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A Whole Person Approach to Working with Individuals Who are Living with Serious Mental Illness

Tuesday, August 11, 2020

2:15 p.m. Eastern Time

Remote CART Captioning

>> Good afternoon. And welcome to today's webinar entitled A Whole Person Approach to Working with Individuals Who are Living with Serious Mental Illness sponsored by SAMHSA. My name is Kelle, and I would like to thank you all for joining us today. Before we introduce today's presenters, I would like to go over a few housekeeping items. Today's webinar is being recorded. The recording, along with the PowerPoint presentation slides will be available, I'm sorry, will be sent via e-mail within 3-5 days to all those who registered. However, you may download the PowerPoint presentation now at your convenience where it says PowerPoint presentation.

Please click on "upload file" to download the slides.

For participants only, audio is being streamed to your computer speakers with no need to connect by phone unless necessary, in which case the phone number is listed in the note section on your screen. If you're having any technical difficulties during this webinar, please type your comment in the Q&A pod on the right side of your screen and someone will be able to assist you. Please also type your questions for the presenters in the Q&A pod and at the end of the presentation, we will ask as many as we can.

At the end of the webinar, we ask that you take a few moments to complete a short evaluation for us. Please know that we do not offer CEU credits for our webinars, but we'll send you a letter of attendance upon request.

My e-mail address will be available at the top of the screen during the evaluation. I would like to thank SAMHSA for allowing us to share this information with you today and again thank you for joining us.

Today's presenters are Allie Franklin, Topher Jerome, and Karis Grounds. Allie joined Crisis Connections as the executive director in 2017 and was recently promoted to CEO in January of 2020. She brings over 20 years of leadership experience to this position. She previously served as the associate vice president of clinical operations at Optum Health Organizations and Washington Health Homes. She has also held leadership positions at group health cooperatives and the Veterans Administration. Allie is a nationally recognized expert on childhood grief and loss and sits on the board of Bereavement Friends. She holds a master's of science in social work degrees from the University of Texas at Arlington and is a licensed independent clinical social worker in Washington state. Topher Jerome is the director of Lived Experience Integration and a senior product manager for Jaspr Health. He spent 12 years developing, implementing, and supervising a variety of programs in intensive psychiatric settings. This includes the implementation of Peer Bridger programs into publicly funded hospital psychiatric programs in Washington state and serving as part of the leadership team for a community behavioral health agency. In addition, Topher has over 13 years' experience in information technology as a project manager web developer and as an analyst and educator in clinical information systems.

As a multiple suicide attempt survivor, Topher brings a personal commitment to the work at Jaspr Health. He is thrilled to be able to combine his professional and personal experience to the work he does.

Karis Grounds is the Vice President of Health and Community Impact, and brings a background of public health, health care access, and sociology. She oversees the community information exchange supporting vision, engagement, and integration of CIE with network hospitals across health and social services.

Through a public health lens, she helps to build relationships and partnerships with health and social services to improve coordinated care and health outcomes for the community.

Prior to working at 2-1-1, Karis worked in refugee health. She is passionate about social determinants of health and advancing holistic health to improve equity locally and nationally. Thank you again to our presenters.

And now we will begin the presentation.

>> ALLIE FRANKLIN: Hi, this is Allie. Thank you so much for having us and thank you very much, everyone for tuning. In our talk today is really around looking at integrated care and looking at the whole person. So, not only are we thinking about what is a person's diagnosis and thinking about from a health lens, but also thinking about what is the role of social determinants of health, and how does understanding social determinants of health contribute to health and wellness for people who are living with serious mental illnesses. So, there's some good research out there that says that lack of access to social determinants of health, so just so we're all on the same page, basic resources. People who have food insecurity, people who are concerned about a lack of stable housing or a lack of access to healthcare or you can have access to all those things and not have access to the transportation that helps you get to the last mile to be able to have access to those things. And that also creates inequities and a lack of access. We know these have been correlated with an increased use of both hospital admissions and also avoidable emergency department care.

In July of 2019, an organization called Ameria Health worked at a study showed that there was a 22% drop in hospitalizations and a 19% drop in unnecessary ER visits when social determinants of health were incorporated in the work that they were doing. We also know that a lot of people get their primary care and their primary source of healthcare through the emergency department. And that an article in 2017 lists that not very many emergency department physicians are oriented to the social determinants of health resources in their communities. The folks who are working on the front lines who are spending more time in the emergency department may not be the folks with the awareness of the available social determinants resources in the community.

Social service systems are often siloed. Meaning that youth systems are often tied together, but they're not often tied together with adult systems or veterans systems. And unfortunately a care may get care from each one of these systems and has to learn how to navigate each one of them. And not only do they feel disconnected, but they may have different ways to enter the system. They may have different types of eligibility requirements that folks may not be aware of. And so, it begins to feel insurmountable to someone who is really needing access to these systems and may not really know kind of what the right questions are or what are the right ways to get to that care.

Another thing that happens is many community systems rely on the user to be the carrier of their own social service history. There may be a medical system that can be shared. In most communities there is not a place that talks about where a person has been referred for social service and social determinants of health resources. A person received a same referral to the same resource over and over and over again without anyone having visibility to whether the person was able to make it to that resource or not. Maybe this isn't a good referral because they're already connected. Or if they didn't connect and they've been given that resource multiple times, if we're able as a community to see, or the caregiver is able to see that the person didn't make it to that system, then we can ask them the next question, which is what were the barriers, or what were the things that kept that person from being able to meet their needs there? Was it a language barrier? Could it be that a person didn't have transportation to get to that particular resource, or that the resource was actually not a good referral or a good fit for the person.

By having the consumer or the person be the carrier of their own social service history, it keeps the system from being able to see where are there potential systemic barriers to people being able to get their care, and also where are there gaps.

What ends up happening also is folks who may have a wider support system, and system around them that's system savvy, they'll be able to access care. And while those who don't necessarily have those systems or support systems around them or access to people who do may end up in those types of care situations that are open 24/7, or the emergency department, which may not be the best place, and often is not the best place for someone to get social determinants of health needs met.

So, how do we help avoid those avoidable ER visits for people ending up in the criminal justice system when it was really a lack of access to social determinants of health supports needed? It really takes a maximum diversion approach. What that means is this commitment that says we want to wrap services around someone and we're going to do everything safe and necessary to find offroads, if you will, so we can help people find safe alternatives to emergency department or to books wherever possible. 24/7 access. If an emergency department is available 24/7 or 9-1-1 is available 24/7, which they are, that means our supports to help folks find other options need to be available 24/7, as well. That could be about diversion beds, or a place where a person could go because they're not safe where they are tonight, but don't necessarily need that highest level of emergency care. It could be about referrals to social determinants of health resources. It could be about utility assistance, food, or housing resources. Or perhaps the key thing is a person is saying I haven't been connected to care and I know I need care. So, I don't necessarily need it tonight. It's not an emergency. So the next day a walk-in appointment for care could be the best plan for someone so they don't have to go to the emergency department.

Another key thing, which is why I'm so excited we have Topher here to talk about peer support, is sometimes folks don't necessarily trust or feel that they have faith in professionals. I know that sometimes the most effective person with dealing, you know, to be able to provide support to someone is the person who has walked in their shoes. So peer support to people with lived experience who have walked through this system, and maybe had to navigate it themselves, who were able to say yeah, it was confusing to me for a while, but here are some of the ways I got through. Or I wasn't sure I could trust a healthcare provider, but here are some of the things that were benefits to me after I got health and support. So you can begin to create a level of trust and support through this peer support. The other thing that it does is we know that having meaningful work is a really important part of mental health and behavioral health recovery. And so peer supports also begin to create a pathway where folks can become trained to become peer support specialists. And by adding a peer support specialist component to crisis lines or in care navigator roles, we can also begin to create an open door or an open space for people who may not have necessarily accessed that care, if they felt that it was being pathologized or treated in a very clinical way. They may connect better to a person in a peer-supportive role.

Also increased complexity in system navigation increases the likelihood that the people that them will be able to access them.

A no wrong door approach. I like to say every door is a right door. Right now if you go to a food bank in many communities and you say I also need housing and legal support, that food bank will probably say I am a food bank, I don't know about these other things. With this approach, they would be able to say would it be okay for me to give you a referral to our community resource exchange. Or would it be okay if someone called you back tomorrow or later to help connect you to resources. In some communities, we're able to have the 2-1-1 system, where that food bank could tell someone, you know, pick up the phone and call 2-1-1, and they can help you find resources. But the other piece is how do we help connect people who may be needing a little bit more than just given a phone number to say to call. How do we help connect people to a warm handoff or to a warm connection through the resources that they have? So that they'll be able to connect to those resources without necessarily having to pick up the phone to call 9-1-1 or to get those resources through emergency departments.

And the other piece is that we've really got to make sure that we're protecting privacy. And so while we're making sure that our systems are interconnected, we also need to make sure that we're doing the right things regarding consent and regarding the information for people so that we're sharing the least amount necessary in order to get someone connected to the resources that they need. That way people understand what it is, what information is being shared and what are they sharing in order to connect to the resources, but also is enough information being shared so we're not giving people resources that they aren't actually eligible for. A lot of times when we're asking people are you a veteran and we've had folks say well why are you asking that question? And the answer is really easy to say because if you're a veteran, we want to connect you to veteran-specific resources. But if you're not, we don't want to send you to a place where you wouldn't be able to be eligible for the resources offered.

And the last piece, and I think it's because I come from a healthcare managed care organization backward is how do you think about network adequacy. How do we bring that lens to the work? That means how do we map out where are the resources so we can look for where the resources aren't. Sometimes, in fact it's a really popular term. It's something called food desert. I'm looking for resource deserts. Let's find the places where the resources are clumped together so we can go and find the places where there aren't resources, and begin to say, "Where would that actionable intel about where the gaps are, how would that begin to drive how dollars are spent and resources are allocated? So a targeted investment might make a big difference in the health and welfare of the community." By saying, you know, it looks like we're having a lot of folks who are going to the emergency department or calling 9-1-1 and we actually saw this in a community that I was working with in the Tacoma area with a lot more 9-1-1 calls that were coming in the hours between when the day shelter was open for homelessness and when the night shelter opened. And so what we noticed is people were getting their needs met both for social connections and resource connection, but in those hours in between there were a lot more 9-1-1 calls in the same area. So really by keeping the day shelter open a few hours longer and opening the night shelter about a half hour earlier we were able to cut down the emergency department calls by a significant amount in that community. So, by being able to think about the whole network and all of the resources, we were actually able to with a very small investment, be able to cut down on those unnecessary costs and uses of 9-1-1.

So, what does Crisis Connections do? Crisis connections is a hot line for nine counties in the state of Washington and also we are the statewide resource for substance use disorder treatment resources. So, people can get immediate access to a same-day appointment for medications for opiate abuse disorder treatment or things that will help them work through their addiction to opiates. 24/7 access to alternative support options. We do that with a program called One Call, which is where in the Seattle/King County area police and first responders can call and get an answer from someone about what are the resources in the area and who has diverse beds that they can offer to that first responder. So if that is a safe alternative, they can take them there instead of considering a jail booking. There's also a triage to see if they need a designated mental health provider, or if peer support would be a good resource to connect them to. And we Set up next-day appointments at any of 45 agencies in our network, at no cost to the person and they don't have to be enrolled in Medicaid services. Our lines are answered by volunteers who have about 60 hours of training, and they're supervised by clinical staff. And one of the things that our community has really leaned into is instead of feeling like they're talking to someone who is using clinical language or clinical voice, they feel like they're talking to another member of the community. But they also know that that member of the community is backed up by all the supports that they need. We also offer peer supports through our warm line. It's exactly what it sounds like. Instead of a hotline, for a hot emergency, this is a line that someone can call when they want to talk to a certified peer support specialist, or maybe it's someone who calls on a regular basis, isn't in a crisis right now, and wants to have that longer conversation. Not intended to be therapy over the line, but it is intended to be that warm connection and the beginning of the connection with someone who could be a mentor or support. It also allows us on the crisis line to have those folks get connected with someone who can have a longer call, so we can make sure the lines are available for someone who is having a hot crisis.

We also have a peer-to-peer line with teenagers answering the line to support other teenagers. And of course, there's texting on that one, because as you know, I have a teenager in my home who doesn't know the phone can do something with a voice. It's all about texting.

And our recovery health line is available either through chat or text or by people going on the computer. I have a screen shot that I'll show you on the next slide that shows you how people can find resources 24/7 and they don't even have to call and connect to someone. They can actually do self-help if they need to.

We do a lot of work around privacy with connecting people. If someone is calling into our 2-1-1 line and they choose not to give their actual name, we give them the option to give us an alias. And if they use that alias every time, then they don't have to give us their demographic information multiple times. And that's really helpful because it saves time for that person, it makes people feel more comfortable, and don't feel like gosh, I keep having to answer these same questions every time I call. It also gives us the ability to do that piece that we were talking about with the longitudinal record, which is to say, hmm, it looks like we've given you this resource to this food bank that is closest to where you're coming from. But it doesn't sound like you've made it there. It doesn't sound like that's been a good fit for you. What was getting in the way? How can I make sure I give you a resource that might be more useful for you?

The other thing that we have in the state of Washington that's Washington wide is called the EDIE, Emergency Department Information Exchange. What that is a small system that says this is someone who is coming to the emergency department. Maybe we see them three or four times in a week, or maybe we see them multiple times in a month. Here is their Act Team or Pact Team resources. Or it might be helpful if you offer these resources or here is the best way to connect with this person because they may have difficulty if you come in asking these questions, but it may be better if you come in with these resources instead. So, it's a way for the emergency department systems to share information so we can best connect with people and give them the most helpful support and also avoid the things that might be triggers or things that don't work particularly well for that person.

And again, we work hard to make sure we're providing the right amount of security and support so that we aren't getting too much information. And so that we can try to avoid stigma wherever possible.

The next thing that I want to show you instead of tell you about is network adequacy. So, on our slide here, you'll see for the Washington Recovery Help Line, we're able to map out by zip codes, by type of resource. We can map out by area.

And you can see everywhere there's a green dot, there's a resource in whatever the search criteria was that I entered in. So, I could enter in. I just want to know what all the resources are for substance abuse disorder resources in the zip code. Or I could go down and select other things and make it more specific. But the big thing that we can do as a system now is we can say gosh, it looks like there are a couple of highly populated areas that have no resources. So, that's information we can actually share back with the state of Washington or with local municipalities to say if you have a grant or U.S.-specific dollars that come available, it looks like it would serve this particular community really well, because they seem to have a resource desert here. So, this is around substance use disorder resources. And you'll see the next one is looking at the social determinants of health. We are also the King County 2-1-1 at Crisis Connections. We have a listing of over 6,000 resources for the King County area with food, housing, rent assistance, legal assistance. We can map this out.

We also share data with the public health department to provide a map of where those resources are. And again, where those resources aren't, to our community, so we can make the determination around where is the best place for us to add additional resources. And, if we have a resource that's being underused, we can also begin to understand is there a population we need to proactively outreach to so that we can make sure that we can get connected.

These are just some of the ways that our team is really working to try to help get people connected so that we can avoid things like 9-1-1 calls or emergency department visits. One of the other key things that we've done is we've actually formed key partnerships with other communities who maybe are even doing a little bit more than what we're doing. And so I'd love to introduce you to Karis Grounds who is one of our friends and partners from San Diego 2-1-1, and we're learning a lot about their community and information exchange and actually looking to build one in King County. Karis?

>> KARIS GROUNDS: Thank you, Allie. And I appreciate the opportunity to be here virtually with all of you. So, I thought I'd start with kind of giving a little background into who we are and it's perfect that I'm going right after Allie, because we are also a 2-1-1, but located in San Diego. And then the Community Information Exchange, I think that Allie was alluding to, is a really great kind of expansion in opportunity to kind of look at a lot of the needs that we're seeing and address them in a more collective way.

So, I think everyone knows and since Allie went before me, it's a little easier to explain this. But essentially a 2-1-1 in general is essentially a three-digit dialing code that's available 24/7 that's a free access to the community health and social service and disaster resources.

And so, of course, they're nationwide.

And then locally we operate our own. And sometimes they're connected with the United Ways, and sometimes they're their own 501(c)(3). A little bit about our San Diego model. This is a little bit about how we cover our area, and also how we've expanded from kind of general I&R we call it, information and referral. We slowly started expanding into more tailored or navigation-like services.

So, again, as Allie was explaining, this is kind of calls that are coming in 24/7. We do have of course calls coming in for behavioral health mental health needs, which we've actually seen increase in light of COVID, those types of calls coming in as people are kind of grappling with what's going on. But we've created more comprehensive, kind of wrap-around services internally with staff that can actually do some more care coordination and support those with mental health crises or we have like a direct line through Optum if you are suicidal or if you have more immediate needs. But 2-1-1 is leveraged for those more mild situations or for those who are looking to navigate what resources are available, or maybe they're concerned about their child or those kinds of things. We have tailored staff that are called health navigators who do that work. That's our core 2-1-1 information and we have navigators and have moved into this more comprehensive care coordination model within our agency, telephonically.

As Allie was explaining, as we were starting to see these navigators make these connections to other resources and specifically those with mental and behavioral health needs, we know that's not the only need, although that's a huge underlying issue that often creates other social needs like food insecurity and homelessness and other social needs. How do we kind of merge those concepts together. And so of course, we have navigators who were kind of doing that and collaboratively working across these different systems of care and silos of data and collaborating with a federally qualified health center or community clinic and also coordinating with a health plan and also coordinating potentially with a food bank or peer support system through NAMI or one of those resources. And instead of having separate communication or a different communication with this individual through e-mail, how do we allow for consent and actually create a systems-change model, which allows for information to be shared across all of these different systems of care. And allow it to be more of a person-centered model than like a system-centered model. So, a lot of times we've heard that around like patient-centered care, where okay, you're putting the patient first. But a lot of times that's in your own organization. I'm putting the patient in my care facility and working with the various departments versus thinking about it more from person-centered. This individual, what do they need? How do we support them with services around them and create the resources and collaboration across those organizations to really support the individual?

And so, we're really moving towards a systems change model, as Allie stated.

King County is looking at doing this and a lot of other communities across the nation are kind of trying to look at this model as a way to share information across health and social services. And a lot of times those with behavioral health or mental health needs are the primary individuals that could benefit from this type of model.

So, just to share a little bit about what we've looked at, we have some of the core elements of the Community Information Exchange include a network of partners that are individuals that have signed legal agreements to essentially share this information across healthcare providers and social service providers. So, you sign a business associate agreement and participation agreement to be in this network. And 2-1-1 is a steward of this network. And all of these organizations, of which we have about 90 organizations, which are in the community information exchange and sharing information across this system, and working collaboratively to govern it and steward it from a community perspective. As Allie stated, each individual opts into this model. So we have about 150,000 people who have opted in to have their information shared across these different systems. That's really our network. And our network is really trying to leverage that community voice to change the way that we are working collaboratively together. The second element of what we've seen is the shared language, and something that we do in our system is the shared social determinant of health risk rating scale. Or we call a comprehensive social assessment continuum that looks at individuals from a crisis to thriving state.

And in this image, if you can see it, I know we're sending out the slides, but essentially we've looked at those individuals with certain health conditions and their associated social determinants of health needs. Cancer, cardiovascular disease, diabetes, and anxiety and depression. And you can look on that right-hand box. But you can see the associations vary based on the health conditions, which was very interesting. Anxiety, depression, medical, financial concerns were a need that callers were calling in about that stated this was their health condition and also needed some sort of resource that aligned with that.

We also see an association with homelessness, utility payments, and food insecurity. So, what's pretty interesting about this, and as Allie was alluding to, a lot of people, there are these other stressors that can add to that complexity of what their situation is. And being able to really, by leveraging models you can start to pull apart what those social and health needs are, those kind of cooccurring social and health needs and then how do we address them in a holistic, better way, so that individuals that are experiencing these types of crises are getting access to those basic needs that are often not thought about.

And so really, for community supports for individuals with severe mental illness, there's a couple of programs locally in San Diego that have kind of tried to address or bridge this. And actually Allie was talking about this a little bit. But we have how do we leverage our 2-1-1 in a more comprehensive way like 9-1-1. So, we actually looked at in articles a few years ago we started, we published an article in JEMS, which is the Journal of Emergency Medical Services. And we created an app in their iPads when they're going out to respond to a 9-1-1 call, there's the opportunity for them to do a social ealert. They call it a RAP, a resource access program, within their iPad.

And they can actually hit a button and it allows for the individual to consent. And if they're experiencing a non-emergency crisis, and it's a non-emergency need. Let's say for example a person is having behavioral health or a mental health crises. Sorry, let's not say crises. Maybe it's a more mild reaction. Or it's a homeless individual who may have some signs of mental illness or behavioral health issues, being able for the medics if they don't need to transport them or they do need to transport them, but we could have a navigator follow up with them. There's the opportunity on the spot with these medics to make a social referral to the 2-1-1 navigators, as I was mentioning before, these wrap-around coordinators, to help them get connected to these services. This is a model that we've had for a few years. And initially a lot of the needs that were popping up were behavioral mental health concerns or senior care support. And sometimes those were one in the same, senior and behavioral mental health, but some were not. So, that was an initial kind of pilot. We've since expanded to some other regions within San Diego. We have published an article that anyone is welcome to look online to find to learn a little bit more about how we roll that model out. That is only a local model. It's not a national model. But I know other communities have looked into replicating this. We do have some initiatives locally with some new funding to be able to do this in a more comprehensive way. But this was kind of the beginning of addressing some of those support needs that were on-the-spot identified from medics in the field.

Another program locally in San Diego that we've looked to do this, and I think this is from the state of California and oftentimes the Medicaid waiver impacted us, the 1115. But our whole person care models is a comprehensive community care kind of model. And behavioral health helps you look at acuity measures and of course behavioral mental health is an acuity measure that we are looking at and know that's a huge need within our population. So, being able to do more comprehensive care coordination, that includes housing and case management services, and isn't just treating for just the behavioral health need is some of the ways that this is leveraged. Again, these models are all integrated into our community information exchange. So, the EMS transport data actually populates into that CIE record for individuals who are consented into the CIE. And you can collaborate with those medics via the community information exchange, similar with whole-person wellness. You're able to make direct referrals to organizations within the CIE that provide those whole-person care health programs. So, you can actually directly refer to those organizations and they will respond saying yes, they qualify, they're eligible, they've been enrolled, we've connected with them. So that information is all shared within there, too.

So, I did mention this a little bit, but again, really that network of providers, that shared language, the bidirectional referral, closed loops that I was just talking about with whole-person wellness that allows for organizations to directly refer with all the patient information as well as social needs within that record directly to organizations and communicate back and forth.

We used a shared technology model so organizations can log in to the community information exchange. But of course we find that data integration is the most important component that people in EHRs are not going to log into a different system. So, our big push is moving around data integration. Can we do bidirectional data sharing from our shared information system to one another? As long as we have a shared language, then we can really communicate to one another through existing infrastructures and technologies.

And then lastly, really the goal is a longitudinal client record that we're using a unified community care plan and there's cross-sector collaboration that really individuals are addressed by their holistic needs and this shared record allows for us to address some of the inequities and the information we can start collecting data as a full system to be able to see what the true needs are. We're able to really work in a more comprehensive way that supports the individual and doesn't silo them from accessing those services. And really helps to create a community of care.

And so, that's really the end-all goal of what the community information exchange is trying to do. And of course, you can learn more at CII San Diego. Here is my information if anyone has any more questions or follow ups. But I'm done.

Thank you.

>> TOPHER JEROME: Thank you. And thank you, Allie, for asking me to join you on this adventure. My name is Topher Jerome. I'm the director of Lived Experience for Jaspr Health in Seattle. We're a small tech start-up. And I'm going to talk specifically around suicide.

And how the use of digital technology and combined with peer support of people's lived experience can really make an impact and specifically our project right now is in the emergency department. But we're looking at expanding to other crisis settings, which could be anywhere from primary care, community mental health agencies, to crisis lines, et cetera.

Anyway, as you all know, I'm sure, that suicide is an increasing epidemic. The numbers are staggering and are increasing especially with the COVID situation right now. There's some best practices around suicide prevention, which are safety planning, lethal means counseling assessment, crisis stabilization, psychoeducation skills training, and really one of my favorite parts is the insight and wisdom from people with lived experience, and caring contacts, which are brief personal contacts that happen after the person has left the emergency department or the crisis setting.

So, in looking at the benefits of digital technology, you know, it really helps deliver evidence-based practice care anywhere and the ideas don't drift like people. If you wake up on the wrong side of the bed, are you really going to deliver the same services the way you did before? It can be programs. Compassionate, kind clinician delivers lots of different kinds of peer support and recovery, which is what I'm going to focus on in a minute. We hear over and over again with the suicide survivor interviews that people are sometimes more willing to be honest when entering information into a computer than when they are talking to a person. And especially younger people right now.

And then use of artificial intelligence. And internet delivery. I'm going to skip ahead, just in the interest of time.

So, there's a study at Boston University done by Brian Jack who created an avatar which helped with discharge planning. They had a situation where they had one in five patients being readmitted within 30 days. So, they created this avatar who worked through this process and it really helped. Their hospital readmits rates were cut in half. Patients loved it. They saved lots of money. Could Nurse Louise help people in crisis settings in the midst of the suicide crisis?

And so, I'm going to skip through some of this. So, with funding through the National Institute of Mental Health, we have a grant to develop this tablet-based application to help people who are suicidal while they're in the emergency department.

And our small team, Linda and Kelly, are the owners of the company. And they got the grant. And Jane Pearson from the National Institute of Mental Health Suicide Research Consortium said well, you got to include people with lived experience. They ended up reaching out to me and we did a focus group, brainstorming about this app. The whole idea here is then all of a sudden it's sort of opened this idea that oh my gosh, we have to have people with lived experience. Not only as just a little plug part of this, but as a major component.

And so absolutely everything we do is the best of suicide science combined with lived experience. It's skipping ahead.

So, with this funding with collaboration from a lot of major health systems around the country, tons of science leaders in the suicide field, as well as people with lived experience, we created this app. And I want to show you a demo, especially get to the lived experience piece. So, I'm ready to share my screen. And I'm going to share. Whoops. Over here.

Already. Sorry, it logged out while the presentation was going on. I just have to log back in. So, the app. This is formatted because it was meant for a tablet. But it's given to a person in a crisis setting. Right now in the emergency department, but this can really be adapted for telemedicine, as I mentioned in different settings. It has four components, a shared experience piece. Videos from people who have lived experience with suicide. As we go through, we're building this connection. We're now introducing this into currently seven hospital systems.

>> Pardon the interruption. I'm so sorry. I don't believe we are actually viewing the app right now. It looks as if we're just viewing your desktop background.

>> TOPHER JEROME: Uh-oh! I'm so sorry. That's embarrassing. (Chuckling) Okay. Hold on. Okay, do you see the app now?

>> We are not seeing the app.

>> TOPHER JEROME: Oh, brother. Well ...Let me try. Do you still see my screen? That's weird.

>> We are seeing your screen.

>> TOPHER JEROME: I'm going to stop the share here and try again. This is the exciting part. How about now?

>> Still the same result. Are you able to switch back to your other desktop?

>> TOPHER JEROME: That's so bizarre. Okay. Well, I guess I will stop the share and just talk about it, unfortunately. Technical difficulties. They're always so fun.

Anyway, so, we've created this app. And it has a whole section about people's lived experience. Huge variety of topics. Wide variety of people.

And they're broken up into two-four minute video clips from people sharing their stories to how has their relationship to suicide changed since their suicidal crisis. What do they need to go home? What kind of resources have helped them? And offering lots of how they used specific skills to get through challenging moments. So, that's the lived experience component. And then we have a few that we call the comfort and skills section, which are things to help just reduce distress in the moment, as well as other skills taught by both people with lived experience, as well as clinicians teaching things like mindfulness and a lot of CBT-related skills. Comprehensive behavior management of suicidalty. It helps create a crisis plan and all of this information is available to them if they happen to have a smartphone or access to a web browser after they leave the emergency department so they can review and return to all of this information. It also has a crisis, imminent crisis or distress survival guide, which will open up things from their crisis safety plan to help them walk through imminent crisis.

It's one of the things, you know, when I was talking to Allie is the idea that how could this modified for use like with crisis lines. Could it be offered in that setting? Right now we're looking at telemedicine options to see right now we're working with Mayo Clinic. And they're using it for groups so they can view all the content remotely because all their groups are remote right now. And show content that we've delivered and use as talking points for their group. You see where I'm going? I've gotten so thrown off by the app not working, my apologies. So, the app, one of the other things that I didn't mention is all of the data including the Lethal Means Counseling and the plan is pulled into a comprehensive tool, which can help providers make determination about dispositions. This is the app. I've done the bulk of the bedside research with the app, and part of the network from the clinical trials right now. I love this quote. It's crazy that an app makes me feel like I have another person there to guide me through. It's one of the best experiences that I've had in the hospital. Over and over and over again it's the videos. It's the people with lived experience. Even though they're not live, we're finding it's a very effective way to deliver messages of hope to people who are suffering or who are in a crisis. And anyway, it's an incredibly exciting project. I'm super excited about the possibilities. I reflect back to my own experiences of being locked up in an emergency department for endless hours, not having anything to do, where things are just getting worse, and I have no idea what's going to happen. What's going on? So this idea that we can offer support in that particular setting and open the door to all different kinds of possibilities. This platform can also be modified for other clinical conditions, right? Depression around cardiac care. (Phone ringing) Sorry, my phone is ringing.

And so anyway, I'm going to wrap up here. Our initial outcomes from the clinical trials is we're seeing a significant decrease in distress and agitation, a significant increase in learning to cope effectively with current and future suicidal thoughts, increased feelings of overall satisfaction within the ED experience, and 100% have recommended Jaspr for other ED patients.

There's all different ways we can think about adapting it. And as we move forward, I'd love to hear people's thoughts. Please contact us about your ideas. So, please feel free to contact me directly or you can contact info@. The com is cut off here on the slide. So thank you.

>> Thank you, Topher. I want to thank today's presenters, Allie and Karis, as well. It was such a great presentation. Right before we launch into Q&A, Topher, would you be open to trying to share the app on your laptop like you did in the dry run, and I can go through a couple of the Q&A questions while you get that set up? And we can try to see if that works?

>> TOPHER JEROME: Okay.

I'm not on my laptop.

>> Okay. I will go through a couple Q&A while Topher gets everything set up and then Topher you can just ping me, you know, in the presenter chat or by just saying something out loud and we will try to turn this into sharing your screen. But let's get started with one of the questions. So, for those of you who still have questions, feel free to enter them in the Q&A box.

One question that we received asked, and I think this is directed towards Karis. How are criminal incarceration and reentry systems integrated?

>> KARIS GROUNDS: Great. Yeah. Great question. So, we have integrated jail alerts into our community information exchange. So, we have through kind of like who is in jail. It integrates in datasets from those individuals who have consented in. We have arrest information in that CIU, which is meant to help individuals who are trying to provide more comprehensive services or have a better understanding of that case management can leverage that information to maybe identify a better care plan or a different case management option based on that information. We are trying to work with some of the reentry programs and we've been in conversations with them to help as people are transitioning out of jail and getting reentered into the system, having kind of those case managers or parole officers essentially be able to leverage the CIE to help make referrals. We don't necessarily want them to have access to that on an ongoing basis. But being able to reconnect them in if the individual is okay with that, as they're leaving, being able to get them set up with housing or food or transportation or other resources through the community information exchange. We have been in conversations about that, knowing that we want them to have specific access to that information, not necessarily ongoing access to that information, but kind of that transition time to be able to connect people into those resources as they're reentering into society.

>> Thank you, Karis. Another question that we (echo) Sorry, there was a little bit of an echo there. Another question that we received related to 2-1-1, asking our community has started using HMIS, which seems like a more focused linking up of resources. This seems like a broader system, where an individual can call in. How expensive is a 2-1-1 system to get?

>> KARIS GROUNDS: I'll answer that in two parts. We have an HMIS system in San Diego. It's integrated into our community information exchange. It's an important component and piece of the puzzle. But people aren't always homeless. We want to think about that continuum of people moving up toward thriving. Maybe it's housing shelter now, but we want to think about rapid rehousing or leverages Section 8, or maybe home repair, if they're a senior in their home. So thinking about housing stability, rather than just a homeless situation. So thinking about it from a comprehensive lens, and knowing that behavioral health is a component to be able to access those resources based on their situation.

And then for the second component around that, around a 2-1-1 being needed. It's not necessary. It is a great resource. I think it's lovely and everyone needs it. But a lot of 2-1-1 aren't the right community information exchange. It could be a backbone information. The information doesn't only flow in from 2-1-1. Any one of those 90 network partners can consent individuals in and share the information. It doesn't require 2-1-1 to enter all the information. It requires a network and a system of care that's leveraging the shared governance and the shared consent form and the shared agreements to be able to do that. So, 2-1-1 is an added resource and we've gotten great value and been able to expand it greatly because of our 2-1-1s. But don't think that that limits you to be able to do that. And think that you've worked through United Way Worldwide and your government to be able to advocate for the need for a 2-1-1 within your community. Unless Allie you know more than I do about how to get a 2-1-1 within your area.

>> ALLIE FRANKLIN: I could add on. Everything you're saying is correct, Karis. But the piece I would add on is as we are looking to learn from San Diego and to implement a community information exchange in King County and also looking at doing something statewide in Washington, what we're looking at is public-private partnerships. And as far as the cost to the community, a lot of it depends on what we already have operating. What we're trying not to do in our area is to start something brand new without any awareness or leveraging anything that's already been done. We're trying to pull together partners who are already doing things like a 2-1-1. Like we have an organization called Within Reach that's doing wonderful things for young families and things for vets. So, we're trying to leverage the dollars that have already been spent to build some of these community information resource networks and pull them together to say how do we build using what we already have so that we don't have to spend dollars recreating the wheel.

And so, the cost when you look at it, would be the cost of what is that? Computer system and then, you know, do you have someone who can be a convener to pull the governance structure together. The cost is highly variable depending on both what is already happening in your community and what the scope and kind of readiness is. So, it's hard to answer that question, but I'm happy to have anybody reach out to contact me. Or I'm sure Karis actually, the San Diego 2-1-1 group actually has an incredible tool kit on their website that talks about what does it take to set up a community information exchange. And I would recommend anyone who is thinking about it go and download that tool kit. It's free. It's amazing. It's literally like this recipe book for how to do this. I will tell you I've downloaded it. It's kind of my Bible for how to do a CIE in our community.

>> Thank you Karis and Allie. That was very helpful. Before we go onto the other Q&A questions that we've received, I think Topher is going to give another go at trying to demo the app for you all.

>> TOPHER JEROME: All right. Let me share my screen. Can you all see the screen that says Welcome to Jaspr?

>> Yes!

>> Yes.

>> TOPHER JEROME: Okay, awesome! Yay! All right. So, this is the app. It's formatted a little odd here because it's meant for a tablet. But as I mentioned, we have the shared story section, comfort and skills, and the takeaway kit. Looking at people's lived experience, we have over 70 videos. They're 2-4 minute clips on a variety of topics. You know, coping with shame, my ER experience, going home, what do I do to stay well. My story, my wish for you are particularly powerful. I'm going to play like a minute of one of the videos. Just to give you a taste of what it's like. And I found all the people's lived experience, as well as doing all the video recording interviews and editing. So this is kind of my baby. So here we go.

>> My life before the emergency department was pretend. I pretended to be okay, I pretended to be happy. I just tried to make everyone feel comfortable and I was breaking down inside. And, you know, when something traumatic happened, I could no longer pretend. I had to break the mask. And that led me to a suicide attempt. Once I was in the emergency department, I did make some decisions. I was really tired of living the lie, pretending that things were good when they weren't, really struggling with depression, and just thought of self-harm constantly, and stuffing everything down. Once I was in the emergency department, all of those feelings towards myself of hatred and disgust, you know, they kind of marinated and were really big.

And once I left, I decided I need to find out what is it, what are these lies I'm telling myself? Why am I saying I'm not a good person? Why do I believe that I don't belong here? What is going onto make me think that this person in front of me isn't worth it? And I wanted to interrupt those thoughts because there's a reason I survived. And I decided to figure out what that reason was.

>> TOPHER JEROME: So, there is the sample. I am also in here. It's pretty powerful. The comfort and skills section has things like paced breathing like you would see on your watch, which it's very simple. Breathe in, breathe out. Puppies is hugely popular to watch somebody in the emergency department who is in a crisis situation go to puppies and watch them laugh. Mindfulness skills. Skills taught by people with lived experience. There's hours and hours of content in here. We're working on building out a section for loved ones, helping them care for their person who has experienced a suicidal crisis. And again, you can see this. You can potentially do all different kinds of content and put it in the framework.

The takeaway kit, this is the suicide interview. It's led by a chat bot. It leads them through the interview, helps build their safety plan. And then they can set up their at-home account. This had already been completed in the sample patient. But it's like a text exchange. Goes back and forth. And then there some places where they can do ordering and move things around. Here, I'm not going to do this right now. It's been completed. And then move onto the takeaway kit, where they have the whole plan available to them that they've created. It favorites anything that they've wanted to choose from both comfort and skills and the shared stories section. And yeah. That's a very high-level quick peek at what we've done. So, now we can go back to Q&A. But thank you for giving me the opportunity to bounce back to this and show you all.

>> Thank you so much, Topher. That was great.

I'm glad we were able to do the live demo. Very powerful stuff there and a great resource. Transitioning back to the Q&A. If you have any questions specific about the Jaspr app, feel free to put them in the Q&A box. I'll get to those very quickly.

The last question where we left off prior to the live demo. Somebody was asking it was their understanding that the literature does not support safety planning as an evidence-based practice. Has this changed?

And I think that's for whoever feels comfortable addressing it.

Topher?

>> TOPHER JEROME: I'm sorry. I got wrapped up in looking at some questions. What was the question?

>> The question was my understanding is the literature does not support safety planning as an evidence-based practice. Has this changed?

>> TOPHER JEROME: You know, we'd have to go to our scientists, the Ph.D. masterminds behind some of this to answer that. It was my understanding that safety planning was indeed helpful. You know. I don't have a definitive answer farce I know.

>> I can bring this. There's a difference between contracting for safety and safety planning. As part of the National Suicide Prevention Hotline group of call centers, we do a lot of safety planning. The idea of having someone create a safety contract is no longer considered to be an evidence-based practice, as far as I understand. I can't speak for all of literature. But we do know that working together with a person to identify what are their resources, what are their supports, kind of what are their mitigating factors for them is something that can help folks. We do that regularly on the National Suicide Prevention Hotline.

And part of our crisis line work is to help people begin to identify what things help them feel less distressed and help them find a path to safety for themselves.

Wearing my clinician hat, that's my clinical answer. Topher, I don't know if you wanted to add anything to that.

>> TOPHER JEROME: No, I appreciate that. And thanks for the distinction between the two. It's helpful.

>> I think I was on mute when I was talking. The next question that we received was directed toward Karis. How do you confirm or follow up that people have attended or visited a referral source?

>> KARIS GROUNDS: So, the way we have the community information exchange set up is it will alert. So we have a relationship with the organization and the agency let's us know how the timeline in which they're going to respond to that referral. And then through the CIE or their existing orders or information like that, we're able to set up those referrals and the agency is able to respond if they accept the referral and then that they're enrolled. And then we also have some data integration that allows for them to get updates, potentially like for example the food bank is integrated with our systems. We can see. It will push it right into their food bank system and allow for those individuals to go and pick up the food when they need to. And as they access food, the dates, that actually populates into our system so we can see when they last went to the food bank and how many times they've gone. Similar infrastructures are built with FQs. We can see when the person we refer to get a medical home and their primary care and when their last appointment was. That information through integration was able to provide those updates into the system so people can kind of know the status of that referral and what the situation is.

>> Thank you. Along the same lines, has an EMS integrated system ever been discussed or considered to extend to police officers to use when responding to calls?

>> Yes, we have explored that. I definitely think that's something that we've looked into with a few of the cities. But I think it's become more relevant with the racial injustice issues going on, or always been around, but heightened right now. I think there's a lot of opportunities to reform the way we're thinking about how police respond.

And that could be leveraged that model, if it's a 2-1-1 or whatever. It could be leveraged to help support individuals in a more comprehensive way. Because I think you're alluding to the fact that a lot of times police are called for like a homeless individual in a mall or shopping area or something like that. And the police don't necessarily, shouldn't maybe need to respond in some situations. Or maybe need to get a more kind of like a wrap-around service kind of provider to help them. So, how do we look at more models like that to support individuals is definitely where a couple police departments, but it's not a nationwide effort. But it could be a model that I think would be a great way to address some of those issues within our community.

>> Thank you, Karis. A couple questions related to the Jaspr app that we received. So, these are going to be directed to Topher. Is the app accessible nationwide? Or do you have to have it referred by a medical professional?

>> TOPHER JEROME: Great question. Right now it's only accessible in just a few emergency departments. And once the person has been in the emergency department and used the app, then they would have access to the at-home app. I see a few people have downloaded the app. And unfortunately we can't give you access right now. We're just in pilot phase now with some of these health partners. Ultimately, our goal is to get it into emergency departments around the country. Yeah.

>> Great. And are there any plans of making the app in languages other than English?

>> TOPHER JEROME: That's probably one of the number-one questions we get. Yes, absolutely. Right now with the funding we have from the National Institute of Mental Health, it does not cover translation into other languages. But as we secure more funding moving forward, it's definitely in our plans.

>> And how have you been able to give access to Jaspr to individuals who can't afford smartphones and internet?

>> TOPHER JEROME: Right. They would have access in the emergency department and then I think that if they don't have their own access to smartphone or internet, you know, they could access it at a friend's house, a library. There's other places where they could utilize the internet.

>> And I think one other question about the app is does the app include videos of LGBTQ individuals?

>> TOPHER JEROME: It's got me! (Chuckling) Yes. There's a couple of us in there.

>> Thank you, Topher. All right.

>> TOPHER JEROME: I see somebody is asking about the website. Sorry. It's . And Jaspr has no "e" in it. So .

>> Thank you. And did you mention it? But for those who have access to Jaspr at home, is it free?

>> TOPHER JEROME: It would be free to them. It would be, we have it licensed through the health system that they would have initial access to. And then that, if we expand it to different ways of delivering it, then there would be, they have to address it method by method. But it would always be free to the individual.

>> Thank you for the clarification. I think that's it in terms of questions. Anybody else have any other questions they want to submit before we wrap up, please feel free to enter it in the Q&A pod. Otherwise, I think that will be it. And I will hand this back over to Kelle.

>> KELLE MASTEN: Again, we would like to take this time to thank our presenters for a wonderful, informative webinar today. Thank you so much! And we'd like to especially thank SAMHSA for allowing us to share this information with you.

We are going to switch the screen now to a short evaluation. Uh-oh. If it works. And we'll ask that you take a few moments to complete that for us. Bailey, my screen just went white. If you don't mind doing that, that would be great.

>> We are on the evaluation.

>> KELLE MASTEN: Okay, great. Thank you. If everyone would take a few moments to fill that out for us, we would greatly appreciate it. Again, thank you for joining us and enjoy the rest of your afternoon.

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