WEBVTT

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- So I want to just take a
moment to welcome everyone

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to our public lecture
series for social work

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and to the Brown Foundation
research lecture in particular.

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My name is Maria Torres and
I'm a new faculty member

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at the School of Social Work.

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And I'll be starting--

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(applause)

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(feedback)

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(laughter)

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Sorry!

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- [Voiceover] It was celebrating.

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- I know, that's some celebration.

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And it's my real privilege and an honor

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to get to introduce Maggie
Alegria to you this evening.

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I have known Maggie since 2004

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when we worked together
on, Maggie hired me

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as a project manager
for the National Latino

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and Asian-American study and really took

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a chance on me as a
clinician that really wanted

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to learn about research.

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Maggie herself is a clinician
and a researcher by training,

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and as you can see from the
bio here, which I'll just

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read a little bit about.

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So Maggie is the director
of the Center for

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Multi-Cultural Mental Health Research

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at the Cambridge Health Alliance

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and Harvard Medical School.

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As a professor of psychology in the

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Department of Psychiatry
at Harvard Medical School,

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Dr. Alegria is the first Latina
full professor at Harvard,

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which I think is really
important to highlight.

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(applause)

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Maggie is currently the PI
of three national institutes

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of health-funded research
studies, the International

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Latina Research Partnership,
Effects of Social Context,

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Culture, and Minority Status
on Depression and Anxiety,

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and Building Community Capacity
for Disability Prevention

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for Minority Elders.

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She's also the PI of the PCORI
Grant, a patient-centered

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outcomes research institute
project, Effectiveness

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of Decide in Patient-Provider
Communication,

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Therapeutic Alliance
and Care Coordination.

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Dr. Alegria has published over 200 papers,

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editorials, intervention
trainings, et cetera.

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I looked at her CV this
morning before I came today

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and it's 56 pages long, which
just tells you, you know,

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this is an incredibly
accomplished and thoughtful woman

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that has dedicated her life
to research that moves forward

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the agenda of individuals
that have been marginalized

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in any way, shape, or form.

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And her research and
influence has incredible depth

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in terms of her work
on different councils,

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public service work, work
with communities, et cetera.

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So it is, I'll let you read
the bio, you have it here,

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but it is a great pleasure and a privilege

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to introduce Maggie to you today.

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- [Maggie] Thank you.

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(applause)

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I think this is one of the best pieces of,

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seeing your trainees become the faculty

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and eventually your boss.

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So I'm hoping that the next step

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will be Maria being my boss.

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(laughter)

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I really want to thank you, because

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coming here at 7:30 is
quite an achievement.

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People being so nice to really share

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a little of their time, especially because

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I know you have 300 other things to do.

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So I'm very grateful.

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I want to thank Mary Ann for inviting me,

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Peggy for the wonderful coffee,

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Irene for the amazing
food that she took me to,

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Maria for the great presentation,

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and Dr. Candelario for an amazing story.

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If you keep me here a little bit more,

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I probably won't go back to Harvard,

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so be careful what you ask for.

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(applause)

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So, let me start by
telling you a little bit

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of why I started to do this work,

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partly because I was doing a lot of work

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describing problems in
immigrant communities,

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but felt eventually that
nothing was happening.

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I've actually been in this
area for, you won't believe it,

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but 30 years, and in 30 years, the change

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is so minimal.

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Actually if you look at disparities,

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they're getting worse, not getting better,

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in mental health care.

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This is one of the areas
there has been no traction.

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No traction, you see a lot of the people

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talking about behavioral health

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and behavioral health, but actually

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there's been no traction whatsoever

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in terms of disparities.

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So I got a little tired
and decided, this is,

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I mean, I have to, someone asked me

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"what's your impact?"

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And I became like, I
couldn't really say anything.

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I said, "Well I have
some publications, but,

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"beyond publications, I mean,
not really a big impact."

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And decided to go into this area.

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I'm going to talk today about
three areas very quickly.

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One, why immigrants do
not seem to access care

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for their mental health
problems, tell you a little bit

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of the problems we have of
why for over the past 40 years

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we've been talking about
this with no traction

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with hopes that you are the generation

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that can make a big difference.

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Second thing I want to
talk a little bit about is

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what have we found out that works.

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(feedback)

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Oops.

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And then finally, I'll talk about funding

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because it's part of the biggest problem

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we have in this arena is that the funding

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is really not allying.

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Oh, okay.

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So even better.

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So I'm going to start
with children, because

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I think for some reason in this country,

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although the demographics
are dramatically changing,

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what we're seeing is,
there's no attention to,

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this is a new landscape.

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The children in schools look like

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nothing we had before.

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And it seems that we
are not really prepared

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to deal with all these immigrant children

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that are coming in.

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By 2050, more than one-third
of the hundred million

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US children will be minorities,
more than one-third.

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But if you think about
it, there's a huge gap

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between the populations,
the size of the populations

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and actually the knowledge that we have

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in how we can serve them.

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So there's a big gap in this area.

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You would think everyone's preparing.

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By the way, I gave a
talk about disparities

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to the state legislators and things,

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and the amazing thing is, we had a group

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of people from the community.

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And everyone was saying,
you know, we talked

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about this 20 years ago,
and again we're talking

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about the same, same
issues, it was so sad.

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And one of the things
that we talk in that brief

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is disparities, I have to say, have become

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better for certain groups,
but not all groups.

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And we have to keep on watching it.

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The other thing is that,
besides not knowing

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a lot about how to help these children,

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these children have special needs

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that we are not prepared to serve.

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They have incredibly high rates of trauma,

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they have, a lot of them have had

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extended parental separation, they have

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few resources to access care because

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they come from high rates of poverty.

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They also have problems
of food and housing,

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especially one of the
areas that you should be

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looking and assessing is food insecurity.

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Food insecurity is tied to every single

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behavioral health outcome you can imagine.

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It's tied to suicide, it's
tied to depression, anxiety,

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you name it, food
insecurity is strongly tied

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to bad behavioral outcomes.

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We also see in these children, especially

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if they are undocumented,
high rates of uninsurance.

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So providers are
struggling to find how can

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I serve these kids that
have such immense needs,

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and so little access to care.

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The other big problem that you'll see

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is the issue of linguistic isolation.

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These kids live in families with

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a lot of linguistic isolation.

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So why do these children do not seem

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to access mental health
for their problems,

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and why has this not
changed for over 40 years?

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You would wonder, I mean,
we all know about it,

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why aren't we changing it?

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Let me show you the rates of children

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in immigrant families that
are linguistically isolated.

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23 percent have no one in their household

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that speaks English.

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So one of the biggest problems

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is actually try getting
services, first in English,

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and then if you don't speak English,

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you are completely wiped out, especially

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in certain areas of Massachusetts

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where you would think that we have

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so many immigrant populations that people

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would be ready to have these services.

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So right now we're running
a project that's on

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mental health and substance abuse.

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I was telling Maria
that one of the biggest

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problems we're having is incredibly

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high rates of suicide ideation.

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Try getting someone to help you,

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the best team that has someone

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that speaks Spanish.

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Forget Spanish, imagine
any Asian languages,

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Mandarin or Cantonese.

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Or try Hatian Creole, or try Portuguese.

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No one.

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To something so serious as suicidality.

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So this is an area where we're having

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terrible, terrible problems
in getting services.

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And if you're in substance
abuse, if your child

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has a substance abuse problem,

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try getting some services
that is non-English.

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Almost nothing.

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The other thing you'll see, and this is

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a very, it's uninsurance,
children by poverty status,

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household income, age,
race, and Hispanic origin.

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But I want you to see non-citizens.

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29 percent of non-citizens are going to

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be uninsured children.

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So this creates a serious problem

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because you don't have
that many alternatives.

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Who are the providers
that are willing to see

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these children without insurance?

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Okay, you have another big, big issue.

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You can see there in terms of less income,

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the children in poverty
are less likely to have

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any access to care.

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I wanted to show you that
in Massachusetts by the way,

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we're actually quite lucky.

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Because if you think about Massachusetts,

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one of the things
Massachusetts is that green,

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very green light, I don't know

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if you can see it here,
we are in Massachusetts.

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And you can see that it's
one of the few places

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that gives medical coverage for children

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regardless of status.

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However, there's questions of whether

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that's going to change with
the Affordable Care Act.

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Because the Affordable Care Act

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is making a distinction between children

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that are documented and legally here,

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and children that are undocumented.

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So we hope that doesn't change,

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but it's something to
be seen, and something

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that might be scary.

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The other thing I wanted to show you

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was quality of care.

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We've been doing work looking at

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quality of care and both
attention deficit disorder

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and depression are really very, very,

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like clear-cut, you know,
easy things to treat.

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Very easy things to treat.

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This is in a study that
we publish, Nick Carson,

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he's one of my colleagues, and this group,

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in 2011, where we saw in a system of care

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that serves a lot of immigrant families,

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we compare in this study,
Haitian, African American

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and White kids to see if they were

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receiving guideline-concordant care

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for attention deficit
disorder and depression.

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And as you can see there,
dramatic difference

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within the same system of care.

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00:12:39.544 --> 00:12:42.944
As you can see there, whites receive,

262
00:12:42.944 --> 00:12:45.124
are much more likely to receive

263
00:12:45.124 --> 00:12:47.503
guideline-concordant care than either

264
00:12:47.503 --> 00:12:50.363
black or Haitian kids.

265
00:12:50.363 --> 00:12:53.884
It's amazing, this is
the same provider, okay,

266
00:12:53.884 --> 00:12:57.004
the same providers in
the same system of care.

267
00:12:57.004 --> 00:12:59.663
Some people have said,
well it's partly a problem

268
00:12:59.663 --> 00:13:02.664
that they go to different systems of care.

269
00:13:02.664 --> 00:13:04.624
But this is not the case.

270
00:13:04.624 --> 00:13:06.584
This is in the same system of care

271
00:13:06.584 --> 00:13:09.044
with the same providers, they get

272
00:13:09.044 --> 00:13:10.624
less quality care.

273
00:13:14.524 --> 00:13:16.863
The other thing I wanted to show you,

274
00:13:16.863 --> 00:13:19.333
is when do people get care?

275
00:13:19.524 --> 00:13:21.854
And this is a very sad story.

276
00:13:22.284 --> 00:13:25.204
So we publish a paper
in psychiatric services

277
00:13:25.204 --> 00:13:28.984
showing that if you look, these are people

278
00:13:28.984 --> 00:13:32.604
that have White, Black
and Latinos, that have

279
00:13:32.604 --> 00:13:36.843
any drug or alcohol dependence or abuse.

280
00:13:36.843 --> 00:13:39.364
These are people that are quite severe

281
00:13:39.364 --> 00:13:44.364
in terms of alcohol, drugs, in
terms of dependence or abuse.

282
00:13:44.584 --> 00:13:47.944
And if you look at the rates
there, you actually see

283
00:13:47.944 --> 00:13:50.704
what we call a reverse disparity

284
00:13:50.704 --> 00:13:54.762
if they were treated in the
substance abuse treatment.

285
00:13:54.762 --> 00:13:57.722
Okay, so you see what we
call a reverse disparity.

286
00:13:57.722 --> 00:14:01.022
That's white are less likely to be treated

287
00:14:01.022 --> 00:14:04.242
in the substance abuse treatment sector

288
00:14:04.242 --> 00:14:09.242
as compared to blacks or Latinos, okay?

289
00:14:09.262 --> 00:14:11.863
But if you look at mental health care

290
00:14:11.863 --> 00:14:14.603
treating these populations, they're

291
00:14:14.603 --> 00:14:17.043
much more likely to be, whites are

292
00:14:17.043 --> 00:14:19.363
much more likely to be treated

293
00:14:19.363 --> 00:14:22.823
in the mental health system,
for the same condition,

294
00:14:22.823 --> 00:14:23.483
by the way.

295
00:14:23.483 --> 00:14:25.463
These are all with the same condition.

296
00:14:25.463 --> 00:14:28.103
Compared to blacks and Latinos.

297
00:14:28.103 --> 00:14:30.823
So when you ask, having been treated

298
00:14:30.823 --> 00:14:33.683
in any of the systems, what you see is

299
00:14:33.683 --> 00:14:37.143
that then there is a
disparities, with whites

300
00:14:37.143 --> 00:14:39.423
being more likely to be treated.

301
00:14:39.423 --> 00:14:40.803
But guess what?

302
00:14:40.803 --> 00:14:45.043
What's really driving the
people that are treated

303
00:14:45.043 --> 00:14:47.763
in the substance abuse system?

304
00:14:47.763 --> 00:14:51.123
Unfortunately, what we see is, Latinos,

305
00:14:51.123 --> 00:14:54.563
no matter if they have a
criminal history or not,

306
00:14:54.563 --> 00:14:56.683
are less likely to be treated.

307
00:14:56.683 --> 00:14:59.223
Once you adjust for the experience

308
00:14:59.223 --> 00:15:02.103
of being in the Criminal Justice system,

309
00:15:02.103 --> 00:15:04.763
but what you see is, once you adjust for

310
00:15:04.763 --> 00:15:09.763
having a criminal history,
or SCS, you then see

311
00:15:11.003 --> 00:15:14.043
that actually the disparities
in the substance abuse

312
00:15:14.043 --> 00:15:18.994
treatment become larger for
both blacks and Latinos.

313
00:15:19.364 --> 00:15:22.644
In other words, most of the
people that are entering,

314
00:15:22.644 --> 00:15:26.264
Latinos and black, to the
substance abuse system,

315
00:15:26.264 --> 00:15:29.304
are being included because
of criminal history

316
00:15:29.304 --> 00:15:31.294
or low SCS.

317
00:15:31.964 --> 00:15:35.224
But they're coming through
a different sector of care,

318
00:15:35.224 --> 00:15:37.654
I mean, which is very worrisome.

319
00:15:38.964 --> 00:15:41.324
I think for elder
immigrants, we're finding

320
00:15:41.324 --> 00:15:44.124
the same, identical story.

321
00:15:44.124 --> 00:15:46.664
Really sad, identical story.

322
00:15:46.664 --> 00:15:49.964
We publish a paper with (unclear)

323
00:15:49.964 --> 00:15:54.324
showing that if you are Latino or Asian,

324
00:15:54.324 --> 00:15:58.924
only one in 10, one in 10 would receive

325
00:15:58.924 --> 00:16:01.464
quality care for depression.

326
00:16:01.464 --> 00:16:04.184
So that means that nine out of the 10

327
00:16:04.184 --> 00:16:06.864
are not receiving any quality care.

328
00:16:06.864 --> 00:16:09.164
And we're talking about depression.

329
00:16:09.164 --> 00:16:13.244
Depression is like, you know, such a,

330
00:16:13.244 --> 00:16:15.344
it's not like we're talking about

331
00:16:15.344 --> 00:16:18.804
a complicated schizophrenia or bipolar,

332
00:16:18.804 --> 00:16:20.424
or something more complicated.

333
00:16:20.424 --> 00:16:22.564
This is for depression.

334
00:16:22.564 --> 00:16:25.364
So the rates are very, very low.

335
00:16:25.364 --> 00:16:27.804
And it's important if you think about it,

336
00:16:27.804 --> 00:16:32.164
because many of our non-English elders

337
00:16:32.164 --> 00:16:34.004
are really in isolation.

338
00:16:34.004 --> 00:16:36.244
We see a lot of depression, a lot of

339
00:16:36.244 --> 00:16:39.564
non-acceptance that they
have a mental illness,

340
00:16:39.564 --> 00:16:42.264
and this is partly because
their support system

341
00:16:42.264 --> 00:16:46.864
has really eroded by family disruption,

342
00:16:46.864 --> 00:16:50.784
occupational demands, and
growing disorganization

343
00:16:50.784 --> 00:16:53.644
of the families in urban environments.

344
00:16:53.644 --> 00:16:56.504
If you think about it,
for a lot of these elders,

345
00:16:56.504 --> 00:16:59.424
they came and sacrificed
for their children.

346
00:16:59.424 --> 00:17:01.844
Work, work, work, work,
with the expectation

347
00:17:01.844 --> 00:17:03.464
that someone's going to support them

348
00:17:03.464 --> 00:17:06.064
and really take care of them, and suddenly

349
00:17:06.064 --> 00:17:09.004
they find that that's
not the norm, necessarily

350
00:17:09.004 --> 00:17:11.204
in this country, and that they're actually

351
00:17:11.204 --> 00:17:14.654
going to be left by themselves.

352
00:17:16.585 --> 00:17:19.305
So this is why I say only 8.6 percent

353
00:17:19.305 --> 00:17:22.245
of Asian Americans report having used

354
00:17:22.245 --> 00:17:24.605
any mental health services, compared to

355
00:17:24.605 --> 00:17:27.545
17 percent of the general population.

356
00:17:27.545 --> 00:17:30.525
So very, very, very limited.

357
00:17:30.525 --> 00:17:33.145
So why hasn't then this changed over

358
00:17:33.145 --> 00:17:35.085
the past 40 years?

359
00:17:35.085 --> 00:17:37.165
I think we have done a lot of work

360
00:17:37.165 --> 00:17:40.365
finding that there are
several things that happened.

361
00:17:40.365 --> 00:17:43.085
First, what we're finding
is that most elders

362
00:17:43.085 --> 00:17:45.385
don't want to recognize that they have,

363
00:17:45.385 --> 00:17:47.525
they don't really want, they don't think

364
00:17:47.525 --> 00:17:50.945
the symptoms are symptoms
of mental health.

365
00:17:50.945 --> 00:17:54.565
So many of them really
report that their symptoms

366
00:17:54.565 --> 00:17:58.165
have to do with some other
thing, like suffering,

367
00:17:58.165 --> 00:18:01.545
like general conditions
of being aged, aging,

368
00:18:01.545 --> 00:18:03.685
but not necessarily that they have

369
00:18:03.685 --> 00:18:05.285
a mental health problem.

370
00:18:05.285 --> 00:18:07.685
There's a huge stigma, especially if

371
00:18:07.685 --> 00:18:09.865
you come from a country where people

372
00:18:09.865 --> 00:18:12.065
are actually secluded if they have

373
00:18:12.065 --> 00:18:13.465
a mental health problem.

374
00:18:13.465 --> 00:18:15.925
So recognizing that they
have a mental health problem

375
00:18:15.925 --> 00:18:18.225
has a different connotation.

376
00:18:18.225 --> 00:18:19.925
And people say a lot, you know,

377
00:18:19.925 --> 00:18:23.225
I'm not going to go
into mental health care,

378
00:18:23.225 --> 00:18:25.745
that's really for the very, very sick.

379
00:18:25.745 --> 00:18:27.385
You know, for the ones that are locos,

380
00:18:27.385 --> 00:18:30.705
or people that are completely
out of their realm.

381
00:18:30.705 --> 00:18:33.665
The other thing we've
seen and we publish a lot,

382
00:18:33.665 --> 00:18:36.565
is what other people call self-reliance.

383
00:18:36.565 --> 00:18:38.645
You know, people in these communities

384
00:18:38.645 --> 00:18:41.165
have a government or have a system

385
00:18:41.165 --> 00:18:43.645
that doesn't respond to them, so the idea

386
00:18:43.645 --> 00:18:45.565
that someone can take care of them

387
00:18:45.565 --> 00:18:49.265
and help them is not in their tool box.

388
00:18:49.265 --> 00:18:51.465
So they believe that actually they should

389
00:18:51.465 --> 00:18:54.725
be self-reliant and try to problem solve.

390
00:18:54.725 --> 00:18:57.285
The second thing is we have, there's very,

391
00:18:57.285 --> 00:19:00.185
very few access to mental health services

392
00:19:00.185 --> 00:19:03.085
for a non-English populations.

393
00:19:03.085 --> 00:19:06.045
There's a lot of unfamiliarity

394
00:19:06.045 --> 00:19:08.505
about the mandates, about who's

395
00:19:08.505 --> 00:19:11.625
eligible to go, and many of these people,

396
00:19:11.625 --> 00:19:14.825
by the way, are not eligible to Medicare,

397
00:19:14.825 --> 00:19:17.905
so they don't really have
a source of insurance

398
00:19:17.905 --> 00:19:20.785
like the other elders that
we have in this country.

399
00:19:20.785 --> 00:19:23.065
So it makes it very hard for them.

400
00:19:23.065 --> 00:19:25.645
There's also lack of access to Medicare

401
00:19:25.645 --> 00:19:29.585
and employer-based coverage and usual

402
00:19:29.585 --> 00:19:31.165
healthcare providers.

403
00:19:31.165 --> 00:19:34.065
One of the biggest areas
where they've shown

404
00:19:34.065 --> 00:19:37.465
is that compared to
the general population,

405
00:19:37.465 --> 00:19:40.365
this population has a lot
of primary care providers

406
00:19:40.365 --> 00:19:44.825
but they don't have a lot of
specialty care provider access.

407
00:19:44.825 --> 00:19:47.066
I don't know if any of
you have tried getting

408
00:19:47.066 --> 00:19:52.066
a mental health for PCPs
in primary care providers.

409
00:19:52.805 --> 00:19:57.385
One of the worst areas
actually, we underlined this,

410
00:19:57.385 --> 00:20:02.385
is if you look at Medicaid,
very, very few providers,

411
00:20:03.946 --> 00:20:08.416
specialty providers, are willing
to take Medicaid patients.

412
00:20:09.006 --> 00:20:12.886
The pay is so low in behavioral health

413
00:20:12.886 --> 00:20:15.406
that very few people
are willing to take it.

414
00:20:15.406 --> 00:20:18.386
It doesn't happen for other specialties.

415
00:20:18.386 --> 00:20:20.625
So behavioral health is one of the ones

416
00:20:20.625 --> 00:20:23.125
that is really the worst, where people

417
00:20:23.125 --> 00:20:26.066
are actually not covering.

418
00:20:26.066 --> 00:20:27.706
But the other thing we have is

419
00:20:27.706 --> 00:20:29.946
fears on documentation.

420
00:20:29.946 --> 00:20:32.846
You cannot imagine how many people

421
00:20:32.846 --> 00:20:35.806
miss their appointments because they see

422
00:20:35.806 --> 00:20:38.966
a policeman and immediately
they turn around

423
00:20:38.966 --> 00:20:40.826
and go back home.

424
00:20:40.826 --> 00:20:43.085
Things like that, that
you would not have thought

425
00:20:43.085 --> 00:20:45.046
are things that happen.

426
00:20:45.046 --> 00:20:46.806
And then there's a lot of poor quality

427
00:20:46.806 --> 00:20:50.386
mental health services,
so the communities here

428
00:20:50.386 --> 00:20:52.786
that people are not getting better,

429
00:20:52.786 --> 00:20:57.646
and that in itself
becomes a vicious cycle.

430
00:20:57.646 --> 00:21:00.305
I wanted to just clearly cover this

431
00:21:00.305 --> 00:21:02.786
because I think there's
a lot of confusion.

432
00:21:02.786 --> 00:21:06.046
In fact, I have (unclear)
which is a person

433
00:21:06.046 --> 00:21:09.746
that works with me on
the issue of immigrants

434
00:21:09.746 --> 00:21:13.306
and the health care laws, and they are,

435
00:21:13.306 --> 00:21:16.027
with all the things that are happening,

436
00:21:16.027 --> 00:21:18.347
especially, what we see is that

437
00:21:18.347 --> 00:21:21.047
the only people that are
eligible, supposedly,

438
00:21:21.047 --> 00:21:23.467
according to the Affordable Care Act,

439
00:21:23.467 --> 00:21:25.327
are people that have been here

440
00:21:25.327 --> 00:21:30.026
for more than five
years as legal residents

441
00:21:30.026 --> 00:21:33.567
or what's called legally here.

442
00:21:33.567 --> 00:21:37.527
So this really is putting a lot of people

443
00:21:37.527 --> 00:21:42.527
at jeopardy of losing
things like CHIP or Medicaid

444
00:21:42.528 --> 00:21:46.568
that were actually covered
here in Massachusetts.

445
00:21:46.568 --> 00:21:48.988
And it's going to be
something to be looked.

446
00:21:48.988 --> 00:21:52.648
So for undocumented
migrants, what you hear

447
00:21:52.648 --> 00:21:55.487
over and over again, is
that they're eligible

448
00:21:55.487 --> 00:21:58.007
for emergency services.

449
00:21:58.007 --> 00:21:59.888
But that's about it.

450
00:21:59.888 --> 00:22:02.368
And this is an area
where people are trying

451
00:22:02.368 --> 00:22:04.968
to fight and actually, the people

452
00:22:04.968 --> 00:22:07.788
from Healthcare for All in Massachusetts

453
00:22:07.788 --> 00:22:11.388
have been advocating
for the immigrant group

454
00:22:11.388 --> 00:22:13.678
to be included.

455
00:22:14.287 --> 00:22:16.788
I think one of the
biggest problems we have

456
00:22:16.788 --> 00:22:20.528
that is now becoming
very obvious to everyone,

457
00:22:20.528 --> 00:22:24.228
including Deval Patrick
when he was in the states

458
00:22:24.228 --> 00:22:28.668
is that we have a
horrendous work shortages,

459
00:22:28.668 --> 00:22:30.227
work force shortages.

460
00:22:30.227 --> 00:22:33.667
By the way, in the IOM I
participated in this report,

461
00:22:33.667 --> 00:22:36.368
it's a great report if
you haven't read it.

462
00:22:36.368 --> 00:22:38.909
It's the Mental Health and Substance Use

463
00:22:38.909 --> 00:22:43.859
of Older Adults in Whose Hands Are We?

464
00:22:44.129 --> 00:22:46.809
And it's basically that you look at

465
00:22:46.809 --> 00:22:50.149
who's taking care of the elders

466
00:22:50.149 --> 00:22:52.569
is people that have no preparation,

467
00:22:52.569 --> 00:22:56.509
zero preparation for behavioral health.

468
00:22:56.509 --> 00:22:59.129
And if you look at a place like Florida,

469
00:22:59.129 --> 00:23:02.549
where they were actually
looking at who comes

470
00:23:02.549 --> 00:23:06.869
into behavioral and
psychotropic medications

471
00:23:06.869 --> 00:23:09.489
and the rates of psychotropic medication

472
00:23:09.489 --> 00:23:11.089
three months after you have been

473
00:23:11.089 --> 00:23:15.829
in a nursing home, are exponential.

474
00:23:15.829 --> 00:23:19.049
Three months and people go into

475
00:23:19.049 --> 00:23:23.129
amazing rates of psychotropic medication.

476
00:23:23.129 --> 00:23:27.589
People that had never had
a mental health problem

477
00:23:27.589 --> 00:23:29.509
in their life, and suddenly they're coming

478
00:23:29.509 --> 00:23:31.509
into nursing homes and are getting

479
00:23:31.509 --> 00:23:33.309
psychotropic medications.

480
00:23:33.309 --> 00:23:35.889
And maybe some needed it, but we were

481
00:23:35.889 --> 00:23:38.509
so concerned that this report covers,

482
00:23:38.509 --> 00:23:41.829
we need to do something rapidly.

483
00:23:41.829 --> 00:23:43.109
But I mean rapidly.

484
00:23:43.109 --> 00:23:45.510
And the work force is not there.

485
00:23:45.510 --> 00:23:49.270
We don't have our work force
trained for the elders.

486
00:23:49.270 --> 00:23:53.060
No geriatric work force whatsoever.

487
00:23:53.170 --> 00:23:55.990
So, anyone who's here and wants to go into

488
00:23:55.990 --> 00:23:59.950
geriatric social work,
believe me, you have

489
00:23:59.950 --> 00:24:02.430
your career for sure.

490
00:24:02.430 --> 00:24:05.210
I'm not kidding, I'm
not kidding, if you look

491
00:24:05.210 --> 00:24:07.890
at this report, please
look at this report,

492
00:24:07.890 --> 00:24:10.390
you'll be convinced immediately,

493
00:24:10.390 --> 00:24:12.330
but I mean immediately.

494
00:24:12.330 --> 00:24:17.090
I think we have also very
serious problems in what

495
00:24:17.090 --> 00:24:18.970
we have been offering people in terms of

496
00:24:18.970 --> 00:24:20.470
our practice models.

497
00:24:20.470 --> 00:24:22.770
I'm very concerned our practice models

498
00:24:22.770 --> 00:24:26.630
are really not made for
immigrant populations.

499
00:24:26.630 --> 00:24:28.750
The idea that you can get someone

500
00:24:28.750 --> 00:24:33.750
to come 16 times, 16 times
during three months for care,

501
00:24:35.350 --> 00:24:37.790
it's someone that really does not know

502
00:24:37.790 --> 00:24:40.850
the life of an immigrant family.

503
00:24:40.850 --> 00:24:44.030
So it's, some of the
concerns that they raise

504
00:24:44.030 --> 00:24:45.770
are real concerns.

505
00:24:45.770 --> 00:24:47.830
The other thing is that there is

506
00:24:47.830 --> 00:24:50.790
a lack of understanding
of the unique stressors

507
00:24:50.790 --> 00:24:52.930
that immigrants go through.

508
00:24:52.930 --> 00:24:55.170
All the issues of acculturation,

509
00:24:55.170 --> 00:24:56.890
all the issues that have to do with

510
00:24:56.890 --> 00:24:59.750
the living circumstances of immigrants

511
00:24:59.750 --> 00:25:03.510
are so unique, and I think it's an area

512
00:25:03.510 --> 00:25:05.910
that we need to train more people

513
00:25:05.910 --> 00:25:08.910
so they can really understand and talk

514
00:25:08.910 --> 00:25:11.050
to their clients, you know, like,

515
00:25:11.050 --> 00:25:13.210
we know about what you're talking about.

516
00:25:13.210 --> 00:25:15.430
There's also time limitations.

517
00:25:15.430 --> 00:25:18.030
Actually, we did some
work on trying to see

518
00:25:18.030 --> 00:25:21.210
what patients value, and
it's really interesting

519
00:25:21.210 --> 00:25:24.610
because one of the differences
I've even presented here.

520
00:25:24.610 --> 00:25:26.890
But one of the big differences we find

521
00:25:26.890 --> 00:25:30.470
between white, Latinos,
and African Americans,

522
00:25:30.470 --> 00:25:33.150
is that minority people value time

523
00:25:33.150 --> 00:25:34.990
while whites value more, how much

524
00:25:34.990 --> 00:25:37.373
it's going to cost me.

525
00:25:37.373 --> 00:25:39.793
But isn't it interesting that time

526
00:25:39.793 --> 00:25:43.053
is the big, if you tell
people you're going to

527
00:25:43.053 --> 00:25:47.453
come for 16 sessions, they
go like, not a chance.

528
00:25:47.453 --> 00:25:49.633
So I was telling Maria that we have now

529
00:25:49.633 --> 00:25:52.873
a clinical trial, which by the way, Judy,

530
00:25:52.873 --> 00:25:55.493
that's here, is one of the clinicians,

531
00:25:55.493 --> 00:25:57.073
so she can tell you more about it,

532
00:25:57.073 --> 00:25:59.233
but one of the things we do now,

533
00:25:59.233 --> 00:26:01.833
is we tell people it's 10 sessions.

534
00:26:01.833 --> 00:26:04.433
And if people say no way, no way I'm going

535
00:26:04.433 --> 00:26:08.153
to 10 sessions, we go,
how about if you try two?

536
00:26:08.153 --> 00:26:11.443
Try two, and if you don't
like it, you're done.

537
00:26:11.733 --> 00:26:14.333
But try two, so it's a different concept

538
00:26:14.333 --> 00:26:16.093
of you have to have a commitment,

539
00:26:16.093 --> 00:26:19.173
a lifetime commitment to treatment.

540
00:26:19.173 --> 00:26:22.233
Because people see time as something

541
00:26:22.233 --> 00:26:24.473
so serious and of the essence.

542
00:26:24.473 --> 00:26:27.073
The other thing is, they have less access

543
00:26:27.073 --> 00:26:29.333
to prescription medications.

544
00:26:29.333 --> 00:26:32.173
And one of the things you better find out

545
00:26:32.173 --> 00:26:34.833
is what are they taking,
because believe me,

546
00:26:34.833 --> 00:26:37.133
one of the biggest problems we're finding

547
00:26:37.133 --> 00:26:41.273
in minority communities
is benzodiazepines.

548
00:26:41.273 --> 00:26:45.113
People are taking benzodiazepines
like there's no tomorrow.

549
00:26:45.113 --> 00:26:48.573
And it's a big, big
problem, as a recent JAMA

550
00:26:48.573 --> 00:26:50.073
article pointed out.

551
00:26:50.073 --> 00:26:52.373
People are just trying benzodiazepines

552
00:26:52.373 --> 00:26:54.693
as a way to cope.

553
00:26:54.693 --> 00:26:57.633
The other issue we're
finding, it's very hard

554
00:26:57.633 --> 00:27:00.533
to convince some of this
immigrant populations

555
00:27:00.533 --> 00:27:02.574
that self-care is important.

556
00:27:02.574 --> 00:27:04.974
That if you can't take care of yourself,

557
00:27:04.974 --> 00:27:06.794
you can't take care of your children,

558
00:27:06.794 --> 00:27:09.374
you can't take care of your jobs,

559
00:27:09.374 --> 00:27:11.954
because they actually believe that they

560
00:27:11.954 --> 00:27:16.084
are of very low priority in the
things that they're housing.

561
00:27:16.134 --> 00:27:18.294
They're being evicted from their homes.

562
00:27:18.294 --> 00:27:21.034
They have problems with
their kids at school.

563
00:27:21.034 --> 00:27:24.774
They're having problems in terms
of their domestic violence,

564
00:27:24.774 --> 00:27:28.634
and you're asking them to
take time for themselves,

565
00:27:28.634 --> 00:27:31.654
and that seems like, no way.

566
00:27:31.654 --> 00:27:34.074
The other thing that we
have is they typically

567
00:27:34.074 --> 00:27:36.214
have multiple jobs, so one of the problems

568
00:27:36.214 --> 00:27:39.274
we're seeing is people cannot tell you

569
00:27:39.274 --> 00:27:41.234
when they can see you.

570
00:27:41.234 --> 00:27:44.674
So the idea of an appointment does not

571
00:27:44.674 --> 00:27:47.334
become operant in this population.

572
00:27:47.334 --> 00:27:50.395
They get called in the
morning and they are told

573
00:27:50.395 --> 00:27:52.895
that morning at what time they have to

574
00:27:52.895 --> 00:27:54.535
be in their jobs.

575
00:27:54.535 --> 00:27:56.595
So if you, if they have to choose

576
00:27:56.595 --> 00:27:59.315
between your appointment or their job,

577
00:27:59.315 --> 00:28:01.456
guess what's going to win?

578
00:28:01.456 --> 00:28:04.776
So the idea of making an appointment

579
00:28:04.776 --> 00:28:07.696
for next week, it's not operant.

580
00:28:07.696 --> 00:28:10.716
So what we do is, we actually accommodate

581
00:28:10.716 --> 00:28:13.256
to your time, and you call us and then

582
00:28:13.256 --> 00:28:16.426
we try to set you up
that day if necessary.

583
00:28:16.656 --> 00:28:18.306
It's a very different approach.

584
00:28:19.456 --> 00:28:21.996
And then, they typically have to pay

585
00:28:21.996 --> 00:28:24.476
more out of pockets because they typically

586
00:28:24.476 --> 00:28:29.176
are underinsured, if they're
in employer-based insurance.

587
00:28:29.176 --> 00:28:32.306
So they have to pay for more.

588
00:28:32.656 --> 00:28:37.296
We also see like I said,
treatments are too long,

589
00:28:37.296 --> 00:28:41.116
they require a high
level of health literacy,

590
00:28:41.116 --> 00:28:43.496
there are actually very few treatments

591
00:28:43.496 --> 00:28:48.496
that address non-language English, LEP,

592
00:28:48.516 --> 00:28:51.976
linguistic, people that
don't have language

593
00:28:51.976 --> 00:28:53.996
English proficiency.

594
00:28:53.996 --> 00:28:55.696
So we have, one of the problems is,

595
00:28:55.696 --> 00:28:57.856
changing everything and being able

596
00:28:57.856 --> 00:29:01.176
to provide care in the language you speak.

597
00:29:01.176 --> 00:29:03.376
And let me tell you
the importance of that.

598
00:29:03.376 --> 00:29:05.816
The IOM did a committee of what is

599
00:29:05.816 --> 00:29:08.516
the language you need to get good care.

600
00:29:08.516 --> 00:29:12.456
And unless you can
speak English very well,

601
00:29:12.456 --> 00:29:16.356
very well, not well,
very well, you should not

602
00:29:16.356 --> 00:29:20.136
be having your therapy in that language.

603
00:29:20.136 --> 00:29:22.356
Because there's obvious
that there's problems

604
00:29:22.356 --> 00:29:25.536
in diagnosis, problems
in treatment adherence,

605
00:29:25.536 --> 00:29:27.516
problems in misdiag--

606
00:29:27.516 --> 00:29:28.896
You know, all sorts of problems

607
00:29:28.896 --> 00:29:30.796
that are going to happen if you're not

608
00:29:30.796 --> 00:29:33.536
able to speak the language very well.

609
00:29:33.536 --> 00:29:36.256
But ask people, how well is, how,

610
00:29:36.256 --> 00:29:38.276
what is the chance that they can get

611
00:29:38.276 --> 00:29:40.596
the treatment in their language,

612
00:29:40.596 --> 00:29:42.316
in their primary language.

613
00:29:42.316 --> 00:29:43.556
And I don't know if people have

614
00:29:43.556 --> 00:29:45.896
tried going to another country

615
00:29:45.896 --> 00:29:48.756
and translating in your mind, but if you

616
00:29:48.756 --> 00:29:53.116
translate in your mind, you
sound very disorganized.

617
00:29:53.116 --> 00:29:55.396
And when you translate in your mind,

618
00:29:55.396 --> 00:29:57.756
something that's not your language,

619
00:29:57.756 --> 00:30:00.036
what you see is people,
clinicians thinking,

620
00:30:00.036 --> 00:30:02.696
this person has a cognitive impairment.

621
00:30:02.696 --> 00:30:05.136
And they don't have a
cognitive impairment,

622
00:30:05.136 --> 00:30:07.436
they're just translating
in their own mind.

623
00:30:07.436 --> 00:30:10.196
Or people saying, this
person is so disorganized.

624
00:30:10.196 --> 00:30:13.756
They have a real big
problem in disorganization.

625
00:30:13.756 --> 00:30:16.595
But if you have to think and translate

626
00:30:16.595 --> 00:30:19.888
and repeat back, imagine how hard it is.

627
00:30:20.218 --> 00:30:21.808
Imagine how hard it is.

628
00:30:22.118 --> 00:30:24.337
I tell people I fight
with my, when I fight

629
00:30:24.337 --> 00:30:26.557
with my husband, it
takes me double the time.

630
00:30:26.557 --> 00:30:27.438
(laughter)

631
00:30:27.438 --> 00:30:29.718
Because I have to think
about what I want to say,

632
00:30:29.718 --> 00:30:31.838
and then say it in English, and it's

633
00:30:31.838 --> 00:30:33.498
really more complicated.

634
00:30:33.498 --> 00:30:36.138
And by the time you say it,
it doesn't sound the same.

635
00:30:36.138 --> 00:30:38.457
I tell him, he's at an advantage.

636
00:30:38.457 --> 00:30:41.798
But he says no, I'm still
at an advantage fighting.

637
00:30:41.798 --> 00:30:43.287
So...

638
00:30:43.517 --> 00:30:46.617
I think the other thing
is, we have a lot of things

639
00:30:46.617 --> 00:30:49.678
that people, when they
are talking in treatment,

640
00:30:49.678 --> 00:30:52.798
are things that you might
miss, like things about

641
00:30:52.798 --> 00:30:55.978
social mobility, or remittances.

642
00:30:55.978 --> 00:30:58.417
How you have to send
money to your country.

643
00:30:58.417 --> 00:31:01.238
Or how you're taking
care of your grandmother,

644
00:31:01.238 --> 00:31:03.778
the aunt, and the other, and you're only

645
00:31:03.778 --> 00:31:06.138
15 years old and you're taking care

646
00:31:06.138 --> 00:31:07.898
of a lot of family.

647
00:31:07.898 --> 00:31:10.618
You have to talk about separation.

648
00:31:10.618 --> 00:31:13.038
The issue of the narrative of separation,

649
00:31:13.038 --> 00:31:17.757
we're now doing some
help for the (unclear)

650
00:31:17.757 --> 00:31:19.897
Cambridge School system, who had 800

651
00:31:19.897 --> 00:31:23.478
unaccompanied minors
in the last two years.

652
00:31:23.478 --> 00:31:28.018
And the issues, teachers
are, you know, dying,

653
00:31:28.018 --> 00:31:30.458
because suddenly these kids come,

654
00:31:30.458 --> 00:31:34.678
they're 12, 10, and
they're acting as adults

655
00:31:34.678 --> 00:31:37.377
and they don't want to
be treated as children,

656
00:31:37.377 --> 00:31:39.597
because they've lived on the trains

657
00:31:39.597 --> 00:31:42.398
on their own for two
years, and this person

658
00:31:42.398 --> 00:31:44.498
wants to treat me like a 10-year-old?

659
00:31:44.498 --> 00:31:45.978
Is she kidding me?

660
00:31:45.978 --> 00:31:47.897
And so, all the problems that you have

661
00:31:47.897 --> 00:31:50.877
of this separations and trauma

662
00:31:50.877 --> 00:31:53.778
are not things that people can confront.

663
00:31:53.778 --> 00:31:57.297
The other issue we're
having is language barriers.

664
00:31:57.297 --> 00:32:00.858
Language barriers really are problematic

665
00:32:00.858 --> 00:32:03.097
for therapeutic alliance.

666
00:32:03.097 --> 00:32:06.238
We've actually done
some work, which I think

667
00:32:06.238 --> 00:32:09.937
it's really interesting,
coding the communication

668
00:32:09.937 --> 00:32:14.218
that goes on where the
diet is a different diet.

669
00:32:14.218 --> 00:32:17.918
That is, if you're Latino
and your provider's Latino,

670
00:32:17.918 --> 00:32:21.518
versus if you're white and
your provider is Latino,

671
00:32:21.518 --> 00:32:25.258
versus your provider is
Latino and you're white,

672
00:32:25.258 --> 00:32:27.818
you know all the combinations.

673
00:32:27.818 --> 00:32:29.858
And I can tell you, you won't believe it,

674
00:32:29.858 --> 00:32:33.658
but language is very
different in those diets.

675
00:32:33.658 --> 00:32:36.579
How people spend the time, how people

676
00:32:36.579 --> 00:32:39.339
use the communication, how they use

677
00:32:39.339 --> 00:32:44.199
issues of warmth, affect,
interpersonal dynamics

678
00:32:44.199 --> 00:32:47.139
in that communication
is very very different

679
00:32:47.139 --> 00:32:49.699
depending on the composition of the diet.

680
00:32:49.699 --> 00:32:52.459
And these are things that
people don't understand,

681
00:32:52.459 --> 00:32:55.679
people say, well why are
people so dissatisfied

682
00:32:55.679 --> 00:32:57.759
with the communication
with their providers?

683
00:32:57.759 --> 00:33:01.579
Why are Latinos and African
Americans so dissatisfied?

684
00:33:01.579 --> 00:33:05.299
But it's that the communication
is different in those diets.

685
00:33:05.299 --> 00:33:08.419
There's also issues
about misinterpretations,

686
00:33:08.419 --> 00:33:13.359
I mean, we published two
articles on misinterpretations

687
00:33:13.359 --> 00:33:15.099
in behavioral health care.

688
00:33:15.099 --> 00:33:17.539
And I can tell you they're worth seeing.

689
00:33:17.539 --> 00:33:20.899
Amy Bauer is the first author.

690
00:33:20.899 --> 00:33:23.399
But it's basically
showing you the problems

691
00:33:23.399 --> 00:33:25.819
that there are when the providers

692
00:33:25.819 --> 00:33:27.799
don't speak the same language and

693
00:33:27.799 --> 00:33:30.019
it's through interpreter's services.

694
00:33:30.019 --> 00:33:32.379
And we have all types of interpreters.

695
00:33:32.379 --> 00:33:36.099
Great interpreters, some
average interpreters,

696
00:33:36.099 --> 00:33:38.259
and a lot of lousy interpreters.

697
00:33:38.259 --> 00:33:41.859
And you would be amazed the missing

698
00:33:41.859 --> 00:33:44.619
of information that happens when people

699
00:33:44.619 --> 00:33:47.479
cannot interpret correctly.

700
00:33:47.479 --> 00:33:49.339
So what are some of the key findings

701
00:33:49.339 --> 00:33:50.799
that we find?

702
00:33:50.799 --> 00:33:54.459
So we did a paper, and
this is a shocking paper,

703
00:33:54.459 --> 00:33:57.659
I think it was really
interesting, where we actually,

704
00:33:57.659 --> 00:33:59.919
I'm not going to go
through the whole paper,

705
00:33:59.919 --> 00:34:02.699
but what we find is that
neighborhood clinics

706
00:34:02.699 --> 00:34:07.059
in the area where people
live are really critical.

707
00:34:07.059 --> 00:34:10.019
For example, Latinos, if you think

708
00:34:10.019 --> 00:34:11.839
in terms of disparities reduction.

709
00:34:11.839 --> 00:34:14.459
Latinos utilize community health centers

710
00:34:14.459 --> 00:34:19.459
700, 700 percent higher than whites.

711
00:34:20.019 --> 00:34:23.779
And African Americans use it 550 more

712
00:34:23.779 --> 00:34:26.719
in percentage than whites.

713
00:34:26.719 --> 00:34:30.160
So community clinics are
so central to the lives

714
00:34:30.160 --> 00:34:32.800
of these people that
having community clinics

715
00:34:32.800 --> 00:34:36.700
in their areas can make a huge difference.

716
00:34:36.860 --> 00:34:40.161
However, we actually did simulations

717
00:34:40.161 --> 00:34:43.901
using well, what if you put
a community health clinic

718
00:34:43.901 --> 00:34:45.701
in the neighborhood.

719
00:34:45.701 --> 00:34:50.201
And what if you gave universal
health insurance to people.

720
00:34:50.201 --> 00:34:53.560
And guess what, the sad, sad thing is that

721
00:34:53.560 --> 00:34:57.501
still, 59 to 66 percent of people

722
00:34:57.501 --> 00:35:00.421
would still not go to care.

723
00:35:00.421 --> 00:35:02.721
Would still not go to care.

724
00:35:02.721 --> 00:35:06.201
And what we're thinking
is why would that be?

725
00:35:06.201 --> 00:35:07.741
Why would that be?

726
00:35:07.741 --> 00:35:11.141
And I think one of the
biggest issues that we have

727
00:35:11.141 --> 00:35:14.801
is the patient-provider interaction.

728
00:35:14.801 --> 00:35:17.461
I think we've been doing a lousy job

729
00:35:17.461 --> 00:35:20.941
with our minorities in the system of care,

730
00:35:20.941 --> 00:35:23.991
and not necessarily
having a good experience.

731
00:35:24.921 --> 00:35:27.221
So one of the things that we, I'm going to

732
00:35:27.221 --> 00:35:29.080
aggregate, I'm going to show you now

733
00:35:29.080 --> 00:35:30.981
some of the work that we're doing,

734
00:35:30.981 --> 00:35:34.201
is that people should
leave the clinic walls.

735
00:35:34.201 --> 00:35:36.560
That if we are going to be effective

736
00:35:36.560 --> 00:35:37.741
in what we're doing in terms of

737
00:35:37.741 --> 00:35:40.001
disparities reduction, we have to go

738
00:35:40.001 --> 00:35:42.141
beyond the clinic walls.

739
00:35:42.141 --> 00:35:44.341
We can't wait for people to come to us.

740
00:35:44.341 --> 00:35:46.801
By the time they come to us, they are

741
00:35:46.801 --> 00:35:49.400
so disempowered, and so complex

742
00:35:49.400 --> 00:35:52.141
in their problems, that it's very little

743
00:35:52.141 --> 00:35:53.421
what we can do.

744
00:35:53.421 --> 00:35:55.401
So I think going outside the clinic walls

745
00:35:55.401 --> 00:35:57.560
might be very necessary.

746
00:35:57.560 --> 00:35:59.661
And I'm happy to later on discuss this.

747
00:35:59.661 --> 00:36:03.441
The other thing is that
the safety net pools

748
00:36:03.441 --> 00:36:08.441
are being eroded so quickly, that people

749
00:36:08.521 --> 00:36:13.161
I think, are going to
because we are taking

750
00:36:13.161 --> 00:36:15.761
some of those funds out, I'm very worried

751
00:36:15.761 --> 00:36:17.760
that this, our people are not going to be

752
00:36:17.760 --> 00:36:21.800
included in many of the care.

753
00:36:21.800 --> 00:36:25.640
Very quickly, we know
that supply of providers

754
00:36:25.640 --> 00:36:28.640
can be a great source for
people to access care.

755
00:36:28.640 --> 00:36:32.140
The more provider
availability that we have,

756
00:36:32.140 --> 00:36:36.301
the more likelihood people
are likely to use care.

757
00:36:36.301 --> 00:36:37.761
This is what we're trying.

758
00:36:37.761 --> 00:36:39.441
I'm going to go very quickly to tell you

759
00:36:39.441 --> 00:36:41.200
the things we're trying.

760
00:36:41.200 --> 00:36:42.800
So, we think that you need to do

761
00:36:42.800 --> 00:36:45.161
multi-system interventions.

762
00:36:45.161 --> 00:36:49.022
All the way from
patient-provider interaction,

763
00:36:49.022 --> 00:36:50.542
and I'll tell you a little bit about what

764
00:36:50.542 --> 00:36:52.782
we are doing about that, improving

765
00:36:52.782 --> 00:36:55.642
the patient-provider interaction.

766
00:36:55.642 --> 00:36:57.502
I think you need to do interventions

767
00:36:57.502 --> 00:37:00.442
in clinical care to make
sure that you increase

768
00:37:00.442 --> 00:37:02.842
the evidence based interactions

769
00:37:02.842 --> 00:37:05.282
and clinical care that we provide.

770
00:37:05.282 --> 00:37:09.442
So that there is competency
in evidence-based care,

771
00:37:09.442 --> 00:37:14.082
but also in helping work
with providers, PCPs

772
00:37:14.082 --> 00:37:16.942
so that they can actually
enter people in care.

773
00:37:16.942 --> 00:37:19.162
And then I think we
have to do interventions

774
00:37:19.162 --> 00:37:20.502
at the community.

775
00:37:20.502 --> 00:37:23.662
We're doing a lot of
work, doing interventions

776
00:37:23.662 --> 00:37:26.382
in community agencies where we bring

777
00:37:26.382 --> 00:37:28.922
the providers to the community agencies

778
00:37:28.922 --> 00:37:32.822
to provide the care before
people get very sick.

779
00:37:32.822 --> 00:37:34.702
So it's actually training people

780
00:37:34.702 --> 00:37:38.422
in the community agencies to be the people

781
00:37:38.422 --> 00:37:41.842
that provide the first line of services

782
00:37:41.842 --> 00:37:44.262
and refer cases that are more severe

783
00:37:44.262 --> 00:37:46.822
to actually professionals as a way

784
00:37:46.822 --> 00:37:49.702
to try to intervene with bringing in

785
00:37:49.702 --> 00:37:53.082
community capacity and
building community capacity

786
00:37:53.082 --> 00:37:55.902
to make sure that people
are serviced early on.

787
00:37:55.902 --> 00:37:58.202
And then we have, I
think we have to do more

788
00:37:58.202 --> 00:38:00.602
in policy and market forces, especially

789
00:38:00.602 --> 00:38:03.602
market forces, we're
talking more about policy,

790
00:38:03.602 --> 00:38:05.502
but I don't think we have done enough

791
00:38:05.502 --> 00:38:08.702
market forces in terms of trying to work

792
00:38:08.702 --> 00:38:12.182
with how can we get
insurers to do a better job

793
00:38:12.182 --> 00:38:14.052
of what they're doing.

794
00:38:15.082 --> 00:38:17.742
So why are clinicians failing to engage

795
00:38:17.742 --> 00:38:20.192
and retain diverse patients?

796
00:38:20.562 --> 00:38:22.422
I think part of the problem is,

797
00:38:22.422 --> 00:38:24.542
they're really unaware of the patients

798
00:38:24.542 --> 00:38:28.542
cultural interpretations
about what they're talking.

799
00:38:28.542 --> 00:38:31.822
So when they define the
problem for the patient,

800
00:38:31.822 --> 00:38:34.802
there's very little overlap between

801
00:38:34.802 --> 00:38:37.202
how that patient defines the problem

802
00:38:37.202 --> 00:38:40.102
and how the provider defines the problem.

803
00:38:40.102 --> 00:38:41.982
And I think if you don't
have a good overlap

804
00:38:41.982 --> 00:38:45.902
at the startup point,
there's very limited chance

805
00:38:45.902 --> 00:38:47.302
that you're going to make it.

806
00:38:47.302 --> 00:38:50.482
Minorities who perceive that clinicians

807
00:38:50.482 --> 00:38:53.682
do not understand their cultural views

808
00:38:53.682 --> 00:38:56.082
are seven times at higher odds

809
00:38:56.082 --> 00:38:59.122
of ending treatment prematurely.

810
00:38:59.122 --> 00:39:01.622
So this is a basic, basic thing,

811
00:39:01.622 --> 00:39:04.822
and it's not necessarily
only cultural formulation,

812
00:39:04.822 --> 00:39:07.842
it's actually making
sure that when you use,

813
00:39:07.842 --> 00:39:11.242
when you're defining the
problem for that Asian,

814
00:39:11.242 --> 00:39:14.082
that you're using the
same words, that you're

815
00:39:14.082 --> 00:39:17.442
explaining the problem
from the same narrative,

816
00:39:17.442 --> 00:39:20.202
that you're using the situational examples

817
00:39:20.202 --> 00:39:23.542
that that patient says
that they're having,

818
00:39:23.542 --> 00:39:27.422
so there's a big overlap in that narrative

819
00:39:27.422 --> 00:39:29.462
and the narrative of the patient.

820
00:39:29.462 --> 00:39:31.402
Because if not, you're going to lose them.

821
00:39:31.402 --> 00:39:34.202
So this is an example of
one of the interventions

822
00:39:34.202 --> 00:39:37.282
we have done, it's called
a decida intervention,

823
00:39:37.282 --> 00:39:40.142
and it's an intervention
to try to make sure

824
00:39:40.142 --> 00:39:42.822
that patients can tell you about

825
00:39:42.822 --> 00:39:47.122
what they want in care,
what they want in care,

826
00:39:47.122 --> 00:39:51.662
and it's their agenda that
gets serviced in care.

827
00:39:51.662 --> 00:39:54.122
It's called decida, and basically it's

828
00:39:54.122 --> 00:39:58.422
a patient activation and
self-management intervention.

829
00:39:58.422 --> 00:40:01.482
And the general idea is, you help patients

830
00:40:01.482 --> 00:40:05.422
to formulate questions to their provider

831
00:40:05.422 --> 00:40:08.182
as a way to make sure that they say

832
00:40:08.182 --> 00:40:10.942
what's of interest to them, what they want

833
00:40:10.942 --> 00:40:14.062
to cover in the session,
what are their questions

834
00:40:14.062 --> 00:40:18.322
that they have, so we teach
them how to formulate questions,

835
00:40:18.322 --> 00:40:21.562
how to focus on key decisions, and this

836
00:40:21.562 --> 00:40:23.402
is a very big change.

837
00:40:23.402 --> 00:40:25.642
Because people think about care

838
00:40:25.642 --> 00:40:29.062
as people come and vent out, right?

839
00:40:29.062 --> 00:40:32.603
But if you think about
care as key decisions

840
00:40:32.603 --> 00:40:35.163
in your life, in your treatment,

841
00:40:35.163 --> 00:40:38.263
in your relationships, and your options,

842
00:40:38.263 --> 00:40:40.163
what are your options?

843
00:40:40.163 --> 00:40:42.343
What are your options that you have

844
00:40:42.343 --> 00:40:44.703
in those areas, that's actually

845
00:40:44.703 --> 00:40:46.783
empowering to the patient.

846
00:40:46.783 --> 00:40:48.423
That really activates the patient

847
00:40:48.423 --> 00:40:49.943
and gives them a source.

848
00:40:49.943 --> 00:40:52.443
And then how to manage disease,

849
00:40:52.443 --> 00:40:53.483
their own disease.

850
00:40:53.483 --> 00:40:56.083
The more people know about their illness,

851
00:40:56.083 --> 00:40:57.683
the better they can do questions

852
00:40:57.683 --> 00:41:00.903
and be activated in their care.

853
00:41:00.903 --> 00:41:03.563
So, we, I'm not going to cover this,

854
00:41:03.563 --> 00:41:06.803
but we actually do only three trainings,

855
00:41:06.803 --> 00:41:09.463
they're 45 minutes by a care manager,

856
00:41:09.463 --> 00:41:11.163
someone that's trained in this,

857
00:41:11.163 --> 00:41:14.863
and we teach the, the care manager

858
00:41:14.863 --> 00:41:17.543
teaches the patient how to do questions

859
00:41:17.543 --> 00:41:21.723
and we've actually shown
that it works very well.

860
00:41:21.723 --> 00:41:24.063
We've actually published saying it

861
00:41:24.063 --> 00:41:25.043
works very well.

862
00:41:25.043 --> 00:41:27.464
Let me tell you what happened, however.

863
00:41:27.464 --> 00:41:32.464
We only got somewhat,
not really strong effect,

864
00:41:32.624 --> 00:41:35.104
and we went back and did focus groups

865
00:41:35.104 --> 00:41:36.664
with patients trying to figure out

866
00:41:36.664 --> 00:41:38.464
well, what's going on?

867
00:41:38.464 --> 00:41:40.624
Well what we found is, providers

868
00:41:40.624 --> 00:41:43.584
were not happy with
activating their patients.

869
00:41:43.584 --> 00:41:44.184
(laughter)

870
00:41:44.184 --> 00:41:46.064
They really don't like people that come

871
00:41:46.064 --> 00:41:48.204
with their sessions, to their sessions

872
00:41:48.204 --> 00:41:51.464
with a list of questions, priorities,

873
00:41:51.464 --> 00:41:53.684
and want to discuss these things.

874
00:41:53.684 --> 00:41:56.104
It was really, really challenging.

875
00:41:56.104 --> 00:41:58.805
So, we started getting people saying,

876
00:41:58.805 --> 00:42:01.585
what are you doing with my patients?

877
00:42:01.585 --> 00:42:05.065
They're asking me what
diagnosis do they have,

878
00:42:05.065 --> 00:42:06.485
they've been in care for 10 years,

879
00:42:06.485 --> 00:42:08.265
this is the first time they've asked me

880
00:42:08.265 --> 00:42:09.625
what diagnosis they have.

881
00:42:09.625 --> 00:42:13.285
Why I am not in this clinical trial.

882
00:42:13.285 --> 00:42:15.485
Why are you giving me this medication?

883
00:42:15.485 --> 00:42:17.765
I found out that there's three other types

884
00:42:17.765 --> 00:42:20.165
of medications that have less side effects

885
00:42:20.165 --> 00:42:22.865
and now you're bringing
me this medication.

886
00:42:22.865 --> 00:42:25.765
So, the thing we had is providers

887
00:42:25.765 --> 00:42:28.305
were not necessarily that happy,

888
00:42:28.305 --> 00:42:29.905
and in fact some providers actually

889
00:42:29.905 --> 00:42:31.905
were very unhappy.

890
00:42:31.905 --> 00:42:36.825
So now we're actually doing
intervention for providers.

891
00:42:36.825 --> 00:42:41.825
And I can tell you, doing
patients is a piece of cake.

892
00:42:44.085 --> 00:42:46.885
Try doing interventions with providers.

893
00:42:46.885 --> 00:42:49.785
This is a coaching that we give providers.

894
00:42:49.785 --> 00:42:51.485
And what we did with providers,

895
00:42:51.485 --> 00:42:54.185
is we audiotaped their sessions.

896
00:42:54.185 --> 00:42:55.765
And give them feedback.

897
00:42:55.765 --> 00:42:58.365
By coding their sessions and giving them

898
00:42:58.365 --> 00:43:02.145
direct feedback of what they're doing.

899
00:43:02.145 --> 00:43:06.465
And believe me, they are like, oh my god.

900
00:43:06.465 --> 00:43:08.945
Because you send them a page and then

901
00:43:08.945 --> 00:43:10.845
you call them on the
phone, and you tell them

902
00:43:10.845 --> 00:43:12.665
okay, look at your feedback.

903
00:43:12.665 --> 00:43:15.545
And it's a life-changing experience.

904
00:43:15.545 --> 00:43:17.105
You could say.

905
00:43:17.105 --> 00:43:20.785
So, I think patient
activation and self-management

906
00:43:20.785 --> 00:43:24.365
is critical to help patients
have their own voice

907
00:43:24.365 --> 00:43:26.665
and get the care that they want,

908
00:43:26.665 --> 00:43:29.465
not the care that you're
planning to give them.

909
00:43:29.465 --> 00:43:32.805
Which is a big change of alternatives.

910
00:43:32.805 --> 00:43:37.125
I think we need to test
good evidence-based care,

911
00:43:37.125 --> 00:43:40.365
that people can receive
in a low-resource setting.

912
00:43:40.365 --> 00:43:42.425
I think we can't think
that people are going to

913
00:43:42.425 --> 00:43:45.465
go to NGH, or they're going
to go, we have to think

914
00:43:45.465 --> 00:43:49.505
of what can we give that's
low-resource, high quality?

915
00:43:49.505 --> 00:43:51.985
High quality, good care.

916
00:43:51.985 --> 00:43:53.465
And that's what we're trying to do,

917
00:43:53.465 --> 00:43:56.025
make sure that they
get really good quality

918
00:43:56.025 --> 00:43:59.025
and that clinicians have a back up,

919
00:43:59.025 --> 00:44:02.065
a real good back up, so you get stuck,

920
00:44:02.065 --> 00:44:06.065
you get the resources and
the supervision needed.

921
00:44:06.065 --> 00:44:09.425
The next thing I wanted to tell you is,

922
00:44:09.425 --> 00:44:12.146
trying to make sure that our interventions

923
00:44:12.146 --> 00:44:15.666
are actually interventions
that are tailored,

924
00:44:15.666 --> 00:44:18.226
culturally tailored to that population.

925
00:44:18.226 --> 00:44:22.906
So what we're doing is, this
is a depression intervention.

926
00:44:22.906 --> 00:44:26.206
It's very short, it's only six sessions.

927
00:44:26.206 --> 00:44:28.806
Actually, Judy again was part of our

928
00:44:28.806 --> 00:44:32.886
spectacular clinician
team of social workers

929
00:44:32.886 --> 00:44:34.806
and psychologists that were trained

930
00:44:34.806 --> 00:44:37.546
on this intervention, it is very short,

931
00:44:37.546 --> 00:44:38.909
as you can imagine.

932
00:44:38.909 --> 00:44:41.309
And then the other thing we tested it,

933
00:44:41.309 --> 00:44:44.009
can it be given by phone?

934
00:44:44.009 --> 00:44:47.609
So we randomized to
having the intervention

935
00:44:47.609 --> 00:44:49.889
by phone, or in person.

936
00:44:49.889 --> 00:44:53.629
And the end story is that basically,

937
00:44:53.629 --> 00:44:56.929
so we did, before I tell
you how we actually did

938
00:44:56.929 --> 00:45:00.589
the cultural adaptation, we adapted

939
00:45:00.589 --> 00:45:04.909
the training in terms of
language, culture and context.

940
00:45:04.909 --> 00:45:08.889
So we made it very, very
tailored to where they are.

941
00:45:08.889 --> 00:45:11.389
We looked at issues that have meanings

942
00:45:11.389 --> 00:45:13.109
and values to people.

943
00:45:13.109 --> 00:45:16.309
So we use analogies that
people would understand

944
00:45:16.309 --> 00:45:21.309
as having meaning in their country.

945
00:45:21.369 --> 00:45:26.090
We actually train
master-level social workers

946
00:45:26.090 --> 00:45:29.810
and psychologists a six to eight session,

947
00:45:29.810 --> 00:45:34.710
and it's actually committed
behavioral training.

948
00:45:34.710 --> 00:45:36.890
It's actually information on depression

949
00:45:36.890 --> 00:45:38.950
and motivational interviewing.

950
00:45:38.950 --> 00:45:43.230
But one key issue, one
key issue that we added

951
00:45:43.230 --> 00:45:46.490
is care management services
for other problems.

952
00:45:46.490 --> 00:45:49.530
Because if you think about
it, behavioral health

953
00:45:49.530 --> 00:45:52.030
is only one aspect of their life.

954
00:45:52.030 --> 00:45:53.270
These are people that have problems

955
00:45:53.270 --> 00:45:56.330
with housing, with legal authorities,

956
00:45:56.330 --> 00:45:58.470
with you name it, they have it.

957
00:45:58.470 --> 00:46:01.110
So this is a care manager that would serve

958
00:46:01.110 --> 00:46:02.670
for the other things.

959
00:46:02.670 --> 00:46:06.510
I want to show you how
we change the manual

960
00:46:06.510 --> 00:46:08.850
because instead of showing people

961
00:46:08.850 --> 00:46:12.010
things that were very wordy, and very like

962
00:46:12.010 --> 00:46:16.150
conceptually driven, we
use a lot of visual images.

963
00:46:16.150 --> 00:46:18.730
To convey the messages, and make it,

964
00:46:18.730 --> 00:46:20.250
like negative thoughts.

965
00:46:20.250 --> 00:46:22.690
When we pilot-tested the intervention,

966
00:46:22.690 --> 00:46:24.730
people were like, well I really like

967
00:46:24.730 --> 00:46:26.630
your intervention, but I never got

968
00:46:26.630 --> 00:46:28.450
what was negative thoughts.

969
00:46:28.450 --> 00:46:30.110
And that's like critical.

970
00:46:30.110 --> 00:46:31.550
If you don't understand negative thoughts,

971
00:46:31.550 --> 00:46:33.850
it's the big piece of the intervention.

972
00:46:33.850 --> 00:46:36.850
So we have to create images to tell people

973
00:46:36.850 --> 00:46:39.010
about negative thoughts.

974
00:46:39.010 --> 00:46:41.690
And then we did a lot for health literacy,

975
00:46:41.690 --> 00:46:45.030
because actually, 30 percent of our sample

976
00:46:45.030 --> 00:46:50.030
actually had less than
sixth grade education.

977
00:46:50.130 --> 00:46:52.931
Okay, so one of the things
you have to think about,

978
00:46:52.931 --> 00:46:54.571
and we actually had like three cases

979
00:46:54.571 --> 00:46:56.971
where people didn't read at all.

980
00:46:56.971 --> 00:46:59.471
So the idea of giving homework,

981
00:46:59.471 --> 00:47:00.971
take this and read it in your house

982
00:47:00.971 --> 00:47:03.591
and come back, was non-existent.

983
00:47:03.591 --> 00:47:05.991
So clinicians had to think very carefully

984
00:47:05.991 --> 00:47:07.531
what they do.

985
00:47:07.531 --> 00:47:11.151
Basically, we found that people that were

986
00:47:11.151 --> 00:47:13.751
in the phone were much more likely

987
00:47:13.751 --> 00:47:18.531
to initiate care than
people that were in person.

988
00:47:18.531 --> 00:47:22.031
So given the option of having
the intervention by phone

989
00:47:22.031 --> 00:47:25.351
really made a big difference
in initiating care.

990
00:47:25.351 --> 00:47:27.691
We lost 21.5 percent of people

991
00:47:27.691 --> 00:47:30.411
that never came to care
compared to only 10 percent

992
00:47:30.411 --> 00:47:32.251
when we used the phone.

993
00:47:32.251 --> 00:47:33.811
So you make a big difference.

994
00:47:33.811 --> 00:47:38.111
But we actually found not
only meaningful reductions

995
00:47:38.111 --> 00:47:40.491
in depression, but we actually found

996
00:47:40.491 --> 00:47:44.051
meaningful reductions in
anxiety symptoms, too.

997
00:47:44.051 --> 00:47:48.391
So it's one of these
types of interventions

998
00:47:48.391 --> 00:47:53.041
that's good for depression
and for anxiety.

999
00:47:54.132 --> 00:47:56.042
So this is the story.

1000
00:47:56.412 --> 00:47:58.252
One of the things that people loved

1001
00:47:58.252 --> 00:48:00.152
is the idea that they could take

1002
00:48:00.152 --> 00:48:03.852
the intervention on their phone in the bus

1003
00:48:03.852 --> 00:48:06.692
going to work, they could take it,

1004
00:48:06.692 --> 00:48:09.092
believe it or not, in their car,

1005
00:48:09.092 --> 00:48:10.432
driving to work.

1006
00:48:10.432 --> 00:48:12.192
People could take it at lunch,

1007
00:48:12.192 --> 00:48:14.612
in their lunch hour, so it took away

1008
00:48:14.612 --> 00:48:19.182
from the demands of
having an intervention.

1009
00:48:19.532 --> 00:48:22.412
I want to finish by the
National Institute of Health,

1010
00:48:22.412 --> 00:48:25.552
I really, really, I'm very worried

1011
00:48:25.552 --> 00:48:28.482
on how we're focusing, oops.

1012
00:48:29.992 --> 00:48:34.792
We're focusing so much
on the biological body

1013
00:48:34.792 --> 00:48:37.692
and so little on the social component

1014
00:48:37.692 --> 00:48:39.892
of people's lives and how this

1015
00:48:39.892 --> 00:48:42.672
is going to have terrible repercussions.

1016
00:48:42.672 --> 00:48:46.672
So we're focused on
illness, not on wellness,

1017
00:48:46.672 --> 00:48:49.032
and we're really losing the point

1018
00:48:49.032 --> 00:48:52.802
of focusing on how can we view this?

1019
00:48:53.632 --> 00:48:57.972
I also think that we're still on the basic

1020
00:48:57.972 --> 00:49:00.452
science of the brain, but there's

1021
00:49:00.452 --> 00:49:03.802
very little interest for
services and treatments.

1022
00:49:03.972 --> 00:49:06.012
And given everything I've told you,

1023
00:49:06.012 --> 00:49:09.572
this is just, I think, a tragic thing

1024
00:49:09.572 --> 00:49:13.943
of why we don't improve
in our service delivery.

1025
00:49:14.113 --> 00:49:16.373
So I think, rather than think of

1026
00:49:16.373 --> 00:49:19.133
clinical services, which
I think are important,

1027
00:49:19.133 --> 00:49:23.273
I think we also have to
move to community activation

1028
00:49:23.273 --> 00:49:25.893
and actually trying to
get the prevention dollars

1029
00:49:25.893 --> 00:49:28.143
to serve our costs.

1030
00:49:29.434 --> 00:49:33.014
I think that the biggest problem we have

1031
00:49:33.014 --> 00:49:35.894
is that now the institutes
are not spending

1032
00:49:35.894 --> 00:49:38.553
any money on adaptations,
very little money

1033
00:49:38.553 --> 00:49:41.634
on adaptations, very very little money

1034
00:49:41.634 --> 00:49:44.834
on immigrant provider interactions,

1035
00:49:44.834 --> 00:49:48.013
and very little money on diagnosis

1036
00:49:48.013 --> 00:49:49.973
of multi-cultural populations so that

1037
00:49:49.973 --> 00:49:51.574
we can serve them right.

1038
00:49:51.574 --> 00:49:54.364
So to me this is a huge problem.

1039
00:49:54.553 --> 00:49:59.094
So, I think if you're lost,
you're in good company.

1040
00:49:59.094 --> 00:50:01.934
Because we're all trying to figure out how

1041
00:50:01.934 --> 00:50:06.774
is it possible that there's
not sufficient information

1042
00:50:06.774 --> 00:50:11.233
to try to improve the care
for immigrant populations

1043
00:50:11.233 --> 00:50:13.924
given everything I've shown you.

1044
00:50:13.974 --> 00:50:18.134
So it's a call for all of you
to advocate for what we need,

1045
00:50:18.134 --> 00:50:22.224
which is more on-service
delivery to improve this.

1046
00:50:22.454 --> 00:50:26.834
So, I don't think we're seeing
that the (unclear) phase

1047
00:50:26.834 --> 00:50:30.033
of addressing language, I
don't think they're excluding

1048
00:50:30.033 --> 00:50:34.034
socio-cultural factors in
thinking about the illness,

1049
00:50:34.034 --> 00:50:37.394
and who gets invited?

1050
00:50:37.394 --> 00:50:41.134
I mention this because who gets invited

1051
00:50:41.134 --> 00:50:43.874
to say what's important priority?

1052
00:50:43.874 --> 00:50:47.333
If I invite 20
neuroscientists to come to me

1053
00:50:47.333 --> 00:50:48.654
and tell me, what do you think

1054
00:50:48.654 --> 00:50:52.613
is the most important
topics for mental health

1055
00:50:52.613 --> 00:50:55.234
today, guess what, you're going to get

1056
00:50:55.234 --> 00:50:57.434
neuroscience topics.

1057
00:50:57.434 --> 00:51:00.834
So we need to have more social workers

1058
00:51:00.834 --> 00:51:04.534
in the picture, saying how social context

1059
00:51:04.534 --> 00:51:07.594
is such an important aspect,
and social conditions

1060
00:51:07.594 --> 00:51:10.734
are such an important context in life.

1061
00:51:10.734 --> 00:51:15.393
So I think future
generations assigned the,

1062
00:51:15.393 --> 00:51:17.854
are going to say, how could well-meaning

1063
00:51:17.854 --> 00:51:20.934
and highly-educated researches working

1064
00:51:20.934 --> 00:51:23.193
in their usual circumstances, studying

1065
00:51:23.193 --> 00:51:25.814
diverse populations of patients,

1066
00:51:25.814 --> 00:51:28.074
create a pattern of results that appears

1067
00:51:28.074 --> 00:51:31.293
to be discriminatory and not well-suited

1068
00:51:31.293 --> 00:51:33.894
to represent their problems and solutions

1069
00:51:33.894 --> 00:51:37.254
to their mental health service needs?

1070
00:51:37.254 --> 00:51:38.654
So thank you.

1071
00:51:38.654 --> 00:51:40.765
(applause)

1072
00:51:48.055 --> 00:51:49.985
So I'm very happy to take questions.

1073
00:51:51.175 --> 00:51:52.185
Yes.

1074
00:51:52.715 --> 00:51:54.645
(inaudible question)

1075
00:52:10.755 --> 00:52:12.435
I completely agree.

1076
00:52:12.435 --> 00:52:15.755
But in between the transition, in between

1077
00:52:15.755 --> 00:52:17.995
the transition, I think
it's really important

1078
00:52:17.995 --> 00:52:22.935
to train the work force that is now

1079
00:52:22.935 --> 00:52:26.595
on how to do a better
patient-provider interaction.

1080
00:52:26.595 --> 00:52:29.935
Because I think, I mean, again, I think

1081
00:52:29.935 --> 00:52:31.595
it's very courageous by the way

1082
00:52:31.595 --> 00:52:34.435
of the clinicians that are
willing to be audiotaped

1083
00:52:34.435 --> 00:52:36.215
and given feedback, I have to tell you,

1084
00:52:36.215 --> 00:52:38.715
I take my hat to them,
because it's not easy

1085
00:52:38.715 --> 00:52:43.155
to lend yourself after
maybe 30 years of practice

1086
00:52:43.155 --> 00:52:46.535
to have someone hear your
tapes and give you feedback.

1087
00:52:46.535 --> 00:52:50.135
But I think that is a critical aspect

1088
00:52:50.135 --> 00:52:51.955
of improving our work force.

1089
00:52:51.955 --> 00:52:55.135
There's one person on
the back, you , yeah.

1090
00:52:55.135 --> 00:52:56.175
And then I'll come here.

1091
00:52:56.175 --> 00:52:59.545
(inaudible question)

1092
00:53:02.315 --> 00:53:03.815
Sure, thanks.

1093
00:53:03.815 --> 00:53:07.135
She's asking if you want to get providers

1094
00:53:07.135 --> 00:53:09.135
out to community agencies, what type

1095
00:53:09.135 --> 00:53:11.725
of community agencies
are you talking about?

1096
00:53:11.875 --> 00:53:13.835
So for example, for the elders,

1097
00:53:13.835 --> 00:53:16.495
we're actually going to elder services.

1098
00:53:16.495 --> 00:53:19.415
Community agencies that treat the elders.

1099
00:53:19.415 --> 00:53:21.175
And what we're doing is, we're working

1100
00:53:21.175 --> 00:53:23.655
right now with six community agencies

1101
00:53:23.655 --> 00:53:27.155
that serve elder, all
ethnic minority elders.

1102
00:53:27.155 --> 00:53:30.775
And we're building
capacity in those agencies

1103
00:53:30.775 --> 00:53:35.335
to provide behavioral
health care of a person

1104
00:53:35.335 --> 00:53:38.275
trained there that we supervise

1105
00:53:38.275 --> 00:53:40.375
and provide the care, and the idea is

1106
00:53:40.375 --> 00:53:43.575
that we'll do that for
the first two years,

1107
00:53:43.575 --> 00:53:45.635
and then the last three years is helping

1108
00:53:45.635 --> 00:53:48.495
the community keep doing it on their own,

1109
00:53:48.495 --> 00:53:52.185
sustaining and being
able to get paid for it.

1110
00:53:52.515 --> 00:53:54.055
That's the strategy.

1111
00:53:54.055 --> 00:53:55.605
There was someone here, yes.

1112
00:53:55.795 --> 00:53:58.745
(inaudible question)

1113
00:54:26.956 --> 00:54:29.556
Yeah, that's a excellent question.

1114
00:54:29.556 --> 00:54:32.496
How about clinicians
that speak the language

1115
00:54:32.496 --> 00:54:34.836
of the patient very well.

1116
00:54:34.836 --> 00:54:38.096
So the jury is out.

1117
00:54:38.096 --> 00:54:40.726
So we don't have an exact answer to this.

1118
00:54:41.056 --> 00:54:44.856
It seems that it varies
more for some populations

1119
00:54:44.856 --> 00:54:46.366
than for others.

1120
00:54:46.776 --> 00:54:50.016
And we actually don't
understand why is that.

1121
00:54:50.016 --> 00:54:54.156
So there's some evidence
that it does matter

1122
00:54:54.156 --> 00:54:57.456
for certain groups more like, for example,

1123
00:54:57.456 --> 00:55:00.336
and I'll, the data
that's out there suggests

1124
00:55:00.336 --> 00:55:04.476
that for Latinos, it's
actually good enough.

1125
00:55:04.476 --> 00:55:07.496
But for other populations, it's not.

1126
00:55:07.496 --> 00:55:08.936
Like Asians.

1127
00:55:08.936 --> 00:55:11.096
They're not finding the same results

1128
00:55:11.096 --> 00:55:14.076
in the study that they
have done on Asians.

1129
00:55:14.076 --> 00:55:15.776
Why is that?

1130
00:55:15.776 --> 00:55:18.756
I mean first of all, there's
not tons of studies on this

1131
00:55:18.756 --> 00:55:23.756
to start, but the idea is
maybe it's more difficult.

1132
00:55:24.016 --> 00:55:27.396
Because it's not only, I
want to be clear about this,

1133
00:55:27.396 --> 00:55:32.396
it's not only the linguistic
proficiency of the provider,

1134
00:55:32.817 --> 00:55:35.917
but there's something about how you speak,

1135
00:55:35.917 --> 00:55:39.457
how you relate, how
you, all the non-verbal.

1136
00:55:39.457 --> 00:55:41.377
That might be very important.

1137
00:55:41.377 --> 00:55:43.777
For some reason, don't ask me why,

1138
00:55:43.777 --> 00:55:46.537
it's not as important with Latinos,

1139
00:55:46.537 --> 00:55:48.857
at least the evidence that has come out.

1140
00:55:48.857 --> 00:55:51.877
And some people think it has to do with,

1141
00:55:51.877 --> 00:55:53.657
Latinos are one of the groups that have

1142
00:55:53.657 --> 00:55:58.657
higher inter-racial
marriages, so it might be

1143
00:55:59.337 --> 00:56:03.377
that they're for some reason more open,

1144
00:56:03.377 --> 00:56:05.317
I don't know, we really don't know.

1145
00:56:05.317 --> 00:56:06.637
But it's a really good question.

1146
00:56:06.637 --> 00:56:08.817
Just to tell you, we did in this study

1147
00:56:08.817 --> 00:56:11.397
that I talked to you about communication,

1148
00:56:11.397 --> 00:56:14.617
look at providers that spoke Spanish

1149
00:56:14.617 --> 00:56:19.417
with Latino patients, their
communication was different.

1150
00:56:19.417 --> 00:56:21.897
So although they spoke the language,

1151
00:56:21.897 --> 00:56:24.287
still their communication was different.

1152
00:56:24.497 --> 00:56:25.817
Yes.

1153
00:56:25.817 --> 00:56:28.667
(inaudible question)

1154
00:56:33.017 --> 00:56:34.907
Care.

1155
00:56:52.878 --> 00:56:54.638
So, I think it's going to be interesting,

1156
00:56:54.638 --> 00:56:56.078
it's still ongoing.

1157
00:56:56.078 --> 00:56:58.278
We did publish recently a paper

1158
00:56:58.278 --> 00:57:01.778
in Psychiatric Services actually on that.

1159
00:57:01.778 --> 00:57:05.838
So it's having a big impact
on screening on Latinos,

1160
00:57:05.838 --> 00:57:08.198
but not on the other groups.

1161
00:57:08.198 --> 00:57:10.898
One, except Brazilians by the way.

1162
00:57:10.898 --> 00:57:14.858
So it's , well, including
Brazilians in the Latino group.

1163
00:57:14.858 --> 00:57:18.078
It's not having an impact screening yet

1164
00:57:18.078 --> 00:57:21.078
on Asians that we're seeing, or in

1165
00:57:21.078 --> 00:57:22.698
African Americans.

1166
00:57:22.698 --> 00:57:26.698
Two, it's only on screening,
so we're not seeing

1167
00:57:26.698 --> 00:57:29.078
the effect in quality.

1168
00:57:29.078 --> 00:57:30.878
So I think it's going
to be really interesting

1169
00:57:30.878 --> 00:57:33.058
seeing whether that also translates

1170
00:57:33.058 --> 00:57:35.078
to quality care.

1171
00:57:35.078 --> 00:57:36.778
So I think we have to be, I mean

1172
00:57:36.778 --> 00:57:38.558
I know everyone's very excited

1173
00:57:38.558 --> 00:57:42.018
about integrated care, and I have to say,

1174
00:57:42.018 --> 00:57:44.258
I'm very skeptical.

1175
00:57:44.258 --> 00:57:46.418
Partly because I'm worried about

1176
00:57:46.418 --> 00:57:51.418
having enough time for the
behavior health component.

1177
00:57:53.538 --> 00:57:55.328
So we'll see what happens.

1178
00:57:55.738 --> 00:57:56.998
Yes.

1179
00:57:56.998 --> 00:58:00.488
(inaudible question)

1180
00:58:15.339 --> 00:58:19.839
Yeah, I actually review
for Katie Willging, who was

1181
00:58:19.839 --> 00:58:22.699
the one who was doing the evaluation.

1182
00:58:22.699 --> 00:58:25.179
I think you have to be careful.

1183
00:58:25.179 --> 00:58:28.379
I don't have an opinion
yet, because the data

1184
00:58:28.379 --> 00:58:32.439
that I saw was actually
at the very beginning.

1185
00:58:32.439 --> 00:58:35.679
I think there is a lot to be learned

1186
00:58:35.679 --> 00:58:39.499
from shamans and from
people that are doing,

1187
00:58:39.499 --> 00:58:43.499
like, if you look at astrologers

1188
00:58:43.499 --> 00:58:45.459
and things like that, why do we

1189
00:58:45.459 --> 00:58:47.559
invest so much money in them?

1190
00:58:47.559 --> 00:58:48.899
I mean it's a big question.

1191
00:58:48.899 --> 00:58:52.199
So actually, when I've
gone to several conferences

1192
00:58:52.199 --> 00:58:54.359
relating to that, because
I was very interested.

1193
00:58:54.359 --> 00:58:57.339
And I mean, they go because they go

1194
00:58:57.339 --> 00:59:00.339
wherever the patient wants to go.

1195
00:59:00.339 --> 00:59:03.379
They respond to the question
the patient has to go.

1196
00:59:03.379 --> 00:59:06.199
But whether they're going to be effective,

1197
00:59:06.199 --> 00:59:11.199
I don't know whether the
integration of native healers

1198
00:59:13.119 --> 00:59:14.299
is going to be important.

1199
00:59:14.299 --> 00:59:16.279
I think for certain populations,

1200
00:59:16.279 --> 00:59:18.459
it has turned out to be very important.

1201
00:59:18.459 --> 00:59:20.799
So for children's asthma, there's

1202
00:59:20.799 --> 00:59:23.339
a very good work that Glorisa Canino did

1203
00:59:23.339 --> 00:59:26.259
on children's asthma,
and integrating healers

1204
00:59:26.259 --> 00:59:27.740
in asthma care.

1205
00:59:27.740 --> 00:59:30.179
And it actually helped to talk,

1206
00:59:30.179 --> 00:59:32.320
because the person felt more open

1207
00:59:32.320 --> 00:59:34.959
to disclosing what they were getting

1208
00:59:34.959 --> 00:59:36.699
from the healers, and sometimes

1209
00:59:36.699 --> 00:59:38.500
there was something that was going to be

1210
00:59:38.500 --> 00:59:40.180
very problematic.

1211
00:59:40.180 --> 00:59:41.520
Or was going to be substituted

1212
00:59:41.520 --> 00:59:43.119
for the actual medication.

1213
00:59:43.119 --> 00:59:45.860
So I think there are
components that are important.

1214
00:59:45.860 --> 00:59:48.320
But I think we have to, all of the same,

1215
00:59:48.320 --> 00:59:51.649
I'm a big believer in evaluating.

1216
00:59:52.220 --> 00:59:53.369
Yes.

1217
00:59:53.419 --> 00:59:57.170
(inaudible question)

1218
01:00:10.839 --> 01:00:12.250
That...

1219
01:00:16.160 --> 01:00:18.060
Can I answer your first one?

1220
01:00:18.060 --> 01:00:21.700
Let me just, you know,
to make sure I answer it.

1221
01:00:21.700 --> 01:00:24.620
So, we, the reason we didn't follow them

1222
01:00:24.620 --> 01:00:27.060
longitudinal, is this
was one of the things,

1223
01:00:27.060 --> 01:00:28.580
I don't know if people heard about it,

1224
01:00:28.580 --> 01:00:31.500
what was it called challenge grants?

1225
01:00:31.500 --> 01:00:33.440
So the government had some money,

1226
01:00:33.440 --> 01:00:35.180
and put out there, well we have,

1227
01:00:35.180 --> 01:00:38.760
write your thing, actually
it's really interesting,

1228
01:00:38.760 --> 01:00:41.860
because this challenge grant
was only for two years.

1229
01:00:41.860 --> 01:00:44.100
Actually then, we had
a known-cost extension

1230
01:00:44.100 --> 01:00:45.899
and took it to three years.

1231
01:00:45.899 --> 01:00:48.730
But we couldn't follow
people for enough time.

1232
01:00:49.320 --> 01:00:51.560
We're now doing the study with the elders

1233
01:00:51.560 --> 01:00:54.820
using the same type of intervention,

1234
01:00:54.820 --> 01:00:56.220
a little more expanded because

1235
01:00:56.220 --> 01:00:57.720
we're including other things.

1236
01:00:57.720 --> 01:01:01.580
But we'll have a chance to
follow people for 12 months.

1237
01:01:01.580 --> 01:01:04.780
We're actually doing a
study on mental health

1238
01:01:04.780 --> 01:01:07.780
substance abuse for people
that have dual pathology

1239
01:01:07.780 --> 01:01:10.040
and those we'll follow for a year.

1240
01:01:10.040 --> 01:01:12.070
So we'll have more information.

1241
01:01:12.780 --> 01:01:16.410
(inaudible question)

1242
01:01:41.541 --> 01:01:44.341
I really am so glad you
asked that question.

1243
01:01:44.341 --> 01:01:46.401
Because I can tell you the first thing

1244
01:01:46.401 --> 01:01:50.441
clinician told us is the phone won't work.

1245
01:01:50.441 --> 01:01:51.981
Because we won't be able to have

1246
01:01:51.981 --> 01:01:55.591
the same therapeutic alliance
as we have in person.

1247
01:01:55.821 --> 01:01:57.701
We actually tested that and found

1248
01:01:57.701 --> 01:02:00.251
that that's not true.

1249
01:02:00.281 --> 01:02:02.061
I think it has, the reason we actually

1250
01:02:02.061 --> 01:02:05.641
describe that in the paper, is we think

1251
01:02:05.641 --> 01:02:09.181
so many of these immigrant populations

1252
01:02:09.181 --> 01:02:12.581
maintain a connection through the phone.

1253
01:02:12.581 --> 01:02:15.021
That they are used to having this

1254
01:02:15.021 --> 01:02:17.221
connection by phone, and in fact,

1255
01:02:17.221 --> 01:02:19.401
what we found in certain cases

1256
01:02:19.401 --> 01:02:21.821
where the provider, this we didn't allow

1257
01:02:21.821 --> 01:02:25.541
if you were in the telephone arm,

1258
01:02:25.541 --> 01:02:27.321
and by the way, clinicians had to be

1259
01:02:27.321 --> 01:02:28.621
in both arms.

1260
01:02:28.621 --> 01:02:30.241
So it was not an effect of clinician

1261
01:02:30.241 --> 01:02:32.001
being one arm and not the other,

1262
01:02:32.001 --> 01:02:33.441
so you have to be in both arms.

1263
01:02:33.441 --> 01:02:36.061
But anyhow, what we found is that

1264
01:02:36.061 --> 01:02:38.781
the therapeutic alliance, there was

1265
01:02:38.781 --> 01:02:41.221
no significant difference
across the two groups.

1266
01:02:41.221 --> 01:02:43.211
And we measure that.

1267
01:02:44.921 --> 01:02:46.301
Questions, yes?

1268
01:02:46.301 --> 01:02:50.511
(inaudible question)

1269
01:03:09.202 --> 01:03:11.782
Yeah, so let me tell you, in clinical care

1270
01:03:11.782 --> 01:03:15.102
it's more difficult, because, I mean,

1271
01:03:15.102 --> 01:03:17.562
and this is where cultural
humility comes in.

1272
01:03:17.562 --> 01:03:19.982
You might say to the
person, I have no clue

1273
01:03:19.982 --> 01:03:22.622
what is this word that you're using.

1274
01:03:22.622 --> 01:03:24.962
Or trying to find out someone that can

1275
01:03:24.962 --> 01:03:26.602
help you with a wording.

1276
01:03:26.602 --> 01:03:29.782
So one of the things,
just for the clinical care

1277
01:03:29.782 --> 01:03:31.902
what we did is, we actually have

1278
01:03:31.902 --> 01:03:34.702
a bilingual committee that is made of

1279
01:03:34.702 --> 01:03:38.462
people from many, many, like
Spanish-speaking countries

1280
01:03:38.462 --> 01:03:40.242
when we were doing Spanish, so it was

1281
01:03:40.242 --> 01:03:42.842
not only like, Puerto Rican Spanish

1282
01:03:42.842 --> 01:03:45.322
or Salvadoran Spanish or whatever.

1283
01:03:45.322 --> 01:03:47.462
And what we do is we put like,

1284
01:03:47.462 --> 01:03:50.462
all these words, slash,
slash, slash, slash.

1285
01:03:50.462 --> 01:03:53.922
So the person can look
when they are doing,

1286
01:03:53.922 --> 01:03:55.302
like which of the words are they

1287
01:03:55.302 --> 01:03:57.642
you know, it's going to be this person

1288
01:03:57.642 --> 01:04:00.162
is from Argentina, well I can start

1289
01:04:00.162 --> 01:04:02.562
doing different words.

1290
01:04:02.562 --> 01:04:05.442
We also, I mean, for questionnaires,

1291
01:04:05.442 --> 01:04:07.982
when we do questionnaires, we actually

1292
01:04:07.982 --> 01:04:11.022
allow what they call throttling.

1293
01:04:11.022 --> 01:04:13.122
So you can go back and forth, and

1294
01:04:13.122 --> 01:04:15.902
the same, it will show
you many, many words.

1295
01:04:15.902 --> 01:04:17.962
And that's how we try to compensate

1296
01:04:17.962 --> 01:04:20.882
for, because there's not one Spanish,

1297
01:04:20.882 --> 01:04:22.962
and there's not one Chinese, and there's

1298
01:04:22.962 --> 01:04:25.223
not one Creole.

1299
01:04:25.223 --> 01:04:26.663
I mean if you think about it, there are

1300
01:04:26.663 --> 01:04:30.083
many iterations depending
from where you come.

1301
01:04:30.083 --> 01:04:32.143
So I think that that's where we train

1302
01:04:32.143 --> 01:04:35.043
our clinicians about cultural humility.

1303
01:04:35.043 --> 01:04:37.083
Because it's not only language.

1304
01:04:37.083 --> 01:04:38.703
I mean, we have everything from

1305
01:04:38.703 --> 01:04:41.703
sexual orientation to people, how they

1306
01:04:41.703 --> 01:04:45.703
dress, how they react,
and so we really think

1307
01:04:45.703 --> 01:04:47.843
it's important for you
to make a connection

1308
01:04:47.843 --> 01:04:50.403
and we do a lot of things to try to create

1309
01:04:50.403 --> 01:04:52.313
that environment.

1310
01:04:54.063 --> 01:04:55.363
Yes.

1311
01:04:55.363 --> 01:04:58.633
(inaudible question)

1312
01:05:05.144 --> 01:05:06.994
Sure.

1313
01:05:08.044 --> 01:05:11.124
Well, I mean, I think you know,

1314
01:05:11.124 --> 01:05:12.964
I have to say there are limits

1315
01:05:12.964 --> 01:05:16.304
to what data can do.

1316
01:05:16.304 --> 01:05:19.764
That's actually one of the reasons

1317
01:05:19.764 --> 01:05:22.064
my last grant, the last grant

1318
01:05:22.064 --> 01:05:24.784
I have submitted was more, not only

1319
01:05:24.784 --> 01:05:27.904
bringing the data, but actually

1320
01:05:27.904 --> 01:05:30.784
working with community groups,

1321
01:05:30.784 --> 01:05:35.484
stake holders, policy makers, to try to

1322
01:05:35.484 --> 01:05:37.804
help them generate the intervention

1323
01:05:37.804 --> 01:05:39.244
that they wanted.

1324
01:05:39.244 --> 01:05:42.384
Because I actually found that although

1325
01:05:42.384 --> 01:05:44.124
you might bring, like for example,

1326
01:05:44.124 --> 01:05:45.184
let me give you the example of

1327
01:05:45.184 --> 01:05:47.224
patient-provider communication.

1328
01:05:47.224 --> 01:05:50.584
I mean, everyone agrees that we do

1329
01:05:50.584 --> 01:05:52.664
biases, stereotypes, everyone,

1330
01:05:52.664 --> 01:05:54.564
I mean, there's no question.

1331
01:05:54.564 --> 01:05:57.564
People agree less on
whether they're doing it.

1332
01:05:57.564 --> 01:05:59.844
That's obviously.

1333
01:05:59.844 --> 01:06:02.724
But I would say that you know,

1334
01:06:02.724 --> 01:06:06.105
they're willing to even take that on.

1335
01:06:06.105 --> 01:06:08.805
But it's something very
different when you tell them

1336
01:06:08.805 --> 01:06:11.725
like the coaching, we
do a 12-hour coaching.

1337
01:06:11.725 --> 01:06:14.645
And what we find is
that the coaching helps,

1338
01:06:14.645 --> 01:06:16.965
because it creates awareness, and it also

1339
01:06:16.965 --> 01:06:19.465
will help in why we're focusing on

1340
01:06:19.465 --> 01:06:21.545
these components of our training.

1341
01:06:21.545 --> 01:06:24.625
But actually, it's not that effective.

1342
01:06:24.625 --> 01:06:26.285
I think what's really effective

1343
01:06:26.285 --> 01:06:29.485
is telling you what you are doing

1344
01:06:29.485 --> 01:06:33.665
that doesn't work that might be changed

1345
01:06:33.665 --> 01:06:37.265
and might get you along with your patient.

1346
01:06:37.265 --> 01:06:39.365
And that really triggers something

1347
01:06:39.365 --> 01:06:42.085
different in people,
because it's not like,

1348
01:06:42.085 --> 01:06:44.785
everyone does biases, and everyone

1349
01:06:44.785 --> 01:06:47.885
does stereotypes, it's, you're doing this.

1350
01:06:47.885 --> 01:06:50.245
And this is attributional error.

1351
01:06:50.245 --> 01:06:52.165
And when you do an attributional error,

1352
01:06:52.165 --> 01:06:54.425
you distance yourself from the patient.

1353
01:06:54.425 --> 01:06:55.865
So this is what you could do.

1354
01:06:55.865 --> 01:06:58.765
You could do x and y
and it's very different.

1355
01:06:58.765 --> 01:07:00.665
It's a very different component.

1356
01:07:00.665 --> 01:07:03.965
I think the same happens
for policy makers.

1357
01:07:03.965 --> 01:07:06.925
We can give them all the data we want,

1358
01:07:06.925 --> 01:07:09.925
but they have to be part of the solution.

1359
01:07:09.925 --> 01:07:12.515
To make a change.

1360
01:07:14.325 --> 01:07:15.775
Other questions.

1361
01:07:18.965 --> 01:07:20.465
Yes.

1362
01:07:20.465 --> 01:07:23.675
(inaudible question)

1363
01:07:28.285 --> 01:07:29.615
Oh.

1364
01:07:40.765 --> 01:07:41.915
Sure.

1365
01:07:45.725 --> 01:07:47.165
You know, unfortunately, this was

1366
01:07:47.165 --> 01:07:50.385
a big epidemiologic study, so we know

1367
01:07:50.385 --> 01:07:53.345
that there are many things.

1368
01:07:53.345 --> 01:07:55.905
I can tell you what qualitative work,

1369
01:07:55.905 --> 01:07:57.745
which I think does a better job

1370
01:07:57.745 --> 01:08:01.365
of trying to capture why
are people not coming.

1371
01:08:01.365 --> 01:08:03.705
I think there are many issues.

1372
01:08:03.705 --> 01:08:05.565
I think the biggest one is, people

1373
01:08:05.565 --> 01:08:07.525
really don't think they have a problem

1374
01:08:07.525 --> 01:08:10.923
that's so serious that they
need professional care.

1375
01:08:10.923 --> 01:08:13.963
I think that's a huge, huge problem.

1376
01:08:13.963 --> 01:08:16.363
And unfortunately we know that

1377
01:08:16.363 --> 01:08:21.303
it takes 15 years, 15 years of disorder

1378
01:08:21.303 --> 01:08:23.522
for people to start going to care.

1379
01:08:23.522 --> 01:08:25.663
That's really the time lapse that it takes

1380
01:08:25.663 --> 01:08:28.054
for people to start going to care.

1381
01:08:28.464 --> 01:08:31.064
So to convince people earlier on

1382
01:08:31.064 --> 01:08:33.444
in their illness trajectory means

1383
01:08:33.444 --> 01:08:35.844
you have to be really convincing

1384
01:08:35.844 --> 01:08:38.404
about why they should do it earlier.

1385
01:08:38.404 --> 01:08:41.104
And I don't think we do
a good job about that.

1386
01:08:41.104 --> 01:08:43.944
I think there is a lot that can be done

1387
01:08:43.944 --> 01:08:46.964
with motivational interviewing,

1388
01:08:46.964 --> 01:08:48.924
but I think you need other strategies

1389
01:08:48.924 --> 01:08:50.384
to convince people they should

1390
01:08:50.384 --> 01:08:52.224
go to care earlier.

1391
01:08:52.224 --> 01:08:54.724
So that's one big issue.

1392
01:08:54.724 --> 01:08:56.764
I think the second big issue is,

1393
01:08:56.764 --> 01:08:59.164
I don't think care is very accessible

1394
01:08:59.164 --> 01:09:01.824
for people that are working today.

1395
01:09:01.824 --> 01:09:04.104
I think people have a lot of issues

1396
01:09:04.104 --> 01:09:07.144
in going to care if
they're working full time.

1397
01:09:07.144 --> 01:09:10.004
And so it's very
difficult to maneuver that

1398
01:09:10.004 --> 01:09:13.964
unless you have a community health clinic,

1399
01:09:13.964 --> 01:09:18.604
you know, 15 minutes down your work.

1400
01:09:18.604 --> 01:09:20.664
And that's very unlikely.

1401
01:09:20.664 --> 01:09:21.864
And I can tell you because I hear

1402
01:09:21.864 --> 01:09:23.904
a lot of, when I'm doing supervision,

1403
01:09:23.904 --> 01:09:26.204
I hear a lot of tapes.

1404
01:09:26.204 --> 01:09:27.504
And you can see people saying,

1405
01:09:27.504 --> 01:09:29.644
I can't come that frequently, no,

1406
01:09:29.644 --> 01:09:31.584
you know, I can come in two months.

1407
01:09:31.584 --> 01:09:32.804
Well in two months you don't even

1408
01:09:32.804 --> 01:09:34.544
remember who's this person.

1409
01:09:34.544 --> 01:09:36.504
I mean, their problem is probably

1410
01:09:36.504 --> 01:09:38.544
a lot more severe.

1411
01:09:38.544 --> 01:09:40.444
So I think thinking about how we can

1412
01:09:40.444 --> 01:09:42.604
provide care and work in ways that

1413
01:09:42.604 --> 01:09:45.344
don't require people to come all the time,

1414
01:09:45.344 --> 01:09:47.184
I think is critical.

1415
01:09:47.184 --> 01:09:49.304
I think the third thing that we,

1416
01:09:49.304 --> 01:09:51.264
I have to say, I don't think we're

1417
01:09:51.264 --> 01:09:54.104
providing that great care, I think

1418
01:09:54.104 --> 01:09:56.944
we're doing a lot of venting out

1419
01:09:56.944 --> 01:09:59.544
and hearing people vent out, but not

1420
01:09:59.544 --> 01:10:02.504
necessarily helping people gain

1421
01:10:02.504 --> 01:10:04.404
greater insight.

1422
01:10:04.404 --> 01:10:06.764
And doing more illness management.

1423
01:10:06.764 --> 01:10:07.964
And part of that is because it's

1424
01:10:07.964 --> 01:10:10.664
very labor-intensive to do that.

1425
01:10:10.664 --> 01:10:13.524
But I think we need better training.

1426
01:10:13.524 --> 01:10:17.504
So I think those three things are drivers

1427
01:10:17.504 --> 01:10:20.664
of why we're not getting good care.

1428
01:10:20.664 --> 01:10:22.414
And people to go to care.

1429
01:10:23.224 --> 01:10:24.824
Thank you very much.

1430
01:10:24.824 --> 01:10:25.764
Really appreciate it.

1431
01:10:25.764 --> 01:10:28.474
(applause)