WEBVTT

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- Okay, so can everyone hear me okay?

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Yes?

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Great.

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Well I really want to welcome you all

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to our Lydia Rappaport lecture
series, our public lecture,

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and it's a small group so I'm really

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looking forward to the conversation.

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But before that I'm looking forward to

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Dr. Cabassa's presentation and I'll start

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with just a little introduction of

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Dr. Leopoldo Cabassa.

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He is an associate professor at the

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School of Social Work
at Columbia University.

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And he joined the faculty at Columbia

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in July of 2012.

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He holds an appointment
at the New York State

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Psychiatric Institute,
where he is the assistant

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director of the New York
State Center of Excellence

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for Cultural Competence.

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In terms of his education and training,

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Dr. Cabassa received his M.S.W. and Ph.D.

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from the George Warren
Brown School for Social Work

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at Washington University in St. Louis.

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He began his career as
a social work researcher

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with a post-doctoral fellowship at the

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School for Social Work at the University

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of Southern California, where he also was

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an assistant professor.

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And he there also had a joint appointment

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at the USC Keck School of Medicine,

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Department of Psychiatry
and Behavioral Science.

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Dr. Cabassa has taught
graduate level courses

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on research and evaluation
methods, foundation

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of social work practice,
and social work with

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Latino populations.

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And his research has been
published extensively

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and he's also been in journals and written

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different book chapters.

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In terms of his research, Dr.
Cabassa works in the field

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of health and mental
health services research

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for racial and ethnic minorities.

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Specifically he conducts
studies on ways to reduce

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the stigma towards mental
illness among Hispanic population

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and on developing, testing
and implementing interventions

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to improve the physical
health of under-served

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populations with a serious mental illness.

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His research program blends quantitative

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and qualitative methods
in community engagement

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to understand the factors
that fuel racial and ethnic

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inequities in health
and mental healthcare.

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And he uses his knowledge
to inform the development

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and implementation of interventions
to reduce disparities.

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Dr. Cabassa's work as
been supported by the

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National Institutes of
Health and the New York State

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Office of Mental Health.

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His current research portfolio
includes two NIH projects

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aimed to promote the
physical health of Hispanics

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with serious mental illness.

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Specifically he has a
Mentor Research Scientist

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Development Award called
Implemeting Health Care

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Interventions for Hispanics
with Serious Mental

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Illness and is currently doing an R01,

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a research project grant, that is titled

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The Peer Led Healthy Lifestyle Program

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in Supported Housing.

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So, I want to really welcome
Dr. Cabassa to the stage

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and I look forward to his presentation.

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- Buenos Nochas, good evening.

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It is a really a pleasure to be here

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and an honor to be here.

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Before we begin I want to thank

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for the invitation.

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She is still a great
colleague, even if she's

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in a different school,
but we miss you a lot

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and it's wonderful to
be here and to be able

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to contribute to your school.

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And to be here at Smith College.

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And Maria for a gracious host.

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It's been a great afternoon of interviews

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and dinner and conversation, so looking

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forward to the visit tomorrow, as well.

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So today I'm gonna talk about some work

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that actually we are at
the end stages of this work

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and thinking about the
next steps of where we're

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gonna take it.

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So it's great to be out in the world

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presenting this stuff,
but working, hearing

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people's reactions and
comments, I'm looking

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forward to the Q and A
to talk about the work

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that we've been doing.

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This is a work focusing
on how do we improve

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the physical health of people
with serious mental illness,

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people that have schizophrenia,
bipolar disorder,

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particularly Latinos.

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And what I'm gonna talk about today,

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some interventions that we really adopted

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and co-developed with our
partners, our community

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partnership, a public
outpatient mental health clinic,

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that helped us figure out
how to take an intervention

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that seemed promising for the situation,

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that I'm gonna be talking about,

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but help us develop it in the real world

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with real clinicians and
clients at this clinic

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and help us sort of co-develop this.

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That's what we're doing.

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And studying that process.

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So it's been a five year journey

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and a great adventure to us.

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So today I'm going to
present you sort of how

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we got there and what we're
learning from that approach.

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Let me move this so I
can know where I'm at.

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There we go.

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So before we begin I want
to acknowledge the funders,

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because that study was funded by the

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National Institute of Mental Health.

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It did receive funding from
the New York State Office

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of Mental Health, since we were
working at a public agency.

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And this is really a team effort.

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All the collaborators that you see here

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were really involved in this
project and I do want to say

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that none of it would
he been possible without

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the involvement, the
sweat, blood, and tears

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that everyone did for
this particular project

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and their engagement with this process.

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And it was a really
multi-disciplinary team

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of social workers, nurses,
psychiatrist, peer advocates

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in the community, primary care physicians,

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that really helped us
develop what I'm gonna

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be talking about.

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And then also I always
cherish the opportunity

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to work and mentor students
and we had great students

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throughout this five year project who

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cycled through the project
and provided their input

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throughout, from my
doctoral students who were

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care managers in this
project, as well as the M.S.W.

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students who provided data
collection and opportunities

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to analyze some of the data.

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So this was really a team
effort, and everything

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I'm gonna be talking about
today, I owe a great debt

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to all the people who
are listed here and also

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to the clients who participated in this.

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So, I do want to start
with a quote that really

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got us started into this process.

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This is one of the first
projects that I ever did

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in New York.

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I was tasked with the great
opportunity of figuring out

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what were the healthcare
needs of Latinos and

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African Americans in
northern Manhattan that had

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serious mental illness.

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And we went about it by doing
a large qualitative study

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of six behavior health
organizations in the neighborhoods

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of Washington Heights,
in Harlem, in Inwood,

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and really talking to almost
everyone who would talk to us.

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Directors, project managers,
clients, family members,

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community leaders, the clients themselves.

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And the idea was to really
figure out what was going on

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with these agencies and
how were they addressing

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the physical health
needs of this population.

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And here's a quote from
an administrator of the

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clinic that actually we
ended up working with

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and partnering for this
project that I'm gonna be

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talking about that is
really addressing this issue

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of the fragmentation of
care and how patients

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get lost navigating between
the healthcare system

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and the mental health system.

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And it's basically someone saying,

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"Our patients, partly
because of their illnesses,

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"their cultural and language
issues, because the system

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"is not very well organized,
they often get lost

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"in the system.

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"The patients just get overwhelmed.

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"You're not feeling
well, you have symptoms,

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"of psychosis, you don't
speak the language,

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"and you're trying to
figure out what office

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"to go to.

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"It can be overwhelming and patients get

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"frustrated and they don't get the care

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"that they need."

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And the whole process,
the whole purpose for

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this project, from the
work that we have been

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developing over the
past five, seven years,

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is actually to figure out how do we get

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the care that people need to improve their

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physical health and
addressing equity stuff

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for this population.

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So we really want the intervention

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that we're gonna be talking about today,

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is how to help someone navigate that maze.

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That labyrinth between one system of care

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and the other.

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And that's one solution to this problem.

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Another solution could be
to destroy the entire system

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and actually combine them
so people don't have to

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navigate between this maze.

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But our process is sort of figuring out

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how to work throughout
the maze of the system

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and figuring out how to help them

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and get the care that they need.

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At the end of the day
that's sort of the outcome

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that we wanted to improve.

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So today I'll talk about the need for

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these types of
interventions, I'll describe

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our bridges to better health and wellness,

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(speaking in Spanish)

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and present study findings and next steps.

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And the next steps, it's
really a conversation

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with you about where do
you see, what are your

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reactions to this work
that we have developed.

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So, first of all, just
to give some definitions,

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what I'm talking about
is a population that

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has serious mental illness.

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So people who have schizophrenia,

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that are recovering and
living with schizophrenia,

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bipolar disorder, and these are disorders

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that interfere with major life activities

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and impact their functions.

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And when you work in the
public mental health system,

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this is the population
that you're serving,

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these are the people who have these types

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of disorders.

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Around 10 million adults
in the U.S. report

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serious mental illness in the past year,

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and they constitute five
out of the ten leading

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causes of disability worldwide.

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So these are costly
disorders and they impact

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not only the individual,
but their families and

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communities in figuring out
how to help this population.

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The problem that we're focusing on within

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the people with serious mental illness

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is their physical health.

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People with serious mental illness die

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at an earlier age that
the rest of the population

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that don't have these disorders,

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and it's mostly due to natural causes.

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To cardiovascular disease, to diabetes,

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to hypertension, high cholesterol.

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And this is a major issue
for this population.

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They're dying at an earlier
age than the rest of us.

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They're not benefiting from the healthcare

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that's available to all
of us in this country

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and other places.

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And the statistics that I present here,

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the up to 32 years,
the median of 10 years,

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this is actually from a
med analysis that looked

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at global studies all over the world

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and found this disparity and mortality

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between people who have
serious mental disorder

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and the general population.

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In the U.S., the best data that we have

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when we look at our community sample,

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has to do with the health
survey in this country,

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the National Health
Interview survey, and they

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found an eight year gap
between psychotic disorder,

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eight to ten year gap, and people with no

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psychiatric disorders.

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So this is the disparity
that we're trying to address.

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How to reduce early
mortality and morbidity

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among this population.

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Our work looks at the
intersection of having

260
00:11:22.049 --> 00:11:24.442
a serious mental disorder
and being a racial

261
00:11:24.442 --> 00:11:26.237
and ethnic minority.

262
00:11:26.237 --> 00:11:28.548
And when we started this
project, we really wanted to

263
00:11:28.548 --> 00:11:30.890
understand that double intersection.

264
00:11:30.890 --> 00:11:33.164
You have a serious mental
illness, you're recovering

265
00:11:33.164 --> 00:11:35.805
from that, that has major
implications to your health,

266
00:11:35.805 --> 00:11:38.457
and you're also a racial or
ethnic minority in this country,

267
00:11:38.457 --> 00:11:39.470
particularly Latino.

268
00:11:39.470 --> 00:11:42.226
That also carries some
inequities in physical health

269
00:11:42.226 --> 00:11:45.231
and mental health and access to care.

270
00:11:45.231 --> 00:11:46.088
And our question was,

271
00:11:46.088 --> 00:11:47.127
"Is there a double burden?"

272
00:11:47.127 --> 00:11:51.717
Are you at double risk for
having poor physical health

273
00:11:51.717 --> 00:11:54.082
if you already have these
two vulnerabilities,

274
00:11:54.082 --> 00:11:56.159
given the disparities that we know exist

275
00:11:56.159 --> 00:11:59.334
in both of these populations.

276
00:11:59.334 --> 00:12:02.065
In a systematic review we did
of over 30 years of research,

277
00:12:02.065 --> 00:12:04.572
we did find some evidence for this.

278
00:12:04.572 --> 00:12:07.912
Latinos with serious
mental illness compared

279
00:12:07.912 --> 00:12:10.514
to non-Hispanic whites
or non-Latino whites

280
00:12:10.514 --> 00:12:13.348
with similar mental
disorders have higher risk of

281
00:12:13.348 --> 00:12:15.179
cardiovascular related
mortality, meaning they die

282
00:12:15.179 --> 00:12:17.405
at an earlier age.

283
00:12:17.405 --> 00:12:20.795
They have higher rates of
diabetes, of metabolic syndrome,

284
00:12:20.795 --> 00:12:23.333
which is a condition that puts
you at an even higher risk

285
00:12:23.333 --> 00:12:24.997
for cardiovascular disease.

286
00:12:24.997 --> 00:12:28.492
And to experience the negative
metabolic abnormalities

287
00:12:28.492 --> 00:12:31.120
of anti-psychotic
medications, particularly

288
00:12:31.120 --> 00:12:33.109
weight gain, which is a common side effect

289
00:12:33.109 --> 00:12:36.125
of anti-psychotic medications.

290
00:12:36.125 --> 00:12:37.855
The interesting component
of this lit review,

291
00:12:37.855 --> 00:12:40.327
and it was very interesting
because you're beginning

292
00:12:40.327 --> 00:12:42.459
to identify the gaps in the literature,

293
00:12:42.459 --> 00:12:45.862
was that most of these
studies were really small.

294
00:12:45.862 --> 00:12:48.113
They were between four and 200 people,

295
00:12:48.113 --> 00:12:50.673
it was mostly clinical samples,

296
00:12:50.673 --> 00:12:53.285
and they rarely differentiated
between different

297
00:12:53.285 --> 00:12:56.016
Latino groups and rarely,
if ever, differentiated

298
00:12:56.016 --> 00:12:57.705
between gender.

299
00:12:57.705 --> 00:13:00.122
So although there's evidence
indicating a disparity

300
00:13:00.122 --> 00:13:03.023
in the Latino community,
we know very little.

301
00:13:03.023 --> 00:13:05.089
And these are the people
that are getting services

302
00:13:05.089 --> 00:13:08.043
and then not only that,
participating in research,

303
00:13:08.043 --> 00:13:10.121
and we're still seeing some
of the disparities there.

304
00:13:10.121 --> 00:13:12.813
So we're really just
scratching the surface

305
00:13:12.813 --> 00:13:16.813
about what's really going
on in this population.

306
00:13:19.821 --> 00:13:22.263
We found one study that
actually differentiated

307
00:13:22.263 --> 00:13:26.073
between different Latino
groups, particularly

308
00:13:26.073 --> 00:13:29.477
Cubans, Mexicans, and then other Latinos,

309
00:13:29.477 --> 00:13:32.715
which is half of humanity in the Americas.

310
00:13:32.715 --> 00:13:35.717
So it becomes uncertain
how these disparities

311
00:13:35.717 --> 00:13:38.148
actually exist, and
it's a really big issue.

312
00:13:38.148 --> 00:13:40.411
For doctoral students who want an area

313
00:13:40.411 --> 00:13:43.375
of dissertation work,
this is one that needs

314
00:13:43.375 --> 00:13:46.143
lot of work to figure out
where those disparities

315
00:13:46.143 --> 00:13:47.226
really exist.

316
00:13:48.523 --> 00:13:50.745
So when you look at the
physical health of people

317
00:13:50.745 --> 00:13:52.003
with serious mental illness,

318
00:13:52.003 --> 00:13:54.361
there's a lot being written
about the modifiable factor,

319
00:13:54.361 --> 00:13:57.076
the things that we can
change to improve the health.

320
00:13:57.076 --> 00:13:59.416
And I think I made a colloquial approach

321
00:13:59.416 --> 00:14:00.938
because there's many different factors

322
00:14:00.938 --> 00:14:02.572
that influence the health of someone.

323
00:14:02.572 --> 00:14:04.690
So I took if from the
environment, unstable housing,

324
00:14:04.690 --> 00:14:07.408
poverty, food and
environment, medical care,

325
00:14:07.408 --> 00:14:08.614
health behaviors.

326
00:14:08.614 --> 00:14:11.256
And today we're gonna
focus on medical care.

327
00:14:11.256 --> 00:14:12.878
One aspect of these disparities.

328
00:14:12.878 --> 00:14:14.896
And I do want to indicate
that the intervention

329
00:14:14.896 --> 00:14:17.392
that we're looking at
focuses on medical care,

330
00:14:17.392 --> 00:14:20.068
but future work that we're
doing is actually looking

331
00:14:20.068 --> 00:14:21.926
at health behaviors, as well.

332
00:14:21.926 --> 00:14:24.734
And we cannot ignore the
environment and interaction

333
00:14:24.734 --> 00:14:27.022
of all these issues if
we really want to address

334
00:14:27.022 --> 00:14:29.508
these disparities in care.

335
00:14:29.508 --> 00:14:31.432
So we're gonna focus today on medical care

336
00:14:31.432 --> 00:14:35.020
as one area where we can
intervene as social workers.

337
00:14:35.020 --> 00:14:38.502
So, given the little research
that was done in this area,

338
00:14:38.502 --> 00:14:40.712
we actually began this project
by really understanding

339
00:14:40.712 --> 00:14:44.650
the experiences that
Latinos have accessing care.

340
00:14:44.650 --> 00:14:46.681
So we went to our public outpatient clinic

341
00:14:46.681 --> 00:14:50.866
and asked Latino clients, a
sample of 40 Latino clients,

342
00:14:50.866 --> 00:14:53.480
to talk to us about their experiences

343
00:14:53.480 --> 00:14:56.260
accessing primary care and figuring out

344
00:14:56.260 --> 00:14:58.080
what were some of the issues that came up

345
00:14:58.080 --> 00:15:00.237
as they were trying to
access primary care.

346
00:15:00.237 --> 00:15:01.942
First of all, do they access primary care?

347
00:15:01.942 --> 00:15:03.721
Do they even go to primary care?

348
00:15:03.721 --> 00:15:06.553
And if they do, what type
of services to they receive?

349
00:15:06.553 --> 00:15:08.726
What's the experience that they have?

350
00:15:08.726 --> 00:15:10.324
And we use a mixed method approach here

351
00:15:10.324 --> 00:15:12.914
where we interview, do a focus
group with people, actually,

352
00:15:12.914 --> 00:15:16.162
and then we also do structured,
quantitative interviews

353
00:15:16.162 --> 00:15:18.582
about their experiences with healthcare.

354
00:15:18.582 --> 00:15:20.558
And it was interesting
that almost everyone

355
00:15:20.558 --> 00:15:22.534
that we talked to in this sample

356
00:15:22.534 --> 00:15:25.082
talked about the stress healthcare system

357
00:15:25.082 --> 00:15:26.367
that they were navigating.

358
00:15:26.367 --> 00:15:28.164
They were going to care,
but they were facing

359
00:15:28.164 --> 00:15:29.346
major barriers.

360
00:15:29.346 --> 00:15:32.452
Fragmented care, meaning
psychiatrist's not talking

361
00:15:32.452 --> 00:15:34.376
to a primary care physician,
the primary care physician

362
00:15:34.376 --> 00:15:36.781
not talking to psychiatry
and really having a hard

363
00:15:36.781 --> 00:15:39.915
time communicating between providers.

364
00:15:39.915 --> 00:15:42.731
Long waiting times in all of
these primary care clinics.

365
00:15:42.731 --> 00:15:46.022
Major language barriers,
even in New York City,

366
00:15:46.022 --> 00:15:48.572
in the heart of Washington
Heights, you're still

367
00:15:48.572 --> 00:15:51.341
having language barriers
trying to access care

368
00:15:51.341 --> 00:15:54.281
in your native language, in Spanish.

369
00:15:54.281 --> 00:15:57.086
And there are a lot of
high staff turnover.

370
00:15:57.086 --> 00:15:59.530
Many of these clinics are public clinics

371
00:15:59.530 --> 00:16:03.575
that employ residents, so
there's a high turnover

372
00:16:03.575 --> 00:16:06.279
of doctors that you're seeing,

373
00:16:06.279 --> 00:16:08.138
so every two or three
years you have to start

374
00:16:08.138 --> 00:16:10.894
a whole new relationship
with a primary care doctor.

375
00:16:10.894 --> 00:16:13.365
Think about how that
influences your health

376
00:16:13.365 --> 00:16:15.352
if you have a chronic medical illness?

377
00:16:15.352 --> 00:16:17.470
Diabetes, cardio, hypertension.

378
00:16:17.470 --> 00:16:19.030
Every two or three years you have to tell

379
00:16:19.030 --> 00:16:21.280
someone your story about
how you got that illness

380
00:16:21.280 --> 00:16:23.804
and the challenges that you're having.

381
00:16:23.804 --> 00:16:25.374
That's major issues.

382
00:16:25.374 --> 00:16:27.298
People talked a lot
about the discrimination

383
00:16:27.298 --> 00:16:30.460
and the intersection of
the discrimination stigma.

384
00:16:30.460 --> 00:16:34.162
Discrimination of being a
Latino, of being an immigrant,

385
00:16:34.162 --> 00:16:36.270
and also have a serious mental illness.

386
00:16:36.270 --> 00:16:38.426
And what we saw here is some
evidence of what is called

387
00:16:38.426 --> 00:16:41.390
diagnostic overshadowing, which means that

388
00:16:41.390 --> 00:16:44.368
you go to a doctor, you tell
them you have a physical

389
00:16:44.368 --> 00:16:46.864
health issue or a physical symptom,

390
00:16:46.864 --> 00:16:49.853
and because you are identified as someone

391
00:16:49.853 --> 00:16:51.624
who has a serious mental illness,

392
00:16:51.624 --> 00:16:52.934
you are not believed.

393
00:16:52.934 --> 00:16:55.003
The person thinks, oh,
that's all in your head.

394
00:16:55.003 --> 00:16:57.677
You come in with a pain in your stomach,

395
00:16:57.677 --> 00:17:00.006
the doctor might say that's part of your

396
00:17:00.006 --> 00:17:02.516
psychiatric issues, it's not real.

397
00:17:02.516 --> 00:17:05.414
And that actually influences
what type of treatment

398
00:17:05.414 --> 00:17:07.536
people received and they
talked about experiences

399
00:17:07.536 --> 00:17:10.434
of that, of completely
being missed for things

400
00:17:10.434 --> 00:17:15.284
as cancer or ulcers or
major physical health issues

401
00:17:15.284 --> 00:17:18.570
being dismissed because of
their serious mental illness.

402
00:17:18.570 --> 00:17:21.212
And then people really talked
about their experiences

403
00:17:21.212 --> 00:17:22.886
with their doctor.

404
00:17:22.886 --> 00:17:25.344
That one to one interaction
with that physician

405
00:17:25.344 --> 00:17:27.928
was really important and
some people talked about

406
00:17:27.928 --> 00:17:30.527
having good interactions
that was personal attention,

407
00:17:30.527 --> 00:17:34.694
warm, culturally congruent,
respectful, trustworthy,

408
00:17:36.614 --> 00:17:38.996
and also talked about
very negative experiences

409
00:17:38.996 --> 00:17:43.156
because of stigma, being
rushed, being impersonal,

410
00:17:43.156 --> 00:17:44.144
being disrespected.

411
00:17:44.144 --> 00:17:46.754
So that interaction with
your primary care physician

412
00:17:46.754 --> 00:17:48.900
was really important for
people and it could go

413
00:17:48.900 --> 00:17:50.498
either way.

414
00:17:50.498 --> 00:17:51.965
And then with our quantitative measure

415
00:17:51.965 --> 00:17:54.554
we found low levels of
patient-centered care.

416
00:17:54.554 --> 00:17:57.456
And this is really
important because if people

417
00:17:57.456 --> 00:18:00.316
have a chronic medical
illness and they're not

418
00:18:00.316 --> 00:18:02.240
receiving patient-centered care, meaning

419
00:18:02.240 --> 00:18:04.971
care that talks about your treatment plan,

420
00:18:04.971 --> 00:18:06.906
that discusses with you all the different

421
00:18:06.906 --> 00:18:09.634
medications that you have,
that gives you advice

422
00:18:09.634 --> 00:18:12.261
and action planning around
physical health issues,

423
00:18:12.261 --> 00:18:13.912
then you don't know how to manage your own

424
00:18:13.912 --> 00:18:15.925
physical health component.

425
00:18:15.925 --> 00:18:19.178
So not receiving that from
your primary care physicians

426
00:18:19.178 --> 00:18:20.282
was really important.

427
00:18:20.282 --> 00:18:23.546
And these levels were low
not only to people with

428
00:18:23.546 --> 00:18:25.300
serious mental illness, but to Latinos.

429
00:18:25.300 --> 00:18:28.590
We were able to compare the
race that we were seeing

430
00:18:28.590 --> 00:18:31.308
with this measure that we
use, compare to other samples

431
00:18:31.308 --> 00:18:34.452
at the national level
and they were very low.

432
00:18:34.452 --> 00:18:35.416
Very concerning.

433
00:18:35.416 --> 00:18:38.948
So with this in mind, then
what type of intervention

434
00:18:38.948 --> 00:18:41.278
can we use to address this issue?

435
00:18:41.278 --> 00:18:43.768
And one type of intervention
that's out there

436
00:18:43.768 --> 00:18:46.263
and also received major
attention since we started

437
00:18:46.263 --> 00:18:49.176
this program was healthcare
management interventions.

438
00:18:49.176 --> 00:18:51.880
This is someone who is
in our public outpatient

439
00:18:51.880 --> 00:18:54.012
mental health clinic, usually a nurse,

440
00:18:54.012 --> 00:18:56.248
who connects you to
primary care, to help you

441
00:18:56.248 --> 00:18:59.411
navigate that system, who asseses

442
00:18:59.411 --> 00:19:00.870
your physical health issues,

443
00:19:00.870 --> 00:19:03.692
figures out what type of help do you need,

444
00:19:03.692 --> 00:19:06.642
and then helps you connect to that care.

445
00:19:06.642 --> 00:19:08.344
Helps you figure out that you go

446
00:19:08.344 --> 00:19:09.786
to your primary care physician,

447
00:19:09.786 --> 00:19:11.180
that you ask the right question,

448
00:19:11.180 --> 00:19:12.814
that you share information,
and that you bring

449
00:19:12.814 --> 00:19:15.198
that back to your outpatient
mental health clinic,

450
00:19:15.198 --> 00:19:16.430
to you psychiatrist.

451
00:19:16.430 --> 00:19:18.276
That's a social worker role in many ways,

452
00:19:18.276 --> 00:19:20.110
but in these interventions a lot of this

453
00:19:20.110 --> 00:19:22.072
is being done by nurses.

454
00:19:22.072 --> 00:19:25.036
They focus on care coordination
and it helps the client

455
00:19:25.036 --> 00:19:27.352
with goal setting, patient activation,

456
00:19:27.352 --> 00:19:29.900
which really means getting the patient,

457
00:19:29.900 --> 00:19:33.459
the client himself or
herself, to be engaged

458
00:19:33.459 --> 00:19:35.322
in their own care, to
know their medication,

459
00:19:35.322 --> 00:19:37.178
to know where to go, know what to do,

460
00:19:37.178 --> 00:19:39.624
to manage their illness.

461
00:19:39.624 --> 00:19:42.157
And then problem solve
around things that come up,

462
00:19:42.157 --> 00:19:44.172
if you have a chronic medical issue.

463
00:19:44.172 --> 00:19:45.722
So health care management interventions,

464
00:19:45.722 --> 00:19:47.008
there's quite a lot out there

465
00:19:47.008 --> 00:19:48.009
and they've been tested.

466
00:19:48.009 --> 00:19:49.008
They seem promising.

467
00:19:49.008 --> 00:19:53.894
They seem to address the
issues that we were seeing

468
00:19:53.894 --> 00:19:57.811
in our Latino population
that we were studying.

469
00:19:59.213 --> 00:20:02.713
The thing is that we've identified a local

470
00:20:03.714 --> 00:20:06.002
implementation graft.

471
00:20:06.002 --> 00:20:08.626
We have a problem that is
serious that the clinic

472
00:20:08.626 --> 00:20:11.202
wants us to address,
is seen as an important

473
00:20:11.202 --> 00:20:13.112
component in linking
people to primary care,

474
00:20:13.112 --> 00:20:14.775
helping them with that care.

475
00:20:14.775 --> 00:20:17.258
There's interventions out
there that seem to work.

476
00:20:17.258 --> 00:20:19.062
But then there's major
gaps in how do you take

477
00:20:19.062 --> 00:20:21.352
that intervention and
implement it and use it

478
00:20:21.352 --> 00:20:23.203
in this community clinic.

479
00:20:23.203 --> 00:20:24.618
And what we mean by that is, first of all,

480
00:20:24.618 --> 00:20:26.396
the interventions that were out there,

481
00:20:26.396 --> 00:20:28.542
none were tested in Latinos.

482
00:20:28.542 --> 00:20:29.723
None.

483
00:20:29.723 --> 00:20:32.064
We had major interventions out there,

484
00:20:32.064 --> 00:20:34.446
but they had never
included a Latino client,

485
00:20:34.446 --> 00:20:37.396
a Latino subject in their studies,

486
00:20:37.396 --> 00:20:38.737
for the interventions that were out there

487
00:20:38.737 --> 00:20:40.072
for people with serious mental illness,

488
00:20:40.072 --> 00:20:41.244
when we starts this project.

489
00:20:41.244 --> 00:20:42.908
So, we don't know.

490
00:20:42.908 --> 00:20:43.948
They say everything's promising,

491
00:20:43.948 --> 00:20:46.688
it might address, but
we've never tested it

492
00:20:46.688 --> 00:20:49.145
with Latinos, so that's one gap.

493
00:20:49.145 --> 00:20:50.910
The second gap has to do with the silence

494
00:20:50.910 --> 00:20:52.292
around culture.

495
00:20:52.292 --> 00:20:55.048
And this was very glaring
and it still exists today.

496
00:20:55.048 --> 00:20:57.194
Now we're seeing it over and over again.

497
00:20:57.194 --> 00:21:01.118
The ignorance or the
idea that once you have

498
00:21:01.118 --> 00:21:02.938
a serious mental illness, all the other

499
00:21:02.938 --> 00:21:06.045
intersections of your life,
your culture, your gender,

500
00:21:06.045 --> 00:21:09.177
your sexual orientation,
can get sort of put aside.

501
00:21:09.177 --> 00:21:12.884
You are defined by your mental
illness and nothing else.

502
00:21:12.884 --> 00:21:14.236
And, in fact, that's not true.

503
00:21:14.236 --> 00:21:17.745
People have multiple identities,
multiple intersections,

504
00:21:17.745 --> 00:21:19.461
and culture becomes really important.

505
00:21:19.461 --> 00:21:22.712
Think how culture shapes
how you define your health,

506
00:21:22.712 --> 00:21:24.139
how you communicate your health,

507
00:21:24.139 --> 00:21:26.325
how you communicate with
the healthcare system

508
00:21:26.325 --> 00:21:27.770
and your primary care physician.

509
00:21:27.770 --> 00:21:29.899
And none of that was being examined

510
00:21:29.899 --> 00:21:31.393
in this literature.

511
00:21:31.393 --> 00:21:34.218
In fact, there was a recent
systematic lit review

512
00:21:34.218 --> 00:21:38.818
of almost 30 years of
research of every intervention

513
00:21:38.818 --> 00:21:42.628
out there, on behavioral,
primary care intervention

514
00:21:42.628 --> 00:21:44.566
as well as behavioral
intervention of people

515
00:21:44.566 --> 00:21:47.801
with serious mental illness by Mike Edie

516
00:21:47.801 --> 00:21:50.544
and colleagues, it was published in 2015,

517
00:21:50.544 --> 00:21:54.730
culture and race and ethnicity
weren't even mentioned

518
00:21:54.730 --> 00:21:57.409
in that type of systematic lit review.

519
00:21:57.409 --> 00:21:59.202
I mean, this is major research being done

520
00:21:59.202 --> 00:22:02.856
and this is driving our
policy and it's being ignored.

521
00:22:02.856 --> 00:22:03.844
And it's important.

522
00:22:03.844 --> 00:22:06.031
And you will see how we integrated that.

523
00:22:06.031 --> 00:22:10.202
And then, for our community,
can social workers do it?

524
00:22:10.202 --> 00:22:12.995
These clinics have one
nurse, but they have more

525
00:22:12.995 --> 00:22:15.024
social workers, so can
social workers, because

526
00:22:15.024 --> 00:22:17.923
of the work force this clinic
has, can social workers

527
00:22:17.923 --> 00:22:20.881
take on that responsibility of connecting?

528
00:22:20.881 --> 00:22:23.057
So can social workers
take on that component?

529
00:22:23.057 --> 00:22:26.960
And we thought, it could
work so let's try it out.

530
00:22:26.960 --> 00:22:29.376
So here's where the community
engagement comes in.

531
00:22:29.376 --> 00:22:31.640
We had these gaps, we have this problem,

532
00:22:31.640 --> 00:22:34.240
we have a partner that wants to help us,

533
00:22:34.240 --> 00:22:36.344
so there's many ways we
can go about implementing

534
00:22:36.344 --> 00:22:37.686
and testing this.

535
00:22:37.686 --> 00:22:39.634
One simple way is we as researchers say

536
00:22:39.634 --> 00:22:42.218
this is intervention, we
develop it, we test it

537
00:22:42.218 --> 00:22:45.549
with our students, and we do
a randomized control trial

538
00:22:45.549 --> 00:22:48.710
and everything's fine
and we see if it works.

539
00:22:48.710 --> 00:22:50.801
For me, though, it's not sufficient.

540
00:22:50.801 --> 00:22:52.894
Because we could do that work but then

541
00:22:52.894 --> 00:22:55.026
when I leave and my grant leaves,

542
00:22:55.026 --> 00:22:57.145
nothing gets left behind.

543
00:22:57.145 --> 00:22:59.446
Basically we have published our paper

544
00:22:59.446 --> 00:23:00.774
that some of you might read,

545
00:23:00.774 --> 00:23:02.826
but the actually clinic never learned

546
00:23:02.826 --> 00:23:05.322
the capacity to actually
deliver the intervention.

547
00:23:05.322 --> 00:23:07.520
So what we did is we
developed this collaborative

548
00:23:07.520 --> 00:23:10.221
intervention planning
approach, which is basically

549
00:23:10.221 --> 00:23:13.382
an engagement approach where
we took the stakeholders,

550
00:23:13.382 --> 00:23:15.254
meaning the people who were
going to actually deliver

551
00:23:15.254 --> 00:23:16.954
this intervention in the real world,

552
00:23:16.954 --> 00:23:21.002
the social workers, the
administrators, the nurses,

553
00:23:21.002 --> 00:23:23.925
the primary care clinicians,
and we combined them

554
00:23:23.925 --> 00:23:26.098
with the researchers
and engaged in a process

555
00:23:26.098 --> 00:23:29.166
of figuring out here's
this intervention that

556
00:23:29.166 --> 00:23:30.920
we're gonna use, and
how to we transport it

557
00:23:30.920 --> 00:23:33.246
and use it at this site in this clinic

558
00:23:33.246 --> 00:23:35.521
for this community through our process

559
00:23:35.521 --> 00:23:37.250
of community engagement.

560
00:23:37.250 --> 00:23:40.658
How many of you know about community-based

561
00:23:40.658 --> 00:23:42.575
participatory research?

562
00:23:43.529 --> 00:23:44.790
How many of you have done community-based

563
00:23:44.790 --> 00:23:47.508
participatory research?

564
00:23:47.508 --> 00:23:48.521
Okay.

565
00:23:48.521 --> 00:23:50.628
One of the things in community-based
participatory research

566
00:23:50.628 --> 00:23:52.357
which is really important
is how do you bring people

567
00:23:52.357 --> 00:23:56.348
together and engage them in this process.

568
00:23:56.348 --> 00:23:58.858
The thing is, when you
read this literature,

569
00:23:58.858 --> 00:24:01.871
what actually happens when
you bring all these people

570
00:24:01.871 --> 00:24:04.564
together, when you're there
in a community advisory

571
00:24:04.564 --> 00:24:08.044
board meeting once a
month, what do you do?

572
00:24:08.044 --> 00:24:11.609
What actually goes from the
start of the idea to practice?

573
00:24:11.609 --> 00:24:13.886
And that's what where we
included the intervention

574
00:24:13.886 --> 00:24:16.524
mapping approach, which
is a step-by-step process

575
00:24:16.524 --> 00:24:20.178
of how you take a theory
or intervention all the way

576
00:24:20.178 --> 00:24:23.971
through implementation and evaluation.

577
00:24:23.971 --> 00:24:27.102
How do you transform it
with everyone's input?

578
00:24:27.102 --> 00:24:29.434
And what this provides
you is actually a map

579
00:24:29.434 --> 00:24:32.474
of how you go to A to B
to C to D, all the way

580
00:24:32.474 --> 00:24:33.917
to the evaluation.

581
00:24:33.917 --> 00:24:37.010
And it provides tools
that a community can use

582
00:24:37.010 --> 00:24:39.872
to transform that
intervention, to adapt it,

583
00:24:39.872 --> 00:24:41.886
we actually use it to
adapt this intervention

584
00:24:41.886 --> 00:24:44.577
that you'll see shortly, but it really was

585
00:24:44.577 --> 00:24:46.160
an engagement approach.

586
00:24:46.160 --> 00:24:48.983
It provided a space and a time and skills

587
00:24:48.983 --> 00:24:51.416
for everyone to engage, with our help,

588
00:24:51.416 --> 00:24:54.261
with the resources that we
provided from the grant,

589
00:24:54.261 --> 00:24:56.006
to do this work.

590
00:24:56.006 --> 00:24:58.228
And right now our grant
has ended, but we have

591
00:24:58.228 --> 00:25:01.698
left there in that clinic
people who are trained

592
00:25:01.698 --> 00:25:03.636
and can deliver the
intervention because we used

593
00:25:03.636 --> 00:25:06.092
people in that clinic to
deliver the intervention

594
00:25:06.092 --> 00:25:08.237
for us as part of this grant.

595
00:25:08.237 --> 00:25:09.797
So it's a really interesting,
and I'm happy to talk

596
00:25:09.797 --> 00:25:12.150
about the details, we
published all the details

597
00:25:12.150 --> 00:25:15.517
and all the components of this,
but it was a great journey

598
00:25:15.517 --> 00:25:20.276
and it provided a space to
actually do this at the agency.

599
00:25:20.276 --> 00:25:24.825
And today we're going to talk
about the evaluation process.

600
00:25:24.825 --> 00:25:26.591
So here's our intervention.

601
00:25:26.591 --> 00:25:28.284
It's called Bridges to
Better Health and Wellness.

602
00:25:28.284 --> 00:25:30.468
It's actually adapted from an intervention

603
00:25:30.468 --> 00:25:33.522
called PCARE, that was
developed in Atlanta, Georgia,

604
00:25:33.522 --> 00:25:37.124
by Ben Druss and his
group at Emory University.

605
00:25:37.124 --> 00:25:39.010
The intervention's wonderful.

606
00:25:39.010 --> 00:25:42.220
It actually showed that
it doubled the rate

607
00:25:42.220 --> 00:25:43.892
of preventive primary care among people

608
00:25:43.892 --> 00:25:45.414
with serious mental illness

609
00:25:45.414 --> 00:25:47.322
in public outpatient settings.

610
00:25:47.322 --> 00:25:49.844
And it actually connected people to care

611
00:25:49.844 --> 00:25:53.119
and engaged them in that
primary care service.

612
00:25:53.119 --> 00:25:54.850
The issue was that it was only tested

613
00:25:54.850 --> 00:25:56.928
in an African American community.

614
00:25:56.928 --> 00:25:59.928
The healthcare managers were nurses,

615
00:26:00.934 --> 00:26:03.198
so we had to transform it and what we did,

616
00:26:03.198 --> 00:26:05.456
we actually called Ben Druss and said hey,

617
00:26:05.456 --> 00:26:07.628
your intervention seems
really interesting.

618
00:26:07.628 --> 00:26:09.618
It addresses our need.

619
00:26:09.618 --> 00:26:10.620
Can we use it?

620
00:26:10.620 --> 00:26:12.360
Can you partner with us to figure out

621
00:26:12.360 --> 00:26:14.908
how to transform it for
Latinos and social workers

622
00:26:14.908 --> 00:26:16.780
in Washington Heights?

623
00:26:16.780 --> 00:26:19.380
And he was a partner
in the entire process.

624
00:26:19.380 --> 00:26:21.161
What you see here is
the healthcare managers,

625
00:26:21.161 --> 00:26:23.175
the social worker, they're employed at the

626
00:26:23.175 --> 00:26:25.350
outpatient mental health
clinic and they serve

627
00:26:25.350 --> 00:26:27.700
as a bridge and a monitor
for the mental health

628
00:26:27.700 --> 00:26:30.394
provider, the psychiatrist,
the case manager,

629
00:26:30.394 --> 00:26:31.926
and the primary care providers.

630
00:26:31.926 --> 00:26:33.711
And the idea of bridging, monitoring, and

631
00:26:33.711 --> 00:26:34.682
coordinating is simple.

632
00:26:34.682 --> 00:26:36.266
Figuring out what are
the physical health needs

633
00:26:36.266 --> 00:26:38.918
of the person, what
medication they're taking

634
00:26:38.918 --> 00:26:40.520
and what help do they need and

635
00:26:40.520 --> 00:26:43.182
communicating that
information back and forth.

636
00:26:43.182 --> 00:26:45.432
And being that person
the psychiatrist can call

637
00:26:45.432 --> 00:26:48.746
when they have a question,
when the primary care provider

638
00:26:48.746 --> 00:26:51.308
has a question they can rely
on the health care manager.

639
00:26:51.308 --> 00:26:53.610
And with the client,
basically they're coaching

640
00:26:53.610 --> 00:26:56.640
and coordinating, they're
connecting this person,

641
00:26:56.640 --> 00:26:58.706
they're activating them,
they're engaging them

642
00:26:58.706 --> 00:27:00.279
in their own healthcare.

643
00:27:00.279 --> 00:27:04.076
So think about, someone that
has diabetes for example,

644
00:27:04.076 --> 00:27:06.267
and the primary care
physician says, "You have to

645
00:27:06.267 --> 00:27:08.116
"lose weight and stop smoking."

646
00:27:08.116 --> 00:27:09.328
Wonderful.

647
00:27:09.328 --> 00:27:10.562
How do you do that?

648
00:27:10.562 --> 00:27:12.784
The health care manager
then has a set of tools

649
00:27:12.784 --> 00:27:16.074
that can work around those
issues with the client

650
00:27:16.074 --> 00:27:18.986
in an individualized
manner using basically

651
00:27:18.986 --> 00:27:22.181
behavioral activation
techniques, problem solving

652
00:27:22.181 --> 00:27:24.276
techniques, and action planning.

653
00:27:24.276 --> 00:27:26.446
A step-by-step process on
how you change behavior

654
00:27:26.446 --> 00:27:28.331
and work on it one-on-one.

655
00:27:28.331 --> 00:27:30.686
It's a intervention that'll
last for an entire year.

656
00:27:30.686 --> 00:27:34.354
They meet at least once a
month an they have checkups

657
00:27:34.354 --> 00:27:38.521
throughout the month to
figure out what's going on.

658
00:27:43.566 --> 00:27:46.404
It's all manualized, both
in English and Spanish,

659
00:27:46.404 --> 00:27:49.302
and is really tailored
for the individual needs.

660
00:27:49.302 --> 00:27:51.677
Basically the health care
manager has a tool box

661
00:27:51.677 --> 00:27:53.448
of behavioral techniques that they can use

662
00:27:53.448 --> 00:27:56.166
with the client and then individualize it

663
00:27:56.166 --> 00:27:58.104
to the needs of that
client around issues of

664
00:27:58.104 --> 00:28:00.586
physical health, particularly preventive

665
00:28:00.586 --> 00:28:02.756
primary care issues.

666
00:28:02.756 --> 00:28:06.848
So we didn't measure the
adaptations to this process

667
00:28:06.848 --> 00:28:09.294
using our approach, but we did two levels

668
00:28:09.294 --> 00:28:10.127
of adaptation.

669
00:28:10.127 --> 00:28:12.794
Most studies work on this level,

670
00:28:14.210 --> 00:28:15.198
the cultural adaptation.

671
00:28:15.198 --> 00:28:18.290
Making sure that it's relevant,
appropriate for the group,

672
00:28:18.290 --> 00:28:20.539
for the client population.

673
00:28:20.539 --> 00:28:22.620
But we also had to adapt for the provider.

674
00:28:22.620 --> 00:28:24.832
Remember, the intervention
was done by nurses,

675
00:28:24.832 --> 00:28:26.701
registered nurses, we have social workers,

676
00:28:26.701 --> 00:28:29.573
master-level social workers
we need to adapt it to.

677
00:28:29.573 --> 00:28:31.758
And I'll give you examples
of what that means,

678
00:28:31.758 --> 00:28:33.888
of the type of adaptations that we did.

679
00:28:33.888 --> 00:28:36.622
But we did multiple levels
and this took a lot of time

680
00:28:36.622 --> 00:28:40.789
and creativity in having
clinicians as part of our team

681
00:28:42.158 --> 00:28:44.485
engage in this process,
so it was really helpful.

682
00:28:44.485 --> 00:28:46.502
As researchers we know some of the things,

683
00:28:46.502 --> 00:28:49.958
but the clinicians really
bring a lot of expertise

684
00:28:49.958 --> 00:28:53.325
and wisdom on the type
of things we need to

685
00:28:53.325 --> 00:28:55.105
address and adapt.

686
00:28:55.105 --> 00:28:58.251
So here's an example of
a provider adaptation.

687
00:28:58.251 --> 00:29:00.813
The original trial focused on coordinating

688
00:29:00.813 --> 00:29:03.101
from one community mental health center

689
00:29:03.101 --> 00:29:06.168
to one primary care center.

690
00:29:06.168 --> 00:29:09.053
Big centers, multiple providers,
but it's a one to one,

691
00:29:09.053 --> 00:29:13.220
it's one institution coordinating
to another institution.

692
00:29:14.305 --> 00:29:16.551
That was the reality of the PCARE trial,

693
00:29:16.551 --> 00:29:18.857
big randomized trial, this intervention

694
00:29:18.857 --> 00:29:20.115
when it first started.

695
00:29:20.115 --> 00:29:24.694
Our reality was one
community health center with

696
00:29:24.694 --> 00:29:27.564
multiple different primary
care clinics throughout

697
00:29:27.564 --> 00:29:28.750
the community.

698
00:29:28.750 --> 00:29:30.986
Actually 17 of them.

699
00:29:30.986 --> 00:29:33.326
So imagine the complexity
of coordinating with

700
00:29:33.326 --> 00:29:35.250
17 different organizations.

701
00:29:35.250 --> 00:29:37.341
You see one primary care clinic,

702
00:29:37.341 --> 00:29:39.969
you see one primary care clinic.

703
00:29:39.969 --> 00:29:42.829
Some are mom and pop shops,

704
00:29:42.829 --> 00:29:45.687
some are multiple federally
qualified centers,

705
00:29:45.687 --> 00:29:47.092
some are affiliated to Columbia,

706
00:29:47.092 --> 00:29:49.156
some are affiliated to other universities,

707
00:29:49.156 --> 00:29:50.900
some are not affiliated at all.

708
00:29:50.900 --> 00:29:54.383
So the complexity of
coordination was massive for us.

709
00:29:54.383 --> 00:29:57.233
So we have to actually develop
a care coordination plan

710
00:29:57.233 --> 00:30:01.510
where the health care manager
knew where to contact,

711
00:30:01.510 --> 00:30:04.147
who to contact, how often to contact,

712
00:30:04.147 --> 00:30:07.567
and what type of information
they wanted to share.

713
00:30:07.567 --> 00:30:10.181
And thinking about all the
different medical records

714
00:30:10.181 --> 00:30:12.365
that they have to deal
with, those are massive,

715
00:30:12.365 --> 00:30:15.119
complexity on how we did this.

716
00:30:15.119 --> 00:30:17.617
This actually is a social worker task,

717
00:30:17.617 --> 00:30:19.902
to create relationships
with different people

718
00:30:19.902 --> 00:30:22.089
within that organization, to coordinate.

719
00:30:22.089 --> 00:30:25.285
So this is a major
adaptation from this reality

720
00:30:25.285 --> 00:30:29.285
to this reality and I'll
show you how we did it.

721
00:30:31.348 --> 00:30:33.036
The second was a cultural adaptation.

722
00:30:33.036 --> 00:30:35.598
So clients talked about,
as you can remember,

723
00:30:35.598 --> 00:30:38.108
about their experiences
and the relationship

724
00:30:38.108 --> 00:30:41.266
with their primary care
physician and that personal

725
00:30:41.266 --> 00:30:43.526
experience was really
important for people.

726
00:30:43.526 --> 00:30:47.194
So we wanted to add an assessment tool

727
00:30:47.194 --> 00:30:49.222
that went beyond just the
physical health issue,

728
00:30:49.222 --> 00:30:51.822
but actually asked people
about their experiences

729
00:30:51.822 --> 00:30:54.330
with their health, their
views of their physical

730
00:30:54.330 --> 00:30:56.630
health issue, what they
fear most about their

731
00:30:56.630 --> 00:30:58.774
physical health issues,
what their hopes are

732
00:30:58.774 --> 00:31:00.506
for physical health.

733
00:31:00.506 --> 00:31:02.959
And we used the cultural
formulation interview,

734
00:31:02.959 --> 00:31:06.056
which is actually a tool
that is embedded in DSN 5

735
00:31:06.056 --> 00:31:08.569
and it actually is a patient centered,

736
00:31:08.569 --> 00:31:11.046
or client centered,
interview that really gets

737
00:31:11.046 --> 00:31:14.338
at the story of that
person and their illness.

738
00:31:14.338 --> 00:31:17.365
What do you think causes your illness?

739
00:31:17.365 --> 00:31:20.589
What have you done in the past?

740
00:31:20.589 --> 00:31:23.840
What fears do you have
about your treatment?

741
00:31:23.840 --> 00:31:26.738
What do you do to cope with
this in your everyday life?

742
00:31:26.738 --> 00:31:28.545
What's interesting is
that it gathers all this

743
00:31:28.545 --> 00:31:31.161
very culturally individualized information

744
00:31:31.161 --> 00:31:35.536
from the person's perspective,
but it opens the door

745
00:31:35.536 --> 00:31:37.752
for the individual and
the health care manager

746
00:31:37.752 --> 00:31:40.064
to connect on a more humane level.

747
00:31:40.064 --> 00:31:43.286
It conveys personal libra,
meaning I care for you.

748
00:31:43.286 --> 00:31:44.418
I'm here for you.

749
00:31:44.418 --> 00:31:46.001
It conveys respect.

750
00:31:46.900 --> 00:31:48.759
I'm respecting your point of view.

751
00:31:48.759 --> 00:31:51.061
And then it provides all this information

752
00:31:51.061 --> 00:31:53.206
the health care manager can use to develop

753
00:31:53.206 --> 00:31:54.832
better treatment plans.

754
00:31:54.832 --> 00:31:57.873
It's 16 questions, it's open ended.

755
00:31:57.873 --> 00:31:59.654
It's not easy to deliver,
don't get me wrong.

756
00:31:59.654 --> 00:32:02.237
This takes some time to do one.

757
00:32:03.683 --> 00:32:05.191
I don't know how many
psychiatrists are in the room,

758
00:32:05.191 --> 00:32:07.126
but psychiatrists wrote
it, so they have a whole

759
00:32:07.126 --> 00:32:09.441
different view of the
world, but it provides

760
00:32:09.441 --> 00:32:13.027
this really good approach
of getting in to the

761
00:32:13.027 --> 00:32:15.380
story of the person and
using that information.

762
00:32:15.380 --> 00:32:18.021
And actually clients like this.

763
00:32:18.021 --> 00:32:19.217
Nobody has asked them,

764
00:32:19.217 --> 00:32:21.845
"What do you think causes your diabetes?"

765
00:32:21.845 --> 00:32:25.225
"What do you fear most about
your diabetic treatment?"

766
00:32:25.225 --> 00:32:27.849
"What do you fear most
about your hypertension?"

767
00:32:27.849 --> 00:32:30.889
And it provides all that
information that is necessary.

768
00:32:30.889 --> 00:32:32.737
So it's that cultural adaptations,

769
00:32:32.737 --> 00:32:34.050
we didn't change the
intervention, just added

770
00:32:34.050 --> 00:32:35.550
a component to it.

771
00:32:36.530 --> 00:32:37.891
So as you can see, I like pictures.

772
00:32:37.891 --> 00:32:39.562
So this is another way of
looking at the intervention

773
00:32:39.562 --> 00:32:41.303
using a logic model.

774
00:32:41.303 --> 00:32:43.501
The intervention focuses on an assessment,

775
00:32:43.501 --> 00:32:45.646
a care coordination, and plan activation.

776
00:32:45.646 --> 00:32:49.613
All the red parts are all
the adaptations that we did.

777
00:32:49.613 --> 00:32:51.048
And these are outcomes.

778
00:32:51.048 --> 00:32:54.361
Receive preventive primary
care, patient's assessment

779
00:32:54.361 --> 00:32:56.019
and perception that their
chronic illness care

780
00:32:56.019 --> 00:32:58.775
is improving, patient
activation and health

781
00:32:58.775 --> 00:33:02.637
of efficacy and hopefully
improve their quality

782
00:33:02.637 --> 00:33:04.755
of life and general health status.

783
00:33:04.755 --> 00:33:06.305
So that's sort of what we wanted to test

784
00:33:06.305 --> 00:33:07.843
in this intervention.

785
00:33:07.843 --> 00:33:11.290
So, given that we have
developed this intervention

786
00:33:11.290 --> 00:33:13.675
with community, then we wanted
to test their feasibility,

787
00:33:13.675 --> 00:33:15.561
which basically means can we do this.

788
00:33:15.561 --> 00:33:16.844
Can we get clients?

789
00:33:16.844 --> 00:33:18.119
Can clients come?

790
00:33:18.119 --> 00:33:21.461
And is it feasible for social
workers to take on this role

791
00:33:21.461 --> 00:33:24.973
in a public outpatient
mental health setting?

792
00:33:24.973 --> 00:33:29.001
Acceptability means do clients
actually benefit from this.

793
00:33:29.001 --> 00:33:30.596
Do they come?

794
00:33:30.596 --> 00:33:31.795
Do they find it relevant,
do they find it helpful?

795
00:33:31.795 --> 00:33:35.805
And do they find it as
something that they can do.

796
00:33:35.805 --> 00:33:37.622
And then to explore
the intervention effect

797
00:33:37.622 --> 00:33:39.741
to say have the effects on the outcomes

798
00:33:39.741 --> 00:33:44.448
that we are concerned about
and wanted to see change.

799
00:33:44.448 --> 00:33:46.254
So in terms of the methods of sample,

800
00:33:46.254 --> 00:33:49.357
basically we included Latinos,
18 years of age or older,

801
00:33:49.357 --> 00:33:53.198
with a chart diagnosis of
a serious mental illness,

802
00:33:53.198 --> 00:33:56.082
so they've already had
to have been diagnosed

803
00:33:56.082 --> 00:33:58.165
by a psychiatrist that they
have a serious mental illness,

804
00:33:58.165 --> 00:34:01.334
and they also had to be at risk
for cardiovascular disease,

805
00:34:01.334 --> 00:34:03.338
and this means everything under the sun.

806
00:34:03.338 --> 00:34:07.224
Basically if you're a smoker,
if your BMI is 25 or above,

807
00:34:07.224 --> 00:34:10.358
you body mass index is 25 or
above, if you have diabetes,

808
00:34:10.358 --> 00:34:12.112
if you have hypertension.

809
00:34:12.112 --> 00:34:13.932
I mean in these types of
clinics, that's like 90%

810
00:34:13.932 --> 00:34:15.246
of the patients.

811
00:34:15.246 --> 00:34:17.701
This is so common that we
wanted to be as inclusive

812
00:34:17.701 --> 00:34:18.897
as possible.

813
00:34:18.897 --> 00:34:20.325
And then we excluded
people who were in need

814
00:34:20.325 --> 00:34:22.824
of the toxification at
the time of recruitment,

815
00:34:22.824 --> 00:34:25.465
whether they were suicidal,
homicidal, at the time

816
00:34:25.465 --> 00:34:29.442
of recruitment, that they felt
out of capacity to consent,

817
00:34:29.442 --> 00:34:33.571
so they couldn't give consent
because of capacity issues,

818
00:34:33.571 --> 00:34:35.734
and for those who are 65 years are older,

819
00:34:35.734 --> 00:34:37.992
we did a cognitive impairment
scheme and if they were

820
00:34:37.992 --> 00:34:40.827
cognitively impaired, they
were excluded from the study

821
00:34:40.827 --> 00:34:42.659
because they couldn't
benefit from the intervention

822
00:34:42.659 --> 00:34:43.826
at this point.

823
00:34:45.340 --> 00:34:47.732
So the method of setting
it up, as I said, it's at a

824
00:34:47.732 --> 00:34:49.681
public mental health clinic,
it serves a predominately

825
00:34:49.681 --> 00:34:53.945
Latino population, most
predominately Dominican,

826
00:34:53.945 --> 00:34:58.112
because it's in Inwood, we
used a prepose one group

827
00:34:59.027 --> 00:35:02.725
design, so one group went
through the intervention

828
00:35:02.725 --> 00:35:04.341
for 12 months.

829
00:35:04.341 --> 00:35:06.802
We assess at baseline,
six months, and 12 months,

830
00:35:06.802 --> 00:35:09.025
and we did structured,
quantitative interviews

831
00:35:09.025 --> 00:35:10.686
and also chart abstraction.

832
00:35:10.686 --> 00:35:13.094
So we went to a primary
care clinic and abstracted

833
00:35:13.094 --> 00:35:15.309
information about the
care that they received

834
00:35:15.309 --> 00:35:17.074
at that primary care clinic.

835
00:35:17.074 --> 00:35:18.349
And then at the end of the intervention

836
00:35:18.349 --> 00:35:20.218
we did three focus groups for people

837
00:35:20.218 --> 00:35:22.468
who finished the intervention
and wanted to participate

838
00:35:22.468 --> 00:35:23.908
in the focus group.

839
00:35:23.908 --> 00:35:26.393
People didn't get paid for attending our

840
00:35:26.393 --> 00:35:29.006
health care manager sessions.

841
00:35:29.006 --> 00:35:30.653
They did get paid for the assessment.

842
00:35:30.653 --> 00:35:34.243
$15 for the assessment,
$25 for the focus group,

843
00:35:34.243 --> 00:35:35.743
plus a Metro card.

844
00:35:36.741 --> 00:35:38.210
So, feasibility, we
looked at our recruitment,

845
00:35:38.210 --> 00:35:40.370
assessment completion,
treatment, attendance,

846
00:35:40.370 --> 00:35:42.837
acceptability, we have
a client satisfaction

847
00:35:42.837 --> 00:35:45.247
questionnaire, as well
at the focus group data,

848
00:35:45.247 --> 00:35:47.456
the qualitative data that we received,

849
00:35:47.456 --> 00:35:50.004
and then we have structured measures,

850
00:35:50.004 --> 00:35:51.744
standardized measures, for the concepts

851
00:35:51.744 --> 00:35:54.098
of patient activation, self-efficacy,

852
00:35:54.098 --> 00:35:57.943
perception of chronic
illness, care quality.

853
00:35:57.943 --> 00:35:59.636
The receipt for preventive primary care

854
00:35:59.636 --> 00:36:02.626
was actually a list of
guiding concurrent care

855
00:36:02.626 --> 00:36:04.304
that every adult should receive,

856
00:36:04.304 --> 00:36:06.408
particularly if you are
at risk for cardiovascular

857
00:36:06.408 --> 00:36:08.592
disease, and we looked at
medical chart abstraction

858
00:36:08.592 --> 00:36:12.468
to see if they actually
received it during a baseline

859
00:36:12.468 --> 00:36:15.768
and a 12 month, during our work.

860
00:36:15.768 --> 00:36:17.578
And then we used the SF12
for the physical health

861
00:36:17.578 --> 00:36:21.270
and the mental health
related quality of life.

862
00:36:21.270 --> 00:36:23.582
So fidelity, we have
transformed this intervention,

863
00:36:23.582 --> 00:36:26.470
we want to make sure that
we deliver the intervention

864
00:36:26.470 --> 00:36:28.976
as it was intended, to
make sure there's no

865
00:36:28.976 --> 00:36:30.359
intervention drift.

866
00:36:30.359 --> 00:36:32.020
We have two health care managers.

867
00:36:32.020 --> 00:36:34.423
One health care manager
was a social worker

868
00:36:34.423 --> 00:36:36.960
who was already employed,
had more than 20 years

869
00:36:36.960 --> 00:36:39.699
of experience, and wanted to take this on

870
00:36:39.699 --> 00:36:44.263
and she volunteered her time,
actually she volunteered

871
00:36:44.263 --> 00:36:46.343
some of her time and we
paid for some of her time,

872
00:36:46.343 --> 00:36:49.097
as well, to take on a
caseload of 15 patients

873
00:36:49.097 --> 00:36:50.930
for this intervention.

874
00:36:52.584 --> 00:36:54.796
The other health care
manager was a master level

875
00:36:54.796 --> 00:36:57.524
social work student who was part of our,

876
00:36:57.524 --> 00:37:01.764
a master level student,
sorry an M.S.W. who

877
00:37:01.764 --> 00:37:04.846
graduated from their
master program and was now

878
00:37:04.846 --> 00:37:06.822
a doctoral student in our program.

879
00:37:06.822 --> 00:37:09.394
One health care manager was Dominican,

880
00:37:09.394 --> 00:37:11.904
the other health care manager was Mexican,

881
00:37:11.904 --> 00:37:14.140
so different ethnicities.

882
00:37:14.140 --> 00:37:17.482
They were all bilingual and could speak

883
00:37:17.482 --> 00:37:19.534
both languages.

884
00:37:19.534 --> 00:37:21.694
We actually, for the fidelity, we recorded

885
00:37:21.694 --> 00:37:23.002
every session.

886
00:37:23.002 --> 00:37:25.916
We audio recorded every
session, we had a master level

887
00:37:25.916 --> 00:37:28.973
student listen to all the sessions,

888
00:37:28.973 --> 00:37:31.584
rate the fidelity of what they did,

889
00:37:31.584 --> 00:37:34.108
and then they provided feedback
to the health care manager

890
00:37:34.108 --> 00:37:36.226
to make sure that they're
delivering the care,

891
00:37:36.226 --> 00:37:39.620
the intervention, as it was intended.

892
00:37:39.620 --> 00:37:43.556
So it was more of a
supervision type of approach.

893
00:37:43.556 --> 00:37:45.466
And then we had monthly
supervision meetings.

894
00:37:45.466 --> 00:37:47.633
And once in a while we
will bring one of the

895
00:37:47.633 --> 00:37:49.648
primary care physicians in the community

896
00:37:49.648 --> 00:37:51.145
who was our consultant for our project

897
00:37:51.145 --> 00:37:53.808
to attend the monthly supervision meetings

898
00:37:53.808 --> 00:37:56.052
if we encountered any
major issues that we need

899
00:37:56.052 --> 00:37:58.058
to address, and there were several of them

900
00:37:58.058 --> 00:37:59.808
throughout the trial.

901
00:38:00.800 --> 00:38:03.348
So data analysis, we look at frequencies

902
00:38:03.348 --> 00:38:05.203
and measure of central tendency.

903
00:38:05.203 --> 00:38:07.484
We did a content analysis
of the focus group data.

904
00:38:07.484 --> 00:38:10.732
And then we used linear mix
model, adjusting for the

905
00:38:10.732 --> 00:38:13.099
health care manager
assignment, although we didn't

906
00:38:13.099 --> 00:38:15.946
randomize people, we
had two different people

907
00:38:15.946 --> 00:38:18.477
delivering interventions,
so we wanted to control

908
00:38:18.477 --> 00:38:21.066
to see if there's any
effect, whether someone

909
00:38:21.066 --> 00:38:23.371
who's very experienced
versus someone who's not

910
00:38:23.371 --> 00:38:27.038
as experienced delivering
this intervention.

911
00:38:28.117 --> 00:38:29.282
So, what did we find?

912
00:38:29.282 --> 00:38:31.494
First of all, we were
able to recruit people.

913
00:38:31.494 --> 00:38:33.431
Yes, people did come.

914
00:38:33.431 --> 00:38:35.497
People were interested in participating

915
00:38:35.497 --> 00:38:38.616
and people wanted to
be part of this study.

916
00:38:38.616 --> 00:38:40.504
Our recruitment was 77%, so
most people we approached

917
00:38:40.504 --> 00:38:44.206
actually said yes and they
wanted the health care manager

918
00:38:44.206 --> 00:38:45.219
intervention.

919
00:38:45.219 --> 00:38:47.066
They didn't have to pay for that service.

920
00:38:47.066 --> 00:38:50.185
And we found that 85% of the
people actually completed

921
00:38:50.185 --> 00:38:52.956
the treatment and the study.

922
00:38:52.956 --> 00:38:57.123
So people completed the 12
months of treatment as well

923
00:38:59.057 --> 00:39:00.666
as all the interventions.

924
00:39:00.666 --> 00:39:03.679
We only lost five
people, four dropped out,

925
00:39:03.679 --> 00:39:05.628
they were just not
interested and moved on,

926
00:39:05.628 --> 00:39:07.303
and we lost one person to follow-up,

927
00:39:07.303 --> 00:39:10.310
who actually found a job
and moved somewhere else,

928
00:39:10.310 --> 00:39:11.857
so I hope that person is doing well

929
00:39:11.857 --> 00:39:13.365
because finding a job is really important

930
00:39:13.365 --> 00:39:15.525
for this population.

931
00:39:15.525 --> 00:39:17.720
So feasibility, as I
mentioned, people did complete

932
00:39:17.720 --> 00:39:18.905
the intervention.

933
00:39:18.905 --> 00:39:23.505
Most people, the average number
of visits were 10 out of 12,

934
00:39:23.505 --> 00:39:25.676
once a month, and a medium of 10.

935
00:39:25.676 --> 00:39:28.796
93% of the people attended
nine or more visits.

936
00:39:28.796 --> 00:39:30.354
People got the intervention.

937
00:39:30.354 --> 00:39:32.047
Once they were there they liked it,

938
00:39:32.047 --> 00:39:34.959
they came back, and, as you will see,

939
00:39:34.959 --> 00:39:38.131
they continue to see
their health care manager,

940
00:39:38.131 --> 00:39:41.629
and we had five people who dropped out.

941
00:39:41.629 --> 00:39:43.137
I've been getting this question regarding

942
00:39:43.137 --> 00:39:45.789
well, this is great, but how much time

943
00:39:45.789 --> 00:39:47.495
do people actually spend doing this

944
00:39:47.495 --> 00:39:49.321
and is this actually feasible?

945
00:39:49.321 --> 00:39:50.701
So here's how we broke it down.

946
00:39:50.701 --> 00:39:52.851
Per session, health care
manager spent 80 minutes

947
00:39:52.851 --> 00:39:56.459
in total on all the
things that they need to.

948
00:39:56.459 --> 00:40:00.292
That's 80 minutes for
each client per session.

949
00:40:01.429 --> 00:40:03.265
Most of it was done during the session.

950
00:40:03.265 --> 00:40:04.329
Sessions were about an hour.

951
00:40:04.329 --> 00:40:06.891
People did one hour to 47 minutes.

952
00:40:06.891 --> 00:40:08.569
15 minutes of care coordination.

953
00:40:08.569 --> 00:40:12.069
That means calling people up, finding what

954
00:40:12.975 --> 00:40:15.755
the right medications
are, sharing information,

955
00:40:15.755 --> 00:40:17.731
charting for all the issues,

956
00:40:17.731 --> 00:40:19.385
and then client outreach.

957
00:40:19.385 --> 00:40:22.997
At the end of the day it
was like 20 hours a week

958
00:40:22.997 --> 00:40:25.497
for a caseload of 15 patients,

959
00:40:29.196 --> 00:40:32.385
so a part-time person
could do 15 caseloads

960
00:40:32.385 --> 00:40:35.037
using this intervention,
which seems feasible.

961
00:40:35.037 --> 00:40:37.907
And we're exploring the cost of that

962
00:40:37.907 --> 00:40:39.093
because it's really
important to figure out

963
00:40:39.093 --> 00:40:41.510
how we're gonna pay for this.

964
00:40:42.470 --> 00:40:44.095
So the clients who participated in this

965
00:40:44.095 --> 00:40:47.152
were mostly female, average
age 54 years of age.

966
00:40:47.152 --> 00:40:49.153
This is a lower educated population,

967
00:40:49.153 --> 00:40:50.986
less than high school.

968
00:40:52.137 --> 00:40:53.965
Almost everyone was unemployed,

969
00:40:53.965 --> 00:40:58.215
receiving different
types of social services.

970
00:40:58.215 --> 00:41:00.027
Most of them are insured and that's part

971
00:41:00.027 --> 00:41:01.505
of being part of this clinic.

972
00:41:01.505 --> 00:41:04.736
The majority were Dominican
and actually the U.S. born,

973
00:41:04.736 --> 00:41:07.575
the majority of those
were of Dominican descent.

974
00:41:07.575 --> 00:41:11.437
Almost everyone was
monolingual Spanish speaking.

975
00:41:11.437 --> 00:41:13.711
Some of the bilinguals
actually ended up receiving

976
00:41:13.711 --> 00:41:16.245
interventions in Spanish,
even though they've lived

977
00:41:16.245 --> 00:41:19.403
in the United States for
an average age of 31 years.

978
00:41:19.403 --> 00:41:22.367
These are people who
still prefer to receive

979
00:41:22.367 --> 00:41:25.903
services in Spanish and that
was really important for them.

980
00:41:25.903 --> 00:41:27.841
Mental health characteristics,
most people had

981
00:41:27.841 --> 00:41:31.037
schizo-affective disorders
or major depression

982
00:41:31.037 --> 00:41:32.129
or bipolar.

983
00:41:32.129 --> 00:41:34.494
There were people stabilized,
meaning they're receiving

984
00:41:34.494 --> 00:41:35.977
good outpatient mental health services.

985
00:41:35.977 --> 00:41:39.201
They're not going for
psychiatric hospitalization

986
00:41:39.201 --> 00:41:40.903
and they're not going to ER services.

987
00:41:40.903 --> 00:41:43.606
They're receiving the
right mental health care

988
00:41:43.606 --> 00:41:45.687
and they're staying
outside of the hospital.

989
00:41:45.687 --> 00:41:47.247
They're living in the
community, so this is

990
00:41:47.247 --> 00:41:50.146
a population that is out of the hospital,

991
00:41:50.146 --> 00:41:52.822
it's not going in and out
for mental health issues.

992
00:41:52.822 --> 00:41:56.087
For physical health issues,
most people perceived

993
00:41:56.087 --> 00:41:58.686
their health as poor or fair.

994
00:41:58.686 --> 00:42:00.465
Major diagnosis was
obesity, high cholesterol,

995
00:42:00.465 --> 00:42:01.298
diabetes.

996
00:42:01.298 --> 00:42:04.809
Of course we only recruited
people who had these disorders.

997
00:42:04.809 --> 00:42:08.809
Most people have 2.8
chronic medical conditions.

998
00:42:10.803 --> 00:42:11.868
About 1/3 were current smokers.

999
00:42:11.868 --> 00:42:13.597
And this is really interesting,
when we first started

1000
00:42:13.597 --> 00:42:17.213
this project the psychiatrist
and the provider were

1001
00:42:17.213 --> 00:42:18.953
saying, "No, there's
no smokers around here.

1002
00:42:18.953 --> 00:42:20.825
"Latinos don't smoke that much."

1003
00:42:20.825 --> 00:42:23.609
1/3 of them were reported
smoking, so this was an issue.

1004
00:42:23.609 --> 00:42:26.012
And actually they started
a smoking cessation program

1005
00:42:26.012 --> 00:42:29.496
once we presented some
of the findings early on.

1006
00:42:29.496 --> 00:42:31.121
And then the mean number
of visits, these people,

1007
00:42:31.121 --> 00:42:33.552
interesting enough, were
going to primary care.

1008
00:42:33.552 --> 00:42:36.089
These are not people who are
not going to primary care,

1009
00:42:36.089 --> 00:42:38.065
in fact they're going to primary care.

1010
00:42:38.065 --> 00:42:40.703
The issue is the type of
care that they were receiving

1011
00:42:40.703 --> 00:42:42.298
in primary care services.

1012
00:42:42.298 --> 00:42:45.955
Not going too much to
the ER or urgent care.

1013
00:42:45.955 --> 00:42:47.633
And as I mentioned, they
were going to multiple

1014
00:42:47.633 --> 00:42:51.080
primary care clinics in the community.

1015
00:42:51.080 --> 00:42:53.667
So in terms of acceptability,
people like the quality

1016
00:42:53.667 --> 00:42:55.659
of the care that they received.

1017
00:42:55.659 --> 00:42:59.687
They felt like it met most
or all of their needs.

1018
00:42:59.687 --> 00:43:01.441
They were satisfied with
the amount of services

1019
00:43:01.441 --> 00:43:04.277
that they got and they
thought that it helped them

1020
00:43:04.277 --> 00:43:06.444
and they would recommend a friend.

1021
00:43:06.444 --> 00:43:08.486
In terms of the qualitative
data, most people

1022
00:43:08.486 --> 00:43:11.089
described the intervention
as helpful, fantastic,

1023
00:43:11.089 --> 00:43:14.015
excellent, beneficial,
efficient, this is wonderful.

1024
00:43:14.015 --> 00:43:15.911
And in all my years of doing
research with the Latino

1025
00:43:15.911 --> 00:43:17.529
community, when you do a client

1026
00:43:17.529 --> 00:43:21.603
satisfaction questionnaire,
nobody complains.

1027
00:43:21.603 --> 00:43:23.474
Everybody says wonderful, this is awesome.

1028
00:43:23.474 --> 00:43:27.269
So you have to be careful with this data,

1029
00:43:27.269 --> 00:43:29.647
particularly when you're paying people

1030
00:43:29.647 --> 00:43:32.443
and you receive 12
months of free treatment,

1031
00:43:32.443 --> 00:43:34.132
they're gonna be very happy.

1032
00:43:34.132 --> 00:43:37.241
But they felt, interesting
enough in the qualitative data,

1033
00:43:37.241 --> 00:43:40.333
that they felt that the
relationship they formed with their

1034
00:43:40.333 --> 00:43:42.164
health care manager was really important.

1035
00:43:42.164 --> 00:43:44.677
They felt respected, they
felt the health care managers

1036
00:43:44.677 --> 00:43:47.145
were prepared, were
professional, they treated me

1037
00:43:47.145 --> 00:43:49.433
like family, which is really important,

1038
00:43:49.433 --> 00:43:53.489
and they recommended that
we expand the program.

1039
00:43:53.489 --> 00:43:55.479
And we're actually doing,
now, case history so

1040
00:43:55.479 --> 00:43:58.377
we ask our health care
manager to write a history

1041
00:43:58.377 --> 00:44:01.875
of the cases that they had
and issues that came up

1042
00:44:01.875 --> 00:44:05.307
and we're learning quite a
lot about the relationship

1043
00:44:05.307 --> 00:44:07.595
that they formed with clients
and how important that was

1044
00:44:07.595 --> 00:44:09.178
to this population.

1045
00:44:10.313 --> 00:44:12.705
We also asked, at the
end of the 12 months,

1046
00:44:12.705 --> 00:44:15.363
what they liked most in
an open-ended question.

1047
00:44:15.363 --> 00:44:16.726
And then we coded that.

1048
00:44:16.726 --> 00:44:20.193
And what people liked most
was the health formation

1049
00:44:20.193 --> 00:44:21.026
they were receiving.

1050
00:44:21.026 --> 00:44:23.223
Tips about their physical
health, tips about how to diet

1051
00:44:23.223 --> 00:44:25.639
and exercise, tips about their diabetes.

1052
00:44:25.639 --> 00:44:28.915
We share a lot of physical
health information

1053
00:44:28.915 --> 00:44:32.281
that we provided in Spanish
and people really liked that.

1054
00:44:32.281 --> 00:44:33.789
They loved their relationship with their

1055
00:44:33.789 --> 00:44:36.015
health care manager.

1056
00:44:36.015 --> 00:44:38.303
They liked the care
coordination, having someone

1057
00:44:38.303 --> 00:44:40.785
to worry about where
to go, how to go there,

1058
00:44:40.785 --> 00:44:42.576
how to share information.

1059
00:44:42.576 --> 00:44:44.373
And then they talked
about being activated,

1060
00:44:44.373 --> 00:44:47.732
being more involved, having
someone monitor their health

1061
00:44:47.732 --> 00:44:49.666
so every time they come
to a health care manager

1062
00:44:49.666 --> 00:44:51.225
they get weighed.

1063
00:44:51.225 --> 00:44:53.745
We did our waist circumference,
took their blood pressure,

1064
00:44:53.745 --> 00:44:55.179
and then knowing what their numbers are

1065
00:44:55.179 --> 00:44:57.155
and sharing that with
them was really important.

1066
00:44:57.155 --> 00:45:00.521
And then the health benefits
that they got from this.

1067
00:45:00.521 --> 00:45:01.871
All right, so impact.

1068
00:45:01.871 --> 00:45:03.589
What did we find?

1069
00:45:03.589 --> 00:45:05.877
So, first of all, we were
able to increase patient

1070
00:45:05.877 --> 00:45:07.984
activation, which is really important

1071
00:45:07.984 --> 00:45:10.103
because patient activation
means people feel like

1072
00:45:10.103 --> 00:45:12.171
they're involved in their own healthcare,

1073
00:45:12.171 --> 00:45:15.133
that they know what to do
when they have a crisis,

1074
00:45:15.133 --> 00:45:17.500
that they know what to ask when they have

1075
00:45:17.500 --> 00:45:19.099
a situation for their primary care.

1076
00:45:19.099 --> 00:45:21.816
So we saw a particularly
significant increase,

1077
00:45:21.816 --> 00:45:24.439
particularly from baseline to 12 months

1078
00:45:24.439 --> 00:45:28.195
and this is a moderate
effect for this intervention,

1079
00:45:28.195 --> 00:45:30.407
for this affect on patient activation.

1080
00:45:30.407 --> 00:45:32.615
Self-Efficacy, or the sense of control,

1081
00:45:32.615 --> 00:45:36.411
you can control your health,
we didn't see any effect

1082
00:45:36.411 --> 00:45:39.507
on exercise and asking
support from family members

1083
00:45:39.507 --> 00:45:43.340
and friends, but we did see
improvement in self-efficacy

1084
00:45:43.340 --> 00:45:45.993
in communicating with your
primary care physician.

1085
00:45:45.993 --> 00:45:48.281
So people felt that they
can now ask questions

1086
00:45:48.281 --> 00:45:50.465
from their primary care
physician, that they can

1087
00:45:50.465 --> 00:45:52.452
actually have a better
relationship with their

1088
00:45:52.452 --> 00:45:54.391
primary care physician, that they can,

1089
00:45:54.391 --> 00:45:57.242
if they have any
concerns, they can talk to

1090
00:45:57.242 --> 00:45:59.031
their primary care
physician, and we saw that

1091
00:45:59.031 --> 00:46:02.009
increase from baseline to 12 months.

1092
00:46:02.009 --> 00:46:04.037
And then they felt more
in control managing

1093
00:46:04.037 --> 00:46:05.572
the chronic medical illness, there's a

1094
00:46:05.572 --> 00:46:08.485
self-efficacy around
that that's also improved

1095
00:46:08.485 --> 00:46:10.671
from baseline to 12
months, and it's a moderate

1096
00:46:10.671 --> 00:46:12.421
affect-size for that.

1097
00:46:13.657 --> 00:46:15.477
Patient assessment of
the chronic illness care,

1098
00:46:15.477 --> 00:46:18.077
we asked them, this is a
really interesting measure,

1099
00:46:18.077 --> 00:46:20.781
because it's basically
patients' views on the care

1100
00:46:20.781 --> 00:46:22.057
they're receiving.

1101
00:46:22.057 --> 00:46:23.485
Now, we asked this in two ways.

1102
00:46:23.485 --> 00:46:25.263
We asked them of the care
their receiving from their

1103
00:46:25.263 --> 00:46:27.839
health care manager and
the healthcare that they're

1104
00:46:27.839 --> 00:46:30.023
receiving from their
primary care physician.

1105
00:46:30.023 --> 00:46:33.351
And I like this measure
because it's very behavior

1106
00:46:33.351 --> 00:46:34.184
oriented.

1107
00:46:35.057 --> 00:46:37.473
Basically, did your doctor
tell you about your medications

1108
00:46:37.473 --> 00:46:40.371
and how often did your
doctor tell you about your

1109
00:46:40.371 --> 00:46:42.334
medication in the past six months?

1110
00:46:42.334 --> 00:46:45.637
Did you doctor call you
after your visit during the

1111
00:46:45.637 --> 00:46:46.470
past six months?

1112
00:46:46.470 --> 00:46:48.237
How often did he or she do that?

1113
00:46:48.237 --> 00:46:52.269
Did you feel that your
care is well organized

1114
00:46:52.269 --> 00:46:54.179
and that you're prepared for your visit?

1115
00:46:54.179 --> 00:46:56.075
How often do you feel like that?

1116
00:46:56.075 --> 00:46:57.975
So it's really about
behavioral aspects of your

1117
00:46:57.975 --> 00:47:02.014
healthcare and it actually
matches on the aspects

1118
00:47:02.014 --> 00:47:03.938
of good chronic illness care.

1119
00:47:03.938 --> 00:47:06.500
So we did find improvement
on the care that they

1120
00:47:06.500 --> 00:47:08.114
were receiving from the
health care manager,

1121
00:47:08.114 --> 00:47:10.427
particularly the big
bump was from baseline to

1122
00:47:10.427 --> 00:47:12.861
six months then it got sustained,

1123
00:47:12.861 --> 00:47:15.107
and it's all moderate effect sizes.

1124
00:47:15.107 --> 00:47:17.288
Basically the health
care manager were doing

1125
00:47:17.288 --> 00:47:18.789
what they were supposed to be doing.

1126
00:47:18.789 --> 00:47:19.995
That's what this means.

1127
00:47:19.995 --> 00:47:22.089
It means we trained them
to do this good care

1128
00:47:22.089 --> 00:47:24.481
and they were delivering and
the patients, the clients,

1129
00:47:24.481 --> 00:47:26.693
were actually observing
that and reporting that

1130
00:47:26.693 --> 00:47:29.108
back to us, which is really important

1131
00:47:29.108 --> 00:47:30.853
in these types of interventions.

1132
00:47:30.853 --> 00:47:33.047
And I'm happy during the Q and A to talk

1133
00:47:33.047 --> 00:47:35.484
about the different soft
skills that this has.

1134
00:47:35.484 --> 00:47:36.874
But this is a really interesting measure

1135
00:47:36.874 --> 00:47:39.196
and it's being used right now to address

1136
00:47:39.196 --> 00:47:41.394
whether your services are patient-centered

1137
00:47:41.394 --> 00:47:45.371
around all these issues
in chronic illness care.

1138
00:47:45.371 --> 00:47:47.080
All right, the big outcome has to do with

1139
00:47:47.080 --> 00:47:48.949
receipt of actual care.

1140
00:47:48.949 --> 00:47:52.641
They are better activated,
they are in better control,

1141
00:47:52.641 --> 00:47:54.419
they are receiving the
care that they need.

1142
00:47:54.419 --> 00:47:56.602
When they go to primary
care, do they receive

1143
00:47:56.602 --> 00:47:59.372
preventive primary care that they need?

1144
00:47:59.372 --> 00:48:03.644
And we found a 20%, almost 25% increase

1145
00:48:03.644 --> 00:48:05.259
from baseline to 12 months over the course

1146
00:48:05.259 --> 00:48:07.887
of the year that they
participated in this intervention.

1147
00:48:07.887 --> 00:48:10.291
And this is a large effect size for that.

1148
00:48:10.291 --> 00:48:12.411
And basically what this
means is that different types

1149
00:48:12.411 --> 00:48:15.233
of preventive primary
care about vaccinations,

1150
00:48:15.233 --> 00:48:19.091
about screenings, about
labs, about education,

1151
00:48:19.091 --> 00:48:22.731
about monitoring of your
weight, of your blood pressure,

1152
00:48:22.731 --> 00:48:26.314
and we saw all of this
where is significant

1153
00:48:29.179 --> 00:48:30.292
except in the screening of men.

1154
00:48:30.292 --> 00:48:33.471
Men didn't want to get
their prostate check

1155
00:48:33.471 --> 00:48:37.638
as much as we needed to, but
it didn't read significant.

1156
00:48:39.077 --> 00:48:40.655
But everything else was.

1157
00:48:40.655 --> 00:48:43.778
So over the course of the
year, participating in our

1158
00:48:43.778 --> 00:48:47.103
intervention was associated
with increases in that.

1159
00:48:47.103 --> 00:48:49.054
We can't really say it was caused by it,

1160
00:48:49.054 --> 00:48:50.836
because we didn't have a comparison group,

1161
00:48:50.836 --> 00:48:53.918
but we've seen similar
effects that were seen

1162
00:48:53.918 --> 00:48:58.299
in the original trial
around all of these issues.

1163
00:48:58.299 --> 00:48:59.911
We also examined other outcomes,

1164
00:48:59.911 --> 00:49:02.914
so the same assessment of
the patient's chronic illness

1165
00:49:02.914 --> 00:49:05.083
care received from their
primary care physician,

1166
00:49:05.083 --> 00:49:08.474
the general health status,
overall how do you feel,

1167
00:49:08.474 --> 00:49:10.266
and your health and
mental quality of life.

1168
00:49:10.266 --> 00:49:14.042
So all of them improved or
they were not statistically

1169
00:49:14.042 --> 00:49:14.912
significant.

1170
00:49:14.912 --> 00:49:17.301
Again, this is a small
sample so there might be

1171
00:49:17.301 --> 00:49:20.087
some power issues for
this particular component,

1172
00:49:20.087 --> 00:49:22.830
but they all were improving
in the right direction,

1173
00:49:22.830 --> 00:49:24.688
as we were expecting.

1174
00:49:24.688 --> 00:49:27.647
So overall what we're
finding from this data

1175
00:49:27.647 --> 00:49:30.720
is that, first of all,
Bridges to Better Health

1176
00:49:30.720 --> 00:49:34.075
and Wellness is feasible to be delivered

1177
00:49:34.075 --> 00:49:35.738
by social workers, if
provided the right training

1178
00:49:35.738 --> 00:49:38.156
and the right supervisions
and the right environment

1179
00:49:38.156 --> 00:49:40.419
to deliver this type of intervention.

1180
00:49:40.419 --> 00:49:43.081
They can do it with the right support.

1181
00:49:43.081 --> 00:49:45.201
We found that the Latino
patients that participated

1182
00:49:45.201 --> 00:49:47.697
in this intervention helpful, acceptable,

1183
00:49:47.697 --> 00:49:50.858
culturally compatible,
and reported high levels

1184
00:49:50.858 --> 00:49:53.184
of satisfaction with the intervention.

1185
00:49:53.184 --> 00:49:56.331
And we saw that in the people
who participated in this

1186
00:49:56.331 --> 00:49:58.034
over the course of the intervention,

1187
00:49:58.034 --> 00:50:01.126
we saw significant improvement
on all these different

1188
00:50:01.126 --> 00:50:03.390
outcomes, which are critically important

1189
00:50:03.390 --> 00:50:05.286
to the population and
all of them are actually

1190
00:50:05.286 --> 00:50:08.081
associated with improvement
in health in the long run.

1191
00:50:08.081 --> 00:50:10.500
Although we didn't collect that data,

1192
00:50:10.500 --> 00:50:12.732
we saw improvements in that.

1193
00:50:12.732 --> 00:50:15.114
And this is important because
there are few interventions

1194
00:50:15.114 --> 00:50:18.743
out there that have shown this
promise in this population.

1195
00:50:18.743 --> 00:50:22.577
And here's where I think
it's really good to collect

1196
00:50:22.577 --> 00:50:24.942
qualitative data in an intervention study,

1197
00:50:24.942 --> 00:50:28.804
meaning we also got
information from clients

1198
00:50:28.804 --> 00:50:30.793
about how they saw this whole work

1199
00:50:30.793 --> 00:50:33.210
through focus groups.

1200
00:50:33.210 --> 00:50:35.394
And what we're beginning to find out is

1201
00:50:35.394 --> 00:50:39.581
how is this impacting,
what are the mechanisms

1202
00:50:39.581 --> 00:50:41.076
that we're seeing for this intervention.

1203
00:50:41.076 --> 00:50:42.400
And one of the things that have come up

1204
00:50:42.400 --> 00:50:45.652
is that all of these technical
aspects of the intervention

1205
00:50:45.652 --> 00:50:47.680
need to go through the
relationship that people

1206
00:50:47.680 --> 00:50:49.784
are building with the health care manager.

1207
00:50:49.784 --> 00:50:51.878
So we do need to train
the health care manager

1208
00:50:51.878 --> 00:50:54.087
in all of this, this is all evidence-based

1209
00:50:54.087 --> 00:50:57.376
approaches, and there's
techniques that you can use.

1210
00:50:57.376 --> 00:51:00.860
We need to pay really close
attention on that relationship

1211
00:51:00.860 --> 00:51:03.421
that they're building with their client

1212
00:51:03.421 --> 00:51:05.606
and that relationship, that's
where cultural components

1213
00:51:05.606 --> 00:51:06.854
really come into play.

1214
00:51:06.854 --> 00:51:08.709
How do you make sure
that the person sees you

1215
00:51:08.709 --> 00:51:10.037
as respectful?

1216
00:51:10.037 --> 00:51:12.144
How do you make sure that
you're showing support?

1217
00:51:12.144 --> 00:51:14.640
How do you provide individual attention?

1218
00:51:14.640 --> 00:51:16.162
How do you build trust?

1219
00:51:16.162 --> 00:51:17.892
And this is not new to social work.

1220
00:51:17.892 --> 00:51:20.932
This is really at the heart
of psycho-social intervention,

1221
00:51:20.932 --> 00:51:23.834
that relationship building
that you build with your client

1222
00:51:23.834 --> 00:51:25.637
becomes really important.

1223
00:51:25.637 --> 00:51:28.341
So really, we also need to
pay attention, not only to the

1224
00:51:28.341 --> 00:51:30.462
evidence-based practice,
but how we deliver

1225
00:51:30.462 --> 00:51:33.350
that evidence-based
approach or this promising

1226
00:51:33.350 --> 00:51:34.490
intervention.

1227
00:51:34.490 --> 00:51:38.300
And really learning how to
train someone to do that,

1228
00:51:38.300 --> 00:51:40.238
how to supervise them around those issues.

1229
00:51:40.238 --> 00:51:42.110
And we were able to do that.

1230
00:51:42.110 --> 00:51:45.048
Clients were reporting
that they felt connected

1231
00:51:45.048 --> 00:51:46.319
with our health care manager.

1232
00:51:46.319 --> 00:51:49.262
Now the big question is how
do we take this to scale?

1233
00:51:49.262 --> 00:51:52.212
How do we go on a bigger
sample and provide

1234
00:51:52.212 --> 00:51:54.482
the supervision and the
training that people need?

1235
00:51:54.482 --> 00:51:57.256
We have the beginning components of that.

1236
00:51:57.256 --> 00:52:00.636
It will be the next
challenge to take this on.

1237
00:52:00.636 --> 00:52:02.961
So, limitations of this particular study?

1238
00:52:02.961 --> 00:52:06.994
It's a small sample, we're
talking about 34 Latinos

1239
00:52:06.994 --> 00:52:08.644
who participated in the
study, 40 who participated

1240
00:52:08.644 --> 00:52:11.206
earlier on a needs assessment.

1241
00:52:11.206 --> 00:52:12.620
It's at one site.

1242
00:52:12.620 --> 00:52:16.000
It's a well-engaged, ready to go clinic

1243
00:52:16.000 --> 00:52:19.342
with really innovative clinicians.

1244
00:52:19.342 --> 00:52:20.175
Engaged.

1245
00:52:20.175 --> 00:52:21.199
Dedicated.

1246
00:52:21.199 --> 00:52:23.100
Not every place is like
that, so that's something

1247
00:52:23.100 --> 00:52:25.048
to really take into observation.

1248
00:52:25.048 --> 00:52:26.348
And the single group design.

1249
00:52:26.348 --> 00:52:28.470
We need more rigorous designs to take this

1250
00:52:28.470 --> 00:52:30.938
to a more randomized control.

1251
00:52:30.938 --> 00:52:34.824
The design and actually
to look at a comparison

1252
00:52:34.824 --> 00:52:37.660
group for this type of approach.

1253
00:52:37.660 --> 00:52:39.595
And that's where we're
thinking of doing that.

1254
00:52:39.595 --> 00:52:41.782
This gives you promising evidence to apply

1255
00:52:41.782 --> 00:52:45.276
for a larger grant and
test it in a larger sample

1256
00:52:45.276 --> 00:52:47.642
with multiple sites.

1257
00:52:47.642 --> 00:52:51.809
So in the end, Bridges to
Better Health and Wellness

1258
00:52:52.948 --> 00:52:55.260
seems like an acceptable
and feasible healthcare

1259
00:52:55.260 --> 00:52:56.550
management intervention.

1260
00:52:56.550 --> 00:52:59.954
It's showing promising
results, particularly

1261
00:52:59.954 --> 00:53:01.282
around patient activation, self-efficacy,

1262
00:53:01.282 --> 00:53:02.880
receipt of preventive primary care,

1263
00:53:02.880 --> 00:53:05.130
but we need more evidence
to really understand

1264
00:53:05.130 --> 00:53:08.354
and see the potential that
it has for implementation

1265
00:53:08.354 --> 00:53:10.548
and acceptability.

1266
00:53:10.548 --> 00:53:14.164
And, so, overall, at the
end of this, we're trying

1267
00:53:14.164 --> 00:53:16.362
to develop an intervention
that really addressees

1268
00:53:16.362 --> 00:53:18.034
the physical wholeness of the population

1269
00:53:18.034 --> 00:53:21.494
in a manner that they can
engage with the intervention

1270
00:53:21.494 --> 00:53:24.850
and they can actually benefit from it.

1271
00:53:24.850 --> 00:53:26.228
And I do want to leave you with a quote

1272
00:53:26.228 --> 00:53:28.256
that comes out from one of
the most seminal reports

1273
00:53:28.256 --> 00:53:30.831
in this area, that race is an issue,

1274
00:53:30.831 --> 00:53:33.210
that put this issue on the
map in the United States.

1275
00:53:33.210 --> 00:53:35.886
This is a report from
2006, almost 10 years ago,

1276
00:53:35.886 --> 00:53:39.617
that reported statistics
that people hear about.

1277
00:53:39.617 --> 00:53:41.932
25 years, people with
serious mental illness

1278
00:53:41.932 --> 00:53:43.831
die 25 years earlier.

1279
00:53:43.831 --> 00:53:46.390
That report is the one that
sort of puts it together,

1280
00:53:46.390 --> 00:53:49.239
and this is a quote from
that report that still rings

1281
00:53:49.239 --> 00:53:52.669
true today and it's really
critical for this work that

1282
00:53:52.669 --> 00:53:54.410
"There are multiple strategies to pursue

1283
00:53:54.410 --> 00:53:56.870
"in addressing morbidity and mortality,"

1284
00:53:56.870 --> 00:53:58.555
all these different models of care,

1285
00:53:58.555 --> 00:54:01.934
integrated care, physical
activity intervention,

1286
00:54:01.934 --> 00:54:04.150
health care management interventions,

1287
00:54:04.150 --> 00:54:06.490
health allocation, so there are multiple,

1288
00:54:06.490 --> 00:54:09.391
and all of them can
actually benefit this issue,

1289
00:54:09.391 --> 00:54:10.781
but at the end of the days, how do we

1290
00:54:10.781 --> 00:54:12.861
partner with the people that will benefit

1291
00:54:12.861 --> 00:54:14.134
from this intervention?

1292
00:54:14.134 --> 00:54:17.579
How do we bring them
together to engage them

1293
00:54:17.579 --> 00:54:19.569
in this conversation
and create partnerships

1294
00:54:19.569 --> 00:54:21.063
with the people that we're serving,

1295
00:54:21.063 --> 00:54:22.727
both the clients and the providers,

1296
00:54:22.727 --> 00:54:24.948
to develop interventions
that people can actually use

1297
00:54:24.948 --> 00:54:28.565
and can actually implement
in the real world?

1298
00:54:28.565 --> 00:54:30.449
And that's sort of where
our work is really trying

1299
00:54:30.449 --> 00:54:31.775
to move forward.

1300
00:54:31.775 --> 00:54:34.285
How do we continue to
engage agencies so they can

1301
00:54:34.285 --> 00:54:36.975
be partners with us, we're
partnering with them,

1302
00:54:36.975 --> 00:54:38.691
they're partnering with
us, and we can share

1303
00:54:38.691 --> 00:54:40.809
knowledge to bridge the gap between

1304
00:54:40.809 --> 00:54:42.381
research and practice so we can address

1305
00:54:42.381 --> 00:54:45.867
these disparities in
morbidity and mortality.

1306
00:54:45.867 --> 00:54:47.778
So, that's all I have for tonight.

1307
00:54:47.778 --> 00:54:49.379
Thank you so much for listening.

1308
00:54:49.379 --> 00:54:51.601
I'm welcome to take questions.

1309
00:54:51.601 --> 00:54:53.851
(clapping)

1310
00:55:11.505 --> 00:55:14.402
Maria's getting her physical activity.

1311
00:55:14.402 --> 00:55:15.528
- [Voiceover] Hi Dr. Cabassa.

1312
00:55:15.528 --> 00:55:19.169
It occurs to me in looking
at the grounded theory slide,

1313
00:55:19.169 --> 00:55:21.862
so everyone's talking
about integrated care

1314
00:55:21.862 --> 00:55:24.514
and I think there's been a lot
of discussion in social work

1315
00:55:24.514 --> 00:55:27.605
about how that really could
be a threat to the profession

1316
00:55:27.605 --> 00:55:30.416
because nurses would end up
in what has, historically,

1317
00:55:30.416 --> 00:55:33.902
been a social work role,
and I'm looking at this

1318
00:55:33.902 --> 00:55:36.709
and thinking actually,
there's a really good argument

1319
00:55:36.709 --> 00:55:39.424
for clinical social workers
in these kinds of positions.

1320
00:55:39.424 --> 00:55:43.688
So I guess my question to
you is how does social work

1321
00:55:43.688 --> 00:55:46.614
use these kind of arguments
to really position ourselves

1322
00:55:46.614 --> 00:55:49.148
in the future of this integrated health

1323
00:55:49.148 --> 00:55:51.464
and behavioral healthcare system?

1324
00:55:51.464 --> 00:55:52.490
- That's a great question.

1325
00:55:52.490 --> 00:55:55.361
Actually when we first
started this project,

1326
00:55:55.361 --> 00:55:59.417
I visited Ben Druss in
Atlanta and he had me sit

1327
00:55:59.417 --> 00:56:01.552
down with the nurses who deliver this care

1328
00:56:01.552 --> 00:56:03.996
and the first thing they tell me is

1329
00:56:03.996 --> 00:56:05.490
"We were doing social work.

1330
00:56:05.490 --> 00:56:06.323
"That's what we're doing.

1331
00:56:06.323 --> 00:56:08.482
"We're really doing social
work, connecting people."

1332
00:56:08.482 --> 00:56:10.600
So it's really figuring out what the right

1333
00:56:10.600 --> 00:56:14.018
work force at your
clinic, at your site is,

1334
00:56:14.018 --> 00:56:18.490
and then training people
around this particular

1335
00:56:18.490 --> 00:56:19.336
intervention.

1336
00:56:19.336 --> 00:56:21.090
And social workers can
definitely take the lead

1337
00:56:21.090 --> 00:56:23.000
and actually be part
of the integrated care.

1338
00:56:23.000 --> 00:56:26.265
We bring expertise in
knowing the community,

1339
00:56:26.265 --> 00:56:29.345
on helping someone navigate.

1340
00:56:29.345 --> 00:56:32.102
We do have experiences
in behavioral health

1341
00:56:32.102 --> 00:56:32.935
intervention.

1342
00:56:32.935 --> 00:56:34.664
This is a behavioral health intervention,

1343
00:56:34.664 --> 00:56:37.901
but it's around physical health issues.

1344
00:56:37.901 --> 00:56:40.146
What we do need help is how to communicate

1345
00:56:40.146 --> 00:56:41.671
that with other professionals.

1346
00:56:41.671 --> 00:56:43.904
It's very different, a
nurse telling a doctor

1347
00:56:43.904 --> 00:56:45.947
what to do than a social
worker telling a doctor

1348
00:56:45.947 --> 00:56:49.001
what to do, so we have to
work around those issues

1349
00:56:49.001 --> 00:56:51.707
and having a primary care
physician as a consultant

1350
00:56:51.707 --> 00:56:54.137
was really important
for us to help us know

1351
00:56:54.137 --> 00:56:55.614
this is how you need to
talk, this is how you

1352
00:56:55.614 --> 00:56:58.339
can present the data, present the labs,

1353
00:56:58.339 --> 00:57:01.199
understand and know their language.

1354
00:57:01.199 --> 00:57:03.539
We can do it and there's
a history in social work,

1355
00:57:03.539 --> 00:57:06.108
particularly the people
that work in hospitals,

1356
00:57:06.108 --> 00:57:10.375
health social workers,
so I think there is a big

1357
00:57:10.375 --> 00:57:13.581
opportunity to train,
just that we need to train

1358
00:57:13.581 --> 00:57:15.715
our students for early
on how to work in those

1359
00:57:15.715 --> 00:57:18.410
integrated settings, how
to work as part of a team,

1360
00:57:18.410 --> 00:57:20.775
and communicate with different
people and how to take

1361
00:57:20.775 --> 00:57:24.065
the lead on the things
that they know what to do.

1362
00:57:24.065 --> 00:57:27.806
And most of this integrated
care, for example

1363
00:57:27.806 --> 00:57:30.135
in primary care that are integrated in

1364
00:57:30.135 --> 00:57:33.136
depression care, social
workers can deliver that care.

1365
00:57:33.136 --> 00:57:34.711
Here social workers can deliver this.

1366
00:57:34.711 --> 00:57:37.558
It does take supervision
and it does take resources,

1367
00:57:37.558 --> 00:57:39.792
but definitely it's a good area.

1368
00:57:39.792 --> 00:57:41.706
And an even bigger area
is actually leading

1369
00:57:41.706 --> 00:57:43.408
the organizations.

1370
00:57:43.408 --> 00:57:45.125
When you're integrating
care, a social worker

1371
00:57:45.125 --> 00:57:47.085
can actually lead the
organization and figure out

1372
00:57:47.085 --> 00:57:48.765
how to bring the systems together.

1373
00:57:48.765 --> 00:57:50.220
And that's really critical.

1374
00:57:50.220 --> 00:57:53.626
And training our students
with that leadership role,

1375
00:57:53.626 --> 00:57:56.291
not only delivering the care
but how to organize the care,

1376
00:57:56.291 --> 00:57:58.462
how to work when implementing this model,

1377
00:57:58.462 --> 00:58:01.216
I think is another big
opportunity we can do

1378
00:58:01.216 --> 00:58:04.244
and we're not doing a
good job in the schools of

1379
00:58:04.244 --> 00:58:05.077
social work.

1380
00:58:05.077 --> 00:58:07.041
I think there's a big
opportunity for us to do so.

1381
00:58:07.041 --> 00:58:10.657
And that's where the field is going.

1382
00:58:10.657 --> 00:58:13.930
I think people want to find
jobs, that's where they're

1383
00:58:13.930 --> 00:58:14.763
going.

1384
00:58:14.763 --> 00:58:15.975
That's where they're gonna be employed.

1385
00:58:15.975 --> 00:58:19.208
So figuring out how to train our students

1386
00:58:19.208 --> 00:58:20.718
with all those different skills would be

1387
00:58:20.718 --> 00:58:22.135
really important.

1388
00:58:29.807 --> 00:58:30.640
- [Voiceover] Hi.

1389
00:58:30.640 --> 00:58:33.655
I'm an alum of the Smith
Social Work Program

1390
00:58:33.655 --> 00:58:36.474
and I'm bilingual by culture in Spanish

1391
00:58:36.474 --> 00:58:40.478
and work locally with a large
Spanish speaking community,

1392
00:58:40.478 --> 00:58:44.079
mostly Puerto Ricans, and I
now manage a case management

1393
00:58:44.079 --> 00:58:48.981
program that does some of what
you're talking about here.

1394
00:58:48.981 --> 00:58:51.824
Obviously your research is
to primary care specifically

1395
00:58:51.824 --> 00:58:53.959
and I want to say, just to this school,

1396
00:58:53.959 --> 00:58:55.806
I'm so glad that you
have this gentleman here

1397
00:58:55.806 --> 00:58:58.147
speaking about this, because
a couple of years ago

1398
00:58:58.147 --> 00:59:00.507
I was wanting these kinds of things

1399
00:59:00.507 --> 00:59:02.461
to be here because it's the work that I do

1400
00:59:02.461 --> 00:59:04.722
and I really appreciate
you speaking about it.

1401
00:59:04.722 --> 00:59:08.311
And just the way that you
spoke about population-

1402
00:59:08.311 --> 00:59:10.991
based care, you sort of
answered some of what I

1403
00:59:10.991 --> 00:59:12.873
was thinking, in just
what you were saying,

1404
00:59:12.873 --> 00:59:14.641
that we have to bring it
to schools of social work

1405
00:59:14.641 --> 00:59:18.447
more to talk about how
to really implement it

1406
00:59:18.447 --> 00:59:22.677
across the healthcare
world, but also in our

1407
00:59:22.677 --> 00:59:25.395
really particular
communities, so I just want to

1408
00:59:25.395 --> 00:59:26.731
say you did a great job with that

1409
00:59:26.731 --> 00:59:28.515
and I appreciate your research a lot.

1410
00:59:28.515 --> 00:59:30.432
- Thank you, thank you.

1411
00:59:41.553 --> 00:59:43.619
- [Voiceover] Hi.

1412
00:59:43.619 --> 00:59:45.921
I wanted to thank you for
a very good presentation.

1413
00:59:45.921 --> 00:59:48.338
I really admire the research.

1414
00:59:49.717 --> 00:59:52.837
As I listened to what you've done,

1415
00:59:52.837 --> 00:59:56.337
it's research grounded in a model program,

1416
00:59:58.109 --> 01:00:01.559
drawing on literature,
and I really like it.

1417
01:00:01.559 --> 01:00:04.381
The issue I want to raise
with you is an issue

1418
01:00:04.381 --> 01:00:08.423
raised about model
programs, which is their

1419
01:00:08.423 --> 01:00:12.340
generalizability to larger
context, to the rest

1420
01:00:13.377 --> 01:00:14.877
of the real world.

1421
01:00:17.684 --> 01:00:20.779
Particularly this new and innovative role

1422
01:00:20.779 --> 01:00:23.029
of the health case manager?

1423
01:00:27.646 --> 01:00:28.516
- Health care manager.

1424
01:00:28.516 --> 01:00:30.624
- [Voiceover] Health care
manager, thank you very much.

1425
01:00:30.624 --> 01:00:33.262
I wondered if you could,
here's my question.

1426
01:00:33.262 --> 01:00:37.429
Who pays for that activity
and is the opportunity,

1427
01:00:39.062 --> 01:00:42.812
and if it is a reimbursable
activity, was the

1428
01:00:45.613 --> 01:00:49.780
opportunity for that created
through health reform,

1429
01:00:50.800 --> 01:00:53.518
through the Affordable Care Act?

1430
01:00:53.518 --> 01:00:55.438
- That's a great question
and part of this,

1431
01:00:55.438 --> 01:00:57.532
it's interesting when you
do this type of research

1432
01:00:57.532 --> 01:01:01.758
how the policy environment
shifts under your feet.

1433
01:01:01.758 --> 01:01:04.514
We started this before
the Affordable Care Act.

1434
01:01:04.514 --> 01:01:07.841
It was being developed, we got this grant,

1435
01:01:07.841 --> 01:01:10.716
and then the Affordable Care Act hit.

1436
01:01:10.716 --> 01:01:12.744
New York State participates in the

1437
01:01:12.744 --> 01:01:14.703
Affordable Care Act, they're transforming

1438
01:01:14.703 --> 01:01:18.956
the way that they deliver
paid for services,

1439
01:01:18.956 --> 01:01:20.920
and these types of
interventions is what they're

1440
01:01:20.920 --> 01:01:23.587
looking at as a way to pay them.

1441
01:01:25.834 --> 01:01:27.876
They're starting to
set up patient-centered

1442
01:01:27.876 --> 01:01:29.409
medical homes.

1443
01:01:29.409 --> 01:01:33.118
Particular for people who are
high utlizers of services.

1444
01:01:33.118 --> 01:01:35.260
People with serious mental
illness are high utilzers

1445
01:01:35.260 --> 01:01:36.117
of services.

1446
01:01:36.117 --> 01:01:39.514
And many people will go
often to the emergency room,

1447
01:01:39.514 --> 01:01:43.681
have an avoidable hopitilzation,
people are costing

1448
01:01:45.026 --> 01:01:47.664
the system a lot of
money, so how can we help

1449
01:01:47.664 --> 01:01:49.276
them connect to primary care?

1450
01:01:49.276 --> 01:01:51.741
How do we help them
provide better services?

1451
01:01:51.741 --> 01:01:53.485
They're looking at care
management interventions

1452
01:01:53.485 --> 01:01:54.788
like this.

1453
01:01:54.788 --> 01:01:57.298
So there's an opportunity,
at least in New York State,

1454
01:01:57.298 --> 01:01:59.388
of figuring out how to pay for that.

1455
01:01:59.388 --> 01:02:02.938
Part of what we did in this
outpatient mental health

1456
01:02:02.938 --> 01:02:04.994
clinic, we asked that question.

1457
01:02:04.994 --> 01:02:06.384
How will we pay for that?

1458
01:02:06.384 --> 01:02:08.984
Given the structure of how
services are begin paid

1459
01:02:08.984 --> 01:02:11.088
at that clinic, what can we do?

1460
01:02:11.088 --> 01:02:14.558
What's the financial
plan here behind this?

1461
01:02:14.558 --> 01:02:17.526
And what's interesting,
right now they are receiving

1462
01:02:17.526 --> 01:02:21.478
a grant to actually deliver
primary care at their clinic.

1463
01:02:21.478 --> 01:02:24.130
The state is going to pay
for bringing a primary care

1464
01:02:24.130 --> 01:02:27.208
physician and a health care
manager as part of their

1465
01:02:27.208 --> 01:02:30.966
service provider unit and
pay for those services there.

1466
01:02:30.966 --> 01:02:33.320
So there is an opportunity,
these care management

1467
01:02:33.320 --> 01:02:36.440
interventionist are begin
paid for, and will become,

1468
01:02:36.440 --> 01:02:40.357
I think, I hope, more
common in states that are

1469
01:02:41.719 --> 01:02:43.422
transforming their care
because this is about

1470
01:02:43.422 --> 01:02:44.722
cost containment in a way.

1471
01:02:44.722 --> 01:02:47.817
It's cost containment
and improving quality.

1472
01:02:47.817 --> 01:02:51.145
You know, God forbid what
will happen in the election,

1473
01:02:51.145 --> 01:02:55.513
but I think if it's going,
and the ACA continues

1474
01:02:55.513 --> 01:02:57.774
to go in the way that
it's going, more places

1475
01:02:57.774 --> 01:02:59.711
are going to have this opportunity.

1476
01:02:59.711 --> 01:03:03.677
Whether it's in a mental health clinic

1477
01:03:03.677 --> 01:03:06.692
or in a primary care, where you place the

1478
01:03:06.692 --> 01:03:08.891
health care manager, that's up for debate.

1479
01:03:08.891 --> 01:03:12.685
It's most often when your
patients enter medical homes,

1480
01:03:12.685 --> 01:03:14.753
it's usually in the primary care side.

1481
01:03:14.753 --> 01:03:17.169
The issues with these
clients is they actually like

1482
01:03:17.169 --> 01:03:18.938
going to their mental health clinic.

1483
01:03:18.938 --> 01:03:21.773
That's their entry into the system,

1484
01:03:21.773 --> 01:03:24.751
so having someone there
to navigate and they trust

1485
01:03:24.751 --> 01:03:27.529
and that's where they
come more often seems like

1486
01:03:27.529 --> 01:03:30.326
an important place to be or to place a

1487
01:03:30.326 --> 01:03:33.421
health care manager and
that's where every state

1488
01:03:33.421 --> 01:03:35.834
or every locality will be important.

1489
01:03:35.834 --> 01:03:37.864
You also mentioned the
issue of generalizabilty,

1490
01:03:37.864 --> 01:03:39.356
which is really important.

1491
01:03:39.356 --> 01:03:42.193
In interventions like this,
everyone's integrated care,

1492
01:03:42.193 --> 01:03:44.691
and that's when they're
trying to develope these

1493
01:03:44.691 --> 01:03:47.145
interventions that are generalizable

1494
01:03:47.145 --> 01:03:49.017
across multiple contexts,
but at the end of the day

1495
01:03:49.017 --> 01:03:50.499
you have to make it local.

1496
01:03:50.499 --> 01:03:52.918
You have to localize it
to reality for financial

1497
01:03:52.918 --> 01:03:56.287
issues, for work force
issues, for training issues,

1498
01:03:56.287 --> 01:03:57.990
and some of the work
that we're trying to do

1499
01:03:57.990 --> 01:03:59.730
is figuring out not only
is it generalizable,

1500
01:03:59.730 --> 01:04:01.890
but how do you do it on the ground level.

1501
01:04:01.890 --> 01:04:05.550
What skills or infrastructure do you need

1502
01:04:05.550 --> 01:04:08.299
for that clinic to manage these things.

1503
01:04:08.299 --> 01:04:10.990
Most of the things that
happened while we were

1504
01:04:10.990 --> 01:04:13.475
doing this is that the
state comes up and says,

1505
01:04:13.475 --> 01:04:15.742
"We're going to transform
the healthcare system.

1506
01:04:15.742 --> 01:04:18.579
"We're going to have new
health care manager here."

1507
01:04:18.579 --> 01:04:20.844
But you still have to deliver services.

1508
01:04:20.844 --> 01:04:23.763
You have to sort of transform
your healthcare system

1509
01:04:23.763 --> 01:04:25.695
while you're actually delivering care.

1510
01:04:25.695 --> 01:04:27.110
It's like changing the tire of a car

1511
01:04:27.110 --> 01:04:28.774
while the car's still running.

1512
01:04:28.774 --> 01:04:29.699
You can't do that.

1513
01:04:29.699 --> 01:04:31.543
If you know someone that can do it,

1514
01:04:31.543 --> 01:04:32.723
please let me know.

1515
01:04:32.723 --> 01:04:33.675
But you can't do it.

1516
01:04:33.675 --> 01:04:36.088
So this research is trying
to figure out how do we

1517
01:04:36.088 --> 01:04:38.123
then within this space that they have,

1518
01:04:38.123 --> 01:04:40.695
how do we begin to figure
out how to transform it.

1519
01:04:40.695 --> 01:04:42.595
And what skills and what planning process

1520
01:04:42.595 --> 01:04:43.906
needs to happen.

1521
01:04:43.906 --> 01:04:45.726
And there's different ways to do that,

1522
01:04:45.726 --> 01:04:49.158
and this is just one way
of helping the process.

1523
01:04:49.158 --> 01:04:50.291
But it's a really important question.

1524
01:04:50.291 --> 01:04:54.095
We need training, workforce
development, and then

1525
01:04:54.095 --> 01:04:54.982
financial.

1526
01:04:54.982 --> 01:04:57.117
How is it gonna get paid
and whether the healthcare

1527
01:04:57.117 --> 01:05:00.155
dollars out there will
pay for an intervention

1528
01:05:00.155 --> 01:05:04.300
like this, and then helping
figure out how to do it

1529
01:05:04.300 --> 01:05:05.929
with the staffing that you have.

1530
01:05:05.929 --> 01:05:08.179
That's a critical question.

1531
01:05:09.684 --> 01:05:12.351
I hope I answered your question.

1532
01:05:21.075 --> 01:05:21.908
It's good exercise.

1533
01:05:21.908 --> 01:05:24.129
You're counting your steps.

1534
01:05:24.129 --> 01:05:24.962
- [Voiceover] Good evening.

1535
01:05:24.962 --> 01:05:26.234
I appreciate your presentation.

1536
01:05:26.234 --> 01:05:27.346
Thank you.

1537
01:05:27.346 --> 01:05:29.759
My question, I'm interested
in community-based

1538
01:05:29.759 --> 01:05:32.604
research and you talked
about involvement of

1539
01:05:32.604 --> 01:05:34.595
the community from the beginning.

1540
01:05:34.595 --> 01:05:36.570
Can you talk more about
how you involved them

1541
01:05:36.570 --> 01:05:39.015
throughout and at the
end with the feedback

1542
01:05:39.015 --> 01:05:39.910
and results?

1543
01:05:39.910 --> 01:05:42.030
Where is the community now on this side

1544
01:05:42.030 --> 01:05:43.317
of the research?

1545
01:05:43.317 --> 01:05:44.150
Thank you.

1546
01:05:44.150 --> 01:05:45.890
- That's a great question.

1547
01:05:45.890 --> 01:05:48.295
We started by forming this board,

1548
01:05:48.295 --> 01:05:52.483
which is basically the
providers, representatives

1549
01:05:52.483 --> 01:05:55.575
from the clients, which
we started with a consumer

1550
01:05:55.575 --> 01:06:00.372
advocate, and we engaged
them on here's what we're

1551
01:06:00.372 --> 01:06:01.763
gonna do, here's where we're gonna go,

1552
01:06:01.763 --> 01:06:03.739
and help us throughout that process.

1553
01:06:03.739 --> 01:06:05.261
And they were all along the line

1554
01:06:05.261 --> 01:06:06.873
engaging in this process.

1555
01:06:06.873 --> 01:06:08.471
We met once a month.

1556
01:06:08.471 --> 01:06:10.891
People showed up to these meetings,

1557
01:06:10.891 --> 01:06:11.917
which was fascinating.

1558
01:06:11.917 --> 01:06:13.162
Once a month of their time.

1559
01:06:13.162 --> 01:06:17.353
All we have them was, I
think, a $15 gift card

1560
01:06:17.353 --> 01:06:18.691
for every meeting they attended.

1561
01:06:18.691 --> 01:06:22.025
And I know $15 is not
a lot in New York City.

1562
01:06:22.025 --> 01:06:22.858
But they did.

1563
01:06:22.858 --> 01:06:25.905
So engaging in that process
was really important.

1564
01:06:25.905 --> 01:06:27.829
They helped us on the needs assessment,

1565
01:06:27.829 --> 01:06:32.255
on the intervention, on
delivering the materials,

1566
01:06:32.255 --> 01:06:33.557
on how to translate in Spanish,

1567
01:06:33.557 --> 01:06:35.517
will people actually address it.

1568
01:06:35.517 --> 01:06:37.690
And then, in the recruitment.

1569
01:06:37.690 --> 01:06:40.317
Helping us figure out how to best recruit

1570
01:06:40.317 --> 01:06:42.827
these individuals, how to
present the intervention

1571
01:06:42.827 --> 01:06:45.815
not only so much for the
clients was it important,

1572
01:06:45.815 --> 01:06:47.843
but selling this to the clinicians.

1573
01:06:47.843 --> 01:06:49.677
This was all clinician referral.

1574
01:06:49.677 --> 01:06:53.719
So clinicians needed to
send clients our way.

1575
01:06:53.719 --> 01:06:54.957
So engaging them.

1576
01:06:54.957 --> 01:06:58.124
The last phase that we were in was now

1577
01:06:59.242 --> 01:07:01.634
that we have these results,
where do we go next?

1578
01:07:01.634 --> 01:07:03.442
And that's where having this engagement

1579
01:07:03.442 --> 01:07:05.565
was really important
because now they're going

1580
01:07:05.565 --> 01:07:07.914
through a different
type of transformation.

1581
01:07:07.914 --> 01:07:11.361
Now they're going to get
more integrated care.

1582
01:07:11.361 --> 01:07:14.613
So we're working with the
director on trying to see

1583
01:07:14.613 --> 01:07:16.588
are you going to use this intervention?

1584
01:07:16.588 --> 01:07:18.705
Here's some evidence that it seems to work

1585
01:07:18.705 --> 01:07:21.307
and you have someone at
your clinic who can do this.

1586
01:07:21.307 --> 01:07:22.606
Are you gonna use it?

1587
01:07:22.606 --> 01:07:24.607
And we're in those discussions right now.

1588
01:07:24.607 --> 01:07:26.673
The interesting thing is that the

1589
01:07:26.673 --> 01:07:28.351
director of the clinic left.

1590
01:07:28.351 --> 01:07:29.859
The one that was really engaged with us,

1591
01:07:29.859 --> 01:07:30.812
and got a new person.

1592
01:07:30.812 --> 01:07:33.250
So we're working through
those processes right now,

1593
01:07:33.250 --> 01:07:34.878
and that's part of
community engaged research.

1594
01:07:34.878 --> 01:07:36.411
People go in and out.

1595
01:07:36.411 --> 01:07:39.753
Loretta Jones and Ken Welch talk about

1596
01:07:39.753 --> 01:07:41.965
community participation, people going in

1597
01:07:41.965 --> 01:07:43.473
and out of the bus, they come in,

1598
01:07:43.473 --> 01:07:45.497
they come out, but you're always there.

1599
01:07:45.497 --> 01:07:48.138
You're driving through the process

1600
01:07:48.138 --> 01:07:49.075
and helping people and engaging people.

1601
01:07:49.075 --> 01:07:51.141
So we work through that component.

1602
01:07:51.141 --> 01:07:53.505
We think that the next step is to engage

1603
01:07:53.505 --> 01:07:54.535
other clinics.

1604
01:07:54.535 --> 01:07:57.313
So we did it here, can
we do it somewhere else,

1605
01:07:57.313 --> 01:07:59.485
and how do we build those relationships.

1606
01:07:59.485 --> 01:08:02.061
And being part of the New
York State Psychiatric

1607
01:08:02.061 --> 01:08:05.025
Institute helps, because
we're a research arm

1608
01:08:05.025 --> 01:08:06.793
of the Office of Mental Health.

1609
01:08:06.793 --> 01:08:09.028
So it helps us begin
to look at how to work

1610
01:08:09.028 --> 01:08:10.561
within the public mental health system.

1611
01:08:10.561 --> 01:08:13.657
We also need to engage
other community agencies

1612
01:08:13.657 --> 01:08:17.061
and the trust in building,
and that's a whole process.

1613
01:08:17.061 --> 01:08:20.327
But I think the intervention
at the end of the day

1614
01:08:20.327 --> 01:08:24.160
was stronger because of
all that input of both

1615
01:08:26.044 --> 01:08:28.296
the client and the providers
and the space of them

1616
01:08:28.296 --> 01:08:31.025
to actually talk to each
other about these issues,

1617
01:08:31.025 --> 01:08:33.104
which they didn't have that space.

1618
01:08:33.104 --> 01:08:35.549
And at the end of the
day when they went back

1619
01:08:35.549 --> 01:08:37.005
they said, "We liked those meetings.

1620
01:08:37.005 --> 01:08:38.863
"In those meetings we
talked about real things."

1621
01:08:38.863 --> 01:08:42.881
And providing that safe space
where they could do that.

1622
01:08:42.881 --> 01:08:44.337
Nobody was gonna lose their jobs,

1623
01:08:44.337 --> 01:08:47.027
nobody was gonna be reprimanded.

1624
01:08:47.027 --> 01:08:48.885
They could actually
come and do this and be

1625
01:08:48.885 --> 01:08:49.914
supported by that.

1626
01:08:49.914 --> 01:08:51.683
And that's not easy.

1627
01:08:51.683 --> 01:08:52.931
And we were very lucky.

1628
01:08:52.931 --> 01:08:56.571
I must say, this clinic
was engaged for five years.

1629
01:08:56.571 --> 01:08:58.949
We lost one person on that board.

1630
01:08:58.949 --> 01:09:00.197
That's unheard of.

1631
01:09:00.197 --> 01:09:01.875
I have another project
where the first year

1632
01:09:01.875 --> 01:09:02.912
we lost all the clinics.

1633
01:09:02.912 --> 01:09:04.423
Literally.

1634
01:09:04.423 --> 01:09:06.851
We had to start a whole new thing.

1635
01:09:06.851 --> 01:09:08.697
In this one, they stayed.

1636
01:09:08.697 --> 01:09:10.361
And it was really good to see that.

1637
01:09:10.361 --> 01:09:12.545
So it's working through our process

1638
01:09:12.545 --> 01:09:14.480
and as a faculty member,

1639
01:09:14.480 --> 01:09:15.939
you're a faculty member doing this work,

1640
01:09:15.939 --> 01:09:18.473
it's sort of scary because you're putting

1641
01:09:18.473 --> 01:09:21.241
a lot of engagement on
things that may lead to

1642
01:09:21.241 --> 01:09:24.727
a publication or not
or what type of impact

1643
01:09:24.727 --> 01:09:25.646
are you doing?

1644
01:09:25.646 --> 01:09:27.026
It's a slow process.

1645
01:09:27.026 --> 01:09:29.913
But we were very helpful, very grateful

1646
01:09:29.913 --> 01:09:31.345
for the work that we did.

1647
01:09:31.345 --> 01:09:34.115
And then as a researcher
we published a lot

1648
01:09:34.115 --> 01:09:35.037
of these things.

1649
01:09:35.037 --> 01:09:38.195
So my view of this is
how do we document this

1650
01:09:38.195 --> 01:09:40.206
so other people can do it?

1651
01:09:40.206 --> 01:09:42.039
How to replicate this?

1652
01:09:43.147 --> 01:09:44.799
At least provide some aspect of

1653
01:09:44.799 --> 01:09:46.907
how do we navigate these waters

1654
01:09:46.907 --> 01:09:48.387
so other people could do it.

1655
01:09:48.387 --> 01:09:50.466
I thought that it was really important

1656
01:09:50.466 --> 01:09:52.783
for us to do it because
my other experience

1657
01:09:52.783 --> 01:09:54.835
with CVPR, probably, like you said,

1658
01:09:54.835 --> 01:09:56.631
a lot of it gets done, but it doesn't get

1659
01:09:56.631 --> 01:09:58.409
discussed or published to a larger world

1660
01:09:58.409 --> 01:09:59.411
because it's hard.

1661
01:09:59.411 --> 01:10:01.269
It's hard to document
it and take a step back

1662
01:10:01.269 --> 01:10:02.973
and reflect upon it.

1663
01:10:02.973 --> 01:10:05.107
So hopefully we've done that

1664
01:10:05.107 --> 01:10:07.093
and now we're looking
forward to new partners

1665
01:10:07.093 --> 01:10:10.293
to see if we can do this in other places

1666
01:10:10.293 --> 01:10:11.793
on a larger scale.

1667
01:10:20.211 --> 01:10:23.019
- [Voiceover] No more questions?

1668
01:10:23.019 --> 01:10:26.046
- [Voiceover] I have a question.

1669
01:10:26.046 --> 01:10:27.021
So, thank you very much.

1670
01:10:27.021 --> 01:10:28.975
This is incredibly interesting

1671
01:10:28.975 --> 01:10:31.457
and really valuable research.

1672
01:10:31.457 --> 01:10:33.040
So I was struck by,

1673
01:10:38.699 --> 01:10:40.113
I'm wondering,

1674
01:10:40.113 --> 01:10:41.919
I was thinking about the
clients that came into

1675
01:10:41.919 --> 01:10:44.946
this intervention and
really thinking about

1676
01:10:44.946 --> 01:10:47.473
how remarkable they are
because they did stick it out

1677
01:10:47.473 --> 01:10:51.920
and they really were
vested, at least 10, monthly

1678
01:10:51.920 --> 01:10:54.205
to have them for a whole year.

1679
01:10:54.205 --> 01:10:57.172
Have you thought about the
people that wouldn't come in,

1680
01:10:57.172 --> 01:10:59.810
the people that are the hardest to reach?

1681
01:10:59.810 --> 01:11:03.229
How is their voice kind of,
how are you able to capture

1682
01:11:03.229 --> 01:11:05.205
their perspective?

1683
01:11:05.205 --> 01:11:07.129
- That was harder.

1684
01:11:07.129 --> 01:11:12.079
I think we did not do a
good job of capturing those

1685
01:11:12.079 --> 01:11:14.365
voices of people who dropped out.

1686
01:11:14.365 --> 01:11:16.043
We know of at least one
person who dropped out

1687
01:11:16.043 --> 01:11:20.283
because they got employed
and their lives got better.

1688
01:11:20.283 --> 01:11:21.754
But the other ones didn't.

1689
01:11:21.754 --> 01:11:24.393
The other ones ended up just dropping out,

1690
01:11:24.393 --> 01:11:26.553
not only of our intervention
but of the clinic.

1691
01:11:26.553 --> 01:11:27.386
They left.

1692
01:11:27.386 --> 01:11:29.021
They were lost to follow up in the clinic,

1693
01:11:29.021 --> 01:11:31.780
and that happens in this population.

1694
01:11:31.780 --> 01:11:33.025
If I was going to do this again

1695
01:11:33.025 --> 01:11:35.965
and we had a little more resources,

1696
01:11:35.965 --> 01:11:37.899
we would have then tried to see

1697
01:11:37.899 --> 01:11:39.813
and have an interview
with those individuals,

1698
01:11:39.813 --> 01:11:41.241
if we could get them, to really learn

1699
01:11:41.241 --> 01:11:44.761
about what went on and if there's anything

1700
01:11:44.761 --> 01:11:47.130
that we could have done differently.

1701
01:11:47.130 --> 01:11:50.211
We did record all session and we have

1702
01:11:50.211 --> 01:11:52.366
done fidelity ratings,
but we didn't look at

1703
01:11:52.366 --> 01:11:53.655
a question like that.

1704
01:11:53.655 --> 01:11:56.217
Those people came to a couple of sessions,

1705
01:11:56.217 --> 01:11:59.764
so if there's anything there
that we can learn from,

1706
01:11:59.764 --> 01:12:01.445
I think will be very important.

1707
01:12:01.445 --> 01:12:02.561
But that's hard.

1708
01:12:02.561 --> 01:12:05.851
Intervention research, people do drop out,

1709
01:12:05.851 --> 01:12:07.019
and that's an important question,

1710
01:12:07.019 --> 01:12:09.647
why people drop out and what can we do

1711
01:12:09.647 --> 01:12:12.480
to get them back and to understand

1712
01:12:13.779 --> 01:12:15.612
what happened to them.

1713
01:12:17.024 --> 01:12:20.274
I think we can do a better job on that.

1714
01:12:22.779 --> 01:12:24.845
- [Voiceover] Well, if
there's no more questions,

1715
01:12:24.845 --> 01:12:26.665
I really want to thank
you so much for your time

1716
01:12:26.665 --> 01:12:29.355
and for the important work that
you and your team are doing.

1717
01:12:29.355 --> 01:12:30.188
Thank you for coming.

1718
01:12:30.188 --> 01:12:31.021
- Thank you.

1719
01:12:31.021 --> 01:12:32.521
Thank you so much.