- Okay, so can everyone hear me okay?
Yes?
Great.
Well I really want to welcome you all
to our Lydia Rappaport lecture series, our public lecture,
and it's a small group so I'm really
looking forward to the conversation.
But before that I'm looking forward to
Dr. Cabassa's presentation and I'll start
with just a little introduction of
Dr. Leopoldo Cabassa.
He is an associate professor at the
School of Social Work at Columbia University.
And he joined the faculty at Columbia
in July of 2012.
He holds an appointment at the New York State
Psychiatric Institute, where he is the assistant
director of the New York State Center of Excellence
for Cultural Competence.
In terms of his education and training,
Dr. Cabassa received his M.S.W. and Ph.D.
from the George Warren Brown School for Social Work
at Washington University in St. Louis.
He began his career as a social work researcher
with a post-doctoral fellowship at the
School for Social Work at the University
of Southern California, where he also was
an assistant professor.
And he there also had a joint appointment
at the USC Keck School of Medicine,
Department of Psychiatry and Behavioral Science.
Dr. Cabassa has taught graduate level courses
on research and evaluation methods, foundation
of social work practice, and social work with
Latino populations.
And his research has been published extensively
and he's also been in journals and written
different book chapters.
In terms of his research, Dr. Cabassa works in the field
of health and mental health services research
for racial and ethnic minorities.
Specifically he conducts studies on ways to reduce
the stigma towards mental illness among Hispanic population
and on developing, testing and implementing interventions
to improve the physical health of under-served
populations with a serious mental illness.
His research program blends quantitative
and qualitative methods in community engagement
to understand the factors that fuel racial and ethnic
inequities in health and mental healthcare.
And he uses his knowledge to inform the development
and implementation of interventions to reduce disparities.
Dr. Cabassa's work as been supported by the
National Institutes of Health and the New York State
Office of Mental Health.
His current research portfolio includes two NIH projects
aimed to promote the physical health of Hispanics
with serious mental illness.
Specifically he has a Mentor Research Scientist
Development Award called Implemeting Health Care
Interventions for Hispanics with Serious Mental
Illness and is currently doing an R01,
a research project grant, that is titled
The Peer Led Healthy Lifestyle Program
in Supported Housing.
So, I want to really welcome Dr. Cabassa to the stage
and I look forward to his presentation.
- Buenos Nochas, good evening.
It is a really a pleasure to be here
and an honor to be here.
Before we begin I want to thank
for the invitation.
She is still a great colleague, even if she's
in a different school, but we miss you a lot
and it's wonderful to be here and to be able
to contribute to your school.
And to be here at Smith College.
And Maria for a gracious host.
It's been a great afternoon of interviews
and dinner and conversation, so looking
forward to the visit tomorrow, as well.
So today I'm gonna talk about some work
that actually we are at the end stages of this work
and thinking about the next steps of where we're
gonna take it.
So it's great to be out in the world
presenting this stuff, but working, hearing
people's reactions and comments, I'm looking
forward to the Q and A to talk about the work
that we've been doing.
This is a work focusing on how do we improve
the physical health of people with serious mental illness,
people that have schizophrenia, bipolar disorder,
particularly Latinos.
And what I'm gonna talk about today,
some interventions that we really adopted
and co-developed with our partners, our community
partnership, a public outpatient mental health clinic,
that helped us figure out how to take an intervention
that seemed promising for the situation,
that I'm gonna be talking about,
but help us develop it in the real world
with real clinicians and clients at this clinic
and help us sort of co-develop this.
That's what we're doing.
And studying that process.
So it's been a five year journey
and a great adventure to us.
So today I'm going to present you sort of how
we got there and what we're learning from that approach.
Let me move this so I can know where I'm at.
There we go.
So before we begin I want to acknowledge the funders,
because that study was funded by the
National Institute of Mental Health.
It did receive funding from the New York State Office
of Mental Health, since we were working at a public agency.
And this is really a team effort.
All the collaborators that you see here
were really involved in this project and I do want to say
that none of it would he been possible without
the involvement, the sweat, blood, and tears
that everyone did for this particular project
and their engagement with this process.
And it was a really multi-disciplinary team
of social workers, nurses, psychiatrist, peer advocates
in the community, primary care physicians,
that really helped us develop what I'm gonna
be talking about.
And then also I always cherish the opportunity
to work and mentor students and we had great students
throughout this five year project who
cycled through the project and provided their input
throughout, from my doctoral students who were
care managers in this project, as well as the M.S.W.
students who provided data collection and opportunities
to analyze some of the data.
So this was really a team effort, and everything
I'm gonna be talking about today, I owe a great debt
to all the people who are listed here and also
to the clients who participated in this.
So, I do want to start with a quote that really
got us started into this process.
This is one of the first projects that I ever did
in New York.
I was tasked with the great opportunity of figuring out
what were the healthcare needs of Latinos and
African Americans in northern Manhattan that had
serious mental illness.
And we went about it by doing a large qualitative study
of six behavior health organizations in the neighborhoods
of Washington Heights, in Harlem, in Inwood,
and really talking to almost everyone who would talk to us.
Directors, project managers, clients, family members,
community leaders, the clients themselves.
And the idea was to really figure out what was going on
with these agencies and how were they addressing
the physical health needs of this population.
And here's a quote from an administrator of the
clinic that actually we ended up working with
and partnering for this project that I'm gonna be
talking about that is really addressing this issue
of the fragmentation of care and how patients
get lost navigating between the healthcare system
and the mental health system.
And it's basically someone saying,
"Our patients, partly because of their illnesses,
"their cultural and language issues, because the system
"is not very well organized, they often get lost
"in the system.
"The patients just get overwhelmed.
"You're not feeling well, you have symptoms,
"of psychosis, you don't speak the language,
"and you're trying to figure out what office
"to go to.
"It can be overwhelming and patients get
"frustrated and they don't get the care
"that they need."
And the whole process, the whole purpose for
this project, from the work that we have been
developing over the past five, seven years,
is actually to figure out how do we get
the care that people need to improve their
physical health and addressing equity stuff
for this population.
So we really want the intervention
that we're gonna be talking about today,
is how to help someone navigate that maze.
That labyrinth between one system of care
and the other.
And that's one solution to this problem.
Another solution could be to destroy the entire system
and actually combine them so people don't have to
navigate between this maze.
But our process is sort of figuring out
how to work throughout the maze of the system
and figuring out how to help them
and get the care that they need.
At the end of the day that's sort of the outcome
that we wanted to improve.
So today I'll talk about the need for
these types of interventions, I'll describe
our bridges to better health and wellness,
(speaking in Spanish)
and present study findings and next steps.
And the next steps, it's really a conversation
with you about where do you see, what are your
reactions to this work that we have developed.
So, first of all, just to give some definitions,
what I'm talking about is a population that
has serious mental illness.
So people who have schizophrenia,
that are recovering and living with schizophrenia,
bipolar disorder, and these are disorders
that interfere with major life activities
and impact their functions.
And when you work in the public mental health system,
this is the population that you're serving,
these are the people who have these types
of disorders.
Around 10 million adults in the U.S. report
serious mental illness in the past year,
and they constitute five out of the ten leading
causes of disability worldwide.
So these are costly disorders and they impact
not only the individual, but their families and
communities in figuring out how to help this population.
The problem that we're focusing on within
the people with serious mental illness
is their physical health.
People with serious mental illness die
at an earlier age that the rest of the population
that don't have these disorders,
and it's mostly due to natural causes.
To cardiovascular disease, to diabetes,
to hypertension, high cholesterol.
And this is a major issue for this population.
They're dying at an earlier age than the rest of us.
They're not benefiting from the healthcare
that's available to all of us in this country
and other places.
And the statistics that I present here,
the up to 32 years, the median of 10 years,
this is actually from a med analysis that looked
at global studies all over the world
and found this disparity and mortality
between people who have serious mental disorder
and the general population.
In the U.S., the best data that we have
when we look at our community sample,
has to do with the health survey in this country,
the National Health Interview survey, and they
found an eight year gap between psychotic disorder,
eight to ten year gap, and people with no
psychiatric disorders.
So this is the disparity that we're trying to address.
How to reduce early mortality and morbidity
among this population.
Our work looks at the intersection of having
a serious mental disorder and being a racial
and ethnic minority.
And when we started this project, we really wanted to
understand that double intersection.
You have a serious mental illness, you're recovering
from that, that has major implications to your health,
and you're also a racial or ethnic minority in this country,
particularly Latino.
That also carries some inequities in physical health
and mental health and access to care.
And our question was,
"Is there a double burden?"
Are you at double risk for having poor physical health
if you already have these two vulnerabilities,
given the disparities that we know exist
in both of these populations.
In a systematic review we did of over 30 years of research,
we did find some evidence for this.
Latinos with serious mental illness compared
to non-Hispanic whites or non-Latino whites
with similar mental disorders have higher risk of
cardiovascular related mortality, meaning they die
at an earlier age.
They have higher rates of diabetes, of metabolic syndrome,
which is a condition that puts you at an even higher risk
for cardiovascular disease.
And to experience the negative metabolic abnormalities
of anti-psychotic medications, particularly
weight gain, which is a common side effect
of anti-psychotic medications.
The interesting component of this lit review,
and it was very interesting because you're beginning
to identify the gaps in the literature,
was that most of these studies were really small.
They were between four and 200 people,
it was mostly clinical samples,
and they rarely differentiated between different
Latino groups and rarely, if ever, differentiated
between gender.
So although there's evidence indicating a disparity
in the Latino community, we know very little.
And these are the people that are getting services
and then not only that, participating in research,
and we're still seeing some of the disparities there.
So we're really just scratching the surface
about what's really going on in this population.
We found one study that actually differentiated
between different Latino groups, particularly
Cubans, Mexicans, and then other Latinos,
which is half of humanity in the Americas.
So it becomes uncertain how these disparities
actually exist, and it's a really big issue.
For doctoral students who want an area
of dissertation work, this is one that needs
lot of work to figure out where those disparities
really exist.
So when you look at the physical health of people
with serious mental illness,
there's a lot being written about the modifiable factor,
the things that we can change to improve the health.
And I think I made a colloquial approach
because there's many different factors
that influence the health of someone.
So I took if from the environment, unstable housing,
poverty, food and environment, medical care,
health behaviors.
And today we're gonna focus on medical care.
One aspect of these disparities.
And I do want to indicate that the intervention
that we're looking at focuses on medical care,
but future work that we're doing is actually looking
at health behaviors, as well.
And we cannot ignore the environment and interaction
of all these issues if we really want to address
these disparities in care.
So we're gonna focus today on medical care
as one area where we can intervene as social workers.
So, given the little research that was done in this area,
we actually began this project by really understanding
the experiences that Latinos have accessing care.
So we went to our public outpatient clinic
and asked Latino clients, a sample of 40 Latino clients,
to talk to us about their experiences
accessing primary care and figuring out
what were some of the issues that came up
as they were trying to access primary care.
First of all, do they access primary care?
Do they even go to primary care?
And if they do, what type of services to they receive?
What's the experience that they have?
And we use a mixed method approach here
where we interview, do a focus group with people, actually,
and then we also do structured, quantitative interviews
about their experiences with healthcare.
And it was interesting that almost everyone
that we talked to in this sample
talked about the stress healthcare system
that they were navigating.
They were going to care, but they were facing
major barriers.
Fragmented care, meaning psychiatrist's not talking
to a primary care physician, the primary care physician
not talking to psychiatry and really having a hard
time communicating between providers.
Long waiting times in all of these primary care clinics.
Major language barriers, even in New York City,
in the heart of Washington Heights, you're still
having language barriers trying to access care
in your native language, in Spanish.
And there are a lot of high staff turnover.
Many of these clinics are public clinics
that employ residents, so there's a high turnover
of doctors that you're seeing,
so every two or three years you have to start
a whole new relationship with a primary care doctor.
Think about how that influences your health
if you have a chronic medical illness?
Diabetes, cardio, hypertension.
Every two or three years you have to tell
someone your story about how you got that illness
and the challenges that you're having.
That's major issues.
People talked a lot about the discrimination
and the intersection of the discrimination stigma.
Discrimination of being a Latino, of being an immigrant,
and also have a serious mental illness.
And what we saw here is some evidence of what is called
diagnostic overshadowing, which means that
you go to a doctor, you tell them you have a physical
health issue or a physical symptom,
and because you are identified as someone
who has a serious mental illness,
you are not believed.
The person thinks, oh, that's all in your head.
You come in with a pain in your stomach,
the doctor might say that's part of your
psychiatric issues, it's not real.
And that actually influences what type of treatment
people received and they talked about experiences
of that, of completely being missed for things
as cancer or ulcers or major physical health issues
being dismissed because of their serious mental illness.
And then people really talked about their experiences
with their doctor.
That one to one interaction with that physician
was really important and some people talked about
having good interactions that was personal attention,
warm, culturally congruent, respectful, trustworthy,
and also talked about very negative experiences
because of stigma, being rushed, being impersonal,
being disrespected.
So that interaction with your primary care physician
was really important for people and it could go
either way.
And then with our quantitative measure
we found low levels of patient-centered care.
And this is really important because if people
have a chronic medical illness and they're not
receiving patient-centered care, meaning
care that talks about your treatment plan,
that discusses with you all the different
medications that you have, that gives you advice
and action planning around physical health issues,
then you don't know how to manage your own
physical health component.
So not receiving that from your primary care physicians
was really important.
And these levels were low not only to people with
serious mental illness, but to Latinos.
We were able to compare the race that we were seeing
with this measure that we use, compare to other samples
at the national level and they were very low.
Very concerning.
So with this in mind, then what type of intervention
can we use to address this issue?
And one type of intervention that's out there
and also received major attention since we started
this program was healthcare management interventions.
This is someone who is in our public outpatient
mental health clinic, usually a nurse,
who connects you to primary care, to help you
navigate that system, who asseses
your physical health issues,
figures out what type of help do you need,
and then helps you connect to that care.
Helps you figure out that you go
to your primary care physician,
that you ask the right question,
that you share information, and that you bring
that back to your outpatient mental health clinic,
to you psychiatrist.
That's a social worker role in many ways,
but in these interventions a lot of this
is being done by nurses.
They focus on care coordination and it helps the client
with goal setting, patient activation,
which really means getting the patient,
the client himself or herself, to be engaged
in their own care, to know their medication,
to know where to go, know what to do,
to manage their illness.
And then problem solve around things that come up,
if you have a chronic medical issue.
So health care management interventions,
there's quite a lot out there
and they've been tested.
They seem promising.
They seem to address the issues that we were seeing
in our Latino population that we were studying.
The thing is that we've identified a local
implementation graft.
We have a problem that is serious that the clinic
wants us to address, is seen as an important
component in linking people to primary care,
helping them with that care.
There's interventions out there that seem to work.
But then there's major gaps in how do you take
that intervention and implement it and use it
in this community clinic.
And what we mean by that is, first of all,
the interventions that were out there,
none were tested in Latinos.
None.
We had major interventions out there,
but they had never included a Latino client,
a Latino subject in their studies,
for the interventions that were out there
for people with serious mental illness,
when we starts this project.
So, we don't know.
They say everything's promising,
it might address, but we've never tested it
with Latinos, so that's one gap.
The second gap has to do with the silence
around culture.
And this was very glaring and it still exists today.
Now we're seeing it over and over again.
The ignorance or the idea that once you have
a serious mental illness, all the other
intersections of your life, your culture, your gender,
your sexual orientation, can get sort of put aside.
You are defined by your mental illness and nothing else.
And, in fact, that's not true.
People have multiple identities, multiple intersections,
and culture becomes really important.
Think how culture shapes how you define your health,
how you communicate your health,
how you communicate with the healthcare system
and your primary care physician.
And none of that was being examined
in this literature.
In fact, there was a recent systematic lit review
of almost 30 years of research of every intervention
out there, on behavioral, primary care intervention
as well as behavioral intervention of people
with serious mental illness by Mike Edie
and colleagues, it was published in 2015,
culture and race and ethnicity weren't even mentioned
in that type of systematic lit review.
I mean, this is major research being done
and this is driving our policy and it's being ignored.
And it's important.
And you will see how we integrated that.
And then, for our community, can social workers do it?
These clinics have one nurse, but they have more
social workers, so can social workers, because
of the work force this clinic has, can social workers
take on that responsibility of connecting?
So can social workers take on that component?
And we thought, it could work so let's try it out.
So here's where the community engagement comes in.
We had these gaps, we have this problem,
we have a partner that wants to help us,
so there's many ways we can go about implementing
and testing this.
One simple way is we as researchers say
this is intervention, we develop it, we test it
with our students, and we do a randomized control trial
and everything's fine and we see if it works.
For me, though, it's not sufficient.
Because we could do that work but then
when I leave and my grant leaves,
nothing gets left behind.
Basically we have published our paper
that some of you might read,
but the actually clinic never learned
the capacity to actually deliver the intervention.
So what we did is we developed this collaborative
intervention planning approach, which is basically
an engagement approach where we took the stakeholders,
meaning the people who were going to actually deliver
this intervention in the real world,
the social workers, the administrators, the nurses,
the primary care clinicians, and we combined them
with the researchers and engaged in a process
of figuring out here's this intervention that
we're gonna use, and how to we transport it
and use it at this site in this clinic
for this community through our process
of community engagement.
How many of you know about community-based
participatory research?
How many of you have done community-based
participatory research?
Okay.
One of the things in community-based participatory research
which is really important is how do you bring people
together and engage them in this process.
The thing is, when you read this literature,
what actually happens when you bring all these people
together, when you're there in a community advisory
board meeting once a month, what do you do?
What actually goes from the start of the idea to practice?
And that's what where we included the intervention
mapping approach, which is a step-by-step process
of how you take a theory or intervention all the way
through implementation and evaluation.
How do you transform it with everyone's input?
And what this provides you is actually a map
of how you go to A to B to C to D, all the way
to the evaluation.
And it provides tools that a community can use
to transform that intervention, to adapt it,
we actually use it to adapt this intervention
that you'll see shortly, but it really was
an engagement approach.
It provided a space and a time and skills
for everyone to engage, with our help,
with the resources that we provided from the grant,
to do this work.
And right now our grant has ended, but we have
left there in that clinic people who are trained
and can deliver the intervention because we used
people in that clinic to deliver the intervention
for us as part of this grant.
So it's a really interesting, and I'm happy to talk
about the details, we published all the details
and all the components of this, but it was a great journey
and it provided a space to actually do this at the agency.
And today we're going to talk about the evaluation process.
So here's our intervention.
It's called Bridges to Better Health and Wellness.
It's actually adapted from an intervention
called PCARE, that was developed in Atlanta, Georgia,
by Ben Druss and his group at Emory University.
The intervention's wonderful.
It actually showed that it doubled the rate
of preventive primary care among people
with serious mental illness
in public outpatient settings.
And it actually connected people to care
and engaged them in that primary care service.
The issue was that it was only tested
in an African American community.
The healthcare managers were nurses,
so we had to transform it and what we did,
we actually called Ben Druss and said hey,
your intervention seems really interesting.
It addresses our need.
Can we use it?
Can you partner with us to figure out
how to transform it for Latinos and social workers
in Washington Heights?
And he was a partner in the entire process.
What you see here is the healthcare managers,
the social worker, they're employed at the
outpatient mental health clinic and they serve
as a bridge and a monitor for the mental health
provider, the psychiatrist, the case manager,
and the primary care providers.
And the idea of bridging, monitoring, and
coordinating is simple.
Figuring out what are the physical health needs
of the person, what medication they're taking
and what help do they need and
communicating that information back and forth.
And being that person the psychiatrist can call
when they have a question, when the primary care provider
has a question they can rely on the health care manager.
And with the client, basically they're coaching
and coordinating, they're connecting this person,
they're activating them, they're engaging them
in their own healthcare.
So think about, someone that has diabetes for example,
and the primary care physician says, "You have to
"lose weight and stop smoking."
Wonderful.
How do you do that?
The health care manager then has a set of tools
that can work around those issues with the client
in an individualized manner using basically
behavioral activation techniques, problem solving
techniques, and action planning.
A step-by-step process on how you change behavior
and work on it one-on-one.
It's a intervention that'll last for an entire year.
They meet at least once a month an they have checkups
throughout the month to figure out what's going on.
It's all manualized, both in English and Spanish,
and is really tailored for the individual needs.
Basically the health care manager has a tool box
of behavioral techniques that they can use
with the client and then individualize it
to the needs of that client around issues of
physical health, particularly preventive
primary care issues.
So we didn't measure the adaptations to this process
using our approach, but we did two levels
of adaptation.
Most studies work on this level,
the cultural adaptation.
Making sure that it's relevant, appropriate for the group,
for the client population.
But we also had to adapt for the provider.
Remember, the intervention was done by nurses,
registered nurses, we have social workers,
master-level social workers we need to adapt it to.
And I'll give you examples of what that means,
of the type of adaptations that we did.
But we did multiple levels and this took a lot of time
and creativity in having clinicians as part of our team
engage in this process, so it was really helpful.
As researchers we know some of the things,
but the clinicians really bring a lot of expertise
and wisdom on the type of things we need to
address and adapt.
So here's an example of a provider adaptation.
The original trial focused on coordinating
from one community mental health center
to one primary care center.
Big centers, multiple providers, but it's a one to one,
it's one institution coordinating to another institution.
That was the reality of the PCARE trial,
big randomized trial, this intervention
when it first started.
Our reality was one community health center with
multiple different primary care clinics throughout
the community.
Actually 17 of them.
So imagine the complexity of coordinating with
17 different organizations.
You see one primary care clinic,
you see one primary care clinic.
Some are mom and pop shops,
some are multiple federally qualified centers,
some are affiliated to Columbia,
some are affiliated to other universities,
some are not affiliated at all.
So the complexity of coordination was massive for us.
So we have to actually develop a care coordination plan
where the health care manager knew where to contact,
who to contact, how often to contact,
and what type of information they wanted to share.
And thinking about all the different medical records
that they have to deal with, those are massive,
complexity on how we did this.
This actually is a social worker task,
to create relationships with different people
within that organization, to coordinate.
So this is a major adaptation from this reality
to this reality and I'll show you how we did it.
The second was a cultural adaptation.
So clients talked about, as you can remember,
about their experiences and the relationship
with their primary care physician and that personal
experience was really important for people.
So we wanted to add an assessment tool
that went beyond just the physical health issue,
but actually asked people about their experiences
with their health, their views of their physical
health issue, what they fear most about their
physical health issues, what their hopes are
for physical health.
And we used the cultural formulation interview,
which is actually a tool that is embedded in DSN 5
and it actually is a patient centered,
or client centered, interview that really gets
at the story of that person and their illness.
What do you think causes your illness?
What have you done in the past?
What fears do you have about your treatment?
What do you do to cope with this in your everyday life?
What's interesting is that it gathers all this
very culturally individualized information
from the person's perspective, but it opens the door
for the individual and the health care manager
to connect on a more humane level.
It conveys personal libra, meaning I care for you.
I'm here for you.
It conveys respect.
I'm respecting your point of view.
And then it provides all this information
the health care manager can use to develop
better treatment plans.
It's 16 questions, it's open ended.
It's not easy to deliver, don't get me wrong.
This takes some time to do one.
I don't know how many psychiatrists are in the room,
but psychiatrists wrote it, so they have a whole
different view of the world, but it provides
this really good approach of getting in to the
story of the person and using that information.
And actually clients like this.
Nobody has asked them,
"What do you think causes your diabetes?"
"What do you fear most about your diabetic treatment?"
"What do you fear most about your hypertension?"
And it provides all that information that is necessary.
So it's that cultural adaptations,
we didn't change the intervention, just added
a component to it.
So as you can see, I like pictures.
So this is another way of looking at the intervention
using a logic model.
The intervention focuses on an assessment,
a care coordination, and plan activation.
All the red parts are all the adaptations that we did.
And these are outcomes.
Receive preventive primary care, patient's assessment
and perception that their chronic illness care
is improving, patient activation and health
of efficacy and hopefully improve their quality
of life and general health status.
So that's sort of what we wanted to test
in this intervention.
So, given that we have developed this intervention
with community, then we wanted to test their feasibility,
which basically means can we do this.
Can we get clients?
Can clients come?
And is it feasible for social workers to take on this role
in a public outpatient mental health setting?
Acceptability means do clients actually benefit from this.
Do they come?
Do they find it relevant, do they find it helpful?
And do they find it as something that they can do.
And then to explore the intervention effect
to say have the effects on the outcomes
that we are concerned about and wanted to see change.
So in terms of the methods of sample,
basically we included Latinos, 18 years of age or older,
with a chart diagnosis of a serious mental illness,
so they've already had to have been diagnosed
by a psychiatrist that they have a serious mental illness,
and they also had to be at risk for cardiovascular disease,
and this means everything under the sun.
Basically if you're a smoker, if your BMI is 25 or above,
you body mass index is 25 or above, if you have diabetes,
if you have hypertension.
I mean in these types of clinics, that's like 90%
of the patients.
This is so common that we wanted to be as inclusive
as possible.
And then we excluded people who were in need
of the toxification at the time of recruitment,
whether they were suicidal, homicidal, at the time
of recruitment, that they felt out of capacity to consent,
so they couldn't give consent because of capacity issues,
and for those who are 65 years are older,
we did a cognitive impairment scheme and if they were
cognitively impaired, they were excluded from the study
because they couldn't benefit from the intervention
at this point.
So the method of setting it up, as I said, it's at a
public mental health clinic, it serves a predominately
Latino population, most predominately Dominican,
because it's in Inwood, we used a prepose one group
design, so one group went through the intervention
for 12 months.
We assess at baseline, six months, and 12 months,
and we did structured, quantitative interviews
and also chart abstraction.
So we went to a primary care clinic and abstracted
information about the care that they received
at that primary care clinic.
And then at the end of the intervention
we did three focus groups for people
who finished the intervention and wanted to participate
in the focus group.
People didn't get paid for attending our
health care manager sessions.
They did get paid for the assessment.
$15 for the assessment, $25 for the focus group,
plus a Metro card.
So, feasibility, we looked at our recruitment,
assessment completion, treatment, attendance,
acceptability, we have a client satisfaction
questionnaire, as well at the focus group data,
the qualitative data that we received,
and then we have structured measures,
standardized measures, for the concepts
of patient activation, self-efficacy,
perception of chronic illness, care quality.
The receipt for preventive primary care
was actually a list of guiding concurrent care
that every adult should receive,
particularly if you are at risk for cardiovascular
disease, and we looked at medical chart abstraction
to see if they actually received it during a baseline
and a 12 month, during our work.
And then we used the SF12 for the physical health
and the mental health related quality of life.
So fidelity, we have transformed this intervention,
we want to make sure that we deliver the intervention
as it was intended, to make sure there's no
intervention drift.
We have two health care managers.
One health care manager was a social worker
who was already employed, had more than 20 years
of experience, and wanted to take this on
and she volunteered her time, actually she volunteered
some of her time and we paid for some of her time,
as well, to take on a caseload of 15 patients
for this intervention.
The other health care manager was a master level
social work student who was part of our,
a master level student, sorry an M.S.W. who
graduated from their master program and was now
a doctoral student in our program.
One health care manager was Dominican,
the other health care manager was Mexican,
so different ethnicities.
They were all bilingual and could speak
both languages.
We actually, for the fidelity, we recorded
every session.
We audio recorded every session, we had a master level
student listen to all the sessions,
rate the fidelity of what they did,
and then they provided feedback to the health care manager
to make sure that they're delivering the care,
the intervention, as it was intended.
So it was more of a supervision type of approach.
And then we had monthly supervision meetings.
And once in a while we will bring one of the
primary care physicians in the community
who was our consultant for our project
to attend the monthly supervision meetings
if we encountered any major issues that we need
to address, and there were several of them
throughout the trial.
So data analysis, we look at frequencies
and measure of central tendency.
We did a content analysis of the focus group data.
And then we used linear mix model, adjusting for the
health care manager assignment, although we didn't
randomize people, we had two different people
delivering interventions, so we wanted to control
to see if there's any effect, whether someone
who's very experienced versus someone who's not
as experienced delivering this intervention.
So, what did we find?
First of all, we were able to recruit people.
Yes, people did come.
People were interested in participating
and people wanted to be part of this study.
Our recruitment was 77%, so most people we approached
actually said yes and they wanted the health care manager
intervention.
They didn't have to pay for that service.
And we found that 85% of the people actually completed
the treatment and the study.
So people completed the 12 months of treatment as well
as all the interventions.
We only lost five people, four dropped out,
they were just not interested and moved on,
and we lost one person to follow-up,
who actually found a job and moved somewhere else,
so I hope that person is doing well
because finding a job is really important
for this population.
So feasibility, as I mentioned, people did complete
the intervention.
Most people, the average number of visits were 10 out of 12,
once a month, and a medium of 10.
93% of the people attended nine or more visits.
People got the intervention.
Once they were there they liked it,
they came back, and, as you will see,
they continue to see their health care manager,
and we had five people who dropped out.
I've been getting this question regarding
well, this is great, but how much time
do people actually spend doing this
and is this actually feasible?
So here's how we broke it down.
Per session, health care manager spent 80 minutes
in total on all the things that they need to.
That's 80 minutes for each client per session.
Most of it was done during the session.
Sessions were about an hour.
People did one hour to 47 minutes.
15 minutes of care coordination.
That means calling people up, finding what
the right medications are, sharing information,
charting for all the issues,
and then client outreach.
At the end of the day it was like 20 hours a week
for a caseload of 15 patients,
so a part-time person could do 15 caseloads
using this intervention, which seems feasible.
And we're exploring the cost of that
because it's really important to figure out
how we're gonna pay for this.
So the clients who participated in this
were mostly female, average age 54 years of age.
This is a lower educated population,
less than high school.
Almost everyone was unemployed,
receiving different types of social services.
Most of them are insured and that's part
of being part of this clinic.
The majority were Dominican and actually the U.S. born,
the majority of those were of Dominican descent.
Almost everyone was monolingual Spanish speaking.
Some of the bilinguals actually ended up receiving
interventions in Spanish, even though they've lived
in the United States for an average age of 31 years.
These are people who still prefer to receive
services in Spanish and that was really important for them.
Mental health characteristics, most people had
schizo-affective disorders or major depression
or bipolar.
There were people stabilized, meaning they're receiving
good outpatient mental health services.
They're not going for psychiatric hospitalization
and they're not going to ER services.
They're receiving the right mental health care
and they're staying outside of the hospital.
They're living in the community, so this is
a population that is out of the hospital,
it's not going in and out for mental health issues.
For physical health issues, most people perceived
their health as poor or fair.
Major diagnosis was obesity, high cholesterol,
diabetes.
Of course we only recruited people who had these disorders.
Most people have 2.8 chronic medical conditions.
About 1/3 were current smokers.
And this is really interesting, when we first started
this project the psychiatrist and the provider were
saying, "No, there's no smokers around here.
"Latinos don't smoke that much."
1/3 of them were reported smoking, so this was an issue.
And actually they started a smoking cessation program
once we presented some of the findings early on.
And then the mean number of visits, these people,
interesting enough, were going to primary care.
These are not people who are not going to primary care,
in fact they're going to primary care.
The issue is the type of care that they were receiving
in primary care services.
Not going too much to the ER or urgent care.
And as I mentioned, they were going to multiple
primary care clinics in the community.
So in terms of acceptability, people like the quality
of the care that they received.
They felt like it met most or all of their needs.
They were satisfied with the amount of services
that they got and they thought that it helped them
and they would recommend a friend.
In terms of the qualitative data, most people
described the intervention as helpful, fantastic,
excellent, beneficial, efficient, this is wonderful.
And in all my years of doing research with the Latino
community, when you do a client
satisfaction questionnaire, nobody complains.
Everybody says wonderful, this is awesome.
So you have to be careful with this data,
particularly when you're paying people
and you receive 12 months of free treatment,
they're gonna be very happy.
But they felt, interesting enough in the qualitative data,
that they felt that the relationship they formed with their
health care manager was really important.
They felt respected, they felt the health care managers
were prepared, were professional, they treated me
like family, which is really important,
and they recommended that we expand the program.
And we're actually doing, now, case history so
we ask our health care manager to write a history
of the cases that they had and issues that came up
and we're learning quite a lot about the relationship
that they formed with clients and how important that was
to this population.
We also asked, at the end of the 12 months,
what they liked most in an open-ended question.
And then we coded that.
And what people liked most was the health formation
they were receiving.
Tips about their physical health, tips about how to diet
and exercise, tips about their diabetes.
We share a lot of physical health information
that we provided in Spanish and people really liked that.
They loved their relationship with their
health care manager.
They liked the care coordination, having someone
to worry about where to go, how to go there,
how to share information.
And then they talked about being activated,
being more involved, having someone monitor their health
so every time they come to a health care manager
they get weighed.
We did our waist circumference, took their blood pressure,
and then knowing what their numbers are
and sharing that with them was really important.
And then the health benefits that they got from this.
All right, so impact.
What did we find?
So, first of all, we were able to increase patient
activation, which is really important
because patient activation means people feel like
they're involved in their own healthcare,
that they know what to do when they have a crisis,
that they know what to ask when they have
a situation for their primary care.
So we saw a particularly significant increase,
particularly from baseline to 12 months
and this is a moderate effect for this intervention,
for this affect on patient activation.
Self-Efficacy, or the sense of control,
you can control your health, we didn't see any effect
on exercise and asking support from family members
and friends, but we did see improvement in self-efficacy
in communicating with your primary care physician.
So people felt that they can now ask questions
from their primary care physician, that they can
actually have a better relationship with their
primary care physician, that they can,
if they have any concerns, they can talk to
their primary care physician, and we saw that
increase from baseline to 12 months.
And then they felt more in control managing
the chronic medical illness, there's a
self-efficacy around that that's also improved
from baseline to 12 months, and it's a moderate
affect-size for that.
Patient assessment of the chronic illness care,
we asked them, this is a really interesting measure,
because it's basically patients' views on the care
they're receiving.
Now, we asked this in two ways.
We asked them of the care their receiving from their
health care manager and the healthcare that they're
receiving from their primary care physician.
And I like this measure because it's very behavior
oriented.
Basically, did your doctor tell you about your medications
and how often did your doctor tell you about your
medication in the past six months?
Did you doctor call you after your visit during the
past six months?
How often did he or she do that?
Did you feel that your care is well organized
and that you're prepared for your visit?
How often do you feel like that?
So it's really about behavioral aspects of your
healthcare and it actually matches on the aspects
of good chronic illness care.
So we did find improvement on the care that they
were receiving from the health care manager,
particularly the big bump was from baseline to
six months then it got sustained,
and it's all moderate effect sizes.
Basically the health care manager were doing
what they were supposed to be doing.
That's what this means.
It means we trained them to do this good care
and they were delivering and the patients, the clients,
were actually observing that and reporting that
back to us, which is really important
in these types of interventions.
And I'm happy during the Q and A to talk
about the different soft skills that this has.
But this is a really interesting measure
and it's being used right now to address
whether your services are patient-centered
around all these issues in chronic illness care.
All right, the big outcome has to do with
receipt of actual care.
They are better activated, they are in better control,
they are receiving the care that they need.
When they go to primary care, do they receive
preventive primary care that they need?
And we found a 20%, almost 25% increase
from baseline to 12 months over the course
of the year that they participated in this intervention.
And this is a large effect size for that.
And basically what this means is that different types
of preventive primary care about vaccinations,
about screenings, about labs, about education,
about monitoring of your weight, of your blood pressure,
and we saw all of this where is significant
except in the screening of men.
Men didn't want to get their prostate check
as much as we needed to, but it didn't read significant.
But everything else was.
So over the course of the year, participating in our
intervention was associated with increases in that.
We can't really say it was caused by it,
because we didn't have a comparison group,
but we've seen similar effects that were seen
in the original trial around all of these issues.
We also examined other outcomes,
so the same assessment of the patient's chronic illness
care received from their primary care physician,
the general health status, overall how do you feel,
and your health and mental quality of life.
So all of them improved or they were not statistically
significant.
Again, this is a small sample so there might be
some power issues for this particular component,
but they all were improving in the right direction,
as we were expecting.
So overall what we're finding from this data
is that, first of all, Bridges to Better Health
and Wellness is feasible to be delivered
by social workers, if provided the right training
and the right supervisions and the right environment
to deliver this type of intervention.
They can do it with the right support.
We found that the Latino patients that participated
in this intervention helpful, acceptable,
culturally compatible, and reported high levels
of satisfaction with the intervention.
And we saw that in the people who participated in this
over the course of the intervention,
we saw significant improvement on all these different
outcomes, which are critically important
to the population and all of them are actually
associated with improvement in health in the long run.
Although we didn't collect that data,
we saw improvements in that.
And this is important because there are few interventions
out there that have shown this promise in this population.
And here's where I think it's really good to collect
qualitative data in an intervention study,
meaning we also got information from clients
about how they saw this whole work
through focus groups.
And what we're beginning to find out is
how is this impacting, what are the mechanisms
that we're seeing for this intervention.
And one of the things that have come up
is that all of these technical aspects of the intervention
need to go through the relationship that people
are building with the health care manager.
So we do need to train the health care manager
in all of this, this is all evidence-based
approaches, and there's techniques that you can use.
We need to pay really close attention on that relationship
that they're building with their client
and that relationship, that's where cultural components
really come into play.
How do you make sure that the person sees you
as respectful?
How do you make sure that you're showing support?
How do you provide individual attention?
How do you build trust?
And this is not new to social work.
This is really at the heart of psycho-social intervention,
that relationship building that you build with your client
becomes really important.
So really, we also need to pay attention, not only to the
evidence-based practice, but how we deliver
that evidence-based approach or this promising
intervention.
And really learning how to train someone to do that,
how to supervise them around those issues.
And we were able to do that.
Clients were reporting that they felt connected
with our health care manager.
Now the big question is how do we take this to scale?
How do we go on a bigger sample and provide
the supervision and the training that people need?
We have the beginning components of that.
It will be the next challenge to take this on.
So, limitations of this particular study?
It's a small sample, we're talking about 34 Latinos
who participated in the study, 40 who participated
earlier on a needs assessment.
It's at one site.
It's a well-engaged, ready to go clinic
with really innovative clinicians.
Engaged.
Dedicated.
Not every place is like that, so that's something
to really take into observation.
And the single group design.
We need more rigorous designs to take this
to a more randomized control.
The design and actually to look at a comparison
group for this type of approach.
And that's where we're thinking of doing that.
This gives you promising evidence to apply
for a larger grant and test it in a larger sample
with multiple sites.
So in the end, Bridges to Better Health and Wellness
seems like an acceptable and feasible healthcare
management intervention.
It's showing promising results, particularly
around patient activation, self-efficacy,
receipt of preventive primary care,
but we need more evidence to really understand
and see the potential that it has for implementation
and acceptability.
And, so, overall, at the end of this, we're trying
to develop an intervention that really addressees
the physical wholeness of the population
in a manner that they can engage with the intervention
and they can actually benefit from it.
And I do want to leave you with a quote
that comes out from one of the most seminal reports
in this area, that race is an issue,
that put this issue on the map in the United States.
This is a report from 2006, almost 10 years ago,
that reported statistics that people hear about.
25 years, people with serious mental illness
die 25 years earlier.
That report is the one that sort of puts it together,
and this is a quote from that report that still rings
true today and it's really critical for this work that
"There are multiple strategies to pursue
"in addressing morbidity and mortality,"
all these different models of care,
integrated care, physical activity intervention,
health care management interventions,
health allocation, so there are multiple,
and all of them can actually benefit this issue,
but at the end of the days, how do we
partner with the people that will benefit
from this intervention?
How do we bring them together to engage them
in this conversation and create partnerships
with the people that we're serving,
both the clients and the providers,
to develop interventions that people can actually use
and can actually implement in the real world?
And that's sort of where our work is really trying
to move forward.
How do we continue to engage agencies so they can
be partners with us, we're partnering with them,
they're partnering with us, and we can share
knowledge to bridge the gap between
research and practice so we can address
these disparities in morbidity and mortality.
So, that's all I have for tonight.
Thank you so much for listening.
I'm welcome to take questions.
(clapping)
Maria's getting her physical activity.
- [Voiceover] Hi Dr. Cabassa.
It occurs to me in looking at the grounded theory slide,
so everyone's talking about integrated care
and I think there's been a lot of discussion in social work
about how that really could be a threat to the profession
because nurses would end up in what has, historically,
been a social work role, and I'm looking at this
and thinking actually, there's a really good argument
for clinical social workers in these kinds of positions.
So I guess my question to you is how does social work
use these kind of arguments to really position ourselves
in the future of this integrated health
and behavioral healthcare system?
- That's a great question.
Actually when we first started this project,
I visited Ben Druss in Atlanta and he had me sit
down with the nurses who deliver this care
and the first thing they tell me is
"We were doing social work.
"That's what we're doing.
"We're really doing social work, connecting people."
So it's really figuring out what the right
work force at your clinic, at your site is,
and then training people around this particular
intervention.
And social workers can definitely take the lead
and actually be part of the integrated care.
We bring expertise in knowing the community,
on helping someone navigate.
We do have experiences in behavioral health
intervention.
This is a behavioral health intervention,
but it's around physical health issues.
What we do need help is how to communicate
that with other professionals.
It's very different, a nurse telling a doctor
what to do than a social worker telling a doctor
what to do, so we have to work around those issues
and having a primary care physician as a consultant
was really important for us to help us know
this is how you need to talk, this is how you
can present the data, present the labs,
understand and know their language.
We can do it and there's a history in social work,
particularly the people that work in hospitals,
health social workers, so I think there is a big
opportunity to train, just that we need to train
our students for early on how to work in those
integrated settings, how to work as part of a team,
and communicate with different people and how to take
the lead on the things that they know what to do.
And most of this integrated care, for example
in primary care that are integrated in
depression care, social workers can deliver that care.
Here social workers can deliver this.
It does take supervision and it does take resources,
but definitely it's a good area.
And an even bigger area is actually leading
the organizations.
When you're integrating care, a social worker
can actually lead the organization and figure out
how to bring the systems together.
And that's really critical.
And training our students with that leadership role,
not only delivering the care but how to organize the care,
how to work when implementing this model,
I think is another big opportunity we can do
and we're not doing a good job in the schools of
social work.
I think there's a big opportunity for us to do so.
And that's where the field is going.
I think people want to find jobs, that's where they're
going.
That's where they're gonna be employed.
So figuring out how to train our students
with all those different skills would be
really important.
- [Voiceover] Hi.
I'm an alum of the Smith Social Work Program
and I'm bilingual by culture in Spanish
and work locally with a large Spanish speaking community,
mostly Puerto Ricans, and I now manage a case management
program that does some of what you're talking about here.
Obviously your research is to primary care specifically
and I want to say, just to this school,
I'm so glad that you have this gentleman here
speaking about this, because a couple of years ago
I was wanting these kinds of things
to be here because it's the work that I do
and I really appreciate you speaking about it.
And just the way that you spoke about population-
based care, you sort of answered some of what I
was thinking, in just what you were saying,
that we have to bring it to schools of social work
more to talk about how to really implement it
across the healthcare world, but also in our
really particular communities, so I just want to
say you did a great job with that
and I appreciate your research a lot.
- Thank you, thank you.
- [Voiceover] Hi.
I wanted to thank you for a very good presentation.
I really admire the research.
As I listened to what you've done,
it's research grounded in a model program,
drawing on literature, and I really like it.
The issue I want to raise with you is an issue
raised about model programs, which is their
generalizability to larger context, to the rest
of the real world.
Particularly this new and innovative role
of the health case manager?
- Health care manager.
- [Voiceover] Health care manager, thank you very much.
I wondered if you could, here's my question.
Who pays for that activity and is the opportunity,
and if it is a reimbursable activity, was the
opportunity for that created through health reform,
through the Affordable Care Act?
- That's a great question and part of this,
it's interesting when you do this type of research
how the policy environment shifts under your feet.
We started this before the Affordable Care Act.
It was being developed, we got this grant,
and then the Affordable Care Act hit.
New York State participates in the
Affordable Care Act, they're transforming
the way that they deliver paid for services,
and these types of interventions is what they're
looking at as a way to pay them.
They're starting to set up patient-centered
medical homes.
Particular for people who are high utlizers of services.
People with serious mental illness are high utilzers
of services.
And many people will go often to the emergency room,
have an avoidable hopitilzation, people are costing
the system a lot of money, so how can we help
them connect to primary care?
How do we help them provide better services?
They're looking at care management interventions
like this.
So there's an opportunity, at least in New York State,
of figuring out how to pay for that.
Part of what we did in this outpatient mental health
clinic, we asked that question.
How will we pay for that?
Given the structure of how services are begin paid
at that clinic, what can we do?
What's the financial plan here behind this?
And what's interesting, right now they are receiving
a grant to actually deliver primary care at their clinic.
The state is going to pay for bringing a primary care
physician and a health care manager as part of their
service provider unit and pay for those services there.
So there is an opportunity, these care management
interventionist are begin paid for, and will become,
I think, I hope, more common in states that are
transforming their care because this is about
cost containment in a way.
It's cost containment and improving quality.
You know, God forbid what will happen in the election,
but I think if it's going, and the ACA continues
to go in the way that it's going, more places
are going to have this opportunity.
Whether it's in a mental health clinic
or in a primary care, where you place the
health care manager, that's up for debate.
It's most often when your patients enter medical homes,
it's usually in the primary care side.
The issues with these clients is they actually like
going to their mental health clinic.
That's their entry into the system,
so having someone there to navigate and they trust
and that's where they come more often seems like
an important place to be or to place a
health care manager and that's where every state
or every locality will be important.
You also mentioned the issue of generalizabilty,
which is really important.
In interventions like this, everyone's integrated care,
and that's when they're trying to develope these
interventions that are generalizable
across multiple contexts, but at the end of the day
you have to make it local.
You have to localize it to reality for financial
issues, for work force issues, for training issues,
and some of the work that we're trying to do
is figuring out not only is it generalizable,
but how do you do it on the ground level.
What skills or infrastructure do you need
for that clinic to manage these things.
Most of the things that happened while we were
doing this is that the state comes up and says,
"We're going to transform the healthcare system.
"We're going to have new health care manager here."
But you still have to deliver services.
You have to sort of transform your healthcare system
while you're actually delivering care.
It's like changing the tire of a car
while the car's still running.
You can't do that.
If you know someone that can do it,
please let me know.
But you can't do it.
So this research is trying to figure out how do we
then within this space that they have,
how do we begin to figure out how to transform it.
And what skills and what planning process
needs to happen.
And there's different ways to do that,
and this is just one way of helping the process.
But it's a really important question.
We need training, workforce development, and then
financial.
How is it gonna get paid and whether the healthcare
dollars out there will pay for an intervention
like this, and then helping figure out how to do it
with the staffing that you have.
That's a critical question.
I hope I answered your question.
It's good exercise.
You're counting your steps.
- [Voiceover] Good evening.
I appreciate your presentation.
Thank you.
My question, I'm interested in community-based
research and you talked about involvement of
the community from the beginning.
Can you talk more about how you involved them
throughout and at the end with the feedback
and results?
Where is the community now on this side
of the research?
Thank you.
- That's a great question.
We started by forming this board,
which is basically the providers, representatives
from the clients, which we started with a consumer
advocate, and we engaged them on here's what we're
gonna do, here's where we're gonna go,
and help us throughout that process.
And they were all along the line
engaging in this process.
We met once a month.
People showed up to these meetings,
which was fascinating.
Once a month of their time.
All we have them was, I think, a $15 gift card
for every meeting they attended.
And I know $15 is not a lot in New York City.
But they did.
So engaging in that process was really important.
They helped us on the needs assessment,
on the intervention, on delivering the materials,
on how to translate in Spanish,
will people actually address it.
And then, in the recruitment.
Helping us figure out how to best recruit
these individuals, how to present the intervention
not only so much for the clients was it important,
but selling this to the clinicians.
This was all clinician referral.
So clinicians needed to send clients our way.
So engaging them.
The last phase that we were in was now
that we have these results, where do we go next?
And that's where having this engagement
was really important because now they're going
through a different type of transformation.
Now they're going to get more integrated care.
So we're working with the director on trying to see
are you going to use this intervention?
Here's some evidence that it seems to work
and you have someone at your clinic who can do this.
Are you gonna use it?
And we're in those discussions right now.
The interesting thing is that the
director of the clinic left.
The one that was really engaged with us,
and got a new person.
So we're working through those processes right now,
and that's part of community engaged research.
People go in and out.
Loretta Jones and Ken Welch talk about
community participation, people going in
and out of the bus, they come in,
they come out, but you're always there.
You're driving through the process
and helping people and engaging people.
So we work through that component.
We think that the next step is to engage
other clinics.
So we did it here, can we do it somewhere else,
and how do we build those relationships.
And being part of the New York State Psychiatric
Institute helps, because we're a research arm
of the Office of Mental Health.
So it helps us begin to look at how to work
within the public mental health system.
We also need to engage other community agencies
and the trust in building, and that's a whole process.
But I think the intervention at the end of the day
was stronger because of all that input of both
the client and the providers and the space of them
to actually talk to each other about these issues,
which they didn't have that space.
And at the end of the day when they went back
they said, "We liked those meetings.
"In those meetings we talked about real things."
And providing that safe space where they could do that.
Nobody was gonna lose their jobs,
nobody was gonna be reprimanded.
They could actually come and do this and be
supported by that.
And that's not easy.
And we were very lucky.
I must say, this clinic was engaged for five years.
We lost one person on that board.
That's unheard of.
I have another project where the first year
we lost all the clinics.
Literally.
We had to start a whole new thing.
In this one, they stayed.
And it was really good to see that.
So it's working through our process
and as a faculty member,
you're a faculty member doing this work,
it's sort of scary because you're putting
a lot of engagement on things that may lead to
a publication or not or what type of impact
are you doing?
It's a slow process.
But we were very helpful, very grateful
for the work that we did.
And then as a researcher we published a lot
of these things.
So my view of this is how do we document this
so other people can do it?
How to replicate this?
At least provide some aspect of
how do we navigate these waters
so other people could do it.
I thought that it was really important
for us to do it because my other experience
with CVPR, probably, like you said,
a lot of it gets done, but it doesn't get
discussed or published to a larger world
because it's hard.
It's hard to document it and take a step back
and reflect upon it.
So hopefully we've done that
and now we're looking forward to new partners
to see if we can do this in other places
on a larger scale.
- [Voiceover] No more questions?
- [Voiceover] I have a question.
So, thank you very much.
This is incredibly interesting
and really valuable research.
So I was struck by,
I'm wondering,
I was thinking about the clients that came into
this intervention and really thinking about
how remarkable they are because they did stick it out
and they really were vested, at least 10, monthly
to have them for a whole year.
Have you thought about the people that wouldn't come in,
the people that are the hardest to reach?
How is their voice kind of, how are you able to capture
their perspective?
- That was harder.
I think we did not do a good job of capturing those
voices of people who dropped out.
We know of at least one person who dropped out
because they got employed and their lives got better.
But the other ones didn't.
The other ones ended up just dropping out,
not only of our intervention but of the clinic.
They left.
They were lost to follow up in the clinic,
and that happens in this population.
If I was going to do this again
and we had a little more resources,
we would have then tried to see
and have an interview with those individuals,
if we could get them, to really learn
about what went on and if there's anything
that we could have done differently.
We did record all session and we have
done fidelity ratings, but we didn't look at
a question like that.
Those people came to a couple of sessions,
so if there's anything there that we can learn from,
I think will be very important.
But that's hard.
Intervention research, people do drop out,
and that's an important question,
why people drop out and what can we do
to get them back and to understand
what happened to them.
I think we can do a better job on that.
- [Voiceover] Well, if there's no more questions,
I really want to thank you so much for your time
and for the important work that you and your team are doing.
Thank you for coming.
- Thank you.
Thank you so much.