making sure they can get there. Making sure they have a way of getting to the appointment. Making sure they're bringing everything they need to bring. There might be a surprising amount of information or stuff or papers that they need to come along. And then there's certain kinds of things that need to happen during the appointment for you to help in the process along. So, we're going to talk, we're going to look at that. So, we're going to talk about a client. The client's name is Jeff, modeled on a real person. And we're going to use, I'm going to show you how to use the pocket tool to help and support Jeff during his visit to his PC. Okay, so Jeff is a longtime client of ours. He's been working with us since he was a teenager. He has a diagnosis of schizoaffective disorder, with which he's done well. He's, from a psychiatric point of view, he's done spontaneously. He's had not been in the hospital for well over 10 years. He lives in a supportive apartment on his own. He has some cognitive limitations, but it's a generally cooperative guy who wants to wants to do well. In terms of his medical situations, he has problems, he's very happy, his BMI is way over 35, which is high. High is over 26. He has pre diabetes, which means he doesn't quite meet the criteria for elevated blood sugar that would get him a diagnosis of diabetes, but he's headed that way. And he has high blood pressure. He has elevated lipids. He takes clozapine, which is a special, a typical antipsychotic medication which is super effective and really saved his life. But it's associated with tremendous amount of weight gain. It's a real, it's a real double bind. And he is a, he is a man who lives almost entirely on frozen pizza. And he has had many case managers through the years endeavor to help him branch out in his dietary choices a little bit with limited success. He is receptive to intervention, he wants to be pleasant. He gets, and one of the problems with working with Jeff is he gets rattled if he thinks you're in trouble. He gets flustered if he gets asked questions. So you have to keep this in mind when you're counseling him, when you're advising him and when he's interacting with medical. Okay, so before the office visit with Jeff we look over our thing, handout, job aid, and we think about the things that are before the appointment. We give him a call to remind him. It turns out he doesn't have a transport plan. Good thing to know. Otherwise, this would have been a failure. We help him arrange community transit. He's done this before, but he forgot. We check in with him and discuss how he's doing. He's wondering if he's going to get diabetes. We use our diabetes card to remind ourselves a little bit about the condition and talk with him about it and write down any questions. We actually write down some questions that he may want to discuss further with his doctor. We plan to bring his blood sugar records, his blood pressure records, his medication box. It's a bunch of stuff. And we have his most recent labs that we did at the center, and so we'll bring those. And we make sure that everything that he's wondering about or concerned about is on our list. Anything else before we go? No, let's go. So we get a right there. And at the appointment, we have a different set of checklists, checklist items that have to do with negotiating the environment, communicating effectively. So we, of course, we got him there. But one of the things that happens to Jeff is he goes into the, when he gets there by himself, he goes in and he doesn't want to bother anybody. He's polite to a fault. And so he'll come in the waiting room and sit in the corner and not tell anybody he's there because he doesn't want to bother them. So we kindly remind him to check in. This is the kind of support that we're talking about. You say, can I come, is it okay if I come to the exam room with you? Jeff does want you to. So when you're in there, Jeff explains he's been exercising, which is true. This is one of the things about Jeff, he loves to exercise. So this is one of his blessings. He's trying to cut back on pizza, trying, being the key word. So the primary care provider gives some advice about using the portion control and asks the question if maybe there's one pizza free day possible. Not everything, maybe a baby step, maybe someplace where you get a quick meal. He points out that Jeff's numbers are better. His lab numbers, he's lost a little bit of weight, his blood sugar is a little better. They're not normal, but he's gone in the right direction. Jeff completely, he's in the office, he's completely overwhelmed by the office. He forgot about his questions. So we remind him because we have this on our checklist. At the end, we debrief. We say, Jeff, we did it. We got you there. Things are looking good with your numbers. You're going in the right direction. You've been working at it. Awesome. You write down a summary of what happened because otherwise you're going to forget. I will. And then here's the next step. We rearrange his med box. I neglected to say that we simplified his medications. We identified the potential pizza free day. And we plan the next contact. We write down everything. We share the notes that we made with Jeff so he knows what happens. And we affirm and encourage. It was a long day. Every visit is a long day to the doctor. And then we update, we get back to our team, we update. This is what happened. This is the latest. This is the med change. This is how he's doing. He's doing better. And we update his psychiatric provider about his medication changes. So there's a lot, right? A lot has to happen with a simple office visit. He wasn't even sick and he's doing better. But there's still a lot. So having, in my view, having a structure to help you with. So just reflecting, you know, about, you know, about time when you had a company, maybe it was a client, maybe it was you, maybe it was your mom. What's challenging about it? What are the things that would be most likely to benefit from a plan to approach them? A plan that you might write out ahead of time? And what maybe have you done that's not here that we didn't talk about that was effective or that wasn't effective? So I think now we will go to questions.

Behavioral health staff

Medical care support

Serious mental illness

Evidence-based care

Collaborative care model

Healthy behavior change

Coordination of care