Hello, and welcome. I'm Dr. John Torres, Director of the Digital Psychiatry Division at Beth Israel Deaconess Medical Center and technology expert for SMI Advisor. I'm very pleased that you're joining us for today's SMI Advisor webinar, the Digital Peer Support Specialist Role in Health and Wellness. Next slide, please. 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 answers you need to care for your patients. Next slide, please. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, and one continuing education credit for social workers. Credit for participating in today's webinar will be available until November 28th of this year. Next slide, please. Slides from the presentation today are available in the handout area found in the lower portion of your control panel. Select the link to simply download the PDF. Next slide, please. 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 about 10 to 15 minutes at the end of the presentation for question and answer. Next slide, please. Now it's my tremendous pleasure to introduce today's faculty for the webinar, Dr. Karen Fortuna. Dr. Fortuna is an assistant professor of psychiatry at Dartmouth College and co-founder of the Collaborative Design for Recovery and Health. Dr. Fortuna has approximately 100 peer-reviewed publications, co-authored with patient partners, and is a frequently sought after speaker at national and international meetings. Overall, she's been responsible for conducting or collaborating on over 30 research projects, including topics such as self-management, patient engagement in digital technologies, user-centered design, community-engaged research, and has literally pioneered a new field of study we'll learn about today, digital peer support. Dr. Fortuna is co-chair of the Patient Engagement National Council, 2P CORE, in which she currently is co-leading a project to update community engagement standards and integrate these into 2P CORE's engagement matrix. Dr. Fortuna is also an invited member to 2P CORE's Patient-Centered Approach Methods Committee, the American Psychiatric Association's Smartphone Act Advisory Panel, the Foundation for Opioid Response Efforts Advisory Panel, the Digital Mental Health Collaborative Community, and several more. Dr. Fortuna was the recipient of the Japanese Agency for Medical Research and Development Research Proposal of the Year, Ally of the Year Award for Western Massachusetts Peer Network, and the Faculty Achievement Award from the National Association for Gerontology Education and Social Work. So very diverse in her honors, but I think it's just terrific to have Dr. Fortuna here to tell us about this, because we really have the leading experts. So welcome, Dr. Fortuna, and take it away. Great, thanks. Thanks so much, and thanks so much for having me here today. Really excited to share the current research on digital peer support. I do have some disclosures regarding some consulting services with social wellness and also emissary health. So for today, we're going to identify the recent global advances in the development and implementation of digital peer support technologies for mental health and substance use challenges. We're going to talk about designing ways to utilize peer support services within individuals' respective organizations. People will be able to list ways they can prepare your organization to implement digital peer support services, and then talk about a way to hire and train peer support specialists to offer these types of support services and also evidence-based practices as well. So let's go back to the origins of peer support, and of which, in the documented literature, peer support started in the 1800s in Paris, in which individuals who were patients within a hospital setting, they were discharged, and then they were encouraged to come back and support other individuals. And in this, the administrators, they saw the current patients improving their mental health. And so here is the first documentation of peer support. And then we see throughout history, globally, about these individuals who have a lived experience offering their expertise to other individuals and supporting them through psychiatric and substance use challenges. So today, peer support has expanded to multiple psychiatric settings, inpatient, outpatient, peer-run centers that are in the actual community, primary care settings. We're seeing a lot of integration of peer support specialists in emergency rooms, community settings, and of course, virtual settings. There is a new area of focus around aging services for individuals with mental health or substance use challenges, integrating these services across from aging and mental health and then emergency rooms. And then we see them also in the Veterans Administration as well. So here, peer support specialists are individuals who are trained and accredited to provide support services to individuals that are experiencing mental health or physical health challenges. These individuals have their own lived experience as well, and they can offer services individually, one-on-one base, and or they offer services in augmentative to clinical providers like psychologists, medical doctors, nurses, social workers. So within peer support, in 2020, around COVID-19, there was a huge uptick in the integration of peer support specialists using technology to deliver their support services all the way from a smartphone app to video games. And so when we conducted this research, this was before the COVID-19 pandemic, and we proposed the idea of offering, having a peer support specialist who's an individual with a lived experience to use technology to offer their support services. And when we first proposed this project to our colleagues, the question was one, well, what is a certified peer support specialist? And there was a question around, do they even own technology? And from this cross-sectional study, there was an online survey around smartphone ownership and use. We found that out of 146 individuals, 95% of peer support specialists did own a smartphone. These are personal ownership of a smartphone and or their employers also offer them a smartphone as well. What's interesting about this is that we see a very large age range of smartphone ownership all the way from 28 to 72 years old, majority of which they were willing to use smartphones to support health behavior change in other service users or patients. And they're also very willing to use text messages to support this behavior change as well. So digital peer support has been defined in the scientific literature as live or automated peer support services delivered through technology media. And so within this, it's a little bit different than digital psychiatry in that peer support specialists use any type of technology. It can be a video game. It could be virtual reality. It could be smartphone. It could be texting. It could be apps. It could be so many different things. And in specific States, they're able to bill for video game based peer support or text message based peer support as well. And other things like virtual reality too. So here is a QR code of the digital peer support competencies, which is what was developed with 46 peer support specialists from all over the world about, well, what does a peer support specialist need to know about digital mental health to be offering these types of services? And so here, individuals identified the core competencies that were important to these individuals, understanding things like privacy and confidentiality, informed consent, offering choice in the selection of technologies. What's really interesting is that within this group of peer support specialists, they don't have a whole history of using technology or a whole informal or informal training around this, like psychiatrists may have or social workers or nurses. And so this really began during the COVID-19 pandemic. And so here's another national survey, what this looks like in the United States. And here, a peer support specialist, about 23% of individuals are using smartphone applications. And we asked them, well, what kind of apps are you using to support an individual's recovery in between clinical sessions? And a lot of individuals indicated commercially available apps, things like Calm came up quite a bit as something that individuals were using. We also saw 42% of individuals were using text messaging to offer peer support services to individuals. There's some early research that suggests text messages between peer support specialists and service users or patients that actually can increase a dose of an intervention without actual additional in-person sessions. And so it's an exciting feature of meeting people in the community when they need additional support services without scheduling an appointment with individuals. And within peer support, 62% are using phone calls. There was a recent article that was published, I believe in JAMA Psychiatry, around individuals who have a low socioeconomic status prefer using telephone calls rather than video conferencing services. And so we do see a lot of people, 62%, really engaging in these telephone calls to connect with one another. We have a new study that will be coming out soon as well. And we have found that people with a diagnosis of a serious mental illness is that the majority of them own cell phones and not smartphones. And so using telephone calls as a way to deliver peer support is very promising for this population. And then we see, of course, video conferencing. And then we see some more emerging areas around individuals using video games to offer these support services. And so what happens here is that a peer-run center or an organization will schedule a time. We'll say at four o'clock on Thursday, we're all going to join this video game together. And they play the game together. And as they're playing the game together, they're offering support services through these headsets, through the games. And so some of these places are able to get reimbursement for this. We also see this within the Veterans Administration as well, all playing video games. A veteran's favorite video game offsets challenges and feelings related to post-traumatic stress disorder. So it's an interesting area, an emerging area of research. And then we see about 4% of individuals offering virtual reality peer support services. So another emerging area, which is interesting, people create avatars and they go into these virtual locations and they offer support services to one another. So what do we know about digital peer support? Well, it's the same as digital psychiatry or digital mental health services. There's no geographical or time limitations. What's really interesting about some of these modalities is that if an individual goes onto YouTube or watches a video on someone's recovery narrative, scientifically, it's been found that doing that actually increases a person's sense of hope and their satisfaction with services. And so that's really exciting, knowing that individuals could access these services outside of a clinical environment to support them in between those sessions through asynchronous technology, such as YouTube. Maybe it's 3 a.m., someone needs some extra support services. Well, people can watch recovery narratives and potentially receive that benefit from it. Also too, consistently over time, it engages service users in digital mental health outside of the clinical environment. One of the most exciting things about certified peer support specialists and offering digital peer support is that they consistently show very high levels of engagement, not only in in-person services, but also in digital services as well. So that's a really exciting feature that is theoretically founded on the model of reciprocal accountability. An individual with a similar lived experience to another individual, they're holding each other accountable and the technology is connecting them and connecting that human connection with this. Also expands the reach of peer support services, which we know can support clinical outcomes in between sessions. Here, this is a bit bittersweet in that peer support specialist, they're able to reach more people using technology like texting or telephone calls because you're taking out the transportation. However, it is leading to some potential digital fatigue among peer support specialists. And so there's some work going on to support that group through challenges of having burnout in the workplace. And then we're seeing some emerging research that's increasing the impact of these support services without in-person sessions. And consistently over time, peer support specialists through the use of technology are able to access these really, really hard to reach groups that are generally a very high cost for the healthcare system. So individuals in rural areas, homebound older adults, and individuals with a diagnosis of a serious mental illness. And so what have we found about digital peer support? And in a systematic review of all the digital peer support interventions, from around the world published in 2020, we found feasibility, acceptability of these digital technologies ranging from telephone calls all the way to virtual reality. And there's preliminary effectiveness relating to enhancing the hope, quality of life, empowerment, social support, and recovery of a service user or patient. Supports individuals in enhancing functioning while they're in the community. Consistently over time, one of the most consistent findings we find with peer support is the reduction in psychiatric symptomatology. We see that also in these digital platforms. And then once again, we see this very high level of engagement in services. And now for substance use challenges and other systematic review of recovery support services for people with substance use challenges. We see through digital technologies, a reduction in risky substance use, very high levels of satisfaction and perceived benefit. And again, consistently engagement in these types of services. So I'm going to talk about a program of research that our team has been doing. I work with peer support specialists all over the globe, from Rwanda to Norway to all throughout the United States. And in that, we develop different technologies regarding challenges that patients or service users identify in their own community. And so one of our focus has been increasing the life expectancy of people with a diagnosis of a serious mental illness. And we partner with peers to develop technologies to help support that process. And so we know people with this diagnosis of a serious mental illness. So that's schizophrenia spectrum disorder, bipolar disorder, and treatment refractory major depressive disorder is that they die up to 32 years earlier than the general population. And it's a medium about 11 years. And it has been identified that this has been due to comorbid medical conditions, earlier onset of disease. And as individuals age, there's changes in metabolism as well, in addition to having poor health behaviors, such as having a poor diet, smoking cigarettes, and not exercising. And so what has been addressed within the scientific community when this problem was brought to our team is that we have found that, well, there's a co-location of services. And so here, since there's a high level of medical comorbidity with a serious mental illness, and we think that's what's causing this high mortality rate among this group, is that we'll integrate services, mental health and physical health in the same environment. And then they'll offset all the challenges of accessing these services. So here, our team, we conducted a systematic review of behavioral health homes, these integrated services on cardiometabolic risk factors that are associated with early mortality in these groups. And so through the examination of this, we did see an uptick in, yes, people are being screened for these cardiometabolic risk factors. So screening has increased through this. Now, however, we did not see a very consistent reduction in cardiometabolic risk factors within all of these different types of health homes. And so from there, we looked at, well, of the health homes that were able to make an impact on these cardiometabolic risk factors related to early mortality, what features did they have that may support, you know, supporting an individual's lifespan? And so here, we found that those programs that integrated self-management and also peer support produced the best outcomes within these co-located services. And so we're like, okay, so let's look at self-management programs that are out there for individuals. And so, cause we know that those are high likelihood of impacting early mortality. And here we collected all of the data and a systematic review around general medical and psychiatric self-management programs. And so these are integrated with one another because we know mental health impacts physical health and vice versa. So we found there was nine different interventions that are out there and showing promising clinical effectiveness on potentially increasing the lifespan of these individuals. And so if we have these effective interventions, what's the disconnect here that are actually, why aren't these being integrated across the United States or even globally, right? So we looked at some implementation barriers and we found that these interventions lasted from one year to two year. They required a person with a diagnosis of a serious mental illness to go into the physical location to receive services for one to two years. And they required a high level of resources like space, training time of highly skilled staff, at least master's level to do that. So there's definitely some implementation limitations here. So we wondered at this point, well, what were some facilitators of this? And we saw programs were offering, again, you hear this again, peer support and technology, and then also with these self-management services. And so we said, well, what if we combine these two and create an app for this? So we looked at the evidence around this and we see over after some of our research was conducted, we see increases in self-efficacy, illness self-management, medical self-management, increases in hope, empowerment, recovery, engagement in services and reduction in psychiatric symptoms. And so in learning about this group, we know that there's a 30,000 certified peer support specialists in the United States. This is a Medicaid reimbursable workforce in 47 different states. And the medium annual wage is about $37,000 a year. So from this, we created an app. And so I'll tell you about one of our digital peer support platforms that we created. And in working with this group, it's a highly vulnerable and marginalized population that may have experienced historical traumas related to a potentially non-trauma informed health system. So we know when we engage with a community, we need, who may be marginalized and has a historical trauma that we need to integrate a very intensive community engagement approach. And so here was the approach that we use, and this is called the peer and academic partnership of community engagement. To begin, there was some knowledge building among the researchers, what is the peer support specialist and how do we define the problem from the peer supporters themselves? And here we learned that, well, we think loneliness and sense of belonging and hope, those are the things that are causing early mortality. And the number one thing that we need to address is early mortality within these groups. And then we worked to build, understand peer support specialist capacity in addition to scientific capacity. So we actually built the first version. We took one of these self-management programs called integrated illness management and recovery that has shown very promising clinical effectiveness among people with certified, or people with diagnosis of a serious mental illness. We adapted that and put it on an app and we proposed it to a group of peer support specialists. And at that point they said to me, what is this? And I was like, well, if I took this program that works and I put it on an app. And they're like, no, no, no. This is not the recovery model of mental health. And so we're kind of consulting with them. And they said, we need to engage even greater so we can make modifications to the text, modifications to where certain things are in the app and encourage self-determination and choice in the actual development of the app. And so here we get to this point of this full partnership where we have a community gatekeeper among this historically marginalized community that allows us in promoting this academic inclusion into the peer support specialist network. We have formal meetings once a week where we sit side by side with people, with patients and peer support specialists and other scientists to develop the technology in all of our research meetings. And everyone has equal decision-making authority. We have training on terminology around research and also on the recovery movement and we promote decision-making. So here there's this reciprocal capacity building for one another and we're co-learning from one another. And this has led to a very long-term collaboration where we have over 100 scientific peer-reviewed manuscripts that are co-produced, publications, websites, a lot of different great things that are out there. So when developing these technologies with a specific group, we did learn about certain human factors that will potentially promote engagement outside of the integration of a peer support specialist. And through a series of usability testing with the technology, we learned that a fourth grade reading level works very well for this population to promote learnability of the new skills on the technology. We also recognize the need for limited compound sentences, people with a diagnosis of a serious mental illness and or peer support specialist may have some potential cognitive impairments. And by limiting the compound sentences in the app also promotes uptake of that knowledge. Here we integrate repetition as well for to promote new knowledge and mastery of skill. Having worked with an older adult population and knowing there's normal age-related changes to memory, here you build in repetition to promote mastery of these skills. And then of course, multimodal, knowing that maybe individuals may be hard of hearing or have eyesight challenges as well, you offer the technology to offer many resources so people can access the information. And then on-demand videos for people to access things outside of an actual session time. Other things, a need to exclude hyperlinks which are challenging for people navigating who may have cognitive impairment, limiting color contrast. And again, this is for older adults with normal age-related changes to eyesight. One interesting thing we found was integrating trauma-informed digital principles, which is new. We haven't really thought about that before. So in the first app we created, this is PeerTech, there was a loud bing when people would receive a message and the bing was so loud and it was so high-pitched it would actually cause a hyperarousal response in individuals who had a history of experiencing of trauma. And so the app was actually creating a biological environment where people could become hypervigilant, right? And we learned this from our community partnerships with folks and so we got rid of that bing and very, very glad to do so because if an app is gonna cause a trauma, people aren't gonna engage with it. Also, there was major modification to the language to focus on the recovery model of mental health while the original developers of Integrated Illness Management Recovery worked with patients as partners in developing some of the technology. It was more around not such an intensive engagement process and so here, a lot of the language had to change so a peer support specialist would feel comfortable using it. We also have active tracking versus passive tracking on the phone and so remember, this group, highly vulnerable, highly marginalized, potential historical trauma. There is a high level of disengagement among this group, especially after two weeks when people download apps and they don't use them anymore. One of the reasons people disengage is a high level of monitoring on the technology and so here, we have, rather than passively collecting data, like in things like digital phenotyping, we actually have more active tracking and so here, people enter their information around loneliness or distress and so it's also, again, a little bittersweet because we don't get all of the data in there. However, we have high levels of engagement because people report that they feel comfortable with the app and they don't feel like they're being monitored. And then, of course, we have some recovery outcomes that we look at and we expanded medical and psychiatric self-management to really focus in on social health as well, things like loneliness. All right, so here's what we developed that is being integrated in many places and we're doing quite a few studies on it as well. So on the left-hand side here, you see a peer support specialist side of the app. They have their own app. And then, on the right-hand side here, you have the patient-facing app and so the peer support specialist side, they are trained in providing evidence-based medical and psychiatric self-management using the app. Here, there is a resource library that they use when they sit side-by-side or even through video conferencing or texting that they can access. And here is all the evidence-based practice delivery with prompts and videos to guide them through the delivery of this program. And they also offer peer support as well. And know that this has all been adapted. So what we did with this, and I'll move us up forward in this single-arm pre-post study that we did. And so here, we recruited individuals, 30 individuals, and also a peer support specialist. And we trained them through a very intensive training process. And so all of them are already certified peer support specialists. And in addition to that, they were offered additional training and using technology and also medical and psychiatric and social health self-management, things like loneliness, because that was identified as really, really important for individuals. And this training actually has expanded globally. We have 3,000 people trained all over the country around some of the digital peer support aspects to this. And so things like digital communication skills, literacy, usage, what technologies are available, organizational policies, and confidentiality issues. And so what's interesting about this is that within this group, learning new knowledge could be potentially challenging in that they don't have a basis of these types of technologies as potentially people who have formal training in this area, people who are getting their master's in social work can take a class on digital technologies. This was never available to peer support specialists until 2020. So they're developing new knowledge. And here, we did an education simulation training, and then we incorporated this audit and feedback. And so this is when we really saw people engaging in the technology, the peer support specialists. And so here, we reviewed what they were doing with the technology, and we gave them feedback in a group setting. And then we saw this huge uptick in using technology. So people had to get out there into the real world to start to use the technology to get used to these types of different things. So for the results for that first, actually, this is the second study that we're presenting on here. We did see improvements on increasing empowerment, hope, and also as a person's ability to manage medical conditions. And then we saw some other statistically significant improvements around managing medical diseases, psychiatric conditions, and also patient-reported outcomes on the SF-36 as well. And so here, we integrated some implementation science research to really identify those barriers and facilitators to using these different technologies. And so we interviewed 20 certified peer support specialists and 20 service users with a diagnosis of a serious mental illness. We integrated a thematic analysis and some a priori codes that were developed from the Consolidated Framework for Implementation Science Research. And here, a member checking was employed. And with this, this is a way to offer some validity to the work through our analysis. And so we brought the information back to some of the certified peer support specialists and service users after we did the actual interview. And here, and they were told us, oh yeah, you got it right, or no, you didn't get it right. So here we found out, you know, some of the barriers were around the complexity of the technology, the cost. Is it compatible within a community mental health center? How are the network and communications? So these were all the barriers. And adaptability was a major one that people were really concerned about. Well, what if someone is hard of hearing or has poor eyesight? Will they be able to have access to this technology? And so they wanted technology that was adaptable. And then they saw some facilitators about access to knowledge and information and their knowledge and belief around technology. And what we hear consistently over time through our research is that, they don't have technology that promotes social isolation. And the thought of having technology that doesn't incorporate a live peer support specialist has been consistently cited as something of concern to this group, because they don't want people to isolate in using certain types of technologies. So here they like the technology, but they prefer face-to-face as well. So this led to the digital peer support certification. We're now a peer support specialist on top of their certified peer support specialist training on recovery and mental health and substance use challenges. Now they're trained in technology literacy. What is natural language processing? What is phenotyping? What are the technologies I can use in practice like virtual reality and is it reimbursable? What are some organizational policies and ethical issues about maybe having a Facebook account and service users accessing and befriending individuals? Then hiring, training and supervising as well. Also from this group, they developed the mobile health ecosystem for equity. And here, this will be published in Psychiatric Services in the near future. And here, there's importance to promote access to these technologies through policies like SafeLink and Assurance Wireless that offer people a free access to certain technologies so they can download apps and use them. Also integration of a participatory human-centered design lifecycle. So taking things like working with end users in developing the technology as partners, not as subjects. Here, reducing bias to machine learning, analytics and techniques and being inclusive around who data and algorithms are being built upon. And then promoting inclusivity through mobile health design features. And so this could be using adaptive systems within the actual technology that work in a place that has low Wi-Fi signals, maybe like rural Montana or whatnot. And support decision-making in technology selection as well. And then promoting digital literacy, which there's some great programs out there that are supporting digital literacy. Here, some future work in this has been the expansion of digital peer support to Norway where there's been usability testing. There is a Norwegian version of the PeerTech app that's being deployed. And this was developed in collaboration with social scientists and peer support specialists in Norway and also the United States, which has a very different history of peer support there. There's also a peer support specialist app called Supporting Older Adults Remotely, which is the development of a certified older adult peer support specialist. This is an individual age 50 years and older who has a mental health or substance use challenge and also an experience of aging. This is also a Medicaid reimbursable workforce that working with the team we've been developing. Here, we have a service user, a certified older adult peer support specialist, a large payer system and a social scientist that are collaborating and working together to look at this program. Similarly delivered over 12 weeks, integrates evidence-based practices around successful aging. And we're looking at some outcomes around functioning, independent living status and nursing home placement and medical and psychiatric hospitalization. Also from this group, we just finished up a convening meeting where this whole team of peer support specialists and service users and all of these other groups here, NAMI and SAMHSA and NIH, we're all brought together to identify a lived experience or a service user patient-led research agenda to address early mortality. In here, they identified a new technologies that could be developed and integrated into health systems to help address this early mortality health disparity that we have known about and worked to address for over a century. And now despite our efforts, people are dying younger than ever before. And so there's a strong focus on supporting people around things like loneliness and sense of belonging as potential avenues to increase their lifespan. So here's the awesome group that we work with, probably recognize some great names there. I just wanna thank everyone for this entire program of research that we have been able to move forward. And then there's a bibliography for folks. Cool. Thank you so much for an interesting presentation, Dr. Fortuna. Before we shift to the Q&A, I wanna take a moment and let folks know that we have the SMI Advisor app. It's not PureTech, which we have questions about, but you can use the SMI Advisor app to access resources, education, and upcoming events. You can even complete some mental health weighting scales and submit questions directly to our team of SMI experts. You can download the app now at smiadvisor.org app. So to jump into questions, I think the number one question is more a compliment, this is so neat, this is so exciting, and wow, but I will not make you respond to that. I think the second most popular question is how can people access or partake or kind of get the training and use PureTech? Oh sure, sure. Well first, thank you so much. I'm glad the research is exciting and I think it's fun to do and I work with such an amazing team that we make it, they make it possible. So anyway, thank you so much. Yeah, so for training around this, feel free to reach out to us, feel free to email me and we can schedule a training. And we generally will work with states or large systems and set up the training and train the trainers across the country and also globally too in places like Norway and Australia. So happy to have folks involved and we also have, there's also training on the Certified Older Adult Peer Support Specialist work as well, which we're currently studying in New York City. So just feel free to email and reach out. Another question came up as people said this is clearly some of its app-based, do you feel apps or texting, it's a broad question, it's kind of better, we'll say for lack of a simple word, like do you want peers, like is it, what is better or what is easier for people to use? The app or texting, is that the question? Oh that's an interesting question and I love that it's being asked because within peer support it's different than other clinical, like clinical care. And so peer support is about, even digital peer support, is about meeting people where they are. So if they are over the telephone, we encourage people to use that to connect with individuals. If it's a younger adult and their preference is text messaging, offer that type of service to individuals. And so it's not a requirement to use all the features of the technology, it's really about using the technology in a way that meets the person where they are and where it facilitates that human connection with individuals. Our research will in the future be looking at dose response and so if a certain text message is sent and how many, can we get some outcomes of that? And so as this is an early area of research, I'll be happy to share the evidence around that, but we know that by offering this preference we get these higher rates of engagement among folks. That makes sense. Someone's also asking, what is the best email address to reach out to your team? Is there a best contact information? Oh sure, I don't know if we can put that in the chat, but it is karen.l.fortuna at dartmouth.edu. Please feel free to reach out. karen.l.fortuna at dartmouth.edu. Okay, got it. Another question that people have is saying, is, I'll paraphrase or put something here, is screen time, for some people, is screen time a bad thing? We want people to have less screen time. How does a peer specialist can determine the right dose of screen time, if that makes sense, if we're concerned about it? Yeah, no, I love it and it's screen time for the service user, the patient, and it's screen time for the peer support specialist as well. One of the competencies that they identified was self-care. Self-care is a competency in digital peer support. A peer support specialist needs to know how to take care of themselves and to disengage from the technology. We train them on how using certain types of technology features actually increases the cognitive load and that's why people may feel tired. We let people know, yeah, it's the same with patients and service users as well. What's interesting is that individuals haven't reported digital fatigue in using the technology. One of the great things about it is that they could, again, it's about preference, that people could meet side-by-side and use the app together and walk through it together. Here, you may not have as much screen time rather than just texting as well, but it's also an interesting scientific question, like how much screen time do we need to produce clinical outcomes or to produce burnout among both of these groups, but it really goes down to one of the core principles in peer support and recovery. It's about self-determination and choice and if people choose to not engage through the technology but engage in other ways, then that's okay. It's about, again, meeting the person where they are. That makes sense and this is an interesting question too. It says, are the peer supporters that are in contact with the service users randomly matched to them or do they place them together if they've already worked together? I guess it's about how the matching happens between users and recipients. That's a fascinating question and people have been scientifically exploring that empirically for decades now. What's interesting is that an article back in the 1990s, I think by Dr. Davidson, found that matching individuals based on symptomatology, it didn't produce any different outcomes than matching people just based on availability. Here, the peer support specialists are employees and we wouldn't match maybe a psychiatrist or a psychologist to their lived experience with another individual because, of course, they're protected about even us asking those questions. Here, people become available and then they're assigned that way and then the service user has the option or the client has the option to say, I'd like to work with someone else, similar to how it works in the clinical environment as well. It has been explored scientifically in the 1990s and that was in person and it hasn't been explored digitally yet. Potentially, that is another question but I do not think it'll matter. If we integrate it into an employee system, it wouldn't be aligned with the American Disability Act to ask people what their diagnoses were and able to match them. Really good question. People are asking again for your email. I'll say it's karen.l.fortuda.dartmouth.edu. This is an interesting question. It says, I believe that most people use Google Mail or Gmail. Would Google Meet be something that you think peer support specialists could be utilizing to facilitate this? I like that question for many reasons. One of which is that that tool offers a transcription service that you don't have to enter it yourself because if you use something like Zoom, you have to hire someone to do closed captioning for you or type it in yourself. That's obviously very challenging and cost prohibited but other services like Google, you literally will share your screen and then open up the captions at the bottom. If you're working with individuals that may need extra support around reading what is saying, you can do that feature on that. I don't know if this service is HIPAA compliant and so that would be one of the questions that in order to provide these types of services, we would need to explore if that were HIPAA compliant. That was the number one competency that came up was protecting the rights of service users and that is making sure that the tools that we're using have a high level of security that protect the privacy and confidentiality of individuals. That makes sense. As we know, the federal government restricted some of those HIPAA rules around COVID of what platform you could use and as the federal government may declare again in the federal government's way that COVID may be over soon, we may see some interesting changes around what we can and can't use from a HIPAA point of view. So a good question. And then someone is, Katie is saying that she thinks HIPAA may be compliant in the chat. A related question is that are these apps available for free? Do people subscribe to it? Do they get a grant? Do they work with the organization? Clearly you've put a lot of resources into this and it must need some support. Yeah, yeah, yeah. I think all of all of the above. There is a research portion of the app and then there's a commercial portion of the app as well. So there's a subscription model that people can reach out for and my email is open so you can hear the emails coming through. But yeah, so there's a lot of different options. We work with other scientists and what's really cool too is we made it in a way that it doesn't only have to be mental health peer support. We're actually working with people with multiple sclerosis and we're training them and offering peer support in the app. You can actually enter any information, any videos, any resources, any guiding principles that you want. So if you wanted to integrate something like cognitive behavioral therapy, that's probably not going to work with peer support specialists because of their philosophy and principles and guiding practices, but it can be used as a platform to study with another potential population. We have another interesting question that came in around access to devices and technology. I'll field this one. In essence the question is saying, do people with different serious mental illnesses have access to the type of phones or internet connection that they can kind of engage in digital peer support? The answer overwhelmingly increasingly is yes, they have access to the devices and they often have access to high-speed internet. We certainly are aware that not everyone has a smartphone, not everyone has access to high-speed internet, but it's interesting the data actually supports that a lot of people with serious mental illness may be smartphone dependent and what that means is they actually rely on the phone as a primary device to connect to the internet. They actually may not be per se using a computer. Even if people don't have access to a smartphone, as alluded to earlier, there are federal programs like the Lifeline program from the FCC that actually can help your patient obtain a very impressive smartphone device and a very inexpensive data plan as well. So I think in some ways the engineering world is solving for us smartphones that are very accessible and inexpensive and I think the broadband internet is catching up. There's a lot of money at least in the US that's being invested even this year into kind of increasing internet connectivity for all Americans. So I think as we begin to kind of that infrastructure reaches everyone, it really does kind of put the onus on thinking about how we use that to support digital mental health with the exact type of program say that Dr. Fortuna is introducing us to us here. So again I'll be bold and answer this one and just say I think the access is less of an issue how we use it for mental health and make sure people can equitably connect and benefit from it and say engaging the peer workforce as Dr. Fortuna said. That's probably the new challenge and the kind of thing that makes sense for us as a community to put our efforts into and work towards. I know it is true that not every person will have a device but every person increasingly has the ability to have a device and if they don't will likely have one very soon. So thank you. Maybe with that we'll cut the questions not that there's so many more good ones but just to make sure we we finish on time. But if there aren't any topics 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 advisors webinar roundtable topic discussion board. There's an easy way to network and share ideas of other commissions who are partaking in this webinar. Also if you have questions about the webinar or any topic related to evidence-based care for SMI you can get an answer within one business day from our SMI advisor team of experts to services available to all mental health commissions, peer support specialists, administrators and anyone else in the field who works with people with SMI. It's completely free and confidential. SMI advisor is just one of many SAMHSA initiatives are designed to help clinicians implement evidence-based care. We encourage you to explore the resources available on mental health addiction and prevention through those TTCs, technical transfer centers, as well as the National Center for Eating Disorders and Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opiate epidemic. And now to claim credit for partaking in today's webinar you'll need to have met the requisite attendance threshold for your profession. Verification of attendance can take up to five minutes sometimes it's quicker. You'll then be able to select next to advance and complete the program evaluation before claiming your credit so it should be easy to do. And finally please join us next week on October 6 for Jennifer Snow presenting update on 988 what mental health professionals need to know. Again for those who may not know 988 is the new suicide crisis number hotline. It's certainly relatively new in the field and it'll be great to get an insider's view on this. Again this free webinar will be October 6 from 3 to 4 p.m. on Thursday Eastern Time so noon if you're in West Coast time. Thank you again for joining us. Thank you so much to Dr. Fortuna for sharing this amazing program. Until next time take care. Thank you for participating in today's free course from SMI Advisor. We know that you may have additional questions on this topic and SMI Advisor is here to help. Education is only one of the free resources that SMI Advisor offers. Let's briefly review all SMI Advisor has to offer on this topic and many others. We'll start at the SMI Advisor website and show you how you can use our free and evidence-based resources. SMI Advisor's mission is to advance the use of a person-centered approach to care that ensures people who have serious mental illness find the treatment and support they need. We offer several services specifically for clinicians. This includes access to education, consultations, and more. These services help you make evidence-based treatment decisions. Click on consult request and submit questions to our national experts on bipolar disorder, major depression, and schizophrenia. Receive guidance within one business day. It only takes two minutes to submit a question and it is completely confidential and free to use. This service is available to all mental health clinicians, peer specialists, and mental health administrators. Ask us about psychopharmacology, recovery supports, patient and family engagement, comorbidities, and more. You can visit our online knowledge base to find hundreds of evidence-based answers and resources on serious mental illness. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Harvard, Emory, NAMI, University of Texas at Austin, and more. Browse by key topics or search for a specific keyword in the search bar. Access our free education catalog to find more than a hundred free courses on topics related to serious mental illness. You can search the education catalog by topic, format, or credit type to find courses that fit your needs. SMI Advisor also offers live webinars each month that let you learn about evidence-based practices and participate in live Q&A with faculty. Check out our education catalog often to find new courses and earn continuing education credits. For individuals, families, friends, people who have questions, or people who care for someone with serious mental illness, SMI Advisor offers access to resources and answers from our national network of experts. The individuals and families section of our website contains an array of evidence-based resources on a variety of topics. This is a great place to refer individuals in your care for information about their conditions. They can choose from a list of important questions that individuals who have SMI typically ask. SMI Advisor worked with experts from the National Alliance on Mental Illness to develop these important questions and many of the resources in this section. Watch videos on important topics around SMI, such as what to know about a new diagnosis. They can also find dozens of fact sheets, infographics, and links to other important resources. To access even more evidence-based resources for individuals and families, visit our online knowledge base. All content in our knowledge base is reviewed by our team of national experts from the American Psychiatric Association, Mental Health America, National Alliance on Mental Illness, and more. Browse by key topics and select view all to uncover a list of resources on each topic. SMI Advisor offers a smartphone app that lets you access all of the same features on our website in an easy-to-use mobile-friendly format. You can download the app for both Apple and Android devices, submit questions, browse courses, and access clinical rating skills that you can use in your practice with individuals who have SMI. SMI Advisor also created My Mental Health Crisis Plan, a smartphone app that helps individuals in your care to create a crisis plan. The app is available on both Apple and Android devices. It helps people prepare in case of a mental health crisis. They can make their treatment preferences known and specify who should be contacted and who should make decisions on their behalf. The app even guides individuals through the process to turn their crisis plan into a psychiatric advance directive. Thank you for your interest in SMI Advisor. Access our free education, consultations, and more on smiadvisor.org at any time.

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