Hello and welcome. I'm Dr. Benjamin Druss, Professor and Rosalind Carter Chair in Mental Health at the Rowland School of Public Health at Emory University and health systems expert for SMI advisor. I'm pleased that you're joining us for today's SMI advisor webinar tele-mentoring and education for treating SMI in rural settings. Next slide. 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. Next slide. Today's webinar has been designated for one AMA PRA category one credit for physicians. Credit for participating in today's webinar will be available until November 25th, 2022. Next slide. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area 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. Next slide. Now I'd like to introduce you to the faculty for today's webinar, Dr. Lori Rainey. Dr. Lori Rainey is a board certified psychiatrist and principal with Health Management Associates in Denver, Colorado. She's considered a leading authority on the collaborative care model and the bi-directional integration of primary care and behavioral health. Her work focuses on service evaluation, gap analysis, and design and training of multidisciplinary teams to implement evidence-based practices to improve the identification and treatment of mental illness in primary care settings, and improve the health status of patients with serious mental illness in behavioral health settings. Dr. Rainey served for 15 years as the medical director of a community mental health center in rural Colorado, where she fostered the development of a full range of evidence-based services, including the development of a telepsychiatry program, working in and deploying psychiatric providers in correction settings, developing an inpatient psychiatry treatment unit, managing the psychiatric medical team, and implementing prescribing best practices, including metabolic monitoring, encouraging medication assisted treatment of substance use disorders, and establishing hospital-based psychiatric consultation. Thank you, Dr. Rainey, for leading today's webinar. I'm really looking forward to it. Thank you, Dr. Druss, and welcome, everybody. It's good to be here from my mesa top in rural Colorado. I have really spent quite a bit of time doing this work. So we're going to advance to the next slide just to let you guys know, no financial, no relationships or conflicts of interest for me associated with this presentation. We want to do several things today. One is to really help people sort of think about what it might look like working in rural settings. If you're thinking about working in rural settings, we're going to do a poll here in just a second to see where the audience is currently working. We're going to think about technology solutions for getting education if you are out in rural settings, some things that were available to me when I started and some things that were not because of the technology limitations back then. And then just I want to talk about some of the challenges I faced when I in working in rural areas and solutions I found because I have spent my 30 year career living in rural areas just throughout my career. And it's been a lot of fun. I want to be able to talk a little bit with you guys about that. So that's what we hope to accomplish today. Now, how do we get to the poll? We get to open up the poll real quick. Do I need to click that one myself? I think the poll is open. The poll is I can't see it. OK, the poll is open. OK. Is that the first screen? The first question has been answered and the second one is up now asking, are you current are you considering working in a rural area? OK, thank you. Just to get a sense of what where you guys are located. What do we have? Maggie, I can't see the poll screen, so whenever if you can just tell me what you got. 80 percent of people are considering working in a rural area, 20 percent are not. And I'll look at the other one. OK. And it looked like 43 percent are actually currently working in a rural area and 57 percent are not. OK, great. Well, it's really nice to hear that we have a number of people on the call today that are that are thinking about working in a rural area. So that's great. So I'm going to talk to you a little bit about that experience and and see if we can work with you and convince you or get you at least the juices flowing about what it might be like to work in a in a rural area. So here's sort of my professional timeline. Finishing medical school, going to do my adult psychiatry residency up in Maryland at Shepherd Pratt. And then as you know, in my program, several people had gone to the Indian Health Service and had called back to our training program and said, hey, you guys have to come out West. It's beautiful out here. The Navajo Nation is an amazing place to work. The Indian Health Services has a number of benefits, loan repayment and some other things. But just kind of this cool idea of doing, you know, working a public service, working for the government. So the first thing I did was pack up my bags and drive from Baltimore all the way out to Cayenta, Arizona. For any of you that have been to Monument Valley, it's just south of there. If you've been to the Grand Canyon, it's a little bit east of there. But really went out to this reservation that's the size of West Virginia and took up residence as the psychiatrist in that clinic. The only psychiatrist in that particular clinic, it was a very small outpatient center. My second job, as Dr. Druss mentioned before, I was medical director of a community mental health center in rural Colorado, down here close to Durango, Colorado or Mesa Verde for any of you who have been out here. And then after sort of spending a lot of the time doing this work in public sectors, I have been doing some consulting around integrated care. I still work out on the reservation, seeing patients and sort of doing more dabbling in different things, but never moved away. Still sitting on my mesa top in rural Colorado, doing this work. So I've got a number of different things I'm doing now. But the bulk of my career is really working in the public sector. And it was really nice, you know, working in a community mental health center. A couple things happen when you go to rural areas. Number one is you're pretty quickly can be put in charge of things. So with the Indian Health Service, I was the director of the Counseling Services Department right after leaving my residency. And I took the job as medical director of the community mental health center. And for those of you out in rural areas, you may find you may have found that it's actually sometimes difficult to find or get psychiatrists to be medical directors. So kind of stepped right into that role. So oftentimes, in rural areas, you will very quickly be the person that's in charge of the program. So this is kind of what my my timeline has looked like professionally. Now we all know about workforce shortages. And again, just to highlight for those of you that are working in rural areas, I'd really be curious where you are. You can kind of see how the bulk of this is out west. I'm in Colorado. You can see the corners and edges and just really where we are hurting for for psychiatrists and really trying to encourage in a number of different ways, ways to get folks out into these areas. 96% of counties had some unmet need for mental health prescribers like psychiatrists and psychiatric nurse practitioners. And then 77% is actually severe. And you can see the ones that are just dark. There's a swath across the western part of the United States. There are little pockets in Georgia and South Carolina, Tennessee, you can see the other pockets that are out there. But really, the issue we're facing is in the West. And of course, in Alaska, and I've done some work for the Indian Health Service, you know, thinking about clinics and how to really think about psychiatric care in primary care, trying to really address some of the issues around a shortage of prescribers. I don't like the word prescriber, but you guys know what I mean, those of us who can prescribe psychotropic medications. So where do I live? I practice here currently in the southwest corner of Colorado. I work, I'm a staff psychiatrist with the Mountain Ute Nation. I work for the Indian Health Service, and their office is actually located in Albuquerque. So I'm right here in this little corner. And Durango is like right here, for those of you who've been out this way. When I moved out here, though, I was in Arizona, the Navajo Reservation takes up the upper right hand corner of the state. And like I said, it's the size of West Virginia. And these are kind of the vast landscapes, if you look to the right, of where I live. I live in this kind of rugged west, rural and frontier. And if I remember correctly, the definition of frontier is less than 15 people per square mile. So rural and frontier area, definitely a way out there. The picture to the bottom right is the photo from my, from my kitchen window, when there's snow on the mountains. So I have lived in this area for quite a while, and love it. It's beautiful. So what are those challenges of remote practice look like? And again, for those of you who've been to Monument Valley, you may recognize one of these, this monument in particular was right, real, literally right above where I live. And you can see the, you can see some of the, one of the homes out on the Navajo Reservation. But this is the landscape that I started in. So what happens in remote practice? Well, most of us are concerned about a community of psychiatric colleagues. How do we, you know, what are we supposed to do? I'm the only psychiatrist in the Kayenta service unit. There's one more psychiatrist an hour down the road, another one, three hours across the reservation. You know, how do you really think about a community of psychiatric colleagues? What do you do? And so, you know, for me personally, it's just really, it was outreach and, you know, looking for who is out there and how do we figure out how to get together in the good old days of driving and calling on the phone. So that was always fun. I joined the American Association of Community Psychiatrists, and I'm hoping that many of you, if you're a psychiatrist on the phone, are part of that organization, because that was a bit of a lifeline for me when I, when I've been out. And really trying to think about, you know, my membership with the American Psychiatric Association, going to meetings, you know, really thinking about how I could connect with other people. So that community of psychiatric colleagues was really important to me. We're going to talk a little bit in a minute about kind of the tele-mentoring that can go on around Project ECHO and how that can also potentially, in some situations, be a nice community of colleagues. They're very, they're limited C&E options. You're not going to anyone's Grand Rounds when you live out in the, in rural areas like this. But I've sort of been a lifelong subscriber to one of the, you know, back in the old days, it was cassettes and then CDs. And now it's podcasts or downloading MP3s. So I've just, that was just something to do. And when I was in the car driving long distances, it was perfect. You can get your C&E done while you're in the car. But I just love, I started with cassette tapes back in the old days when you had tape players in your car. And I would go to, of course, APA meetings, especially the Institute of Psychiatric Services, which has a new name now that I can't quite remember. But that was more clinically oriented, rural oriented, and was very helpful to me. One of the things we're going to talk a little bit about today is limited treatment options, because you don't have, necessarily have the wide range of resources for the SMI population that you might have in a more urban area. You're not going to have a, you're not going to have an ACT team. You're not going to have a first episode psychosis clinic. You're probably not going to have any sort of a day or partial treatment program. And the nearest psychiatric hospital is going to be far, far, far away. Mine was five hours away in Flagstaff or go down south. And it was like an eight or 10 hour drive. So there were, there were issues. And there were issues for, there were issues around tribal sovereignty that is part of, tribes are sovereign nations, and there were issues around even things like being able to commit patients who were in dire need of inpatient treatment. So just a lot of different things. Now, I did a few things like started kind of a mini day treatment center. I started a, set up a nonprofit, started a little teen center to kind of give the adolescents some positive things to do with some education and things that we made available in that teen center. It was really interesting when I first got there, I had a patient who was on a long acting antipsychotic. I was surprised. But the psychiatrists that had been there before me really realized that, you know, with these, with these long distances, these rural settings, we really needed to be thinking long time ago about long acting antipsychotics and how to keep people well when it's actually quite hard to get to the clinic. And I actually used to drive my house, drive my car out to a patient's house to give him injection every two weeks back in the good old days. So I've really advocated for long acting antipsychotics within the Indian Health Service and did a presentation to their pharmacy and therapeutics branch and said, hey guys, you know, we really need to think about expanding, especially when the newer meds came out, really expanding and being able to use long acting medications out here. It's really difficult. I have never prescribed Clozarel on the reservation or in, you know, in that setting. It was just very difficult around REMS. I was able to do that, of course, when in the mental health center, in the community mental health center in town where we had local pharmacies. But there's just some, you know, issues you're going to find that when you're out in rural areas that you're going to have some limited treatment options. I mentioned, you know, no first episode psychosis program. It's really hard to do to do MAT. I taught myself how to do that, which was fine. You can do a lot of stuff now with Project ECHO and remote learning, which was helpful. And there are other challenges out there, you know, dating options, schools for your kids and lack of anonymity. You go into the local grocery store, there's only one and you're going to know quite a few people that are in there. And if that's a concern or issue or you want more privacy in a community, it's a little less of that. When you work in a rural area. So these are just some of the challenges and things I wanted to, you know, just in terms of sharing my own experience and some of the things that I did to sort of address what's going on. For treating the population with with SMI was quite fascinating. I did get to do home visits. You always had to be careful if it rained, you could get stuck in the mud. I had a four wheel drive to get out to some of the Hogan's, which were the traditional homes. We also did this. We also have done this out in the community mental health center work, being able to go out. Patients that have missed long acting antipsychotic, they've missed their injections or for other reasons. Going out and doing home visits is kind of cool. It's one of the things I've been able to do in a rural setting. Your support staff might be a little different. When I was on the reservation, I had traditional healers, public health nurses. They actually had a Indian Health Service as a whole team. That's automatically part of every clinic. Every clinic has dental, mental health, optometry, and primary care. So that's like the core every single clinic has. So all of a sudden, you've got this sort of different looking team. We had to coordinate care with traditional healers when I was on the reservation. There's innovation in the public sector around pharmacy run clinics and PharmDs and others being able to actually run long acting antipsychotic clinics, those sorts of things. A lot of easy coordination with primary care and really thinking about using telepsychiatry as much as you can to get across these, not have to have all this windshield time. It's an hour between the clinics, all the different clinics. It was an hour over and an hour back. So having two hours of people in cars instead of seeing patients, we were able to sort of address that a little bit and increase our slots for the SMI population by not having so much time spent in the car. Our COVID adaptations were tricky because out here, people may have a smartphone, but they're going to use it for texting and use their minutes for phone calls. They don't have bandwidth. They don't have data. And so the experience that I've had here all the way through COVID was a lot of audio only in rural areas. And I have to say, the population that it's very, very difficult to do audio only telehealth is, it was really with my group of patients with schizophrenia and schizoaffective disorder. And so, you know, for me, I ended up with my, I had my case manager actually have the patients come to the back door of my clinic. And then I would one by one kind of see them with masks and temperature checks at the back door of the clinic. I found it quite difficult to do some of the audio only. And I couldn't do video because of the, again, limitations with bandwidth and even having phones. So that was kind of interesting what we ended up having to do there. And as I mentioned before, I was really asking for formulary revisions to get long-acting antipsychotics on the formulary, something besides just haloperidol and perfentazine. I really wanted to get paliperidone and aripiprazole, you know, get other medications on the pharmacy and just did some advocating. So one of the things I would say when you're working out in rural areas is to see, you know, what those barriers might potentially be and how might you advocate? So we ended up getting two long-acting antipsychotics on the National Indian Health Service formulary through the work that I was doing and advocating for and just, you know, really kind of pushing around how to get best treatment out for the SMI population in a rural area. As I mentioned before, you have to be a little creative about the support staff. I actually have now a case manager who came over from the tribe to the Indian Health Service. And then how do you think about peers and others in a rural community that can potentially be part of the service that you're delivering? The therapist in the office is the receptionist at the front desk. All of a sudden, there are all sorts of people that are helping you address, you know, housing and other issues that are going on with the SMI population. And again, you know, first episodes, psychosis programs, things like that, being able to give clozapril. Some of those things are going to be a little bit, they're going to be tricky. They're going to be a little hard to do. You're not going to necessarily have an ACT team because you don't have enough patients to have on an ACT team or the staff to do that. So it's an interesting population to treat. I've really liked being in the Indian Health Service clinic because primary care is right down the hall from my office. And so we have a coordinated effort every year to everyone with SMI gets a physical exam. We're going through that right now. Make sure everyone has their annual labs. Most of my patients are on long-acting antipsychotics who have a serious mental illness. And so being able to really do that coordination with primary care has been really fabulous. Sometimes in rural areas, you may find yourself in a federally qualified health center. That's where we want them. That's where HRSA puts them. And so to be able to work in primary care and work with this population, with primary care providers sitting right there, can be just incredibly rewarding in terms of addressing the physical health, cardiovascular disease, those things that we're concerned about. And I even had a patient who got really stable on their long-acting antipsychotic and he was fine. He just wanted to come to the primary care clinic and have the nurse give him a shot once a month. He was fine with that. What was killing him was his hypertension. So he was able to actually work with primary care providers a little bit more on that. With the exception of in more rural areas, really thinking about Clozarel, we were able to work around and do as many of the things as we could with the resources that we have. So you do have to get creative and really think who's your larger workforce. Now, one of the problems we have with long-acting antipsychotics is psychiatrists, psychiatric providers, sometimes reluctance to use them. And we were talking about these formulary changes that we wanted to make within the Indian Health Service, really. What are all those reasons why we as psychiatrists don't use them? And I will tell you, if you're going to go work in a rural area, I would get quite familiar with how to use them, how to pitch or talk to your patients about long-acting antipsychotics. You're going to, you know, one of my, I guess one of my things that I really try to hammer home for people is the underutilization of these and how, when you go out to a rural area, make sure you're familiar, be ready to use them. The families, the patients, the things that, the traveling and things they don't have to do, the remembering. If you forget, the pharmacy can be an hour away. If you need a refill, just a simple refill of your, if you were on orals, can be a long drive for the families, a lot of gas, a lot of gas money. And so we just really kind of thinking about, you know, putting this on your list of things to know how to do. If you're a nurse, you know, how do we think about these medications? If you're a psychiatrist, you need to really be thinking about this because in rural areas, it's important everywhere, but in rural areas, the long-acting antipsychotics are even more important in my mind. And there's a really nice article by John Kane and his colleagues about just the underutilization. And I know SMI advisor has been very focused, thank goodness, on trying to help folks increase the use of long-acting antipsychotics. So there are resources out there for you. When we, when I made the recommendations to the Indian Health Service, I, you know, 4% of tribal members were, had a, you know, needed this kind of medication and really, what's the standard of care? You want to think about what's the standard of care in the country? And what's the standard of care in my community? Now, you know, malpractice stuff is really what's the standard of care in your community. But to really think, you know, in a larger sort of way, you know, what needs to, what needs to be on your formulary? What needs to be available? And so just, you know, this is what's so fun about working in rural areas is you have a lot of autonomy. You can, you know, think of a good idea and run with it. There's a lot of room to do that in rural areas that you won't find in more urban metropolitan areas where everything's sliced out. You know, you're an addiction psychiatrist. You're a community psychiatrist. You're a child psychiatrist. You're a CL psychiatrist. You know, whatever that, you're a forensic psychiatrist. When you work in rural areas, yes, you're all the above. And that's really where I've ended up in my career, which has been lovely. But to really be able to be, you know, innovative or to come to an organization or come to a community and bring in a service that is really standard of care was quite exciting for me to be able to do this. And it was fun presenting to pharmacy and therapeutics committee. Now, I want to switch over and talk a little bit about technology and sort of how it is affecting how we think about in rural areas in particular, but also across behavioral health. What are all those things? And believe me, you know, COVID gave us all quite the jump start. But what we're kind of thinking about, I'm going to take these ideas out, you know, to our rural areas, is remember that workforce shortage slide that I showed before. What I like to say about this slide is, you know, for a virtual visit, for telepsychiatry, what are all those things we can do before we actually directly see a patient? What are all those other, you know, things that could happen along the trajectory? And how does technology use to provide these services? Because if you've, you know, you really need some help if you're out in a rural area and you're, you know, you've got a panel of patients. It's tough to get anyone in, you know, whatever that tends to look like because of the limited number of psychiatrists there. You really want to, you want to lean as much as you can on primary care and to think about, again, how do you coordinate with them? So when I think about the spectrum of really, how do we use technology for behavioral health? I really kind of look at it this way, that from on the left, what are patients using? And we're starting to see a lot of apps for, you know, SMI populations around diet and exercise and pill reminders, medication reminders, those sorts of things. What are those things that are patient-facing? And again, we have issues here with, you know, rural areas. Who has a cell phone and who doesn't? What is it? I think 80 percent of the population has a smartphone or maybe even more, and a lot of people with SMI have one too. So what we just think about, what are those potential patient-facing technology? And then when I sort of think about, you know, building the primary care's capacity, so I was always in the clinic, I was expected to come to morning rounds. We had morning rounds. It was me and the family medicine docs, internal medicine, the pediatricians. We all sat, and what we did was review cases from the emergency room the night before, anything else that was going on. So just being able to sit there and talk and do a little, they could do a little stump the chump, ask me questions about things that had gone on. Just really to be able to provide that educational piece to the primary care providers was really important, because it might help have the primary care doctor take care of the patient instead of me, because they had that certain level of knowledge around that. So when I think about building their capacity, you know, what are those things? Decision supports, giving them algorithms to potentially help. If I, because I only go out there once a month, so that's the rest of the month. The patient's going to walk in, the PCP's going to go, what do I do now? They're out of risperidone, but what do I do now? They haven't had their shot in two months. Is there a loading dose? How do I restart this? But to give people algorithms, some sort of clinical decision supports, e-consult we're going to talk a little bit more about in a few minutes. Project ECHO we're going to talk about too, which is a way of, you know, getting education about certain things. The collaborative care model of integrated care, there's a new study out now using it for PTSD and bipolar disorder. So it's showing some utility in treating some serious mental illnesses. We're excited about this. It's helping again and assisting our primary care colleagues and doing some of this work with us backing them up. And then tele-psychiatry. So, you know, there's working and going to a remote area and then there's beaming into a remote area. And I really say as much as we can, let's save that direct evaluation for those patients who need it the most, which would of course be our SMI population. So, you know, you as a rural psychiatrist, how do I keep my time freed up so that I can use my time on the patients who need me most? And once a patient's better and they're stable, how can I actually get them back to primary care? So these are the kinds of things that, you know, you need to be thinking about as you're trying to address the shortage and address, you know, the limitations, building up wait lists. These are the kinds of things we don't want to do, especially hospital discharges for SMI patients out in the hinterlands is quite challenging. We want to make sure we have the time freed up to do those things. So technology is absolutely our friend, both for our education and for helping other colleagues like primary care providers do this work. So let's think about kind of, let's think about a couple of these technology-based solutions for education and really tele-mentoring. So Project ECHO, I went down there. The mothership is down in Albuquerque and they, before COVID, had an ECHO immersion course. Now, I think you do it by video. Some of you guys may have done the ECHO immersion course. It's three days of pretty intensive learning and listening, but actually also participating in an ECHO hub. The goal is to, they say, you know, move knowledge, not people, is to get education about how to do things. So for the SMI population, what does that look like? Is it clausereal? Is it long-acting antipsychotics? Is it reducing cardiovascular risk? There's all kinds of different things we can do. And what happens in, it's typically an hour and 15 minute commitment. There's an educational component, 15 to 30 minutes. So you start the tele, they have a very prescribed way of doing an ECHO session, but that 15 to 30 minutes of education, followed by case presentations, followed by, it's just a really interesting, everyone pitching in on what they think a solution might be. So it's not just the people. You have an expert hub of nurses and physicians and psychiatrists and addiction psychiatrists and social workers and all kinds of great people. Primary care, sometimes they're, depending on what your condition is that you're focusing on, really having in that more typically in an urban metropolitan hub, because that's where the experts are, really having the ability to, you know, present these cases and have a group of experts give input on what to do. But also they have you, your colleagues give you input on what to do, which I really like because it begins to really develop a tele-mentoring program. You don't feel so all alone when you're out there and you've got this, you know, this one hour a week, you're doing your tele-ECHO session. So it begins to create a community of learners. And it started in New Mexico when it was, there were all these patients with Hep C and there was really no way to get the education out to, or to get all those patients. You couldn't all go to Albuquerque. There was one GI doc at Albuquerque who was a Hep C expert and he's sitting there. These patients are going to die waiting to see him. And so they come up with this idea of let's move knowledge, not people. Let's train the primary care providers in how to do the Hep C treatment in order to be able to provide that. So now the whole idea of using that for about any diagnosis or treatment. So for instance, the University of Maryland had had kind of a clozapine Project ECHO and you could sign up and be a part of that. So the ECHO hub is somewhere in typically again an urban area, but you're able to beam out to these rural areas, provide education that you need, let you do present cases, and then get that feedback on a particular issue that you have, but then everyone that's listening also gets that feedback. And it's case-based learning, right? It's what we all enjoy as medical folks, but the ability to have your own patient, get advice on what to do, see what happens, apply that to the next patient, and the next patient, and maybe a colleague that you pass in the hall asks you, hey, how do you do this? And you tell them. Okay, so case-based learning. It's really how adults learn. And I'm going to show you just some photos here in a minute of an ECHO hub, so you might get a better sense of it. But then also e-consult, which allows us a connection to specialists via telehealth platform. Actually, I'll give you an example of something where something a little different was done in LA. So here's just a diagram of what's going on with Project ECHO. And again, you can see some of the hubs, and a lot of these hubs are out west where, you know, we're out here really needing that extra education for our staff. And the education can be for physicians, it can be for nurses, it can be for everybody, it can be for the team. It just depends on what the ECHO is. And, you know, even, you know, for like SMI Advisor, like University of Maryland did, really kind of figuring out what is it that folks need, and then where do we beam that out from? Where is the hub? Where is the specialist hub? And then who needs the intervention? So what happened is it used to be more regional, but now you can tap in, and some of you may have already done this, you can tap into, for instance, an MAT ECHO for opioid use disorder. And it was grant-funded in New Mexico, but they offer it up across the country. You just got to get your time zone straight. But they offer it up across the country. So what we've ended up with are some sort of super hubs and smaller, you know, individual hubs for Project ECHO. And you don't have to do the, you know, the straight-up Project ECHO. You can do anything that's ECHO-like. So just, you know, having groups, having folks on Zoom and doing, you know, a little education and then, you know, having people present cases. There are things you can do that aren't strict to their very specific agenda, but I really do like how the group is really able to come together as a community of learners for the time that they're doing it. Usually the ECHO's will last 12 to 16 weeks because they're teaching a topic, like teaching primary care doctors how to treat anxiety, depression in primary care or Hep C, or teaching us or primary care doctors how to treat opioid use disorder in rural areas, or teach us how to prescribe and introduce long-acting antipsychotics to patients. There's all sorts of things. And the sky's been really the limit with Project ECHO and, again, huge expansion of it in the last couple of years. I'm really looking at, again, moving knowledge, not people, getting that education, case-based learning out there. And the primary care providers are like, oh, we can do this. And as psychiatrists out there, if we have a community of psychiatrists that are participating in an ECHO, what you end up with is something that looks like this. And so this is sort of what your screen looks like. So here's the hub. You got, here are all the experts, pre-COVID, no masks, sitting tightly around a table. You've got the primary care doc, the GI doc, the social worker. These are all the people in the hub. And then the clinics around the side, these are those rural primary care clinics. They're beaming in for the session that day. And there can be typically, you know, 10-15 would be the max. And so all these different clinics are, they're pitching cases. They're listening to each other. They're developing, again, this is a real sort of this tele-mentoring program. It's really interesting to watch this happen because really, you don't feel so alone out there. If you were all primary care docs here trying to treat depression and anxiety, and the hub that I was in during the immersion training, they were really, you know, working on some pretty difficult patients. And it was really nice to be in the hub and listen to, their colleagues would sort of give them suggestions first. And then the experts in the hub would give suggestions around, you know, what to do with patients. And I just put on the left, you know, what are some options for SMI? Well, lung action and psychotics, clozapine, cardiovascular risk. You can have a first episode psychosis or coordinated specialty care program. That could be an echo. There's all kinds of things we could do with this with the SMI population, just to sort of, you know, keep in mind technology has really changed the way to do things. When I first got out to my rural area, to the Navajo reservation, we certainly didn't have this sort of technology, tele-psychiatry. If you had a machine, if you had anything even that resembled a polycom, you were lucky. And I didn't for many, many, many years. So it just wasn't an option. But to have all these folks sitting on the screen, the hub, the other clinics, and you've picked a topic. These are typically you pick a topic and you go through 12 to 16 weeks of training to get it right. And it's just really, it's just really cool to be a part of it. It's fun to be part of the hub and it's fun to be out on the spoke also. And what about e-consult? So e-consult is a way, at least if you're out there and you want some help, because I had to sit there and think, okay, who at what university can I call? I barely had a computer to even send emails back in 1993. You know, who do I call? What do I do? Now, there are systems, e-consulting, basically what e-consult is, is an electronic, a platform, where you can communicate back and forth to a specialist. It's asynchronous, meaning I'm going to send the request in and I'm going to, it's going to take a, you know, a day or two or a few hours, whatever it is, for me to get the response back. And the response back can have anything from, here's what I suggest you do, I've attached two articles, and could you give me a little more information because I'm not quite sure and I want to make sure I give you a good consult. So those are the kinds of things that we could do, you know, to be able to have the education or to have the knowledge that we need. If it's something where you're stepping a little bit, you know, out on an edge, which can certainly happen, you know, for me, the stretch for me was beginning to prescribe some of the statins and hypertensive meds for patients. So stepping out on the edge a little bit like that, I always wanted to have a primary care person in my back pocket that I could call. It's really interesting in LA. I don't know if anyone is here from that region, from California, but they actually set up an e-consult platform where a psychiatrist who had a patient in their office, high A1c, high blood pressure, something going on, a cut, a rash, whatever it is, could send an e-consult to a primary care provider. So a psychiatrist or psychiatric nurse practitioner sending an e-consult to a primary care provider because they had a patient in front of them who's got a physical health issue and they need some help. And that's typically our SMI population. So it's really cool what LA did around providing that. It's both, again, it's case-based learning, right? I have a specific question, but when they email me back and say, start lisinopril, five milligrams, wait three days, recheck blood pressure, if still X, double it, 10 milligrams, they start giving me this information. I can apply that to the next patient and the next patient and the next patient. So really thinking about how these technologies can help you, how that can get set up is really helpful. And a lot of things are done in rural areas. Your state Medicaid agency, your state behavioral health agency, they're always looking for ideas and thoughts. So being able to pitch that, I think is just super important. And here's just the thing I was telling you about with LA County. There are activities going on with SMI advisor. How do you work with academic centers? A lot of grants out there right now, especially for Project ECHO. And what's the issue? What's going on with you in your rural area? Who are all your local psychiatrists, your friends, your colleagues, the people that are out there? And then what might you need or want in the way of education that's not necessarily like me and my cassettes driving from Kayenta to Window Rock, which is about a three-hour drive, had my cassettes in the car and could listen to them, but to actually have more of a community of learners and what might that look like so that you don't feel quite so isolated out in a rural area. And that's absolutely what we set up. I wish we had something like SMI advisor back then, but it was just nice to figure out how to do a little bit of that ourselves. And I want to just wrap up here with just thinking about reflecting back on the experience that I have. And it really, as I mentioned before, when you're in a more urban metropolitan area around an academic center, it feels like there's more restrictions on what you can do. Rather than when you're out in a rural area, you're it. And I try to tell, I did this when I first got, of course, the Indian Health Service. I said, I'm not a child psychiatrist. I can't see anyone under the age of 18. And then folks kind of look at you and say, well, you know more than I do, which is absolutely true. So then I lowered it to 16 and then I lowered it to 13. And then I said 10. And now I've out in the rural areas, I've treated kids down to five. So you get to do a lot more. I had a child psychiatrist in my back pocket. I could call if I got concerned. So you just end up being able to stretch and do more than you might do in an urban area where you're going to refer the patient to that specialty. And it really kind of pushes you a little bit. In my adult residency, I had child, I had addiction work. I spent six weeks in forensics. I did CL. I did med-surg. We did all of these things, but we don't sometimes feel comfortable when we leave residency, just really thinking about, gee, I'm not an addiction psychiatrist. And I'll tell you, every psychiatrist treats addictions, whether you're an addiction psychiatrist or not. So when you get out there, there's just a lot more opportunity to be innovative and to push the boundaries a little bit. It was really nice for me to be able to work with the federally qualified health centers. If you're out in a rural area, there are plenty, there are your primary care, your other medical providers are certainly a community of medical folks that are out there. And being able to do that collaboration with primary care was great. It was great to just, I would drive an hour out to this rural clinic on the edge of the border between Colorado and Utah. And it was just such a fun day. They had a little restaurant and the PCPs, there were three of them. They would all show up at 7.30 in the morning for breakfast. And then I'd go over to the clinic and work with the social worker over there. Again, consulting on patients, not necessarily seeing them and doing the case-based learning with the primary care providers. That was really cool. It was really nice. I set up a tele-psychiatry program across five counties. We didn't have it. The technology was coming and we were all sitting there now watching what's happening with TMS and ketamine and all kinds of different things right now, but kind of watching like for me, when the second generation in a psychotics, when we had long acting formulations of them, you know, you see the technology, the evidence-based practice coming, how do I bring that into my rural area? With tele-psychiatry, it became easier, more feasible to do it. Although we still did drag that cart up and down the hall. I remember how heavy that cart was in the old days with our tele-psychiatry equipment. We set up a program to do cardiovascular disease monitoring with some registries and ways to really think. In 2004, the ADA, APA guidelines came out around cardiovascular risk in second generation in psychotics. It's like, okay, we're going to have to figure out how to do this. We had a sheet of paper with columns on it. We'd check off who'd had a fasting blood sugar or oral glucose tolerance test back in the good old days and just think about how to do that. I was able to, they needed a, they wanted a little psychiatric piece in the crisis intervention training for police officers. My mental health center is like, we need to do something here with, you know, when there's police interactions with people with SMI, we need to really think about, you know, how are we going to do this? What does this look like? I got a, I've had an enormous opportunity to be involved in culturally diverse communities. They're going to be out in the rural areas. And, you know, for me in particular with tribal communities, being able to do things, I, you know, how do you, how do you do a 401c? You actually go online, download the forms and do some things, you know, be innovative, be creative, do some things. But, and it has just been, I would not trade my career for anything. It has been very rewarding personally. I still live out here in rural area. And if I need, if I need some time in the city, I can go to the APA meeting in San Francisco next year and have a nice week in San Francisco. So I find what I need when I need it. And for the rest of it, it's just been a very rewarding career for me. So I wanted to just chance to be able to, to share that piece in and, you know, and, and for us to think about how we treat the SMI population in these areas. Again, these are just some tips here at the end. You guys can do it. You guys have the slides you can download. This is actually a group of my colleagues all, you know, during COVID trying to stay connected in the work, form that support network. So there were eight service units. There were eight psychiatrists. We were spread across a huge rural area. We would get together in the middle once every couple of months, we just, we formed our own support group. You got to go looking for who's close by, where are these other psychiatrists going to conferences? You know, there's your state for your state district branch of the APA. For me, everyone's in Denver and Colorado Springs. If I ever want to go to a meeting, it's a very long drive. None of the meetings are held anywhere in our area. So you got to kind of think about what that looks like. It's worth the drive to Denver or a flight to Denver to go to some of those meetings, find ECHO and other training opportunities. SMI advisor, of course, is a incredible resource with you. Get to know your primary care providers, go to grand rounds. They love it. If you give a talk on updates and depression or anxiety treatment, be a generalist. Like I said before, you're the only one out there. I see inmates. I'll see inmates when I go to the clinic next Friday. I do forensics. I was the jail doc for 15 years with the community mental health center. Did I have forensics training? I had six weeks in my adult psychiatry residency. I'm doing fine out there doing it. And that's where the SMI population often ends up, as we all know now here in the rural areas, it's no different. You can do enormous, just amazing work. CL work with your hospital. They love it. I've been on staff at two local regional hospitals forever. They hardly ever call me, but I'm, you know, courtesy staff if they need me. You know, just how do you think about tiny inpatient units? Pediatrics, you got to learn how to do it in a rural area. Just getting to see a child psychiatrist is going to be tough. And so just again, training, we could do, there used to be a child psychiatry for adult psychiatrist training that they would do at the NAPA meetings. Go, take the course, see what it's like. Addictions, I think we already do. I got my X waiver so that I could be able to offer another step if needed. Just really evaluate all the resources. What do you have for us in my treatment? Have a sense of it before you go. And if you're a resident, I spent the last six months of my residency on an ACT team in a day hospital. I did an administrative psychiatry one month with the CEO of our hospital. I tailored that last year. Once I realized, I think I knew in December that I was going to a rural area, I spent the rest of my residency really picking electives that got me prepared to do this. Okay. Got a big bibliography at the end. And that concludes the presentation. Dr. Druss, I don't know if we have some questions or we can just open it up to questions for folks, especially people that might have questions that are considering working in a rural area. And because it's unique, those of you who are already out there in rural areas, what have you found? What keeps you connected? What have you found that makes the reward work either rewarding or challenging? It could be either. We'll take either comments. Yeah. Thank you so much, Lori. That was really just wonderful presentation. Very inspiring. It makes me want to move to a rural area to do this kind of work. It's just really fascinating. Yeah. As Dr. Rainey said, if you do have questions, there's a question area in the lower portion of your control panel. Feel free to put those in. I do want to, before we shift into Q&A, just want to take a moment, I'll let you know that SMI Advisor is accessible from your mobile device. There's an SMI Advisor app that you can use to access resources, education, and upcoming events, complete mental health rating scales. You can submit questions directly through the app to our team of SMI experts, and you can download that at smiadvisor.org forward slash app. I have a whole bunch of questions. I don't. Just inspired by your talk. First, regarding Project ECHO, it sounds like this is more of an arms-length relationship than something like collaborative care. Does billing or supervision, are there any issues with that, or is it really just a purely educational program? If so, how does that get paid for, Laurie? Project ECHO has been tremendously grant funded. The federal government put a ton of money into it over the last couple of years, and even more with the opioid epidemic and other issues that have been going on. There are no CPT codes. There's no billing. So, you will see places like in Massachusetts, you will see places where the legislation has decided we're going to put $5 million into Project ECHO for X. So, you'll see whatever that is. We're also beginning to see payers, Medicaid, putting some money into it. The real cost for Project ECHO is paying the people in the hub. Those tend not to be just folks who can volunteer and volunteer for 16 weeks, 16, 20 hours of their time. So, that's really the payment, is really paying the folks that are in the hub. So, they can't bill for that service. So, it has to be grant funded, state Medicaid funded, payer funded, or what we're seeing is legislation, especially in New Mexico that's passed, that keeps Project ECHO funded for either particular diagnosis, or they get to rotate through different diagnoses. So, it's not something that we can do with CPT codes. You do have to find another funding source, but it's nice to see payers jumping in, like Medicaid, and knowing it's going to help provide better care to Medicaid beneficiaries. Great. Yeah, thanks. And then similarly for e-consults. Now, e-consult sounds like it's a more traditional kind of service where you've got, where you're actually, there are, there is kind of a relationship, a clinical relationship, or is there? I guess if you have a, if there's an e-consult that's provided, I assume that the consultant is in some way either within the system or affiliated with the system. What are kind of the, both the billing and medical legal issues around doing e-consults? Yeah, so e-consult can be within your system. Dartmouth has a really nice e-consult system. All the primary care providers can e-consult back and forth with the psychiatrist, or the tech companies are getting into it, right? So Rubicon and Arista and I can't, there's several of them. Maybe it's Safety Net. They're all out there and they are providing the service. You can be a psychiatrist or primary care clinic and you just, you just license the service. So there's a couple different ways to do it. There are billing codes now. If you're, you know, asking about a specific question, there are billing codes that both the psychiatrist, who's providing a particular, the answer out to, you know, to the primary care provider, as well as a billing code that primary care provider can use because they requested the consult. So we do, you know, we do see the pieces around that that are, because that's specifically about a patient versus Project ECHO, where you're using one patient example for everyone to learn from, you know, versus one-on-one, this is just one. I think it's much better if you have a relationship with the, with the specialist you're consulting with then, but it doesn't always happen. Sometimes it is just someone who's out there and it's their rotation that day to do the e-consults for that organization. Like with Dartmouth, the psychiatrists kind of rotate who's going to be on that day and take the e-consults from the primary care providers. Great. Also kind of shifting a bit to the earlier part of your talk, you had mentioned, you know, that it's just really hard to have formal, you know, we think of evidence-based practices, things like assertive community treatment. How do you think about that? How do you think about kind of pick, at least picking, taking pieces of that sort of cobbling together something that looks like evidence-based psychosocial practices in rural settings? How can providers think about those when you're not able to do the full-on model? Well, the good news is you tend to have smaller numbers. So in the clinic that I work in, we have seven patients with schizophrenia, schizoaffective disorder. One of them's female and the other six are young men. They're actually mostly young men. I got, I only have seven. So if I've got seven, we can start thinking about can these seven, who wants to go fishing with the tribal case manager, who's my, if it wasn't for Patty, I'd be in all kinds of trouble because she's just fabulous. So I got a case manager and she's out there and she's taking them to the grocery store and the thrift store to buy clothes and going by to check their apartment before, you know, the HUD folks come and inspect it, so make sure they don't lose it. So you, you may do, and because you often have smaller numbers, like people said, they all know each other. They're going to each other's houses. My guys with schizophrenia, with them not at one house, we just go to the other. So you do have a small, you don't have hundreds of patients with schizophrenia. I have seven in this really small community and we put together the best psychosocial program we can, Ben, with, with what we have to work with. And between the nurses and my case manager, we make it happen. And it's kind of fun because it's on a small scale and you know everybody and you know what's going on. You know who you're worried about. Yeah. Well, again, thank you so much. That, you know, really, again, just fascinating and inspiring. I think that's all our time for questions. So I do want to let folks know before we wrap up that if there are any other topics that are covered in this webinar that you'd like to discuss with colleagues in the mental health field, you can post a question or comment on SMI Advisor's webinar round table topics discussion board. This is an easy way to network, to share ideas with other clinicians who participate in the webinar. If you have questions about the webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of SMI Advisor's national experts on SMI. The 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 have an SMI. It's completely free and it's confidential. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We 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 through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. The 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. Please join us on September 1st as Dr. Emma Morton presents Using Smartphone Apps to Support Self-Management in Bipolar Disorder Opportunities and Challenges. Again, this free webinar will be September 1st from 3 to 4 p.m. Eastern time Thursday. Thank you again so much for joining us. Until next time, take care.

mental health care

rural areas

tele-mentoring

education programs

Project ECHO

clinicians

tele-psychiatry programs

evidence-based practices

primary care providers

serious mental illness