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Suicide Prevention and the Collaborative Care Model

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>> WEBINAR OPERATOR: Hello and thank you for joining the National Institute of Mental Health Office for Research on Disparities in Global Mental Health 2018 webinar series.
 
This presentation is entitled Suicide Prevention and Collaborative Care Model.

Please note all lines are in a listen only mode.  If you would like to ask a question during today's presentation, you may could so at any time through the Q&A pod located on the lower right-hand corner of your screen. This call is being recorded today.  And it is now my pleasure to turn the wall over to Andrea Horvath Marques.  Please go ahead, ma'am.

>> ANDREA HORVATH MARQUES: Good morning, good afternoon, and good evening, everybody, wherever you are.  I would like to welcome you to the Global Mental Health, Mental Health Webinar Series.  This webinar series is sponsored by the Office for Research in Disparities and Global Mental Health.  My name is Andrea Horvath Marques.  I'm the Chief of the Mental Health Disparities Program, and our role here is coordinate NIMH efforts in mental health disparities research.  So, we help to promote and support research and partnership initiatives in order to help to better understand the mechanisms and the factors that underline disparities.  And the goal is to fill the critical knowledge gap that impacts that mental health in the elimination of mental health disparities.

So there's a few reasons.  One example as you may be aware, September is the Suicide Prevention Month.  And just a few days before that, we are holding this webinar, important webinar and that's going to be talking about suicide.  So, today I'll be moderating this webinar as we already mentioned Suicide Prevention and Collaborative Care Model.  This presentation will provide an overview of some opportunities to address suicide prevention while delivering mental health service in primary care using collaborative care model.

You know that according to CDC in 2016, data has shown that suicide is the tenth leading cause of death over all in the U.S.  Claiming more than 45,000 people in the U.S. So, NIMH is working with NIH and other agencies and other collaborative partners to address that.

And I'm just going to highlight for you before we start meeting some examples of that.  NIH partners with the National Action Alliance for Suicide Prevention, helping, supporting a comprehensive research agenda.  And the goal is to reduce the U.S. suicide rate by 20% in ten years.  Doing those partnerships, NIH is also partnering with them on various suicide initiatives, and NIH currently funds several dual suicide grants.

We have here at NIMH an expert in this area, Dr. Jane Pierson.  You can reach out to her about those grants. So there is another effort that NIH is doing.  I won't have time to talk about them.  But I'll be happy to share with you later if we have time and you can also reach out to me.

But I also want to highlight two other projects that are important.  One that NIMH intramural researchers developed, a toolkit that asks suicide screening questions.  So, it's available to the public and could be used in medical settings everywhere.  So, I'm going to send you the link about that one, too.  And finally, I just want to highlight a very relevant reporting initiative that our office has been partnering with the Health Resources and Services Administration (HRSA), to implement a two-year implementation collaboration, implementing collaborative care models in eleven nurse-led safety net clinics that is supported by HRSA.  And NIH is supporting this initiative by doing a contract with AIMS Center and the University of Washington to provide training to those clinics to implement collaborative care with fidelity.

So, the next question, what I said, why primary care and why collaborative care?  Dr. Anna Ratzliff will be able to answer those questions for us, and so I’d like to welcome her.  Dr. Anna Ratzliff, she is a national expert on collaborative care especially on training teams to implement and deliver mental health treatment in primary care settings.  Dr. Ratzliff is the Director of AIMS Center called-- that means “Advancing Integrated Care Solutions.”  And she's also the Director of the University of Washington’s Integrated Care Training Program for residents and fellows.  Anna is mentoring teams in primary care to deliver mental health care.  She's also mentoring her son's robotics team.  So, she's not only the using her skills in mental health, but also in the communities within her own life.  I'm sure she's going to be able to provide us a lot of information here. 

So, before I start, I want to remind you that this call, this webinar is being recorded.  And it's going to be archived in our website.  The speaker will have around one hour to speak, and then we're going to have 25 minutes to 30 minutes of Q&A.  I want to have the last five minutes to summarize a little bit of the main topics that was raised in this meeting.

And I want to ask you to please write your questions on the Q&A.  Because we're going to have so many people today, we would like to have the questions be written as she is speaking.  But I’m going to be asking those questions to her by the end of the webinar, so please cope with us a little bit.  And in case we don't have time to answer all those questions, Dr. Ratzliff was kind enough to send her-- to write the email so you can directly send an email to her or to us.  And we're going to be doing our best to answer your questions as soon as possible.  So, thank you very much for joining us.  And over to you, Anna.

>> ANNA RATZLIFF: Great.  Thank you so much for the introduction, I'm really excited to be here and to be able to present this webinar.  I am passionate about increasing access to mental health treatment and effective mental health treatment and have had the privilege really of working in collaborative care since I finished my residency training in psychiatry at the University of Washington.

So, I have been working out in communities, mostly safety net communities, first delivering collaborative care as a psychiatric consultant to a primary care team in clinics throughout Washington State.  And most recently having the opportunity to really lead implementation and training efforts through my roles at the University of Washington.

So today, I'm really excited to talk about how you might use collaborative care and implementation of collaborative care as an opportunity to really address that tragic, those tragic numbers that we talked about at the beginning, you know, the fact that over 45,000 people die by suicide every year in the United States.

So, let me go ahead and get started.  I think it is a good question to start with why are we talking about primary care when we're talking about suicide prevention?  And I think that these numbers are really the reason that we start there.  And it's really going to be important to talk about what are the opportunities within primary care settings to really address those numbers and be able to be more likely to recognize and support and help people that are at risk for suicide.

So, one of the things that was really striking to me when I started looking at the data around suicide is that nearly 50% of patients who die by suicide had seen a primary care provider in the month before they attempted suicide.  And I think it's really important to understand that that creates a real opportunity, and then probably one of the most systemic opportunities for us to recognize and identify and support people at risk for suicide.

We also know that most of the people who die by suicide have a behavioral health disorder, but that very few of these people actual receive access to mental health care in the last month of their life.  And so thinking about how we can both increase access to mental health care in primary settings and how that may be an opportunity to go ahead and improve access to suicide prevention is a really important thing as the context of why we will be talking about collaborative care today.

So, I want to talk a little bit about screening for suicide risk and where the current state of suicide screening is before I move into talk about collaborative care.  So, in May of 2014, the U.S. Preventative Services Task Force concluded that the current evidence around screening was insufficient to recommend screening in adolescents, adults and older adults in primary care.  However, they continued to recommend screening for depression, and recommend specifically delivery of collaborative care, mental health parity and other depression care because of that high comorbidity.

The Joint Commission has however has actually issued an event alert around the same time.  This basically said that it is important to review each individual patient's personal and family medical history risk factors.  And they actually put forth a recommendation to screen in pre-setting, specifically primary care behavioral health care settings and ED rooms.  So, I think there's a growing movement to really think about broad screening for both depression and suicide risk within primary care settings.

So, one of the things I wanted to look at when I first started thinking about suicide prevention and primary care is what has been showed to be effective in terms of psychosocial interventions.  This paper in the 2000s has a nice summary of the common treatments that have been either demonstrated to prevent suicide attempts or to reduce suicidal ideation.  And I think it's really important to note that most of these, many of these are therapies, collaborative assessment and management of suicidology-- and a collaborative care model are really more interventions that include systems and how you’d think about changing systems of care.  So, we'll spend the majority of the time today on this presentation, talking about what the collaborative care model is because it is one of these interventions that has been shown to reduce suicide ideation in large trials.  And at the end of this presentation, I'm going to come back and talk about what I think are the three core places where we might get really nice opportunities to make a big difference around suicide prevention in primary care settings.

So, I like to start by really thinking about where does mental health care happen, and why I think collaborative care is an opportunity to increase access to effective mental healthcare.

So, if you consider this pyramid and think of the spectrum of places that people might interact and engage in mental health treatment, you can start with thinking about the majority of patients actually are in primary care settings or are managing their symptoms with self-management.  And data around that show that it’s about 60% of patients who get no care at all, so would be in self-management, and about 20% of patients in the whole population that needs care that get primary care, in a primary care setting to address their mental health condition.

I think that makes it so that there's a real opportunity to enhance the quality of care by bringing in models like collaborative care to primary care settings, because that's where we're most likely to capture patients, identify patients with depression and in this case that are at risk for suicide and be able to intervene.

But I think it's important to understand that that's really expanding the capacity of primary care, and there will be many patients that need to be served in special care settings or be in the hospital.  So, it's also important to think how you coordinate efforts across these levels of care, so you can continue to have a good continuity of care between these different levels or steps of care.  We'll talk about that in the end because that's an important opportunity if a patient is identified being at risk of suicide, how are we going to make sure they don't fall through the cracks as we have to refer them or coordinate care around those people at risk?

So, what I'm going to do is spend the next little bit of this presentation really talking about collaborative care as a better way to provide mental health services in primary care settings.  This work - I've largely been engaged in this work through the AIMS center.  And at the AIMS center site, we have a really nice seven-minute video called “Daniel’s Story” which introduces the patient experience and the team experiences of delivering collaborative care.  So I think if you're excited about my presentation and haven't experienced collaborative care for yourself yet, this is a good way to go and get a bit more what it's like for a patient and family to be able to get their mental health care delivered in a primary setting.  So, I encourage you to go to the AIMS website, and in the bottom left corner you will find Daniel’s Story.

So collaborative care itself has an incredibly strong evidence base.  There are more than 80 randomized controlled trials, that’s getting close to 100 randomized controlled trials, that have shown that collaborative care as a model is more effective than usual care for common mental health conditions, especially depression and anxiety.  And we know many of the patients at risk for suicide are struggling with these common mental health conditions.

So, I'm going to walk through one of the core components of collaborative care and then really talk about the principles of collaborative care.  And I do that because I want to make sure people understand why collaborative care is different from primary care.  I also think it's important to understand that even if your clinic system can't go straight to collaborative care, their core principles that are important to think about in any system of care how you may be able to deliver those.

So collaborative care starts in the primary care setting, and it starts with a medical provider and a patient.  And it really then says how can we wrap around additional team members and practice support to really make sure that we are systemically able to identify and deliver treatment to patients that are struggling with mental health conditions such as depression.

This is based off of the chronic illness model.  So, you'll see that this diagram has a lot of the core components that you might see in other chronic illness models, care models such as those used to address diabetes.  So you want to start how you get that practice team ready to deliver treatment and care in a different way, and really thinking about the patient as a core member of the team that educating them, activating them is going to be an important part of care plan.

In collaborative care, in addition to the primary care provider and the patient you add two additional roles.  Typically, this is a behavioral health care manager who is embedded in the primary care setting.  This person is often a licensed social worker, could be a nurse.  Could be any kind of any counselor, someone with special behavioral health training.  They often are located in that primary care set settings and could be available to assess the patient as well as deliver a brief intervention.

In collaborative care the psychiatric consultant is someone who is added to the team. And one of the real benefits to the psychiatric consultant's role is that this is a person who may or may not actually have direct patient care with the patient and may or may not actually be located physically on site with the team.  And the advantage of having a model where that psychiatric consultation doesn't have to be on the ground is that it really opens up the opportunity to use technology, such as simple technology even the telephone, to allow psychiatric expertise to be delivered to that primary care setting even if that psychiatrist isn’t physically located close to the practice.

Most of them their work is delivered through regular caseload reviews with the behavioral healthcare manager.  These usually happen once a week.  This is a big part of my job when I first did my work in the University of Washington.  I would get on the phone with my care manager and spend about an hour, and we’d talk about five to eight patients.  For each of those patients I provide a written case review, helping to clarify a diagnosis and develop a treatment plan including evidence-based therapy delivered by the care manager and medications that would be prescribed by primary care provider.

In most collaborative care teams that means the psychiatric consultant doesn’t see most of the patient directly.  But in many systems that psychiatric consultant is available for that next step of care.  For example, a primary care provider has a direct question that they want to ask of the psychiatric consultant or if you might need to see that patient directly.  A lot of programs are using telepsychiatry approaches to be able to have that function of delivering a small percentage of patients to do in-person or direct services.  In typical primary care settings, that's about 10% of the patients that end up needing to be seen in person. 

Collaborative care also introduces several important practice supports.  The first one is regular use of an outcome measure.  The most common one being the PHQ-9 for depression.  This is really important because one of the key aspects of collaborative care is that you're going to keep measuring whether or not the patient is getting better for their diagnosable mental condition.  And if they’re not, the team is going to figure out what is the next treatment adjustment that you have to make.  And I'll talk about why we think that's the important critical factors in the increased improvement you get in collaborative care.

Another important factor is to use a population registry.  And a population registry is a list of all the patients that have been identified that have needs.  And that we are going to continue as a team to look at that registry, engage those patients, adjust treatments until the patients are better, or until we determine gosh, they really need a high level of care and transfer them to a specialty setting.

The next practice support are treatment protocols.  This means the team is trained up to deliver evidence-based brief behavioral interventions that can be delivered in primary care settings.  These have often been adjusted to be shorter-duration sessions.  For example, problem solving treatment often is 30-minute sessions, and often doesn't last as long as some of what you see in specialty settings.  So, six to ten sessions are pretty common for the behavioral interventions delivered in primary care. 

And lastly, psychiatric consultation which I described to you.  That's that ability for the psychiatric consultant to regularly look at case reviews and provide input to the team.

So, in the original trial, of one of the largest trials to date of collaborative care the IMPACT study, collaborative care as I described it was tested against usual care.  So, in this study 1,801 patients were randomized at the patient level to either usual care, the primary care provider could do anything they normally do, or collaborative care where they would actually get all of those practice supports that I described.

And in that study, they found that in collaborative care, twice as many people improved.  There's a 50% greater improvement in depression in 12 months for approximately 50% of the population.  And this doubled the effectiveness compared to usual care.  On this figure, the beige bars are the impact or collaborative care arm, and usual care is the purple arm.  So that means that in typical usual care only 20% of patients are getting better.  I think that's an important fact to understand because that means even if a patient has made it into primary care, the chances that they'll show improvement for their depression are pretty low, unless you start thinking about these systemic measures to make sure that they're getting better.  And collaborative care is one of those strategies to improve the likelihood that a patient will improve.

I think this is really important data to understand that this happened in a wide variety of organizations.  So, there were eight different settings.  These were small rural to larger urban practices, kind of no matter what size practice it was or what usual care was available, collaborative care still out-performed in this trial.

This is one of the reasons I'm so passionate why taking collaborative care and collaborative care principles and making sure that we're thinking about how to get them implemented out in our community settings.  So, in addition to improved depression, patients reported less physical pain, better functioning and higher quality of life.  I really like the image here with the patient.  I mean, that's the purpose of really delivering collaborative care is to get patients back living their lives.  And that's important when you think about suicide prevention, right?  Because when people are depressed, they become hopeless and that puts them at greatest risk for wanting to act on suicide ideation.

Collaborative care also demonstrated greater patient and provider satisfaction.  And there were data that showed that if you do deliver collaborative care it also allows you to reduce healthcare cost.  Specifically, what they looked at in the study is looked at the healthcare cost over the four years after collaborative care intervention was delivered.  And they saw savings of about six and a half dollars to every dollar spent and most of that was avoided physical health care costs.  I think we think about, when we think about risk factors for suicide, addressing people's medical care so they have improvement in their medical condition may also be protective against risk for suicide.

Okay.  So collaborative care has also been shown to be effective treatment for other conditions.  So, the evidence base has been established for depression in a wide variety of populations.  Anxiety, post-traumatic stress disorder, chronic pain, dementia and recently have studies this can be effective treatment for substance use disorders.  There is emerging evidence around ADHD and bipolar disorder.

So, I hope I've convinced you that collaborative care is an important strategy to think about when delivering mental health services in primary care settings.  What do we think the secret sauce is for this type of delivery and what are the core things, because there’s a lot of pieces to collaborative care that we really think are important, to drive the outcomes.  There's been a consensus process that’s really identified five core principles that I think are important to think about when we think about delivering collaborative care.  And I think if you're in a practice setting where collaborative care is impossible tomorrow, think about which one of these, or one of these principles you might take and use in your setting can be a really important way of getting started with collaborative care.

These principles are really population-based care, identifying a population and using a registry and track and make sure no one falls to through the cracks.  That concept will also be really important once we start talking about suicide prevention. Once somebody is identified at risk we really want to be able to track and make sure that we're continuing to engage them in care until we think that they're more stable.

Measurement-based treatment to target.  I talked a little bit why I think that’s important and I have a couple of nice slides to explain that in a few slides.  Patient-centered team collaboration.  Using a team and wrapping that team around where the patient is likely to show up especially in primary care.  The ability to increase access to evidence-based care, both medication and psychotherapies.  And then in most systems when they do this model of care, they look at the systems level and making sure that they're having good population impact and then enough patients are getting better.  And that's what we mean by accountable care.

So, I'm going to go through each of these principles and talk what those strategies actually looks like as part of the clinical care before I move onto thinking about how this can help suicide prevention.

So, the first is principle is really population-based care.  This is the figure from one of the registries we used.  This is a free one that the AIMS center makes available based off of Excel.  You can see you how a registry can be a powerful tool for a team that's doing proactive care for patients.  So, what you can see in this is each line going across is an individual patient.  And what you can see is you can actually sort the columns, for example, by PHQ-9 and that is what the purple arrow is pointing to.  And what you can see there is that you can sort this column and quickly identify who the patients that aren't improving?  Who are the patients who estimate have a high PHQ-9 score, indicating they have still active depression symptoms?  And it can allow you to make sure you actually address those patients’ needs, make a change in treatment, intensify treatment and that you’re trying to get that patient better.

We also use our registry to indicate patients that we need to keep a close eye on.  So, in this particular registry all the way over on the right-hand side, there's actually these different colored boxes.  That red box there, that case is that patient that has been identified as having safety risk.  And that allows the team to quickly see, who are the patients we need to pay extra attention to in a systematic way to make sure we're able to address any increased risk for suicidality.

The next principle that I want to talk about is measurement-based treatment to target.  This has been shown to be an effective strategy.  I think this is a really nice patient case that I’ll spend a couple of minutes talking about because I really want to give a sense of how collaborative care can deliver measurement-based treatment to target.  This is an actual patient that I was taking care of.  It was a young woman.  We know that transitional age issues could be a population that are sometimes difficult to engage in treatment.  She’s shown up in her primary care provider’s office, reporting that she was feeling like depression was getting in the way of her participating in school.  She was enrolled in college.  And it was a pretty high stakes situation that she was at risk for losing her financial aid if she didn't complete the semester.  And she was worried that her depression was going to prevent her from doing that.

She was identified by her primary care provider as likely having depression.  Seen by a behavioral health care manager actually that day.  That behavioral health care manager administered a PHQ-9 and she had a score of 15.  Also administered a screen for anxiety, screened for bipolar disorder and PTSD.  This is a safety net population that had a high prevalence of trauma.

After that assessment, the care manager felt this was depression with secondary anxiety because of all the stress and worry this patient had about her schooling.  The patient and the behavioral health care manager talked about her treatment plan and really decided that the patient's preference was to start with psychotherapy, and they started that day doing some basic CBT.

I was a psychiatric consultant and I talked to a care manager a few days later.  I said it sounds like you did a nice assessment and I agreed with your assessment.  I think this is a reasonable plan. I planted the seed if the patient doesn't get better since it's such a high-risk situation, we should probably consider medication as an augmentation strategy sooner rather than later if she isn't responding to the CBT.  The care manager saw her again the next week.  Her score had come down a little bit. You can see it came down to 12. I think the patient was really relieved that she was engaged in treatment.  But when the care manager checked in with her the next week, she actually said she wasn't doing as well as she reported that last visit.  She was actually really struggling to do her CBT homework and was quite worried. The care manager reached out to me and said, do you think this is the time to think about medications and I said absolutely.  Here's my recommendations: let’s start some fluoxetine.  The PCP can prescribe that.  Let's start at 10, make sure she tolerates it, have her go up to an effective dose of 20 soon as she tolerates it.

The care manager, you know, made sure that that happened.  The nurse reached out to the patient made sure the prescription happened.  And about a week later, the care manager called the patient.  The patient actually said my symptoms still pretty high. You can see she had a 17 score on her PHQ-9.  I don’t think this medication is working. Which isn’t surprising for most patients, they don’t see benefit in that first week.  But because we had that care manager, because we were doing that measurement base treatment to target over time, that care manager had an opportunity to say, that's really normal, to provide some psychoeducation.  That's normal that you're not going to respond right away. But we can actually…that's actually a good sign that you're tolerating the medication we can go up to the effective dose.  I'm going to talk to the team about giving you instructions on how to do that.  What we saw is that the patient then actually had a pretty rapid response over the next few weeks.  The care manager checked in with her one more time by phone and the patient said she was doing much better.  She came back into the clinic about a month later and PHQ-9 dropped to four.  which is considered a response to remission of her depression symptoms.

I think that this is a really nice story of a couple of things.  First, that it took a couple of trials and a couple of changes to get this patient onto the right medicine.  And so, making sure that we had a systematic way to make sure that happened was really important for her to be able to have a timely intervention around her depression.  I think it also points out that having somebody who's tracking that and using those data to actually make sure those interventions or those changes happen is really critical if you want patients to actually have an effective response to treatment.

There is a lot of opportunity for psychoeducation I think you can hear in this.  I think you can imagine that this is a patient who had reported past suicidal ideation you can see that frequent contact by that care manager would be an important strategy to make sure that you can monitor her response to that.  So, I think you can think about not only, how does this help the patient get effective depression treatment, but how these same structures would be useful for patients at risk for suicide.

And I just want to show some other data.  This is from the Mayo Clinic.  This is a nice paper that showed when they delivered collaborative care in their system for 7,000 patients, what they found that patients that got collaborative care got better in about three months or 86 days compared to almost 2 years for patients without collaborative care.  So, it's not the patients who don't get better from their depression, it's just going to take a long time.  You can imagine a patient that's at risk of suicide.  It makes a big difference in their risk if you can get them better in 90 days versus almost two years.

The next principle is patient-centered team collaboration.  I think you’ve gotten a nice sense from the stories that I have already described of how really having that patient, and that primary care provider, getting support from the care manager and the psychiatric consultant can make a big difference.  I think it’s also important because it allows the patient to really have access to a full range of treatment options.

The next principle is really evidence-based mental health treatment, and I think that’s really important.  It provides the opportunity to use our full range of medication and psychotherapy options to help patients get better. I think getting access to care is a huge deal.  For many patients they may not be able to make it into specialty settings directly. And so, if we think about mental health diagnosis is a huge risk factor for suicide, getting access to treatment for their mental health is something that really collaborative care offers a tremendous opportunity. 

And I think that's really what I'm trying to focus on is that you know if you think about treating patients for depression and anxiety, we really need a biopsychosocial approach.  You want to make that full range of treatment available.  You want to support the whole person.  There may be social factors that are also important to consider.  You can think how this is important when you might be addressing concurrently suicide risk factors.  You know thinking about that full person and how you might approach multiple risk factors at the same time is really important.  And having someone that’s designated in primary care to actually support the delivery, to be able to have time to discuss pros and cons and really engage the patient in treatment is one of the real advantages of collaborative care.

The last principle is accountable care and I really think about increasing access.  You often have to think as you design your care delivery system how we're going to help as many patients as possible with often limited resources.  And collaborative care really leverages some of the scarce resources in our system.  There are just not enough psychiatrists in the country to actually provide direct services.  And so, thinking about, how do you leverage limited psychiatric expertise, and also leverage that over distances through mechanisms like telepsychiatry, can really help think about access issues.

We also make sure that there's accountability.  We make sure that we're screening patients to identify all those patients in need.  And then we’re really measuring to make sure that both the patient and the population level were getting enough patients better.  So many times, in collaborative care systems we’ll look at things, are we hitting the benchmark of getting 50% of the patients showing improvement in their depression treatment?

So, I think that's really the core principles of collaborative care.  I hope that I've convinced you that there are interesting ideas in there no matter what you're setting that you might think about.

I want to talk a little bit about why this is relevant to suicide prevention.  I think there are, you know, there are many disparities and access to mental health care and especially members of minority and racial groups in the United States.  They are less access to mental health services, less likely to use community mental health services, more likely to use inpatient hospitalization and emergency rooms and more likely to receive lower quality care.

So, thinking about collaborative care is an opportunity to also increase or address disparities in mental health care is really important.  And we have some important reasons to do that when you think about suicide.  We know that some of our racial and ethnic groups are at risk for suicide especially American Indian/Alaskan Native youth.  And, thinking how collaborative care can could be an opportunity, to both engage people in more effective mental health treatment, but also potentially in suicide prevention. 

I want to talk about the evidence base around collaborative care for disparity populations.  This first figure comes from the IMPACT trial.  They actually looked at the individual racial and ethnic groups and what their responses were.  And you can see that for both Black and Latino population they have just as much benefit if not in some cases even more benefit from having access to collaborative care.  And I think that's a really important thing to appreciate is that improving access to collaborative care is a way to address disparities in mental health access potentially.

I also have done some work locally in our Washington State program which is called the Mental Health Improvement Program.  I was fortunate enough to serve in a culturally-sensitive clinic for Asian populations in Seattle.  And that clinic actually, we were really curious about do we get the same outcomes in that patient population as we do to other populations served by this program?  And what we found just to-- this is a busy table.  But to break it down, essentially we had the same outcomes whether you're an Asian American or a white patient in served in these population.  But what we really saw is we got so many more patients engaged in mental health care, by offering collaborative care in that culturally-sensitive clinic.  And so, one of the things that I want people to take away from this, if you have a clinic that serves a disparity population offering collaborative care there is a huge opportunity to offer access to effective mental health treatment.

We also have emerging data that's not quite published yet, but was part of a really interesting implementation project that the AIMS center has been involved in over the last five or so years called the Social Innovation Fund, and you can read more about that project on the AIMS website.  Essentially this was an implementation of collaborative care in clinics in the rural west.  These were trying to understand, what are the adaptations we need to implement collaborative care and hard-to-serve populations with limited access to mental health services.

And one of the exciting opportunities that we had to learn from in this clinic in this implementation was that a large percentage of the patients who are American Indian/Alaskan Native.  It was really one of the larger populations we had a chance to evaluate.  And what we've seen in the early analysis is we're seeing good outcomes in those population, comparable to between the American Indian/ Alaska Native population and the White population which would be consistent with what we see in other populations.  And really, I think it's an important opportunity to think about if we're trying to improve access to mental health treatment for our disparity populations.

The last slide that I’ll just show is more work that's been done in our Mental Health Improvement Project in Washington State.  And this was really to address that there are sometimes there are high-risk populations.  And this particular population is high-risk mothers in King County.  This program specifically targeting engaging these populations.  And what they found is that in all of the populations, we saw significant improvement of depression when that population was engaged in this treatment. So, I'm really- I think this is a really important set of data because, if you think about the opportunity when you're addressing a mother who has depression, you're not only improving her outcomes of mental health but also probably improving the outcomes of mental health for her child.  And so, when we think about what are the kinds of populations that we really want to target with collaborative care, to me, high-risk mothers, perinatal and postpartum depression is a particularly important population to be thinking about.

It's also important in population from a suicide prevention perspective.  Interestingly perinatal women, that year, after childbirth are, you know, that suicide is more likely the cause of death in that population than hemorrhage which is what people usually think as a complication of childbirth.  So really thinking about how addressing depression in this population is not only helping with mental health access but it’s probably also addressing suicide risk.

Okay, so I think there's a lot of opportunities within collaborative care.  And the implementation of collaborative care to go after suicide prevention.  And a lot of that has a lot to do with reducing suicidal ideation and effectively treating depression and anxiety and other common mental health disorders.

One of the exciting things I had an opportunity to do within the collaborative care realm though is really think about, how do we change systems.  You can tell from my descriptions of collaborative care that there’s a lot of different things you do differently when you're delivering collaborative care.  You change your workflows, you change your team.  And as you're making those changes, if you're thinking about the opportunities for suicide prevention as part of those, I think you have an opportunity to really change things at the healthcare level.

So, I'm going to talk through three main areas that I think are really key opportunities within the implementation of collaborative care that go beyond just the opportunity that I described to improve depression treatment.

So, the first one of these is really the opportunity to train primary care providers.  I think one of the really powerful experiences I’ve had in the last couple of years was to be asked to design a training for primary care providers for the University of Washington. So, in Washington State, we actually have a law that requires all providers to have six hours, all medical providers, to have six hours of suicide prevention training.  And in designing a program for this, I had an opportunity to think about what are the key skills that the average primary care provider needs in order to really be making a meaningful contribution to suicide prevention?  And as a result of that we created the six-hour course.  In the next few slides, you'll see the materials from that presentation.  If you're interested in knowing more about that course we do have the web address there.  And it is a course that people can register and take.

What I think about is that we really felt that one of the things we wanted to talk about is sort of how do you recognize and then how can you meaningfully manage, what can you manage in a primary care setting?  So, there’s a lot of opportunity to actually think through that.  I'm going to talk about the few highlights in the next few slides.

I feel like as you're talking about how we do better depression treatment; how do you do good suicide risk assessment and management is something you should be doing as part of every collaborative care implementation.

So, you know the reason I think that this is important is because medical professionals are trusted professionals.  And they often are treating conditions that increase risk for suicide, both mental health and physical health reasons.  And that you know medical providers I think that if properly empowered can really be a key source of being a trusted relationship that can be leveraged when a patient is at risk for suicide.  They often have long-term relationships with their patients.

Lastly, I'll just say, you know the medical profession itself is a population that is and can be a high risk of suicide themselves.  Though there may also be an opportunity in that training to prevent the death of a colleague.  So, I think that's another reason why it's really important to think about suicide prevention in primary care settings.

What can a medical professional do?  Thinking about how to educate patients to make homes safer.  We prescribe medications.  Medications are part of the most common means used to make a suicide attempt.  People often are using medication overdoses.  So, talking about those, how does a patient keep themselves safe, but also how do they make their home safe.  You know, who accesses their home?  Are there kids or teenagers that might be at risk with access to medication in, you know, medicine cabinets?  How can you actually keep those safe, could be part of a public health conversation.

Thinking about how do you identify and screen for patients at risk.  And we talked about that.  There's an increasing, I'll talk about this on another slide—but there's a lot more emphasis of screening for depression in primary care.  And with that comes the opportunity to screen for people at risk of suicide.

Really training people to be comfortable asking directly and assessing risk for suicide.  I think It's really important to ask, are you thinking about killing yourself, are you thinking about dying by suicide in the context of a trusted relationship can be important.  I think sometimes people can be cautious and say things like “are you thinking of hurting yourself?” and really correcting that that's not adequate assessment of suicide is really an important opportunity for training.

Giving people practical strategies for safety planning and removing dangers, removing means, removing access to means is really important.  Giving people a chance to practice that skill can be a key training needed for medical providers.

Talking about, how do you facilitate next steps to care, and actually how do you track patients to make sure once you've identified a patient at risk you keep them on your radar and keep them engaged in care can be really important.

And then of course thinking about how do we engage our medical professionals and really be the practice champions for the changes you need to support systematic suicide prevention?

There's practical tools that are easy and free and available.  So, the SAFE-T is a really good example of that.  The SAFE-T is freely available.  It helps with kind of walking a provider through a good suicide assessment for evaluation and triaging to the right level of care.  This in combination with the National Suicide Prevention Lifeline can be a good place to start for any practice.

I also think getting people comfortable using like the Colombia Suicide Severity Rating Scale to help with that assessment of suicide is a great opportunity within primary care settings. This is a great tool.  It's six questions, it's fast.  It kind of gives guidance about what are questions that would put that person in the higher risk category.

And then you know practical steps really, you have to think about screening and you have to think about assessment.  If you can teach people these two things, I think you really have got pretty far.  And so that's a real opportunity. 

This is what a good safety plan includes.  Make sure everyone knows this.  Thinking how safety planning tools could be embedded in electronic medical records or, you know, put as a paper copy within your practice setting is a great place to start in terms of thinking about planning steps.

Okay.  So, I think the second opportunity that primary care really represents, and I've talked about this throughout the presentation, is to increase the detection of patients at risk in primary care settings.  And a huge opportunity comes from using the PHQ-9.  This is a tool that’s now widely used in primary care settings.  And Question Nine on this questionnaire, actually talks about, you know, why you'd want to-- the thoughts that you'd be better off dead, or you would in some way want to hurt yourself.  If somebody is positive on this, they need additional assessment that day.  Practice is really going to implement broad screening for depression using the PHQ-9.  They also need to have enhanced protocols to be able to then assess any person that ends up testing positive on this PHQ-9.  And so, I think talking about suicide prevention in the context of increased depression screening is really important.

The U.S. Preventive Services Task Force recommends depression screening in the general adult population and specifically calls out pregnant and postpartum women.  They basically say screenings should be implemented with adequate systems to place accurate diagnosis and ensure effective treatment and appropriate follow-up.  Collaborative care is a strategy that allows you to really be able to do that.

There also are metrics now that are associated, and many organizations are actually using these metrics to measure the quality in their clinics.  This is the depression remission and response.  So, I also think as people are thinking about using these kinds of metrics or entering into financial arrangements like accountable contracts that include these metrics thinking how you address patients at risk for suicide is part of meeting these metrics is really important.

And the last piece that I’ll focus on is, often when you're doing changes in your system of care to be able to deliver good, collaborative care you will have the opportunity to also do systems changes that can improve protocols and healthcare systems approaches.  This is a screenshot from a recent report, released from the National Action Alliance for Suicide Prevention.  It has some really nice high-level recommendations around places to get started, depending on your practice setting.  And I think it can be a really nice opportunity to actually think about the systems-level changes that need to be in place to really accomplish suicide prevention.

These are the kinds of things that each clinic system should really be thinking about.  How are you going to screen and identify for patients at risk in suicide, especially important in a primary care setting.  How will providers be trained and empowered to support patients at risk?  You know, how will you make sure that the providers know how to engage in a therapeutic and empathetic way with the patient?  How is your practice going to gather appropriate information once the patient has been identified at risk?  Are you going to use the Colombia Suicide Severity Rating Scale?  Are you going to use other things?  Are those already in your EHR or are they in the practice rooms?  How are you going to manage the patient that is at risk?  How is a patient going to be transported to an emergency department if they need that level of care, versus being followed up closely in their outpatient setting?

Removal danger and plan for safety.  Do you have a good strategy to help support means removal?  Do you have information on how to lock and limit access to firearms or lock and limit access to medications?  How are you going to generate a good safety plan?  I think it's really important that safety plans are developed collaboratively with a patient.  And making sure that you do that in an effective way that people feel comfortable with being able to do that is important.  And how will you address getting a patient to a hospital setting if that's what they need, if that level of risk is present in a patient especially in a primary care setting?

And most importantly to me, I think often, you know, systems are getting better at managing that meet acute kind of phase as a patient at risk with suicide.  But I really think thinking about, how do you make sure that patient gets continuous care is important.  How are you going to bring-- if you're in a primary care setting how do you know what patients might have been assessed in an emergency setting, and how are you going to make sure that in 72 hours after they leave the hospital to get them back connected to care?  Because that's a super high-risk time for patients, right?

How are you going to make sure if you're going to send a patient home from an outpatient setting that you have timely follow-up to make sure whatever level of support you gave them was enough to start to see that change in their suicide idealization happen?  How are you going to make sure a patient that might have a mental health condition actually gets effectively engaged in treatment?  To me these are really important things that can only be addressed at a systems level.  And so really thinking, how do we create systems of care that can deliver these kinds of elements as a real opportunity.  And while you're already changing your care-delivered collaborative care, you can incorporate these ideas into that.  Tools like the registry that I already showed you can be effective to help with these kinds of strategies.

Lastly, I really think there's an opportunity for systems change to engage anyone in the system to become a practice champion.  I think often, we think that patients, you know, are at risk and we sort of feel alone with them.  But I think as a medical provider anyone can be a practice champion.  And if people are needing help with that, there are so many great resources now available for clinics and practices.  We have some of part of our all patient safe-- tools, but there's great free resources from the Zero Suicide Movement and I just think that there's really-- I encourage you if you're excited about this idea of how can your system really become a system of support suicide prevention, please go look at those free resources because I just think there were a lot of opportunities for implementation at this point.

So, that's really my key points.  I think there's really a huge opportunity within collaborative care to think about suicide prevention both directly in terms of increasing access to effective treatment for depression and other common mental health disorders.  I think there's a huge opportunity because we see that patients have reduced suicidality if they get their mental health disorders treated.  There is a huge opportunity in movements around increased screening, increased training for medical providers and increased system levels approaches.

I've been excited to partner with The National Institute of Mental Health, and The Health Resources and Services Administration, so NIMH and HRSA, on this partnership around the implementation of collaborative care in HRSA, nurse-led safety clinics, all of these clinics, Andrea mentioned the project in the beginning.  It's exciting to work with these eleven clinics throughout the United States and their ability to deliver collaborative care to disparity populations.  I think it's a really nice example of how a strong partnership can help support effective implementation of a really important model of care.

Okay.  So, um, that's about the time that I wanted to spend presenting.  And I'm just leaving this up that we have lots of resources around how you can implement collaborative care on the AIMS website.  I've also put our suicide prevention training program website up in case people want to look at that.

I want to acknowledge all the good work of the faculty and staff I work here at the AIMS at the University of Washington, as well as partnership with Forefront Suicide Prevention that’s in the University of Washington School of Social Work for all the good thinking and partnership around much of the material I presented here today.

I'm really excited to have a good amount of time to address questions that have come in.  I see that there were a few that have come in.  And then I will be happy to answer additional questions.  And I will turn it over to Andrea to kind of facilitate that section.

>> ANDREA HORVATH MARQUES: Thank you very much, Anna.  I really appreciate your enthusiasm and passion about using this powerful tool to help us reduce suicide in the U.S. and overseas.  I think you’ve given us an amazing presentation.  Giving us an overview of the collaborative care, how this evidence-based intervention can help us. NIH, as you mentioned, and other agencies, have already funded almost 100 randomized control trials showing that collaborative care when implemented with fidelity works.  So, know the next steps now and how to implement them.

And as you mentioned, that one of our partnerships that we agree with HRSA and you in a sense of helping to implement collaborative care in 11 HRSA nurse-led clinics around the U.S.  So without-- we have some time now, and we have questions.  So, I'm going to just-- I'm going to read the questions so everybody can know and Anna is going to be addressing that.

So, Anna, the first question is how collaborative care is superior to integrated care and where mental health professionals are co-located, members of the family care treatment team?

>> ANNA RATZLIFF: Great.  So, I guess I will address that question by really saying, I think that there are lots of ways that people are trying to think about integrated mental health and there's lots of different models and approaches that I think are really helpful for patients.

I'll talk about a few of the things that I think distinguish collaborative care for more general integration models.  And part of how I think about this is there are actually, uh, I think there are-- there is sort of the physical location of people and so, I think that's one dimension of integration, right?  So, if people are physically located in the same place, mental health providers into the primary care setting, I think that's a really good first step in a lot of cases because that allows for there to be collaboration.  There allows to be possibly increased communication just because you're in closer proximity.

However, I think without some of the systems level changes that happened in collaborative care, it could be hard to overcome some of the-- you can still end up being siloed in an integrated setting even if, you know, you're co-located.

So, what I would really say are the distinguishing features of collaborative care are those measurement-based treatment target and the systems to make sure it happens routinely.  So for example, having a registry, for example, helps make sure that every patient that's identified that's put on that registry, you have an opportunity to track their response to treatment over time and kind of prioritize those patients who aren’t getting better to be effectively engaged in care.  In some other models of integration there aren’t necessarily a systematic approach to make sure whatever intervention you give them that day is something that results in an improved outcome.  So, I think all integration is really a huge opportunity.  I think there are systems-level things about collaborative care that probably drives the outcomes, the improved outcomes we seen in the collaborative care research.

>> ANDREA HORVATH MARQUES: Thank you, Anna.  Um, our next question is somebody's asking you is what type of mental health provider typically serve as the health care manager?  Umm, and what would be the--so yes...

>> ANNA RATZLIFF: Yes.  So I see this question.  It's really around who might serve in that behavioral healthcare manager role.  So, and most implementations of collaborative care, we really think of that role as having two functions.  And most of the time that can be, most implementations that's one person.  It can sometimes be more than one person that shares tasks.  But the two tasks are really somebody to own that measurement-based treatment -to- target—to make sure routine measurements are addressed, that they’re collected and put in the registry.  That there's coordination of care within the team members.  So that behavioral team care manager function is one important role for that person.

The second part of that and, is the ability to deliver good evidence-based brief behavioral interventions.  Umm, so typically, that needs to be a provider-type that it's within the scope of practice for that provider to both do assessment and delivery of therapeutic intervention.  So, there's some variability across states, different states.  So, who are eligible providers to be in that role?  Umm, so it's important to understand your local state politics.  In our state, Washington State, umm we often have licensed social workers in that role.  We see nurses in that role that have had behavioral health training.  Umm occasionally we’ll see a psychologist in that role.  Typically, those are folks that are umm-- psychologists are likely to be reserved to deliver longer-term psychotherapy for patients or evidence-based behavioral interventions.

Umm, there are new collaborative care billing codes that are available.  And for those codes there is some more definition on who can serve in that behavioral health care manager role.  Umm, so if you're thinking about billing for collaborative care it would be important to understand those differences.  Umm, there are specific rules for FQHCs and RHCs that really allow a broad range of providers to be in that role.  Really the guidance is around somebody with a bachelor's level with specialized behavioral health training.  Umm in non-FQHC settings and RHC settings, rural health center settings, umm that language is a little bit more aligned with somebody that’s more like a master's level person.  But I would refer to you to also, I would encourage people to actually look at that.  What I’ll say practically because I have done a lot of implementation around this is you need a person in that role who is flexible and organized, and somebody who has enough training and at least a few evidence-based brief behavioral interventions, at least one, but ideally a couple that really feels comfortable delivering both in a different way that you might if you're in a traditional mental health setting.  Umm, so we've seen people, coming from emergency settings, things like that.

>> ANDREA HORVATH MARQUES: Thank you, Anna. Yea, so I'm going to ask a practical question that is coming, and I know that you're going to be able to help us to answer that.  And I think that's one of the questions that people get really, umm, concerned working in the primary care center who does not have experience in mental health and with suicide.  And that's why we are addressing this.  Umm, so the question is, after primary care's physician's screen for suicide, assess the patient, and the patient is for risk of suicide, so what is the next step?  What am I going to do?

>> ANNA RATZLIFF: Right, so that's great.  So, I think, umm, that's one of the reasons why I think talking about suicide prevention protocols are really important because I think having a plan in that practice before you’re faced with a patient for the first time is really important.  Umm, and I'll kind of talk about two scenarios because I think there’s two different settings where you could imagine that, and I work with all of these.  So, the first setting might be, you know, a clinic that does have an embedded behavioral health provider.  So, I mean somebody that has a social worker or someone on staff who might be available to assist with them.  So often in those clinic situations is that person is identified at risk they might have a warm hand-off to that behavioral health provider for support around doing additional assessment.  I think it's important to emphasize that just because a patient has reported a positive response on a PHQ-9, question nine, for example, that doesn't equate with needing an assessment in the emergency room.  So, often that patient can be assessed and even managed in the primary care setting.  And it's important to build our system’s capacity effectively, because otherwise we're just filling up our ERs and that isn’t necessarily therapeutic for the patient or helpful for our systems of care.
 
So, umm, you know, in a system where you have a behavioral health provider that might include a warm handoff.  Umm typically that involves doing a careful assessment of additional risk factors, protective factors, and past history of suicide attempt and current assessment of intention and plan, and sort of acuity of that suicidal ideation.

Umm because really a question, a positive question on PHQ-9 can range from anything from “occasionally I wake up and I wish I wasn't alive” to “I have a gun at my house and I’m thinking about hurt-- about dying tonight.”  And it’s really important because those are important because those are very different situations and you have to be able to in a nuanced way figure out where that patient is and what would be the appropriate level of care.

Umm, specific tools that are helpful for that are that SAFE-T and the Colombia Suicide Severity Rating Scale.  So, I see a lot of practices using that combination to be able to complete that assessment and then a risk determination process.  Umm, so that's one scenario.

The second scenario is your primary care provider, and I work with a lot of these in a two-person practice in the middle of rural Washington.  And there is no one else for miles around you, and you have a patient who’s just now reported a positive score on a PHQ-9.  And for that primary care providers they’re probably going to need to provide a level of comfort of doing that assessment themselves.  So, I- this is where I really think making sure we have primary care providers getting comfortable with the Colombia Suicide Severity Rating Scale, comfortable with taking that SAFE-T and really making a suicide risk assessment and determining level of care.

You know, mild cases, probably need, you know, follow-ups but not immediate follow-up.  Moderate cases, umm, you know—sorry, in any case I think you need a safety plan until making sure a primary care provider can do that.  Umm, some of that safety planning may include means removal, so I think you have to develop some comfort with that.  And I think some of the patients will need transfer to emergency services and you're going to need a plan for how to do that.

In all of these cases, if a primary care provider is ever stuck and not quite sure what to do next, they can always call the Suicide Prevention Lifeline.  And so I think that's a really important number.  Every time I start with an implementation, I make sure everybody has that number right away, because that is a way to get guidance and that primary care provider can call right there with the patient in the room and work through trying to come up with next steps if they’re at a loss.  So, umm that's kind of my default.  But I think it's also important to develop capacity to manage some of those patients and primary care themselves.

>> ANDREA HORVATH MARQUES: I think we have that number on the screen. Umm if we don’t-- if we do, I’m going to ask them to put it on -

>> ANNA RATZLIFF: Great.

>> ANDREA HORVATH MARQUES: …On the slide.  Umm, umm…Jenny, if you can help us with that while I'm going to read the next question.  And I see here there were a lot of very practical questions, and I like that because then it's real world-- like how are we going to be working with it and how can this help us, right?  Umm, and so there's another question that I think is very interesting and I’ve already thought about it.  Like I mean-- in a primary care setting the patient kind of has contact with so many different levels of people, the nurse, from-- starting with the receptionist and so on.  And so, and, how—so the question is, how many of those staff members are going to be working with the patient?  Umm, how much do they have to be trained on the collaborative care model and how will they be helping the patient also?  Who is going to be connecting with him?  What does the patient think about the collaborative care model?  How do you work with this?

>> ANNA RATZLIFF: Yea, I think that's a great question.  So, um, so, you know, I-- one of the things we talk about is that when you actually develop collaborative care or any integration of mental health services into a primary care setting, we think really the entire team, which includes the entire primary care provider staff pool needs to have some level of exposure to both what you're doing, you know, when your model integration is, and what to do if you identify a patient that you're worried about for whatever reason, whether it's, you know, being at risk, worry they're at risk for suicide, or reporting suicidality to you, if there's other concern about how to engage patients or take care of patients. 

What’s really interesting is I think often those front desk staff people, appointment schedulers, umm medical assistants, can be the one that a patient might disclose something to, or might the person that noticed a change in behavior.  I mean my sense is from working in a lot of primary care settings that umm, we have incredibly astute front desk staff and medical assisting staff and they often know the patients really well and it might be a team member who notices, “gosh that person seems more anxious today or more hopeless today” or maybe that person makes the off-hand comment to the medical assistant and not the medical provider.

So one of the things I really encourage teams to think about is when you develop safety protocols, really both having a-- a pathway for if somebody who's a non-clinician identifies a patient at risk, how they connect that person, how is that hand off, how's that transfer of information going to happen in the clinic?  Umm, that also that everyone in the clinic is aware of how you manage suicide and patients at risk in that clinic.  So, I-- I love this question because I think it's absolutely true, umm, that the person at risk might not be the person that has the most training, umm who notices the person at risk might not be the person with the most training. 

It's interesting, in Washington State they actually have required basically suicide prevention training of any medical professional any level, umm-- and even pharmacists, OTs, PTs, dentists, everyone.  Because essentially, you know, we don't know who the patient is going to actually confide in or umm talk to.  So, I think for everyone to feel like they have a role in suicide prevention is really important. So, umm-- great question.  I think everybody should really seek some level of training.  I don't think we expect the medical assistant to actually manage the patient with risk, but we would want them to know what to do if they were the one that identified a patient at risk.

>> ANDREA HORVATH MARQUES: Thank you.  So, umm-- another very interesting question, something what we've been talking before we opened this webinar, Anna, is about using collaborative care in other settings outside the U.S.  And umm-- we're going to be able to share a few papers, written papers also, showing how we are having this had – bi-directional modeling, of like bringing collaborative care outside to other areas in the U.S.  And how can we have some models being used outside the U.S. and bring it back in the U.S., and how those things help each other.  So, but collaborative care has already been shown to be implemented in different areas, but the question, and Anna’s going to be talking a little bit more about this, is, somebody from Indian Health Service, sorry-- this is from Indian.  This is inside the U.S.-- I'm so sorry.

>> ANNA RATZLIFF: Yes, that's okay.

>> ANDREA HORVATH MARQUES: Yeah--yeah.  But umm-- this is from an Indian Health Service clinic inside the U.S.  I'm sorry.  I was thinking about India, hahaha!  I'm having a hard—so they’re having a hard time to buy in from the primary care providers inside in those clinics.  So-- and that's another question that we were talking about.  How do you advise the people who wants to start implementing those how to get them on board on that?  And that’s a very relevant question.  And I think Anna will be able to help us, give us some answers.

>> ANNA RATZLIFF: Yeah, I think that's a great question.  So, umm-- you know, we get a range of response when we're working with clinics around implementation from the primary care providers.  I think doing, getting a good understanding about what are the pain points and challenges that those primary care providers are facing, umm and trying to think about linkages between how collaborative care could be helpful for those challenges is going to be really important in a good implementation.

Umm-- I'll talk about a few key strategies that we’ve found helpful with primary healthcare providers.  The first is that finding a champion from among the pool of primary care providers is really helpful.

Umm, so you know, whether we like it or not, I think sometimes healthcare can be tribal.  And really trying to think about who are the people, umm you know, who are the like-minded people that, that-- in identifying someone who’s really a champion from that group to-- to actually be the one that carries the messages back of excitement around implementation can be really helpful.

Umm, so I think, you know, it starts with a good needs assessment and then finding somebody who is a champion among those.  Who's the earlier adoptor, right?  So, the other thing is we all come with a range of comfort around change.  And my sense is that, umm, there are people who really are comfortable with change and are the people who are always wanting to do something new.  And there are people who would be much more cautious adopters of something different. So, you want to find that early adoptor and get them engaged.

Umm-- I think often primary care providers, there's kind of two responses that I also get from primary care providers.  One is “I'm already doing a good job taking care of my patients.”  And so, one of the things, you know, --“and why do I need something new?” can be a response.  And to that I actually say, let's look at the data.  If you are doing well already, then maybe you don't need something new.  But odds are you're not getting quite as good outcomes with your patients as you think you are because honestly none of us are.  Umm, I think almost anywhere that you look there's always opportunities to improve the number of people that are responding to treatment.  Umm, so that's one thing.  So getting good data from the clinic, what percentage of people have depression?  What percentage of those patients actually achieved response or remission to their depression?  And if you don't have those data saying well at the very minimum, we need collaborative care to be able to start to generate those data, can be a really important engagement strategy.

Umm, the other thing that I sometimes get is discomfort with being in the prescriber role, really feeling much more comfort with referring that patient out to specialty behavioral health.  And what I often then do is really talk about the reality of the lack of access to referrals and some of the data that we have around patients actually following through.  So, the reality is, I think sometimes a primary care provider can feel like they've met their obligation by putting the referral in.  But if we look at that referral completion rate, umm...data show about half of the patients at least don't follow through, that might be even lower for some mental health or substance conditions.  And then when they are referred, they may only go to two visits.  Umm, so one of the things I think that’s really important is again if you have data on how many patients a person has referred have actually made it to treatment or actually engaged in behavioral health.  And if that number is low, saying here's an opportunity to build a capacity here.  You have a trusted relationship with your patient.  Maybe we can-- if we help you do this, this is something you can do here, can be another strategy to really engage primary care providers.  So those are a few ideas.

>> ANDREA HORVATH MARQUES: Thank you, thank you. And I think that umm --please feel free if you want feedback from us, we can provide you later. Umm…

>> ANNA RATZLIFF: Yes, I guess I want to address the question you talked about sort of international populations because I think it's a really interesting point.  So, one of the things that I guess I would say is, umm, I think collaborative care has been adopted and adapted for global settings.  But there's also a lot we learn from those adaptations.  One of the things that I think is an interesting concept within collaborative care is this concept that kind of the foundation of collaborative care, that we're going to task share.  There were a series of tasks that need to be done to deliver effective care and we’re going try to figure out who in our team can do them.  So, umm people always ask me how does collaborative, you know--who exactly, what exactly should everybody be doing on the collaborative care team?  And I’ll actually say well actually it's looks a little different in every setting which is why we have principles because we have to make sure the principles get done.  But honestly how that actually gets put together, umm in the different settings can actually look kind of different depending on that clinic setting.

Umm and I think that's what we see when we see adaptations in global settings.  A lot of times, umm you know, we're often using a licensed person in the role of a care manager.  In many low-resourced settings, in certain low-resourced countries, there's no licensed social worker to serve in the behavioral healthcare manager role.  And so, one of the things that you see a lot in some of the global adaptations of collaborative care, or collaborative care ideas, is really thinking about who is available.  And a lot of those settings it can be a community health worker.  And so, you have seen some adaptations of really thinking about how much can you actually deliver?  Can you adapt behavioral interventions to their sort of most essential core elements and teach someone with a fairly limited education how to deliver that behavioral intervention, for example in primary care.  Thinking about things like behavioral activation.  You know, thinking about how do we activate patients, is something that a community health worker can be really well-positioned to do. 

Umm, so I think there's a lot of opportunities as we move forward and really try think about addressing some of the implementation challenges around collaborative care.  I think we’re going to continue to have to get creative how to stretch and make a whole range of ways that we might engage patients.  And maybe there are some ways to do that with a-- a range of staff and providers.  So, I think that's one of the exciting opportunities that comes out of some of the global work.

>> ANDREA HORVATH MARQUES: Thank you so much, Anna.  Umm, and I have other questions that I just want to address everybody, a reminder that I just asked to put on the screen the phone number and the SAFE-T assessment as Anna was talking about as an important information to have. And all the-- remind you also that the slides and this webinar is being recorded.  And there's going to be storage, archived in our website.  It's going to take a few weeks, but we're going to have that.  Meanwhile if you need anything, any piece of other information, we can provide you, please send us an email.  I'm also going to send my email, so you have it and Anna's email.

So, our next question, Anna is that, you already answered a little bit about that, like some of the differences between collaborative care model and other models of integration care.  And somebody's asking specifically about the mental health integration from Intermountain Health in Utah.  So I don't know if you can address particularly about this one.  But I would like you to…

>> ANNA RATZLIFF: Sure.  I mean, I think there were a lot of similarities between Intermountain and collaborative care.  I think again, I think each model has its own team and who they kind of divide up as roles on the team members.  Umm, so my understanding of Intermountain is that they have specific team roles for each of the provider types.  I know that they have built some infrastructure to do some registry-type functions.  I'm not particularly familiar with their particular registry.  I haven't personally seen it.  Umm, but I think that would be something, you know, that might be interesting to look at.  My understanding is that they have an embedded behavioral healthcare manager kind of person, umm as well as they often are using psychologists or social work in that role.  Umm, I think that's very similar to the collaborative care model.  I think they may use a combination of a behavioral health provider and care manager—whereas in sometimes in collaborative care that is one person.

Umm, I think that, you know, in many ways there were a lot of similarities between those models.  Umm, so those are a few top things I can kind of think about.

Some models are a little bit, umm, and I think Intermountain is one of those in most of the implementations, are really focused on immediate access, so same day access, you know, warm hand-offs or warm connections to patients.  Umm, I think that's a—that’s a really important strategy for engagement.  So, I'll just talk about that a little bit.  I think that, you know, in many cases because the collaborative care manager is embedded, there is an opportunity for warm connections or warm hand-offs.  So patients who might be identified being connected that day to a behavioral health provider, I think there were a lot of good reasons to do that.  One of the things we see, the longer the time between a patient is identified and when they actually get care, the less-- if that time is longer the chances of them effectively engaging go down and pretty, pretty precipitously.  Like, you know, even a couple of days can make a big difference about the likelihood somebody will engage in care.  Umm, so the sooner we can get that person connected to behavioral health provider if there's a need, the better.

Umm, so in that case, I think thinking about in collaborative care teams one of the things they have to work only in their workflows is kind of the tension between being reactive, being able to quickly see a patient, engage a patient and the benefit of that in terms of engagement, and the work that needs to be done to be proactive, to be able to go out and get the patients who aren't coming in who need reengagement in care need tracking and treatment over time.  Umm, so I guess I’ll just say that in any model, there's always going to be the tension between those two roles.  And I think, you know, there's never going to be enough provider time and capacity to do everything.  So most teams have to actually kind of think about, you know, where's their priority for their system of care?  Does every provider do both of those things?  Do they meet the engagement things with the behavioral healthcare manager as part of a collaborative care team or use other resources?  All those are really important considerations as you think about building your team, and especially if you're thinking about including suicide prevention as part of that.

So, I think there are a lot umm, you know, important-- what I always come back to, no matter what model you are talking about, is, what are your real goals for behavioral health integration?  How are you thinking about your team and being able to achieve those goals and how are you going to measure whether or not you got those goals.

A really important function of collaborative care when we do implementations is to have metrics to make sure we're reaching the goal.  A big metric we're often are focused on is patient outcomes: are they getting enough of our patients better?  We look at patient access:  do we have enough patients being engaged in care?  If we are not seeing those numbers where we are, and typically a team is looking at that, you know, weekly or monthly, then we're thinking about, what are our continuous quality improvement strategies to get the outcomes we want to get.

Umm, so one of the things I always say is, you know, it's less important in my opinion what exactly the perfect model is if you're getting patients engaged in care and you're actually seeing the kinds of access levels and outcome levels that you're hoping to accomplish, that's where I really tend to focus on when I'm working with an implementation with a team.

>> ANDREA HORVATH MARQUES: Thank you, Anna.  Umm, just one more question and then we're going to summarize.  So, in your experience, because you've been implementing in those—umm, collaborative care in different areas , with different communities and places, what is--what are the main challenges that you face, umm when-- and I know probably it's different, different in different areas.  What do you think is one of the main challenges that you already face?

>> ANNA RATZLIFF: I think the hardest—I mean I think the hardest thing is changing, right?  I mean I think many people get comfortable with delivering care.  And so, thinking about becoming, being more protocolized, more systematic can be hard.  I think thinking about, um, I mean, I would say-- the other thing that I would put in that category is I still think financing can be challenging around collaborative care and integrated care in general.  So, I think really from the beginning of the effort, really thinking about financial sustainability and building a model or a system that's financially sustainable for your organization is really important.

Umm, I think your people are important.  So, we see sometimes challenges with the clinics either having a hard time hiring for a certain position, or when there's turnover in the team that being a threat to implementation.  So, again thinking about from the beginning, how are you going to train your team?  How are you going to stay working and functioning as a good team together can be really important?  Umm, so those are a couple of areas that we often see practices struggle and we often work hard to try to find ways to help them.

>> ANDREA HORVATH MARQUES: Thank you, Anna.  Umm--so I have another question here before I go to summarizing and we go to finalize.  Somebody is asking about the role of the care manager itself, and how that role in the clinic can be more official.  And how you have a title on that?  How people are being paid on the system, so can you say a little bit about that?

>> ANNA RATZLIFF: Yeah, I think this is an interesting question.  I mean I think one of the things is that, umm, this can be a really hard job.  You know, trying to think about, how do we give adequate recognition and compensation to the care managers, the behavioral health providers that are integrated is really important.  Umm—I mean I don’t have all the answers to this, because that’s obviously a huge challenge in systems to think about.  I think increasingly organizations are going to be at risk for a whole-person care.  And so I think there's going to be a lot of organizations really thinking about how do they integrate behavioral health and physical health together.  And I think it will be important to make sure that as there is money tied to that, that some of that money gets paid adequate salaries to the providers.  So, I don't have an easy way to do that.  I think that's a lot of advocacy and policy work to do that. 

Umm, the second thing that I’ll say is that I think it can be isolating to be the only behavioral health provider in a largely primary care setting.  And so, one of the things we’re trying to figure out is how do we create communities of people in that role across communities.  And I think that's been one of the real benefits of some of the implementation projects that we have is that we often are training care managers from a bunch of different clinic systems together, and they feel that they have kind of a community.  In Washington State we're trying to think about, how could we create programs, maybe something like an ECHO program which is one we did in Washington State, to give people a sense of community across, you know, different primary care settings.  So I think trying to figure out how you can connect to a community so you aren’t so isolated in that role could be an important strategy to address the some of challenges that are coming up in this I-- I wish I had a perfect answer around the policy thing.  I think that's going to be longer, umm-- and more challenging to address.  But it is something I think people are thinking about.

>> ANDREA HORVATH MARQUES: Thank you so much, Anna.  So, for the interest of time I'm going to briefly just summarize a little bit about what we talked about today and also-- I'm going to share with you some other information that can be helpful for people who are interested in helping to reduce suicide in the U.S. and overseas.

So, I'm very happy and thank you again, Anna for sharing so much information and your experience in implementing collaborative care in clinics around the U.S. and other places.  Umm, so we learned today how collaborative care model as a systematic approach to improve care of depression and others common mental disorders including suicide in primary care, and the importance of that.  We had evidence-based intervention that we can use.  And I really appreciate it if you can, if you have-- --for being here and listening to us.  If you have any other questions about that, please free to send it, ask us questions.  I also added my email to your access.  You have Anna's email.  So, we can provide you references, papers and other contacts.

I also want to remind you that, as I mentioned, September is Suicide Prevention month.  So, we're going to be having a lot of information coming out.  So, I encourage you to visit our website.  I'm going to also add the website here, social media.  And you can connect by Twitter, Facebook, YouTube, Google, and LinkedIn.

I also would like to highlight that our director, Dr. Gordon has a Twitter account.  The Twitter account is “@NIMH director”.  So, you can also follow him, follow us, NIMH, also on the Twitter.  And also, I want to highlight that next webinar, our next webinar is going to be September 11 at 4:00 PM Eastern Time.  It's going to be about Using Simulation to Evaluate Social Determinants of Health in People with Mental Illness: Potential Use and Findings in Discussions with Policymakers, Community Groups, Consumers and Advocates.  That is going to be led by Dr. Margarita Alegria from Harvard.  And she’s going to be joined with other speakers.  It's going to be an exciting, how can we use big data and modern research techniques to help us to understand and address social determinants of health.  So please stay tuned, sign up for that, too.  We're also going to send you the information about it.

And finally, I want to remind you that in, save the date that we're going to have our global mental health conference that's going to be held in April 8 and 9, 2019.  It's going to be called “Global Mental Health Research Without Borders.  Everybody's invited, it's free.  It’s a lot of resources about global mental health going on in the U.S. and overseas.

To finalize, I want to thank you all for your participation and being here.  Anna, thank you so much for your kindness and sharing so much exciting projects, programs and research that you've been working with.  Thank you. 

>> ANNA RATZLIFF: Thank you!