ED Talk: Kimberly Hoagwood

Okay, I think we’re going to go ahead
and get started so that we have time at the end for some questions, so it’s
a true honor to introduce our speaker today, Dr. Kimberly Hoagwood.
I’ll tell you, it’s really daunting if not impossible to sum up her scholarly work
and impact she’s had on children’s mental health services. Just to give you
an idea of what I was dealing with her CV is 41 pages long. So this is only
going to be a cliff notes, of the greatest hits. But Dr. Hoagwood received her
PhD in School Psychology from University of Maryland, and so for the
students of school psychology here, her career is a testament to the
varied, interesting and important work that can be done with a school psychology degree. She first worked as a staff psychologist
in schools and residential centers and then shifted to a career in research
first as a program director, for the Texas Education Agency here in Austin,
then at the National Institute for Mental Health, where she eventually
worked as the Associate Director for Child and Adolescent Research.
Later, she was appointed Director of Youth Services and
Evaluation Research for the Office of Mental Health of the
state of New York and in New York, she’s also the Director of the
Advance Center of Mental Health Implementation Science in States,
for Children, Adolescents and Families. And is the Vice Chair for research in the
Department of Child and Adolescent Psychiatry at NYU.
She has co authored or authored an astonishing 211
peer reviewed articles and I’m not including the ones that are
under review, or in press, as well as lots of chapters in books, and I can tell you
I’ve read, probably not all 211, but a lot of them. They are among my most
cited and quoted references. So some of my favorite Kimberly Hoagwood quotes
include “70-80% of children who receive mental health services
receive them in school.” Raise your hand if you have ever quoted
that? I think a lot of us have. Another good one. “The ethical and
scientific challenge for our field inheres in the sluggish movement
of effective practices for children and families into the systems that are tasked
to serve them.” I like that one a lot. And maybe my favorite is, “It’s
difficult and perhaps foolhardy to try to improve what you do not
understand.” I think I’ve quoted that like ten times this year. So please
join me in welcoming Dr. Hoagwood for her talk today, entitled
“Implementation Research in State Systems for Children with
Behavior Health Needs- Getting in Front of the Power Curve.” (applause)>>Thank you. Thank you so much,
it’s just wonderful to be here. To be able to talk with you about
some of the things that I think are really, really exciting, going on
in the field of children’s mental health. Especially in these times which are
pretty troubling and uncertain and chaotic to say the least. But I think
we’ve got some real glimmers of hope so, I’m going to talk with you about
the work that is happening both within our center in New York
which is an NIMH-funded services research center, in
collaboration with the New York State office of Mental Health. So I’m going
to talk a little bit about that but also give you a sense of what is
happening nationally. Because I think it’s pretty great. And I’m very happy to
be in Austin and thank you Sara Kate and others for getting me here. Doesn’t
take much to get me here, I will say that. (laughs) I’m always glad to come
to Austin. So some of what I want to talk about is
as I mentioned, is big picture stuff. Increase in prevalence of children’s
mental disorders and their use of services, the evidence base which I’m
just going to briefly allude to because there is so much there but the bottom
line is that there is a lot of evidence on which to base programs, policies and
implementation. The uncertainty of the current healthcare context, has
some major implications for how we’re trying to think about, not just children’s
services, but also what should be the role of mental health in all of this. And
I think these are good questions for us to be asking, right now.
Pragmatism, what are some practical ways in which we can be helping to
improve children, children’s outcomes and family outcomes within the
current healthcare context and then moving beyond that, so how do we
get in front of the power curve? I have a real interest in aviation, and I
am a solo pilot right now, continuing to work on it and power curve, I’ll give you
a little definition of that actually the power curve in aviation is where
you have to remain in order to stay ahead of the plane. It’s in order to avoid
stalls and the bad consequences of having a stall and so when you’re behind the
power curve, that means you’re behind where the air plane is and you’re
in trouble. Getting in front of that means that you’re thinking ahead
of the plane and you’re able to keep it– to use the aerodynamics in order to
keep it moving. And I think as a field in mental health, we have been behind
the power curve. In many ways. We’re reactive, we’re trying to clean
up problems after they have already gotten fairly entrenched and if we
want to get in front of the power curve which I think we can do, actually
I know we can do it and I think now is actually a very propitious
time for us to be focusing on that it means to be thinking differently
about what we we’re doing with respect to implementation
of programs, policies and practices and so I’m going to
talk a bit about that. And I’m going to move fairly quickly
because I would really love to have questions and interaction. So the
National Context Healthcare Quality and Accountability, just some of the
key things that have happened over the past ten years or so, the
Mental Health Parity and Addiction Equity Act, has been part of the
essential benefits package, that is now under fire, it may or may not
remain but it has been an important piece of legislation for helping to
ensure that people with mental health or addiction problems are
able to get the coverage at the same level as they would for other
chronic illnesses. The ACA, we all have heard about that. One of the
things to keep in mind is that there has been recently legislation
passed called the MACRA Legislation which is Medicaid Authorization and
it includes the CHIP authorization for children with mental health
problems, and that was given support in a bi-partisan way. And
so it is a very important piece of legislation because it effects
the way in which providers are held accountable for the services
that they give, it includes an emphasis on both evidence based practices and
quality measures and it includes an emphasis on pay performance
and value based purchasing so I’m going to talk about that with
respect to kids mental health because I think it is important because it is
bi-partisan but it’s also important because it is very compatible with
the work that as a field we’ve been doing, to create an evidence
based compendium of practices but it effects the way in which
things are paid for. So major impact on states and some of
the impact on states has been the fiscal issues, which I don’t
need to be-labor because we’re all aware of them, I know that
Texas has suffered from that, so has New York, so has every
other state. But the way in which states are responding is that more
and more of the services are being shifted to managed care
and that includes Medicaid services being shifted to managed care.
And it means both a reduction in many of the community based
services, reduction in funds but it also means an interest
in work force development and that work force development–
whoops–let me go back here. The work force development
means an interest in alternative ways of increasing the work force
in the number of states, ours included in New York, we are looking at
parent partners as a part of the professional work force
have a certification program for parent partners and
there is a national certification as well, that still exists and that
is being revitalized but the point is that states and healthcare
industry are looking for ways to augment the work force because
there just aren’t enough people to provide the services that are
needed and this includes certification and credentialing
for people that we might not have thought about in the past
as people who can very much be engaged, eager, very trusted partners
in the work we are doing. I’m just going to give you a little
bit of data about the impairments four-fold increase since 1960 in
neuro-developmental conditions and mental health, so it’s been
a pretty much a constant increase. The psychiatric ED visits
as a percentage of all visits, those are going up as well, so ED is not
the place that you want to send kids and families to for services
but as the community services shrink, this is likely to continue
to be the case. Okay, I’ve got one of these, and the mental
health need and use of services… so both mental health needs as well as use of services have been
on the increase, and we’ll see if that’s, if the use of services is
going to continue to be on the increase under some of the new
healthcare scenarios that we’re seeing, but certainly there has
been an increase in both of those so how states are responding,
I mentioned the work force shortages, moving to Medicaid-managed care,
departments of health increasingly are dictating the service packages,
this is happening in New York so we’re working more and more
with Department of Health, which by and large, in our state does not have
much of an understanding of pediatrics. Or of children’s mental
health, so there is a lot of really basic education that we’re finding that
we’re needing to do and other states are having the same kinds
of things that they need to do. At the same time, we’re seeing
much more of an interest in what should states and health
plans and payers be measuring so if they are providing services
how do they know that they are getting their money’s worth, how
do they know that the services are actually making a difference and what
are those measures look like. And I’m going to spend some
time talking about the development of quality measures. So this slide you’ve probably
seen before. When you think about 17-year odyssey, from the time
of having a finding to the time of actually getting into practice,
that’s basically the life span of a child. They’ve pretty much grown
up in that amount of time. And that is typically how long it takes
from the time that you’ve got some kind of research finding
until you’re about to put it into practice. If you’re able
to put it in practice which is not a given by any
means. And so when we think about
the speed at which changes are happening, the speed at which services are being delivered, this
is just untenable. We can’t have this kind of a gap, we need things
that are going to be brief, pragmatic, feasible, effective, as well as cost
effective. And that is where a lot of the work is happening right
now. So, as I mentioned we have the good fortune to have been
funded by NIMH for the past five years and before that, we
had a developing center, so we’ve been funded for about ten years,
to work directly with New York State Office of Mental Health, in order
to implement effective practices in the children’s mental health system.
In collaboration with New York State Office of Mental Health, we have a
community TA center, CTAC, which has given us access to all three hundred
and forty or so child serving clinics that are part of agencies that are
providing services to kids and families. So it’s an incredible laboratory,
for trying to understand better how to both provide technical
assistance, help improve the practices and study them at the same time.
So, we’ve been very fortunate. Our community TAC center is
focused both on implementing particular evidence based practices
and I’ll talk a little bit about the evidence based treatment dissemination
center, where we are implementing the MAP project. Managing Adapting
Practices of Bruce Chorpita, and others and we’re also focused a lot, not
surprisingly on business practices, so for somebody who is a school
psychologist by training and my partner in this is Mary McKay
who is a social worker by training to move into the business practice
realm has been a real education. And so what we did was we brought
in people who had been the heads the CEOs of some of the major agencies
to help us think about it. We worked with the National Council of
Behavioral Health to help us think about business practices
and how to provide technical assistance to these clinics and
agencies that are drowning in regulation, many of them are
going under. Many of them are merging and so there has been
humongous changes that are happening in the service network.
But what we have done is we are providing now business improvement
practice through webinars, through learning collaboratives, through
individual consultation and we find that that has got to be
done at the same time as we’re doing the clinical
practices and if we can’t marry those two, then we’re
just spitting in the wind, because none of the clinics are going
to listen to us. They need to know how to stay viable and stay
alive, and so this includes open access and centralized
scheduling and concurrent documentation, volume and
productivity et cetera. This, just… just as an example
of how beleaguered the clinics are, the yellow is the target
amount of funds that they should be getting, per
billable hours, so that’s what they need to stay alive
and the green is what they are actually bringing in so
all but one of the clinics in this sample are hemorrhaging.
They are just plain dying. They don’t know how to bill for the
services they are delivering, they don’t know how to capture
the costs appropriately, they don’t know how to engage the families,
so these kinds of data point out to us, where we need to be
directing our efforts when it comes to not just teaching them
how to stay in business but also what kinds of clinical practices
to be able to deliver so that you can get the outcomes. So what we have been focusing
on, is the evidence based treatment dissemination center and the MAP
roll out. And I’ll just show you a few slides of what we have been trying
to do, with this. This started…was funded by OMH in 2006 so we have
been going now 11 years, and it started actually, it started before that, it
started in 2002, right after September 11th, that was where
OMH got first involved in saying, “We need to do something
to deal with trauma. Trauma after September 11th. So how can
you help us develop a model that is going to be able to train clinicians,
front line clinicians, be able to address the trauma for the
children and families.” So that was where we first got started
in trying to develop a model and it’s evolved over time. We’re now doing
the MAP training and have been doing that for a few years now, since 2013.
And it involves a model of training that I’ll just spend a couple of minutes
on. Because it is an adaptation of what Bruce and his colleagues have
done. He’s been a wonderful colleague in saying, “here’s the model,
do what you need to, to make it work in New York,” and so that’s exactly
what we have been doing. So, we have a combination of
in-person training, midpoint check-up, consultation webinars, now for four months
and certification materials. And what we found was, and these are the clinician
certification that’s basically very similar to what Bruce and his
colleagues have out in Los Angeles but the reason that we had to, well before
I go to that, current training over 50, and we’ve had 203 and our passing rate
right now is 95% but the reason we had to do that, is because our
initial training model was not working. MAP version 1, versus
MAP version 2, just shows you some of the differences. We initially had
two days of in person training, three days of webinar training,
no midpoint, we had nine months of calls, we had 14 consultations, we had
about eight to ten clinicians per group and what we were finding is that we
were losing most of the clinicians. They were dropping out of our
training. They weren’t completing the certification requirements. So we
were losing people at a great rate. And we didn’t want to do that. There
was too much of an investment so we adapted our training model
to make it longer when it came to the in person training, more face to
face time, less webinar training time, having a midpoint meeting, but the
main thing that we did, was that we gave them very
individualized IT support. So the thing that was– when we went back
to ask them, “Why the heck are you dropping out, why is this not working
for you?” It had to do with the measurement feedback system, the
dashboard, which was very simple in our minds, it was an Excel spreadsheet
which they could upload any number of outcome measures, but it was
daunting for these clinicians they were not able to do
just the simple use of the dashboard, so we individualized
that kind of IT support, and what we found, was major
changes. So our dropouts went from half, 51% to 12%…12.6%.
Our submitted portfolios went from 35% to 100%, and the passing
portfolios also went up. And we think that it was the combination
of more of that individualized face-to-face time and in particular
the very specific individualized support around the use of the IT
system, the measurement feedback system. So we’re continuing to do that work in the
state, and continuing to tweak the model but right now, it’s something that has
been very well received and we continue to have clinicians signing up. But it’s
an example to me of the way in which you can be both
pragmatic, as well as true to the clinical model and be able to help
engage clinicians despite the burdens and the problems that many of them
are facing. We’re moving now in addition to the EBT training, we’re moving
into quality measures development. And I’m going to spend a little bit of time
talking about that because I think it’s both, it’s really important stuff, but it
can sound like, you know, jargon and it can sound like a lot of
labor for nothing, almost. But to my way of thinking, if we can get our
thinking around quality measures right, we will have our finger on the drivers
for change. And so to me, the quality measures work is some of the most
important work that as a field in children’s mental health, we should
be paying particular attention to. The reason the quality measures are
important is because they are used for accountability standards
and for monitoring the effect of programs more and more, so they are part of
the pay for performance model where the payer in this case, the state,
in my case it’s states, but it could be any payer, is targeting very specific
measures. The health plans are incentivized then, to be able to show
change in those measures, some of these health plans have clinically
integrated network contracts and the physicians or the providers
are also incentivized to be able to perform according to these metrics.
So they are the main drivers for how money is going to flow
and what will be considered a positive outcome. Now the truth
of the matter is, that right now there are less than a dozen quality
measures in pediatric behavioral health for kids, that have been tested, that have
been vetted, that are part of the HEDAS system, and that’s in contrast
to about six hundred and fifty adult measures. Now just think about
that. There has been so much effort to develop the adult measures, very little
effort to develop or test these child measures. And yet, if we are
not doing that as a field, somebody else is going to develop ’em. And
somebody else is going to say, you’re being held accountable for this,
that or the other. So we ought to be getting behind this in a big way.
And getting it right. So I’m going to talk a little bit more about what
that might look like. So what are quality measures?
Well they quantify structures, processes, outcomes and perceptions
of kids and families. They are associated with healthcare, and
they follow the Institute of Medicine which is now called the
National Academies of Science, Engineering and Medicine. Principles,
of– they are effective, safe, efficient, patient centered, equitable and timely.
Those are the IOM principles that all healthcare is trying to abide by.
I’ll talk a little bit about how they are developed. We’ve had the
opportunity to work with the National Committee on Quality
Assurance, NCQA, to develop some measures around adolescent
depression. We’ve also developed some on access to care, which I probably
won’t have time to go into, but can talk about that later. And then
there are a whole slough of other areas that are now being targeted for
development. Now the development of these is… takes a while. The reason
that they are important is because our healthcare in this country is
very costly and it’s not leading to the outcomes that we all hope
would be the outcomes. But we focus on adolescent depression
as a start because, as you all know, this is prevalent, it’s disabling, it
has long term consequences for kids and families, and most kids are
not receiving appropriate care. So it seemed like this would be a good
place to begin in developing the quality measures. The process of that involved a very thorough review of
the literature, of course. So looking at what’s the evidence based on
screening. What’s the evidence base on assessment? What’s the evidence
base on different types of treatment models for adolescent depression?
And if you were to conceptualize an ideal system, and that’s part of
the sort of mental model you engage in. If you were to develop an
ideal system, what would it look like? Well, you’d have children screened.
Adolescents screened. Then there’d be an assessment. You’d want to assess
for suicide. Then there might be a brief support of counseling. There’d be
symptom reassessment. Remission. And then you’d go into different
kinds of treatment options. So this is the, this is the map
of what it should look like. And this was published in
pediatrics a couple years ago. So on the basis of that, the quality
measures were developed. And they have the measure
concept, which is those nine, I think it was, boxes. And
then there’s a denominator. So where are you going to
be getting the data from? In this case, we were using health
records. Some places are using Medicaid data. There are different ways
to do it. And then what would the numerator look like? So it’s being very,
very specific and precise about all of these… All of these different concepts. And then when we’ve done some testing of
this with NCQA in three different sites, one was an FQHC, Federally Qualified
Health Center. Another was a large group practice. Another was sort
of medium sized group practice. We can see that the performance
rate simply for the… the monitoring measure was all
over the place. From 30% to 70% to 73%, and the overall
performance rate was 64%. So this helps the health plan decide
where do they need to be targeting their efforts in order to get that,
that performance rate up. So it’s a way of being very, very
specific, using data that’s out there to be able to say, “These
are our targets for change.” In this case, we want to change screening
or we want to change monitoring. This is where we’re at, this
is where we need to go. So, when we think about quality
measures in the sort of new healthcare front and where the
trends are, the interest right now is in developing collaborative care
models that are going to be able to contain costs and improve outcomes,
and use quality measures as a way to drive some of this change. So
collaborative care has been developed in the adult area for many,
many years. There has been some work in the child area based on
Wagner’s chronic care model, which has the types of elements
that you would always want to have in any kind of consultation.
So access to consultation, clinical service, communication, coordination.
It’s, in a way, it’s like a wraparound model as well. There has been a, a very well done review
research synthesis of collaborative care models in
pediatrics for both mental health and for substance use. And
basically, the main contributors to that have been David Colclough,
Joan Asarnow, Laura Richardson. So there have been three real models
of collaborative care where the effect sizes have been strong. The changes
between the group that was getting the collaborative care model and
those who were getting usual care were robust. There are other ways of
integrating, and you can see in substance use, the effect sizes are actually much
less. So they have a longer way to go, substance abuse. Treatments in
collaborative care approaches. But the point simply is that
despite the fact there is a stronger evidence base on the
adult side, there’s plenty to talk about when it comes to kids’
collaborative care models. Now these have been limited
in their implementation thus far because they’re still pretty
cumbersome. But that is changing. There is work being done to
make them more feasible and to make them easier
to implement. So, collaborative care models are
one of the ways in which accountable care organizations are thinking
about delivering care. And accountable care organizations
are large organizations, organizations of healthcare entities
that are designed to be able to provide services for a particular
population and control the costs and be able to improve the quality.
From the federal standpoint, the Center for Medicaid and
Medicare Services, CMS, has had guidelines for what
adult ACO’s might look like. They have never had any guidelines
for pediatric accountable care organizations. But these
are going to happen. They’re now actually requesting
input on what those guidelines might entail. So, in terms of where
healthcare is moving in the future, ACO’s are likely to be one of the
ways in which we’re going to see healthcare coordinated,
paid for, accounted for. And for kids, we need to be thinking about
it differently than we do for adults. As usual. But there is– there are
groups that are now synthesizing the evidence on what exists in
order to be able to develop some models and be able
to test them further. One such model is Pediatric Health
Home With Stepped Behavioral Health Services and Integrated
Community Based Supports, and it’s shown a reduction in costs
in a five to seven year time frame. So, there’s some good news
that’s out there right now. Sarah, Kate, and I were just
talking about Ken Dodge and some of of his work, and
this comes from Ken’s analysis of many data sets about measuring
children’s developmental outcomes within pedia– could be
within pediatric ACO’s. But he was focusing on measuring
these outcomes, and what does it take to be able to delay initiation
of substance use, for example. So this is based on a lot of data
that shows that if you target some particular areas of concern, child
factors, sociocultural contexts, early parenting problems, et cetera,
then you are able to delay initiation. Now why is this important? These
are the kind of data that are being looked at to develop plans for what
should be measured in order to be able to move services upstream. So
getting in front of the power curve. To be able to offset the costly
trajectories that happen when services do not reach kids
and families in a timely way. So this is an example of a model
that helps to direct the way in which people are thinking about what
should be in these pediatric ACO’s. So some of the types of measures
for tracking children’s development that could predict later savings:
children’s cognitive affect of behavioral development and the
key risk and protective factors. So these would be some specific
tools that are sensitive to intervention effects so you can see a
reduction in risk over a short time. In other words, your healthcare provider
could be, in a new scenario, held responsible for tracking these
kinds of changes with the argument being, if you can show
improvements in cognitive affective behavioral changes, then
you as a healthcare entity are helping to save costs downstream.
That’s, that’s the logic of it. Measures that track points along
individual’s development. So things like attachment, bonding, limitations
on adversity. So healthcare providers focusing on these. Focusing on
kindergarten readiness at age five. Grade level reading at age eight.
Social-psychological cognitive development through high school.
These are specific areas where people are looking for tools where
the idea is healthcare entities — providers, contractors, and states —
would be held accountable for making sure that they’re focusing
on kindergarten readiness. Now that’s not happening right now,
right? We know that’s not happening. But if that was an expectation, then
the argument is, we’d be able to prevent the longer
term societal costs, as well as individual costs
to kids and families. There are also discussions about
population level approaches. So having communities be
responsible for tracking these kinds of larger social issues.
We as a mental health field have not been thinking along these
lines, by and large, right? We’re thinking about individual change.
Individual effective practices. And that’s very important, and I’m
not dismissing that at all. But this is enabling us to think in a
broader way about where we could be putting our expertise
and our efforts to help support a focus on some of these early
intervention approaches, that for which data are quite
compelling. It can prevent later costs to society
and to individuals. Some of the potential tools that are
being discussed: a safe environment for every kid, parent screening
questionnaires, SDQ’s, etcetera. But these are some of the ones
that are being proposed to be used as part of the quality measures for
healthcare providers. An example of use: minimizing
prenatal maternal stress. Decreasing, decreases in some of
the PSQ scores or Adverse Childhood Experiences. Even one
ACE reduction — Adverse Childhood Experiences — can have major
effects on tobacco use, obesity, other healthcare, other
healthcare concerns. So the point, again, is to say as a
mental health field, can we be using the expertise, the knowledge,
the research base that exists, to help get more precise and refined in the
way in which we’re thinking about the types of outcomes that matter
and what our healthcare providers should be focusing on, and what
we as families and mental health practitioners can help support. Another example of improvement in social
and emotional kindergarten readiness, and that’s associated with a number
of healthcare expenses, long term. And so this is the case
that is now being built, and, to me, it’s a really
important development because it’s using knowledge that
has been around for a while to amass it in the service of
helping kids and families, doing it in a healthcare context that,
by and large, has been more reactive than proactive. And I think there’s
some real possibility for positive change here. So, getting in front of the power
curve, to me this means implementing both policies and
practices. If we continue to focus from an implementation side,
standpoint, just on implementing effective treatments or practices
in various systems, that’s all well and good. But we’re not
going to be able to make the strides that I think we can make
and we should be making. In order to do that, that
means we need to be thinking about mental health not
simply from an individual standpoint but from the idea of communities.
Collective, the collective efficacy of our communities, and can we
take the work that we have and build that into stronger community partnerships? Collective efficacy
came from Rob Sampson (inaudible) 10, 15, 20 years ago, I guess,
from the Chicago Project. I think it’s a very important construct
that can be resurrected to combine that with family strengthening
approaches in order to be able to make some of these
changes at a social level in our communities that are going to
help kids and families over the long haul. So, in conclusion, the anti-federalism and the devastating cutbacks
to the safety net are requiring us, I think, as a field,
to rethink what we mean by mental health, and where we
want to be putting our efforts. So are we going to be trying to say,
“Mental health is different. We’re separate. We need to protect
our separate system.” Or do we want to say, “We’re
part of a public health framework, and can we put
our expertise into play to help improve communities,
networks, neighborhoods, larger social groups where we
have not necessarily focused as much of our efforts as
we could.” So a public health approach means paying
attention to collective efficacy. I really do think that literature
is critically important and very valuable, especially if it’s
linked with family strengthening and parent partnerships. We know community social
contexts influence health outcomes. We know there is
a social gradient of education and income in this country
where the wealthier you are, the more educated you are,
the better the health outcomes for kids in families, and the
opposite holds. That has been clearly demonstrated.
So can we be focusing now on social policies and upstream
services to get ahead of that power curve, to get ahead
of the plane so we don’t crash and burn? And support
families and communities. Meaning, means supporting
policies that are going to level that social gradient.
And these include policies that we haven’t paid much attention
to. Earned income support. Housing. Employment. These are some of
the social policies, many of which are under siege right now.
But at the same time, there is an effort in being able
to say, “Can we develop a better healthcare system that
is going to be able to take care of everybody within it?”
And that includes kids and families, and that includes
kids in families where kids are still young and are developing.
So can we be thinking about our contribution within that
broader framework? I think we can. I think that’s where
mental health needs to be. I think that’s where we can make a
big difference. And I think now is a very, very, propitious
time for doing so. Despite what’s happening
federally, this is where the power of communities
and of families, to take the knowledge that we have and
to put it into action, can really make a difference.
There’s a wonderful book I’ve been reading. I highly
recommend it if you haven’t read it. Rebecca Solnit,
“Hope in the Dark.” And she’s updated it a bit
for our current times. But she traces — she’s a historian —
and she traces the history of collective movements over
time and the changes that have happened as a result
of small incremental changes that often we don’t even
see. We’re not even aware that they’re happening.
But they are. And how they lead to bigger
changes in the future. She says we write history with
our feet and with our presence and our collective voice and vision. So thank you once
again for having me. (audience clapping) And I think we have time
for questions, don’t we?>>We do. We have…>>…quite a bit of time. So
I have a microphone and if you have a question, I
will come to you with it. This is very exciting. I did my
internship where Dr. Hoagwood was back in the day, and we were both reminiscing about
Grand Rounds, if you had a question, the chair of child psychology would
come over to you with a microphone.>>Even if you didn’t have a question.
>>Even if you didn’t have a question, he thought you looked like you
maybe wanted to say something so this is my moment
to enact that. So don’t let me waste it.
Give me some questions. Yeah.>>This is so strange. I guess I’m curious with
the Affordable Care Act. What you thought was
the biggest change like positive outcome
that did come out of it, that we may be able to sustain even
with a change in healthcare policy.>>Yeah, that’s a really good question. Well I think that it was
primarily coverage for people that didn’t
have coverage. That was what ACA did was
provide the insurance coverage. So I think that the fact that so
many people who had been uninsured, including kids and families were insured, is a big change. The other– was a big change and continues to be important
and is still being fought for. The essential health benefit I think
is another one which provided the mental health coverage, and that one is up in the air
whether that’s going to remain or not. The macro legislation was kind
of an offshoot of ACA. That, as I mentioned before,
has the bipartisan support. And that is likely to continue,
and much of what I was talking about around quality measures, around
the focus on population health, and community measures,
and value based approaches , and developing drivers. That right now is intact and it
doesn’t look like that’s likely to change. So that’s where I’m thinking we
need to be putting a lot of our efforts. Quality measures, cost offsets, evidence based treatments and practices, fidelity, brief fidelity measures, I think those are all going to
continue to remain important because they tend to be something
that meets a lot of different needs. You know, if you’re tying to save
money, you can do that. If you’re tying to improve outcomes,
you’re going to do that. If you’re tying to be precise about
what kinds of outcomes, you can do that. So I think MACRA, I think the Medicaid
changes that are being, under review at CMS. I think a lot of community action too. Even if all of ACA were to go
away, which hopefully it won’t, but lets say it were, there is so much that can be done
and right now I’m seeing a lot of community efforts to develop their
own ways of measuring what’s happening at a local level. That’s all good stuff, you know,
there’s a lot of energy there. so I really think despite what’s
happening at the Federal level, there’s much that can be done at
both states and at local communities. I remain optimistic.>>Yeah. I think we want it for the
video, so I will rush to you.>>So I was wondering what your
thought are about sort of the additional skill sets that
trainees should develop, to be able to extend this field of
mental health to interact more so with the policy makers because it
strikes me that the perhaps the more traditional training for
mental health providers has less of a focus on that unique
skill set or separate skill set.>>Yeah, that’s a, that’s a very
very interesting question. There was a recent, I still want
to say Institute of Medicine but it’s really National Academy
of Sciences Forum. And National Academy of Sciences
is a independent entity that receives funding from different
agencies for different projects, so it basically is independent
of politics, which is a good thing, and very scientifically based. They had a recent forum
a few months back, on the credentialing and the
certification process for the workforce to be able to support
pediatric — they call it CAB, Cognitive Affective Behavioral health. So children’s cognitive affective
behavioral health. So you had pediatrics,
psychology, social work, psychiatry, parent partners,
and credentialing there, and everybody, all of these
disciplines sort of had their own credentials and expectations
about competencies and skills. But what was very
interesting is that what seemed to be
connecting all of them was a focus on collaboration. On the ability to
collaborate within a team. And I that isn’t something I think as
a field we have spent that much time on. We sort of take it for
granted we’re psychologists, we’re good people, we’re nice,
we’re inviting, so we’re going to be
able to collaborate. But there’s actually, you know to be
able to think about role definition, about the boundaries of what you’re doing and what
others are doing. On how to create a
collaborative team. I think if I were to select some
of those areas of competency building that’s exactly where I’d be because
that’s where health is going. That’s where, I think, mental
health should be.>>I’m wondering what you think the
role of schools is in this idea of expanding mental health into more
of a public health community setting, whether that’s more identification
or service delivery, or how that might fit into
this bigger picture.>>Yeah, excellent. Well, schools are the core
to any community. They are the core. When it comes to kids and kid’s job,
so to speak, being in school is the role of kids. I think that the fact that the Vital Signs Project of
The National Academy of Sciences, the accountable care organizations
that I was talking about, the CMS’s looking for guidelines
for pediatric ACO’s. that they are focusing on school
issues, kindergarten readiness, ability to read, cheating grade
level at various points. That is where, these are
going to be measures that are going to be used for tracking
the health of the population as a whole. Schools are vital to that. So I think as were thinking from
a mental health standpoint, how we can help support
what schools are doing, it’s going to be around some of
the traditional academic measures, which are likely to become benchmarks
for assessing the health of communities. So I think that there is a huge role
for schools. I don’t think it’s something, you know, as school psychologists
and I know all of you or most of you are familiar
with that way of thinking. It’s been largely around consultative
models within the school, supporting families, supporting
kid’s education. I think this opens up another
door for us, frankly. To be able to think about
quality measures, community and population
level measures, and making sure that the work
we’re doing to strengthen the schools is being used as a benchmark to
show the improvement for communities. So I think there’s a lot that
we can be doing. Actually now is the time to
be stepping out and saying we want to be part of
these discussions within the community
on population measures. Robert Wood Johnson has a big,
I think it’s 200 counties initiative. They also have another initiative
around collective supports for states and for
other large entities. And they are focusing on,
what should we be measuring? How do we know if
communities are thriving? What should be our measures? And more and more people
are saying, for kids, it’s got to include school. So we should be
thinking about these broader opportunities
to have an impact, and I think now is the time.>>So I like how you talked about
using business strategies to increase like compensation
for like non-billable hours and engaging the workforce. What ideas do you have, or
even if this is a good idea, about accessing the
private sector for some of these, like some
monetary support, instead of ever having
to rely so heavily on like federal or
state support in dollars? Like, for example, a lot of
large businesses in Austin. Have you ever thought about
going to some of these large software programming and
talking about “This is the community in which we live, this
has value for your company”?>>I think it’s a great idea, and there are some examples
of groups that are doing that in Columbus, Ohio, for example. Where they have a lot of
private businesses that have their headquarters there. Nationwide Children’s Hospital
has created a consortium with some of the businesses to
take responsibility for some of the neighborhoods
around the hospital, actually, and so it’s a consortium of both
private businesses, public sector, so Ohio and Ohio Medicaid is there. The hospital, as well as
community providers. We’ve been working with them
around training parent partners to be part of the mix. And so their, they all are working
together on a few specific goals. They want to increase the
employment in the neighborhood. They want to increase the
school readiness, as I was mentioning before. So I think there’s a huge role
for private industry as well. It means being real clear about what
is the goal, what are the boundaries, and a pooling of
resources so that no one is beholden to just
one funder or another. But I think there’s a real
opportunity, again, as an example of what can happen
at more local levels. And they’ve written up the,
Nationwide Children’s — There’s been some
work on that. Kelly Kelleher is the lead author
on that, I’m pretty sure.>>In our state, we
do have certification for family partners or
parent peer partners, and, but they are not yet
recognized in Medicaid in the state plan. And there is a current bill or two bills in our legislative session
to look at that. Any guidance or advice about how to
make that argument effectively in tight financial circumstances?>>Yeah, Yeah. We are sort of in the same
situation in New York, so it’s been, it’s going to be
part of our state plan the parent credentialing, and we think that it is going to be something
that is going to be billable, but we are not quite there yet. You know, I think that we and
a group called FREDLA, you may be aware of, is compiling all of the
data that they can on the ways to make the
strongest argument. We don’t have a whole lot of
good cost offset data right now, so I think a lot of it is likely to, could be strengthened if it’s linked to some of the
data I was presenting about what you can do with
families to strengthen them at an early age for kids,
and the long term offsets. So reducing ACEs. You know, I don’t think there have
been any studies I’m aware of of parent partners focusing on
working with ACE reduction, adverse childhood. But even if we made a somewhat
tangential argument or a little more tenuous. I think that you could make an
argument that that is what parent partners are doing often. That’s supporting families. That’s helping to reduce
the parent’s stress. Which is helping to reduce some
of those adverse events or at least help them navigate. So I think that’s one idea. The other is I think we can make an
argument for improved networking that parent partners do. And there’s some good data
from Mark Atkin’s group, about networks and when you
create those networks, how that helps to support families
and reduce costs. So I think we have
to do it a little bit, you know, be creative,
but I think we can. There’s data there from other sources.>>I was just wondering if you
had any thoughts out of the Cures Act that had
passed in December which had a lot of things,
but one of the things was pushing NIMH and SAMSA to be better aligned like they
supposedly used to be. But it, being able to break down,
you know, when you talk about it takes 17 years for it to
actually end up in practice, what do you think needs to
happen to actually fix that issue?>>Actually fix that. From
an NIMH standpoint or->>Well, I think that was one
of the goals with that was saying that SAMSA and NIMH
needed to better be partners again. I don’t know if they ever
really were great partners, but I think that was one of the parts.>>Yeah. They were stronger part–
they were administratively together.>>Together.
>>Yeah, and actually when I went to NIMH
they were just separating. It was right at that point. I, you know, I have a lot
to say about NIMH. (Laughter) NIMH’s priorities, I think, have not
aligned with where I think they could be making
the most impact. We’ve been tracking
the trends in dollars for children’s services research
and its just you know, taken a nose dive. I think there are a number of things. I think, one, is having some priorities
around research that’s policy relevant. I think that’s what’s needed. I think connection with SAMSA
in so far as you had… If SAMSA could create frankly, what,
we’ve been able to do in New York, which is, have the service support,
and then put the research on top of that, it creates that partnership. And so I think there are
opportunities for doing that. NIMH in the past has had things
they call rapid awards. So it’s a way to speed up the cycle. Something that’s policy relevant.
Somebody has got a great idea, there’s this opportunity,
but they don’t have the two, three, five, years to get the grant.
Can you do some rapid grant awards? So I think that’s something that can
be reinstated around some key areas. There’s a lot that can be done. I think with the new director,
there’s an opportunity there and I know they’re looking for
ideas around some of the, some key areas, so. That doesn’t necessarily
completely address it, but–>>No, I was just wondering
people’s thoughts on it. There’s an opportunity there.>>I think there is opportunity.
Yeah, I think there is. And I think SAMSA would need
to get more specific in what its priorities are. And I think NIMH needs to
get a little wider, frankly. So there would have to be a
real meeting in the middle. But it could be done.>>Something I always think about
when I talk about these topics is that the onus is on mental health
providers to make this happen. Like, even like from like
technical support, or something, like, I find
in my own research. Like, as a psychologist in
training, I’m providing a lot of technical
support, you know, and doing like those things
as well as the services as well as this, you know. So that’s like the social
workers, the psychologists. What about the medical providers, and like what changes have you
seen in the last like ten years in their approach to integrated care
and how can we make that better?>>Yeah there’s a
long way to go there. I think that the traditional
medical training has not been very helpful for the work that we’re
talking about right now frankly. But I think again the
models are changing because the incentives
are changing. So the slide I showed
where medical providers are incentivized to
follow certain practices. That is happening
more and more. The– there’s some
interesting data about solo medical providers,
how very few there are. That medical providers are now
being put into larger group practices. Those group practices in order
to stay alive from a financial standpoint, are going to need to have
pay for performance, and quality measures. Those quality measures are
going to require collaborative teams, which is what I was
talking about before. So sort of kicking and
screaming in some cases. I think the changes are
going to be happening, and there are, there’s a group,
a consortium of pediatric hospitals around the country. Several in Ohio, Pittsburgh, etc. I don’t know if Dell is a part of that
but boy sure would be cool if they could become part
of this consortium. Where they’re very
much looking at similar tracking of outcomes,
collaborative models, pay for performance approaches,
everything that I’ve been talking about. But within these pediatric hospitals
that are now being held responsible for what’s happening
in their communities as well. So I think things are changing
it’s just, it’s been a slow process, but I think when the
financial incentives change magically, that changes behavior too.>>We have time for one more,
come this side of the room, I’m so happy I was worried that I was
ignoring you by standing over here.>>This is a follow up to the
two previous questions really and I was so glad to hear
you ask that one, ’cause I, and not to put
you on the spot, you’ve done extensive research
on the policy end, the clinical practice end,
the family perspective so you’ve really looked
at all of it, and as someone who works for
The National Alliance in Mental Illness… your data supports what we’ve known,
as family members all along, which is collaborative care works. We need the integrative system but also
as a recovering mental health clinician, the rubber really does meet the road with
this group here in the room, with what they are going to
do when they actually get into the field. All of that said,
my question is, and that 17-year trajectory is
terrifying but it’s reality. So when you have a finding
to implementation 17 years, but then you got the
backtracking of training people, training new clinicians
to do what we knows works, what recommendations do
you have for those of us in the room, and our networks. What can we do now to
support the changes, because we are on the cusp
of so many different things, and some of the incentive is coming from
what’s being pulled out from under us, with what we know is
going to change, it’s just a matter of how is it
going to change. What’s your best
recommendation for us now to sure up the potential
good things that can happen and try to expedite
some of that?>>Yeah, well Terry
(laughing) that’s a–>>But what do we do now?
What can we do now? You’ve got people who
are about to go into this–>>Develop local coalitions, develop those local coalitions and
get people that are in a position to be able to make changes at a local level
agreeing on what do we want to change, how do we want to measure it,
how can we align, the people that
are paying for it. How do we make sure parents
are, their voice is heard. I had the opportunity to work in Sandy
Hook in Newton, Connecticut, a few years ago, and it was a few
years after the horrible shooting there, and part of what they were trying
to do was rebuild their community. And so there are some
blueprints, some maps. Neil Halfon has some,
Communities That Care have them. Dartmouth has some, of how do you
build those community coalitions to be able to be strong and solid. To be able to have the connections
among the providers and to be able to track what you
want to change, and to be able to have the police
and the social services, etc. So I think we need to be thinking
on more of a local level right now. Austin has done that for years
so I’m saying, you know, I think Austin is actually a really
amazing example of that. But I do think that that’s
what we need to do, and that’s where the training
of sort of the future practitioners can be made both relevant
and practical and rigorous too, ’cause we need the input on
what to measure, how to measure it, how to use data to make
those changes stick. And I think if we can
be thinking about the measures, thinking about the data,
and thinking about those collaborative connections,
then we can make a difference, even if it is just within
our neighborhood. But those things trickle out
as Rebecca Solmet said. They trickle, and they make a
bigger difference down the road. That’s my best advice at
the moment.>>Alright, well, that’s a great
note to end on, thank you again
and please join me in thanking Dr. Hoagwood for
coming to Austin. (clapping)

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