In our second episode, The Collaborative Care Model to Optimize Outcomes in Mental Health care, our invited panelists Dr. Maga Jackson-Triche, Madhuri Jha and Kristin Kroeger continue their conversation from the online webinar on the collaborative care model to discuss the reasons for the emergence of the model and its increasing adoption in primary care settings, the economic impact of mental health inequities on health care costs, the true meaning of equity and more.

Transcript

Gabriel Escontrias: [00:00:09] Welcome to the American Psychiatric Association podcast series Looking Beyond Unplugged. My name is Gabriel Escontrias, and I am the managing director of the Division of Diversity and Health Equity at the American Psychiatric Association. In this episode, our invited panelists Dr. Maja Jackson-Triche, Madhuri Jha and Kristen Kroeger continue their conversation from the online webinar on the collaborative care model. We further discuss the reasons for the emergence of the model and its increasing adoption and primary care settings. In addition, the economic impact of mental health inequities on health care costs, the true meaning of equity and much more. I hope you enjoy our podcast.

Maga Jackson-Triche: [00:00:56] Okay. I'm Maga Jackson-Triche, I'm at UCSF. I'm an a ssistant vice chancellor and also a UCSF health executive advisor for Diversity, Equity, Inclusion and Belonging. And I'm a professor of psychiatry.

Madhuri Jha: [00:01:12] My name is Madhuri Jha. My pronouns are she hers. I'm the vice President of Science, Equity and Integration at ETR. I'm also a psychotherapist in private practice and a professor of mental health policy.

Kristin Kroeger: [00:01:24] Hi, Kristin Kroeger. I'm the chief of policy programs and Partnerships at the American Psychiatric Association.

Gabriel Escontrias: [00:01:31] I think the first time when I heard about collaborative care model, I took more of a simplistic approach to it, probably coming from student affairs, and that side the house. What we're doing here in medicine is really what we've done with students now for the past few decades. But just taking the holistic approach and what is their needs and how do we meet those needs and meet them where they're at in the community. So it's interesting to me to now see it, replicate it in a different way. Obviously, in medicine, it makes perfect sense to me.

Kristin Kroeger: [00:01:59] Maybe, maybe just talking about why it hasn't gotten here. I mean, I think maybe the breakdown of the silos of medicine in general and the stigma associated with it and how we've this is really helped to reduce stigma. Right. I mean, and don't forgetting that there is stigma going into a community mental health center or a psychiatrist office, it's still there. Right.

Maga Jackson-Triche: [00:02:18] I think the other thing that's happened, because I've been in medicine a long time, is that we now have really effective treatments for depression because, you know, when I first started out in medicine and as a psychiatry resident, we really we didn't have the evidence for the medications, even for how effective they were. And so the science, I think, has helped move it into primary care. So a lot of primary care doctors didn't want to touch psychiatric meds with a ten foot pole. They would treat anxiety, but they didn't want to treat depression or anything else. And anxiety was treated with medications that we wouldn't treat anxiety with anymore. So I think the science has helped people in the evidence, has helped people feel more comfortable treating it. And so primary care providers, I think, are more willing and they finally acknowledge that so many of the people who are seeing them have treatable medical conditions. There's evidence. And so I think in practice, evidence follows. Doctors follow the evidence and they say, ok, I know this, these medications, medications are really good medications. I can manage this. They may not know what to do with treatment resistant cases, but but most cases are not fortunately, are not treatment resistant. So I think that's one of the things that's helped it. And then bringing so I was in one of the early models of bringing psychiatrists. So one of the first jobs I did out of residency was. Being a psychiatrist in a primary care clinic, and that was in a VA. It was a model that was called the PACE model at UCLA when I was there. And so that's sort of initiated that. And we had primary care docs who had said, Well, I don't know if this is going to work, but it actually did. They're saying, wow, we really we can work well together. We can actually get treatment for these patients. They can help us figure out how to talk to patients like that. And then Jurgen, of course, has really, you know, really expanded the work that he's done at University of Washington. There. So I think it's the evidence that's helped bring it sort of out of the shadows. Sorry, that's kind of a long winded answer.

Madhuri Jha: [00:04:32] I think that's accurate. I think also it's really important to think about like investment in infrastructure. One of the slides I did not include in there is the NIH is investment in mental health research. And compared to overall public health research, it's dramatic. It's about 2% of their budget goes to mental health research versus 98% to other conditions. So we're not from a federal perspective, we're not even investing. We went from four tripled in size with this administration, and now we're rallying to try and increase all these Mental Health Services Act related grants that are going out to clinics and university hospital centers for the first time. But there's this huge fear, again, if the administration changes, all of that money will go away. And what does that mean? So we have to think about these things, too. I'll reference a report that the Moore High School of Medicine, which I was lucky to be a part of and lead, released last year on the economic burden of mental health inequities, again led by Daniel Dawes and myself. And that was important to highlight. How many dollars could we save if we made our mental health care system more equitable and it was $187 billion and it didn't include 5.8 million folks who actually have the highest rate of mental health diagnosis in the country, which is homeless people, people who are in the house, rather, the incarcerated people living in nursing homes. Youth were not included in that number either. And active military. Right. And so all of those categories we know are have a higher risk propensity for mental health diagnosis. And $287 Billion is actually a very conservative estimate. So when you take that number to Congress, all of a sudden there are a lot more eyes open to understand why the investment in the infrastructure for something like collaborative care model in the long run actually saves us money, right? Because then when we think about access points for communities who don't actually access psychiatric care, like I said earlier, a primary care physician is an immediate access point. Someone's likely going to get their Phq nine administered by their PCP from a community that's been marginalized more readily than actively seeking out a psychiatrist. If you embed the mental health service into that facility, it's an immediate access point for them. So I highlight the dollar part of it because it's usually the sticky part that we don't like to talk about that much, but it's really important that we look at how much we invest in it and hopefully in 50 years when we say, okay, this actually saved hospital centers and communities and cities money. In the long run, we can say that we also had that money reinvested into other types of interventions that made these models more holistic. And I think I would add going back to going to stigma, right. I mean, many of us have been doing this for years. I've been doing mental health policy for over 30 years and walking into a congressional office 30 years ago, sharing with them your policy objectives. Thank you very much. Taking the folder and go away. You you you go. 25 years later, they're like, oh, and they're asking questions. Probably 15 years ago, just ten years ago, I have a congressional staffer telling me that their sister, their brother, their their college roommate had ADHD or depression and more openness or I have it more openness to talking about it to now policymakers talking about the struggles of substance use or mental health with their kids as well. So I think it's changing. And I think that's why clearly we're seeing the more of the investment, Right. We're seeing more of the dollars. We're seeing them understand the need for access and look for innovative ways like the collaborative care model now and thinking of how they can improve this and put more dollars towards the systems and the structures that make sense and show positive patient outcomes.

Maga Jackson-Triche: [00:08:28] Right, Right.

Gabriel Escontrias: [00:08:32] Hi. One of the questions I was hoping I would have to ask and Mr. already kind of touched on it was on how to. Well, let me read the question. If optimal health is a human right, how should we position the collaborative care model to ensure its success politically?

Madhuri Jha: [00:08:51] We have to say that it's it's more than just a medical intervention. That's that's where my head is going to actually it's a community intervention. It's a family intervention. It is a anti racist intervention. Right. There's so many different facets. We have to see that in terms of when we look at social and political determinants that indicate barriers as to why we don't have enough folks who are seeking out care like this or we don't have enough hospital systems that invest in the collaborative care model, we if we move it beyond medicine, you actually start to think about what you're doing for that community. Again, going back to the morality example, if there's really only one hospital center in a 50 mile radius, it all has to live in that place, right? And so what we're doing is creating a home. You know, the health home is another intervention that's sort of related that's considered kind of difficult because of the funding that's needed to create a holistic wraparound set of services for people to be able to access that. But in the long run, you're keeping people out of an emergency room. You know, the emergency room catchment for psychiatric diagnosis is for me very irresponsible and at levels that are way too high that emergency physician attendings can actually manage. And the challenge that we have too, is they don't have the time to sit and do the assessment and diagnostic process necessary to actually look at what's going on with someone. And so the misdiagnosis, the number of folks who get who leave an emergency room with a schizoaffective spectrum disorder diagnosis, that's not actually their diagnosis, and then it lives on their medical record and then they're just not on a treatment paradigm that's appropriate for them. Right. So if we see it more than just a medical intervention and we actually see this as a holistic wellness, social service, public health, I don't know how other many qualifiers you want to put in there. That's a game changer, right? Because you're creating an actual safe space for someone to go and get all of their needs met at once. And the only thing I might challenge is maybe in 50 years we start to see the collaborative care model go beyond just an integration of behavioral health care and physical health care. Right? Maybe it also includes touchpoints with other sectors that interface with someone's life. And that's the beauty of a model like this is the flexibility that it has to incorporate different types of disciplines in it, which is the hope that I would have that people continue to invest in.

Maga Jackson-Triche: [00:11:18] When I think of equity, I think of it in fairly simple terms, but of course it's really something really hard to do, but it's everyone getting right care at the right time in the right place. Yeah, everyone being able to do that. And so that means we have a big task ahead of us. But I think it sort of helps me to try to frame it in that way. And then that's the way where we can start looking at our systems and looking at the resources that we have there. But a lot of people, you know, they don't really know what equity looks like. And so we need to sort of socialize kinds of, you know, the way we talk about it. And so I tend to do that and people say, Oh yeah, that sounds great. It sounds Pollyanna. It's actually not Pollyanna. It's because there are some sectors in our community who do get that, you know, So but we need to have that for everyone.

Madhuri Jha: [00:12:18] Can I just also add one more thing to is like we have to also stop thinking about just the comfort of the provider and think about the comfort of the patient. Right? So some of my most loyal cases were ones when I was a treating clinician on Friday nights that would show up at 9 p.m.. I had a mom and her kiddo that came Friday night at 9:00. Was it comfortable for me to be working on Friday night and what I have rather been doing other things socially? Absolutely. But they were my most loyal and most, and that was the only time that mom could bring her child to our clinic for psychotherapy services. Right. So it broadened the traditional safety that we have of like a 9 to 5 hours open, you know, brick and mortar facing place that someone has to go to and say, we're making this a comfortable location for you and we're actually going out of our comfort zone to meet you as well. And that's huge, right? Because that eliminates these power dynamics, too, that I think a lot of folks, especially in child welfare families, that get penalized for not being able to make the psychotherapy requirement for or the psychiatry requirement for their ACS or CPS case, it's often because those parents can't make those appointments. You know, they're scheduled at times where they're working multiple jobs or they have other types of things that they have to do. And so we have to become more flexible with how we're providing the care as well. Again, where the collaborative care model creates the platform for that, There are so many innovations that we can do to make sure that we meet people's needs.

Maga Jackson-Triche: [00:13:47] Well, I think telehealth is really helping with that. I know that we. Noticed at UCSF that a lot of the no show rates went down for people because it was just they could access it on their cell phone care. So I think technology will help a lot with that and making sure people have access to technology to be able to do that.

Gabriel Escontrias: [00:14:07] Well, I think some of your comments may have led us to this question that I'll ask. And it's our last official question before we do, final thoughts and a little wrap up. But why is it important to teach residents and fellows about the collaborative care model and to both medical and psychiatry training programs?

Kristin Kroeger: [00:14:26] I'll just sum it up there. Our future. They they need to understand what collaborative care model is, what their primary roles are in collaborative care, and not only the advocacy piece, but clearly the medical piece, the kit, the treatment piece, the whole care team, and ensuring that they understand patient centered care models specifically.

Maga Jackson-Triche: [00:14:48] Yeah. Yeah. They actually they have to know that. And I'm, you know, I still work a bit with medical students and I'm really excited about the generation of people who are coming through and they're thinking a lot about equity, anti racism and things like that. And this is a viable model to at least start the building blocks of, of equity. And so and that's, you know, that's the future. They're the future. They will help us disseminate that. So I think it's vitally important to do that.

Gabriel Escontrias: [00:15:20] And then in closing.

Madhuri Jha: [00:15:21] Gabrielle can let me add one more thing to that, of course. Not just medical students, primary care, psychiatry. It's our non medical colleagues, our care managers, the social workers, the psychologist, and even some of our bachelor level care care managers as well. I mean, I think everybody needs to understand this model, the evidence behind it, and how they can contribute to it in one way or the other.

Maga Jackson-Triche: [00:15:47] And I've actually go a step further and say other practitioners and other disciplines need to know about the collaborative care model because, you know, I'm a consultation liaison psychiatrist and I've had surgeons who called me about patients who will only see them. You know, they've come in for a particular surgery, but they know they're depressed and they're not sure what to do. So I think it's a model that has wide can have wide application.

Madhuri Jha: [00:16:10] As a non MD, you know, mental health professional. I will say some of my most rich moments have been when I've been invited to go talk about my role on a care team to a group of medical students and the perspective that I provide and what what lens I bring to that. Social workers are rooted in social justice being the foundation actually of our practice. And that's something that some medical students don't actually have an exposure to. It broadens their horizons and they connect with other professors. I think it's really important to introduce that early on. You know, it's been a privilege to here to meet here and meet some fellows who've enjoyed being supervised by nurse practitioners or enjoyed being supervised actually by some hospitals, have a social work supervisor who kind of co leads with an attending and what that means for them to see that power dynamic actually play out and be equity in action. So, you know, I think the more we the more we demonstrate the value of each role and the differences and the beauty that the differences come together to actually play, we actually break down a power silo that I think is a barrier to care and a barrier to also access to care, because we have to think about who has access to medical school. So again, to in order to diversify our population, I have friends who are social workers who are now MDs because they saw themselves in a medical program, you know, and that was beautiful for them to be able to go through that.

Gabriel Escontrias: [00:17:35] So in closing, as you know, you all did an amazing job really bringing your expertise and your unique lens, but also your intersecting lenses. But from each of you, what would be one key takeaway you like them to have after tonight's conversation?

Maga Jackson-Triche: [00:17:52] Uh, for me, I'd like them to want to do it. Don't really want to get activated and engaged and to become an advocate in their area for it to be an advocate.

Madhuri Jha: [00:18:06] I would have to quote my. I'm lucky to call him a mentor. Dr. David Satcher saying there is no health without mental health. You know, he was the first black surgeon general, first person to release a surgeon general's report on mental health in only 1999, which was not that long ago. So when we think about what we want to see in 50 years, that was about 25 years ago, was the first surgeon general to make that there's no health without mental health if your brain doesn't work. This is how Patrick Kennedy says it to you. If your brain doesn't work, your body doesn't work right. So we have to see them as integrated. So that's my takeaway, and I'll always drive that home. It's super i mportant to highlight that those those foundations were set for us not too long ago.

Kristin Kroeger: [00:18:47] So I think policy takes time. It's a marathon, not a sprint and incremental change. We need to we need to really celebrate those successes and encourage others to be involved. So that's where I would go.