NWX-SAMHSA

Moderator: Jane Tobler
October 26, 2010
1:30 pm CT

Coordinator: Welcome, and thank you for standing by. At this time, all participants are in [AUDIO STARTS HERE:] listen-only mode until the question answer session. Today’s conference is being recorded. If you have any objections, you may disconnect at this time.

The PowerPoint presentation, PDF version, the audio recording of the teleconference, and written transcripts will be posted on SAMHSA 10 by 10 campaign Web site at http://www.10x10.samhsa.gov. Our presentation today will take place during the first hour and will be followed by a 30 minute question-and-answer session at which time you may press star 1 to ask a question. I would now like to turn the call over to Ms. Jane Tobler. Thank you, you may begin.

Jane Tobler: Hello and welcome to Tracking Measures – Wellness Measures to Increase Life Expectancy among People with Behavioral Health and Substance Use Disorders. Today’s teleconference is sponsored by the Substance Abuse and Mental Health Services Administration 10x10 Wellness campaign.

SAMHSA is the leading federal agency on mental health and substance abuse and is located in the U.S. Department of Health and Human Services. Through an interagency agreement, SAMHSA is privileged to partner on this effort with the U.S. Food and Drug Administration Office of Women’s Health. The views expressed in this teleconference do not necessarily represent the views, policies and positions of the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration and Food and Drug Administration or the U.S. Department of Health and Human Services.

As the operator mentioned, the teleconference is being recorded and the PowerPoint as well as a PDF version, a transcript and a recording of the teleconference will be posted to the SAMHSA 10x10 campaign Web site. At the end of the entire presentation, you will be allowed to ask questions of our speakers. We encourage you to try to keep your questions to one question a person and upon hearing your name you can say – say your name and then ask a question.

Today we are really excited to be joined by three people with extensive experience and knowledge about data use and surveillance tracking wellness measures. Our first presenter is Dr. Elsie Freeman. Dr. Freeman is the Medical Director for Integrated Care Projects for the Maine Department of Health and Human Services where she works on several work groups on integrated health care, evidence based practices and psychopharmacology quality improvement.

She is a – she is board certified in Pediatrics and completed training in both adult and child psychiatry. Today Dr. Freeman will talk to us about the role of surveillance in improving the health status of consumers of mental health care. Dr. Freeman?

Elsie Freeman: Hi, thank you. What I’m really going to do here is give you a little pep talk about collecting data. I – it would be really great if we could move people in the audience to start thinking about in the place where they are what kinds of things that are relevant to improving the health of our consumers of mental health care. What is it that we should be counting that would move action forward in the place where you are, whether that’s the consumer groups or whether that’s a mental health agency or whether it’s a state agency.

How do we use data to move this agenda forward to improve health? Now we start from a very important piece of data, which is in the early 2000s there were a number of reports about early deaths in people with serious mental illness being cared for in the publicly funded mental health system. These are the folks that are the major focus of SAMHSA’s activities. And Colton and Manderscheid published on the 25 year, the risk of 25 year premature mortality.

And so this actually begins to be a very important part about what you can do with data. It brings attention to an issue that people sort of weren’t noticing. And what it also showed out – showed was when you started matching death certificates to identifiers for people who had been in state mental hospitals you also discovered what the death certificate said they died from.

And I think people generally kind of assume that people with mental illness were dying from suicide or they were dying from injuries. But in fact it turns out mostly – 70% or more – are dying from the same things that are killing other Americans; heart disease, diabetes, strokes, respiratory diseases, lung diseases and worse of all preventable things like pneumonia and influenza.

So then, it – it turned out that it wasn’t what people thought it was and so that really begins to be the beginning. Certainly, in Maine of our focus, which has been on what about all these medical conditions and the things that put people at risk for developing these medical conditions?

We’re really big believers, at least here in where I sit, in the whole notion that data should drive policy. This is very much a belief in our larger health care system and we in the mental health system. And when I talk about the mental health system I am really talking about all of us whether we are providers, consumers, state people, federal people, we have really lagged far behind the health system in terms of collecting data, meaningful data and turning that into action.

So just want to go over, you know, why we need to collect data. First, the example of the 25 year premature mortality is right there. It – it brings attention to a particular issue. Learning that it’s caused mostly by natural causes - by people with heart disease, for example, is the biggest killer – lets us begin to think about focusing our interventions.

We can for example start thinking about how to provide better health care to people who’ve already developed these diseases and we can think about how do you prevent them from happening in the first place.

I think it also lets us say okay here’s our intervention, here’s what we’re doing, how are we doing, did it make a difference because we don’t actually have infinite resources to pursue every good idea. We have to see is what we’re trying to do making a difference.

We - next slide please. Actually, I’ve just jumped ahead several slides haven’t I? Next slide, next slide please. We really need partners and we really need the partners that are in the healthcare and public health systems. They are really the primary care system, the healthcare delivery system especially with health reform is fundamentally committed to the notion of addressing chronic disease, improving chronic disease care, workforce education The public health system has well-developed programs for reducing health risks, whether it is tobacco quit lines, diabetes education, nutrition education, working with communities to get more opportunities for exercise, there are a host of activities happening. And so we really need to link with these systems. I think those at the federal, the state and at the local level.

And very much have driven the kind of direction we’ve taken in any event in- in the kind of data we’re collecting. Because we want the attention of the healthcare systems, the larger healthcare system, we want the attention of the public health systems. They care deeply about the things that are killing our consumers.

And so we need to be talking their language so I think it makes a lot of sense to be using the data systems and the kind of data points that they use. The other reason if we’re using those systems is they’re already out there. We don’t have to collect a lot of this.

And the other reason is because we’ve mostly have been using in our state, I’ll talk about two systems the BRFSS and Medicaid. It provides you local data. It tells you what’s actually going on in your state, in your county. It can tell you what’s going on in the agency where you’re getting your care or giving care. And it turns out like politics, really making change is local. And if you don’t have local data it’s really kind of hard to know, to fire people up. It’s really kind of hard to get - give you what you want them to give you.

So I’m going to start with a couple of different kinds of language. A couple of kind of data systems. Again, encouraging people to learn the language that’s out there in the larger system and not invent our own private one. The behavioral risk factors surveillance system is in every state. It is federally sponsored by the CDC.

It mostly enhances on data about social determinants – social determinants, about things like smoking and chronic diseases like diabetes and heart disease and more recently it has been with SAMHSA’s support doing mental health modules. Unfortunately the mental health modules have been optional, they have not been run in every state so here’s an opportunity to work with your state to include mental health modules in the BRFSS because it’s going to give you really important data on mental health in the general population and that’s just a really important thing to be able to do.

What we found in Maine is right there on the slide. Mostly it’s been depression modules. We almost have been running it for five years and depression is clearly highly prevalent. It’s just as prevalent as diabetes and we have been moving it into actually our public health systems of care as another chronic condition to be paid attention to.

But the most important thing that has come out of our data and that has really made a difference in getting attention from our public health system is again we’re showing them how what we care about which is mental illness really matters to the things they care about which is health risk and chronic disease. And so we have been showing in across Maine that depression is associated with higher rates of smoking, obesity, physical inactivity, poor nutrition. It’s associated with asthma, heart disease, diabetes.

There’s national data on this but really again moved our local agencies and our local providers is - is local data. The other things, the wonderful things that have happened from next slide please.

The things that have happened in Maine because of our including the Maine BRFSS is I think that local mental health and local public health have developed much greater partnership and that has made a huge difference in terms of accessing the services that the – accessing the services that the public health systems have for our consumers. That’s been particularly helpful. The – we’ve gotten a great deal more resources. Next slide please.

What we’ve also done with the BRFSS data is we took the health questions that are in the BRFSS data set and we put them in our SAMHSA sponsored MHSIP consumer satisfaction survey. Again this is something that I think most every state is doing. They’re sampling a subset of consumers and asking them about their symptoms, about – about their satisfaction with the services they’re getting, with their outcome. So we put in these health questions in the survey. Next slide please.

And what we found out that is most importantly that the health risks in the population are in – in the consumer population are much higher than in the general Maine population. Again local data. We found that people have – 25% of our population has diabetes. That is absolute epidemic. That is utterly amazing. It is – the general Maine rate is 8%, so we’re three times the rate.

Heart disease, 10% in the younger population, 20 to 45. It’s only 1% in that group in general. So we begin to paint a picture that people with serious mental illness are actually aging prematurely. They are acting much more like people who in the general population in their 50s and 60s. So now let me just switch a little bit to Medicaid. I think I want to just put a plug in for Medicaid data. Once again our next slide.

It’s in every single state and actually I want to go back one bit. One other point that was important was that on the consumer satisfaction survey if we looked at people who were physically unhealthy, they were much more likely to report poor outcomes from their psychiatric services and were called and much less satisfaction.

They didn’t think their psychiatrist saw them often enough. They didn’t think their housing was okay. Their family wasn’t supportive enough. Across the board if they were physically unwell they really weren’t progressing the way we hoped they were on the mental health side. So next slide please.

Oh going back, we’re doing Medicaid data, which I say, been a major source of data. Next slide please.

And what our Medicaid data has shown us is Medicaid data is really useful because it services data. It’s really there but it can give you pretty much a kind of health record. It isn’t the same as a personal health record. It doesn’t have a lot of information that you’d want to have but it has a lot more than you think to give a picture of somebody’s health.

So what we discovered, for example in the Medicaid data – again, has got the attention of our Medicaid agency – is that 60% of the population with serious mental illness has five or more medical conditions. That’s almost everybody. I mean it’s a lot of medical conditions out there. And then we looked at diabetes. Remember that’s the one that’s the far and away the highest prevalence.

We looked at diabetes and there are standards out there on the healthcare side for what is good care for diabetes. And these are quality interventions like you get an eye exam one a year, you get foot exams. You measure hemoglobin A1C, which is the measure of your managing your blood sugar and the folks with serious mental illness were just not getting those quality interventions at the same rate as the rest of the Medicaid population.

They had more complications. They were having things like diabetic coma, which if you were well-managed you shouldn’t never have. They were getting most of their care in the emergency room. And, you know, you could have a lot of debate about what is a medical home. But I’m pretty sure we would mostly agree it is not an emergency room. So we found lots of interesting things. Next slide please.

What we also found was similar to the finding that we had – similar to the finding that we had on poor outcomes on a psychiatric side for people who were feeling physically unwell. If we look at psychiatric mental health expenditures for the Medicaid population that had - with mental illness, serious mental illness and we looked at how much services they were using on the psych side as a function of their how much – how much medical illness they had.

If they had no medical conditions that’s the first bar. That cost about $11,900 per person, per year just for mental health services. But if they had three or more medical conditions it went up to $24,000. So they were needing more psych services the sicker they were. So I think the - next slide please.

That actually is a very useful thing to get people’s attention as to why we should be paying attention to health if we’re a mental health system. Next slide please.

So we’ve done a number of things here in Maine. The things I really want to talk about the most are that we are now in the process of these - most of the stuff I’ve talked to you about were research projects that were standalone projects. We got the data, we did the analysis and we talk about it.

But we’re about, in December to be able to start doing regular reports, which are going to go to our mental health agencies. So they will know, for example, how many the Medicaid members have diabetes. How many of those Medicaid members are reaching their target measurements. How many of them are getting their hemoglobin A1C measures, how many are getting their fat measured and how many are going to their primary care doctor rather than emergency room.

It will give people actionable targets to begin to think about how they might support better access to primary care. How they might support consumers who already have a chronic disease in getting better healthcare. Similarly how do they - are their smoking cessation programs working.

So we’re going to have these direct reports. We are having a whole bunch of pilot sites that are also beginning to do measurement themselves, other things you can’t get from Medicaid data or BRFSS data like for example do you smoke? And what’s your height and what’s your weight so you can have a measure from the body mass index of obesity. What’s your blood pressure? You got agencies measuring blood pressure.

And that’s just starting right now. We have our first reports from our first pilot site and we’re hoping to spread that across the state. And we’re certainly going to continue with the health questions in the consumer satisfaction survey. But that survey instead of being a random sample is going to be given to every consumer in the system. And then next slide.

What we have done. Again, this is the plug for what you might want to think about doing, is other states have gotten interested in this notion of including health questions in the BRFSS consumer – in the SAMHSA consumer satisfaction survey and that is going to be an optionally URS indicator so would love to encourage you from the many states you come from to explore including those health questions on the consumer satisfaction survey. And I think it’s really pretty important to keep working with our state public health to get the mental health modules included on the BRFSS.

And we’re just watching a Medicaid — a multi-state Medicaid project to look at quality of pharmacy, quality of prescribing of a-typical. So again how do you use the data and how do you get there with other states to begin to move this forward. And the good news about collecting data is that you start getting grant funds which is very helpful and that’s actually what’s let us do a lot of our projects. Thank you.

Jane Tobler: Excellent, thank you so much Dr. Freeman for that important look at the role of surveillance in improving consumers’ lives. Our next presenter is Meghan Caughey. She is the Peer Wellness Coordinator for Benton County Health Services and Consultant to the Addictions and Mental Health and Public Health Divisions of the Oregon Department of Human Services.

She is an award-winning national speaker and consultant who uses her own experience of mental health recovery to advance the field, particularly in the areas of wellness, the arts, and mental health reform. Meghan joins us today to talk about Consumer-Survivor Activism for Quality of Life, Longevity and Well-Being. Thanks for joining us Meghan.

Meghan Caughey: Hi, I’m really happy to be part of this Webinar. Thank you so much. First of all we hear a lot about the people who have serious mental health issues die 25 years earlier than the general population when they’re – when they’re in public service, when they receive public services for their mental health problems.

Oregon did its own report and it looked at the data a little bit differently. It looked at people who have mental health disorders and then people who have both mental health disorders and substance use disorders. And found that the people that had both substance use and the mental health disorders lost an astounding 32.8 years and then over 37 years of life lost.

And for me as a consumer-survivor this is just unacceptable. I must say the even though we’re talking a lot today about data and statistics that this is not a thing about statistics for me. I can hardly even say the word ‘cause I get so passionate about this.

Last week I lost one of my peer workers and a good friend and she was in her 50s and the month before that one of the peer clients in my program lost her life due to smoking a pack and a half for 40 years. And so these are real people that are dying. These are my peers who are dying and I just feel like we have got to do something different. Figure out how to turn this – this tide around. It’s just not acceptable that they were sick and dying at these rates. Next slide please.

So I just I – I’m not sure if you can hear what I’m saying or not, but what I want to talk about is creating a culture of wellness and though what is a culture of wellness mean?

Well the reason I talk about this term is that I believe that if we as peers who have mental health issues have a high expectation that we will have wellness and health in our lives and that we also are able to communicate our expectations to our providers, we’re going a long ways in helping support each other and making health-oriented choices for our lifestyle.

So culture wellness has to do with our peer expectations for our lives as well as supporting each other and our providers of services need to also be participating and creating a culture of wellness. Also I just want to make a small comment that our language can – can sometimes get in our way and sometimes it can be helpful for us.

But yeah I often have, I’m talking about myself as being a mental health consumer, and I recently realized that I don’t want to be defining myself as a consumer because obesity is one of the problems that is adding to people dying to early. So I think if we look at other ways to define ourselves that are not based on consumption that could be really useful. Next slide please.

In our work with our peers we know that trauma-informed care is very, very important. A lot of us have a base of trauma issues involved with our mental health issues. Next slide please.

What I would like to – introduce is the concept of having wellness-informed care. Wellness-informed care is it’s – it relates back to that creating a culture of wellness. It says that we’re holistic people, not just bits and pieces of illnesses.

And it works with us relating to each other as whole people. Also it’s very important that we look at our definitions as being strength-based not looking at it as this is a collection of illnesses, but looking at what we can do to help create our own wellness. And that we support each other with [unclear] and education so that we make good choices.

And the most basic belief of wellness-informed care is that we can all change our lives and have better quality of life by making good choices and by supporting each other. Next slide please.

So a number of years ago, about four years ago, I was working down in Eugene, Oregon and I realized that my peers were dying at this terrible rate and I thought well what I can do and I designed at that time a group, a wellness support group called LOTUS Group and LOTUS is one of those awkward acronyms that stands for Lifestyles Overcoming Trouble Utilizing Support.

It was as I said peer-designed and also this wellness group is peer-facilitated and we use a combination of mindfulness which helps with the cardio problems and also can help with just coping with stress and we have kindness practice. And – the next slide please.

And a time during the LOTUS group where people can check in and talk about what progress they’re making on the goals that aren’t in the wellness, peer wellness action plan. So, next slide.

In each LOTUS group people are encouraged to make what’s called the person driven wellness action plan. And this basically well it’s different than those of you, for those of you who are aware of Mary Ellen Copeland’s WRAP group, or Wellness Recovery Action Plan.

This is a slightly shorter thing. But we look at what people’s strengths are and most importantly what do they really want to be doing in their lives right now. It’s very strength-based. But what has happened to people’s dreams for themselves and figure out how we can help people get to be where they want their lives to be. So that’s the basis of the action plans, the wellness action plan. Next slide.

On the next slide I just wanted people to see what we call kindness practice. We end each of our training groups and each of our other groups with the thing called kindness practice and kindness practice is just something that we all get together and we say this together kind of some wishes that we have for our intention and support for each other for safety and for ourselves for safety for our health, well-being. We say this for ourselves and also for all beings and it just helps set the tone for the way we go through the world and the way we relate to ourselves and each other. Next slide please. Next slide please.

So if we can get the next slide please. So next slide should be talking about the peer wellness program in Benton County and we have health promotion in public health. We are located in Public Health Division for the county. Could we get that next slide please?

Jane Tobler: Meghan there is a technical problem on our end.

Ron Manderscheid: I can – Excuse me I can advance them from here. I just advanced it so I’ll advance it for us.

Jane Tobler: Great thanks great.

Meghan Caughey: Okay so let me tell you about the wellness program. As I said earlier we’re not per se a mental health program we’re actually housed in public health but we train peer specialists, peer wellness specialists. We also are forming a peer wellness coaching program to help people live healthier lifestyles and navigate the mental health and physical health systems.

We use mindfulness and movement in all facets of our – our program. Both in our training and in our work with our peer clients. And some people will find it interested, be interested to know that we are located in a federally qualified health center. So that means that many of our mental health clients, our mental health clients are also getting their primary care services under the same roof.

So because of that we’re able to help integrate the care, be part of the integrated care, the people who are clients of our program receive. Next slide please.

So I think it’s really important that peers, because some are survivors, play a vital role in integrating mental health with primary care through the peer-delivered services that we provide. The kind of traditional way that often healthcare has been approached has been a doctor will tell a client or a peer, you know, you need to stop smoking, you need to lose weight, something like this and this is what I call the top-down approach.

Now we’re working to change this top-down approach through a team approach where the doctors are just part of a team and the client is an active player in their own treatment. When I say that peers should have a role in the integration I like to talk about sideways approach, which means that peers work with each other in the non-hierarchical way to support each other.

And this sideways approach I think is really important because frankly we spend much more time outside of the doctor’s office then with our doctor. And we need to be able to support each other the other 23.5 hours of the day. I will point out that the National Association of State Mental Health Program Director’s Report, which said that people will die 25 years earlier I said that integrating care is one of the ways that would turn that trend of early death and sickness around. Next slide please.

So with our peer wellness program we have a number of tools that we’ve developed that help us measure outcomes. One is our wellness survey and this - this is 13 variables that look at both emotional and physical health and it’s self-administered by a peer client. They did this for about once a month and then an epidemiologist helps the health department compile that data.

And then we also have a work force weekly survey and that survey is actually for the peer specialist, the peer wellness specialist, to take themselves so that they track how they feel about their job as peer specialists and how they’re handling with the stress level. And it answers for us is the work that the peer specialists is doing adding to the peer specialist recovery. We’re working to help other people but we also want a peer specialist to be having work that is healthy for them.

Another thing that we’re developing to use for our data is to use electronic medical records and from that we can look at how people’s weight changes. We can look at people’s body mass index. We can look at diabetes indicators, heart disease indicators, so we’re getting a much more complete view of how the person’s level of wellness is. Next slide please.

So at Benton County, Oregon, at the Health Department we have an impressive peer wellness program – we’re offering peer wellness specialists training. In the spring we’ll be offering peer one as coaching. We have peer specialists that lead Living Well with Chronic Conditions class. We have a mindfulness practice group and all the – all the groups that I’m mentioning are facilitated by peer specialists.

We have a dual-diagnosis anonymous support group, it’s for people with mental health issues plus substance use issues. As before I described the LOTUS group. That’s a peer-led group and then we also have a peer-led veterans’ support group and the veterans’ support group in our county it’s the only services for veterans’ that there are. So we’re kind of leading the way in our county with that.

I’d like to shift now – next slide please – to, the, what we’re doing on the state level. We have the Oregon wellness initiative and for the first year of the Oregon wellness initiative we’re focusing on helping people be free from tobacco.

We call this the Oregon Tobacco Freedom Initiative. And I kind of came up with that name because I wanted to focus on something other than using the word cessation or tobacco control. It’s just as tobacco – freedom from tobacco as a priority and I – I hope that by using the word tobacco freedom it makes it something more desirable than something characterized by deprivation or taking something away from people, next slide please.

So about the Oregon Tobacco Freedom Initiative, I’m consulting for both public health and I’ve consulted addictions in mental health and we are working on developing new policies that will be statewide and publicly run treatment facilities, residential treatment facilities and it will bring them to be smoke free or tobacco free in the year 2012.

And I just want to point out that tobacco use is a huge problem for us consumers, we consumers. Consuming tobacco is – is just really an adding thing to our premature mortality.

A risk – we’re over, we’re closer to half of the market of tobacco use products. So, we’re looking at using peer support and peer input to find ways to make this transition to being tobacco free more successful and to have it be peer – peer-informed, using peer voice to make this a success rather than something that people feel is forced down their throat. So, on my last slide, next slide please.

I’d like to talk a little bit about what has happened this month that I’m very, very excited about. For a couple of years I have worked to get the Governor of Oregon to sign a proclamation where he would – he would designate people with serious mental health issues as being the health disparity population and where – in the, the proclamation, Oregon would embrace the 10x10 campaign goal which is to reduce the number of years that persons with mental health and addiction issues die by ten years in ten years’ time.

So I worked on this very hard. I got a lot of pushback actually that I didn’t expect to find and that’s why it has taken so long. But on the first of October of this year, that’s a month ago, our governor did sign a proclamation designating October as the 10x10 campaign for mental and physical wellness month.

And he encourages everyone in Oregon to join this observance. So what I really want to see happen and I just want to offer this out to anyone who is listening to this webinar who might be a peer of consumer activists, start working on getting your governors to designate us, men- people with mental health challenges in your state as a health disparity population.

We would like to see every state have a proclamation from their governor where people are coming together to work on supporting people with mental health issues to living longer more quality based lives. And we think, I think this really begins at the grass roots.

You know it’s not going to start with the governor deciding, “Oh, I think I’ll do this great thing.” It takes a lot of pushing from--from people that have this going on of people, of their peers being lost, our peers being lost to early death.

So if we could all do some pushing and some creative working with the system, I think we can help bring people together to accomplish the goals that we all want to accomplish. So, the last slide I have is just some of the resources that, next slide please, that people can look at.

There’s a Benton County Wellness survey, I personally call it the wellness model but this last slide just kind of shows you some of the resources that are out there and that’s what I have so thank you very much.

Jane Tobler: Thank you Meghan that was awesome. We really appreciate you providing your insight into the application of mindfulness, the peer specialists and the consumer advocacy efforts in the mental health arena.

Our final presenter today is Dr. Ron Manderscheid, Executive Director of the National Association of County Behavior Health and Developmental Disability Disorders – Directors, I’m sorry, Ron.

Ron has emphasized consumer and family concerns throughout his diverse career. He is the member – a member of the Secretary of Health and Human Services Advisory Committee on Healthy People 2020 and is president-elect of ACMHA, the College of Behavioral Leadership.

He has held a variety of positions within the National Institutes of Mental Health and Chief of the Statistical Research branch. Ron will discuss the mortality crisis and what needs to be done to fix it. Thank you for joining us, Ron.

Ron Manderscheid: Okay Jane thanks very much for inviting me. I’m thrilled to be able to be here and do this. I have a lifelong commitment to solving this problem of premature mortality in our consumer population.

So what I’m going to do today is not talk about very important work as (Elsie and Meghan) have done, but to issue an urgent call to action at the national level. And I’m going to cover a number of areas, looking at what’s going on in those areas, and then what needs to go on in those areas to move the agenda.

To pick up on Meghan’s phrase, we have to get to turn the tide basically. And that’s where I want to go with my presentation here. So, first the data area. What has been done. Elsie and I have and Ben Druss actually reviewed the national data on this topic in 2007 and we called for several things to be done.

We said there needs to be annual data on premature deaths for all state mental health agencies. There needs to be better data on co-occurrence of mental health, substance use, and primary care conditions, and there needs to be development of effective working relationships between SAMHSA, the NIHs, the National Center for Health Statistics and the Centers for Disease Control.

What is the status in this area? So, of those things that I just reviewed, many of those things remain in 2010 mainly unfulfilled. And I would argue to the audience here that there is a need for strong field advocacy to move these issues. We take the issue of state level data. If we don’t have state level data from virtually all states on the numbers of people who are dying prematurely, how can we take effective action on that issue?

We don’t know, for example, whether these numbers are increasing or decreasing. We don’t know whether the causes of premature death are staying the same or changing. There’s just a very urgent need to get that data and we need everybody on this call to take this on as a personal commitment to get that data and see that that data exists in every community mental health center. It exists in every state mental health agency and that that data exists at the national level.

Secondly, data is very important, but by itself it’s not enough. We also need to develop evidence-based practices that link the care for persons with mental health conditions and physical health conditions to evidence-based practices about wellness.

In my mind, it’s totally unacceptable for someone to come in, to be prescribed a second generation anti-psychotic by a psychiatrist and for the psychiatrist not to tell the person anything about the secondary effects of these medications such as metabolic syndrome, or the psychiatrist not to be engaging the person in the physical illness – as Elsie said, 60 percent of the public mental health system clients in Maine have five or more chronic conditions.

That’s just totally unacceptable here. So we need to get to evidence-based practices that are required of our providers so that this situation does not exist. One of the things we need to be publicly available in this, we need a public table that shows the secondary effects of all of the second generation anti-psychotics in the same table.

Recently I was on a FDA work group. We found that Olanzapine was a very serious drug in terms of secondary effects for teenagers. We actually took this information to an FDA panel and there is now a warning label on Olanzapine if it’s prescribed to teenagers. We need more action of that type.

Again, in this area of evidence-based practices, it remains mainly unfilled. So if you go out to a typical provider these days you’re not going to see the types of things I’ve just been talking about.

So, again, I encourage virtually everybody on the phone today to get engaged in this to require, to insist when they go for care that their providers do these things for them. As Elsie says all health care is local. That’s absolutely true. If you don’t insist that your providers do these things, then how can we except that this will ever exist at the national level here.

Third approach here, one of the things that we’ve done very little with, in behavioral health care is looking at the role of the social and physical determinates of health. Let me cite the problem of obesity. So, one way of looking at obesity is to look at a particular person.

Look at their health. Look at their food intake and nutrients and so on, and put them on a particular wellness regimen to address their problem of obesity. Very important, absolutely must be done. We have 25% of the U.S. population that’s obese.

Another very important ingredient in that whole approach is to begin to address the social determinates of health. What are the social factors in our social structure that lead to obesity? Well one of those things is high fructose foods.

So we permit high fructose foods to be produced, served everywhere then we are loading up the person at the front end with social determinants of health that lead to obesity. So we can move this system back upstream and part of our advocacy has to be not only to work with individuals to address the problem of obesity, but also to address the social and physical determinants of health.

One of the actions that have been taken in this area is that the Healthy People 2020 initiative actually has adopted the social and physical determinates of health as the basic model going forward. You want to read more about this, the – the government of Great Britain has actually adopted this as the country-wide approach to the British health service and you can read about that if you go and look at what they’re currently doing.

In this area I would say the goal of doing something about the social and physical determinants of health is partially fulfilled. We need to coordinate this with our consumer community. We need to have a model, a social and physical determinates of health that is applied nationally. And we need to apply it specifically in mental health to the determinants of premature death.

As far as I’m aware the second step on this overhead has not been undertaken by anybody at the present time so I encourage anybody who’s on the phone who’s a researcher, think about this. Do a grant application to the National Institute of Mental Health to begin working on this. Someone who’s on the phone, who’s doing demonstrations, go out, develop a grant to do a demonstration, to work in the community to begin addressing the social determinants of health at the community level.

Okay, next area, national health reform. So, on the problem of premature deaths, in my opinion national health reform can be a godsend because National Health Reform is very consumer-centric and consumer-friendly. It’s very much oriented to moving the agenda toward prevention and promotion and the social and physical determinants of health and it clearly is moving in the direction that Elsie was talking about, of looking at integrated care.

So how do we provide good mental healthcare, primary care, substance use care to the same person. How do we bring the person back together again? So what actions have been taken in national health reform? National health reform has identified major healthcare disparities, as Meghan was talking about, across population groups.

It’s noted that there’s little current focus on improving health education. It’s noted there’s little effort to organize local health and public health advocates and it’s also noted there’s little effort to identify the role of institutional factors and health conditions such as the high fructose foods that I mentioned before.

What is the status here? Get started, get involved, get involved in health reform at the front end of the whole process. You may need to be the purveyor of information about health reform to your local providers. You may actually know more about national health reform then your local providers know.

You can help implement national health reform. An implementation of national health reform can begin to address the problem of premature deaths that we are talking about here.

Final area I want to cover is what’s called frame analysis or how people look at things. I think it’s very important that we talk among ourselves about these issues and I would assume most of the people who are on the phone today are people who are associated with the mental health field in some way. However, it’s very important that we also talk to other people and that when we talk with them, they understand what we’re talking about.

So what frame analysis does is try to understand how people from the community who are not associated with any issue come to understand it. And there’s been a lot of work done very recently on frame analysis of how people in the community view mental illness and view mental health.

And in fact, if you dig into this the way that people who’ve done frame analysis do, you’ll find that most people in the end, when all is said and done, think that, you know, most of these things are very individualistic, you know, that – that if you have a mental illness you probably have it because it’s your own fault, etc., etc., etc. They don’t see these things tied into the social structure of the community. They don’t see these things tied into how we live our life as a society.

So for us in mental health this is a fundamental issue in how we’re able to discuss and promote positive mental health outside of the mental health community. So we’re going to have to do work that’s needed right now to begin moving the agenda to change the perception of the community, about how the community views mental illness and views mental health.

I think personally national health reform will help accelerate the development of that change and I think some of these things are ready beginning to occur because I just got an article literally this afternoon that said you cannot have good public health unless you address mental health. That’s exactly the kind of message we want to get out there and we want to work on.

So with that I want to come back again. My bottom line here, so this is an urgent call for national action on data, on evidence based practices, on implementing national health reform and on frames.

We want to commend and I want to commend and I’m sure Elsie and Meghan join me in commending the Center for Mental Health Services for undertaking and sustaining the 10x10 initiative and pledge. Without that we would not even be having this call today. So thank you very much.

Jane Tobler: Ron, thank you for that excellent presentation on the various healthcare systems and their very important roles in mental healthcare and helping to get us to where we need to be to turn the tide. We appreciate it and if you would continue to move the slides that would be terrific.

Ron Manderscheid: Okay I always have multiple roles here.

Jane Tobler: Yes you’ve been important. We had a little technical glitch over here so we certainly appreciate it. We have – we have a few more presentations before we take questions from the audience so the first thing I’m going to ask our speakers to do is to give us your vision. So Dr. Freeman if you could be the first please to talk about your vision.

Elsie Freeman: Well my vision is it would be really - whenever I’m doing any presentations locally or nationally or writing for grants I wind up with this cumbersome language in which I’m talking about mental health or behavioral health and physical health and public health. It is kind of odd because I think health is about all of these things.

And so I - my vision is we get a world where when I’m talking about healthcare everybody that I’m talking to says I mean all those things and I don’t have to kind of get these long cumbersome sentences.

I think that on a practical level when we talk about healthcare reform it should include attention to mental health. When we’re talking about quality of life and health outcomes, it should include mental health, not just physical health, which is a lot of what happens on the national scene.

And when we’re talking about mental health outcomes when we sit in our world of SAMHSA and CMHS, we should be talking about health which is what we’re doing here but it’s not universal so that’s my vision.

Jane Tobler: Excellent, thank you Dr. Freeman. Meghan could you give us your vision please?

Meghan Caughey: Well, I spoke earlier about creating a culture of wellness. For me that means that there will be a - that we can have a paradigm shift in how we treat ourselves and support each other and I would like to see peer services working, having a vital role and being well-funded at all levels so that peers can be supporting each other.

And also I really want to see consumers drive the policy making and the implementation of policy because policy affects all of us so we need to really take the reins, so to speak, of the healthcare movement and make – make the horse run, run to get us to where we want to be. So, just supporting each other, moving our communities, our states, our national governments to make the changes that we need so badly. Thank you.

Jane Tobler: Thanks Meghan. Ron would you give us your vision please?

Ron Manderscheid: Okay my vision is very simple. My vision is a world in which people who develop mental health issues do not die prematurely. And what’s on this overhead are things that need to be done in order to get us there. We got to have data.

We got to have these evidence-based practices. We got to implement national health reform and we need to empower our consumers to take charge of their own lives. And I think if we do these various things we will get to that point. In order to get there I think we got to do what Meghan told us before, we got to do some pushing.

So I want to do some pushing and I want to encourage all of you to do some pushing on this so that we, in our lifetime, see the day when there’s no difference in longevity between a person who develops a mental health condition and anybody else in the population.

Jane Tobler: Excellent thank you so much. We are going to get to questions in a minute so if you want to start thinking of your questions and pressing star 1 on your telephone keypad you may do that. But I would like to point out on Slide 51 we have the presenter’s contact information, if you have questions or you’d like to follow up with them later, that’s Slide 51.

On Slide 52 there are additional links to additional resources that talk a little bit about what we’ve been talking about today, as well as the resources that were listed on the earlier PowerPoint presentation. On Slide 53 we have the speaker biographies beginning. So we have Dr. Elsie Freeman and more information and more background on her on Slide 53.

On Slide 54, we have Meghan Caughey and Meghan’s information is on it. On Slide 55, we have our final presenter, Ron, and his information on it. So if you want to know more information about our speakers I encourage you to look there.

And now we have finished the end of the presentation so we will now take questions from our callers. Again, if you want to ask a question on your telephone keypad to be placed in the queue and give the operator your name. If you do not wish your full name to be announced please only give your operator your first name.

Upon hearing the operator announce your name, please ask your question. And after you’ve asked your question your line will be muted allowing the presenters to give a chance to respond. So operator if you’re on the line we’ll take our first question.

Coordinator: Our first question comes from Melanie, your line is open.

Melanie: Yes my question is when I’m thinking of healthcare reform and also the integration of mental health, physical health, also spiritual health and social health, it makes me think of managed care. So do you see us in the future actually building Medicaid or having more of a computation that focuses on prevention?

Ron Manderscheid: I assume that’s directed to me, Ron Manderscheid. So the way I would answer that is that several things are going to be in play at one time. Right now we send about 96 cents of every dollar on care and only 4 cents of every dollar on prevention and promotion. The goal of health reform is that within ten years we’re spending no more than about 70 cents out of every dollar on care and up to 30 cents a year on promotion and prevention.

So I would see a lot more promotion and prevention activities in the future. Including those that focus in on mental health and substance use conditions. So that’s one.

Another big movement here in health reform is to move toward integrated care through accountable care organizations. What I mean by that is that a person in effect goes through one door and gets all the different care that they need. If they need mental health care they get it, if they need medical care they get it, if they need dental care they get it, etc., etc., etc.

In order to get us there we’re going to have to do a lot of changing in behavioral healthcare. So some of the things we’ve clung to in the past such as carve outs including Medicaid carve outs and managed care carve outs are not going to be viable in the future. So we have to begin working toward the integrated care in the way that Elsie was talking about that.

Medicaid is going to provide a lot of new resources to mental health and substance use care because the estimate would be that a third of the newly enrolled people in Medicaid will have mental health or substance use conditions at the time they enroll.

And the estimate would be, you know, for us in behavioral healthcare of the 32 million people who’ll be newly enrolled in insurance at least 10 or 10-1/2 million will have these conditions. So there’s going to be a lot of new dynamisms in Medicaid that will have impact on our mental health and substance use care world as well. So let me stop there.

Melanie: Okay.

Jane Tobler: Thank you operator next question please.

Coordinator: From Dee, your line is open.

Dee: Hello, first of all thank you for this presentation and I strongly agree and support everything that SAMHSA and the presenters have said in terms of need for data collection, reporting, and the innovative interventions and programs.

However, the one thing missing in having health in all of these things, you know, healthcare being broad, Ron just mentioned it and I was waiting to hear, what about bringing in dental care. It seems to be a very neglected piece in terms of Medicaid and I think it’s even been eliminated from – in California we call it MediCal – has been eliminated as a benefit for folks. So what’s going to be done about MediCal dental care inclusion in reform?

Ron Manderscheid: Well again, you know, I think as CMS defines the essential benefit for the Medicaid expansion there is no doubt in my mind that that must include dental care. We’ve had cases and cases I know of personally in Maryland where we had a teenage boy literally die for lack of decent medical - decent dental care and that boy was in fact a Medicaid enrollee.

That became a huge issue and the people at CMS said they have addressed this. So I think to your point we need to watch the action here. You need to watch as CMS evolves the essential benefits under Medicaid going forward in national health reform and we need to watch that the types of benefits that you’re talking about and are concerned about are actually there.

Elsie Freeman: And I think the other thing I would add, this is Elsie, is that talking on the data side, I mean we’ve done a lot with – with kind of a lot of the health indicators that the traditional health system follows, say diabetes care. We actually haven’t looked at dental status. We wound up because we had limitations on the number of consumer questions not to be able to ask those, though I think we should have.

And I think that there is huge data that some part of our mortality crisis is the lack of dental care and we really probably should start to find ways to present that because that would be the argument for why you really want to include it. Not just for its own sake but because it’s actually adding to people’s mortality.

Ron Manderscheid: Yeah excellent point.

Dee: Thank you.

Jane Tobler: Thank you operator, next question please.

Coordinator: Next question is from Kathy. Your line is open.

Kathy: I’m with Art, can you hear me?

Elsie Freeman: Yes we can hear you.

Kathy: I’m with a managed Medicaid carve out system in Oregon and we’ve been working very hard with our provider system and our advocates to develop a whole range of wellness education supports to deliver in the – in the current mental health outpatient system.

And we’re running into a major barrier at the audit level at the State in which they are still defining very narrowly that the Medicaid benefit has got to show that all of your treatment plans and progress notes are documented in terms of changes in the mental health condition.

And I’m wondering if there’s any movement to - from SAMHSA to CMS, to get CMS to free up the State and say that we’re not going to get punished with audit findings if we’re just mental health dollars to address the physical health needs of the people that we’re treating.

Jane Tobler: Dr. Freeman do you want to address that?

Elsie Freeman: We aren’t having a problem with that so I’m not sure that that’s a CMS issue. It is on the Medicare side. Medicare is kind of clear, for example, if a primary care provider actually codes a mental health service...

Kathy: Right.

Elsie Freeman: You lose – you lose reimbursement, lose some of your reimbursement. But we have not, your Medicaid regulations are largely set at your state level. They’d have to conform with CMS but we have, we do use mental health dollars for health and wellness services.

Kathy: So I’m wondering is there a way to get some formal guidance from CMS to a State that says that’s allowable.

Elsie Freeman: Well we seem to think it’s allowable. We don’t seem to have a difficultly with it. So on the Medicaid side.

Kathy: Okay because that’s not what we’re getting from our state, they still think it’s Federal.

Ron Manderscheid: Let me comment on that also. I think there’s two levels of issue. One level of issue is that it’s not a regulatory question, it’s an audit question.

Kathy: Right.

Ron Manderscheid: And as an audit question it’s a different level of issue and there’s been consideration dialogue between SAMHSA and CMS on this. There’s also been considerable dialogue up in the Congress on this issue that we need to address this urgently because it prevents people from getting the integrated care I was just describing. If you’re going to have an audit that kicks out every encounter that has a certain characteristic that’s a problem.

The issue is and Elsie’s absolutely right. In some places it’s an issue and other places it’s not. And therefore I guess my recommendation to you would be to contact Barbara Edwards who runs the disability program for Medicaid at CMS and have her weigh in on this issue in Oregon for you.

Kathy: Thank you.

Jane Tobler: The next question we have via email and, Ron, I think this would be a good one for you. What is the history of this health disparity? I understand research shows it in the 1930s, it was also shown as 15 to 20 years in the mid-1990s, and reached 25 years in the mid-2000s.

Ron Manderscheid: Okay let me quickly address that. So there’s a long history and to looking at this issue it isn’t something that just came along in 2006 when we published that article. And in fact, there’s data going back into the 1920s and 30s that shows there was a disparity between the longevity of a person with a mental health condition and people from the general population.

What you’re referring to in the second part of the question is well how has this changed over time? I did some work now over 20 years ago where I looked at this issue in 1986 and then we looked at the issue again in 2006. And we would estimate that in 1986 the disparity was about 15 years and that in fact the disparity has grown in the meantime to about 25 or a little more than 25 years.

So you have to, in a sense of epidemiology, have to ask the question well what has changed. Well a whole host of things have changed. Medications have changed, so you have the second generation anti-psychotics. Not all of which, but some of which, lead to the metabolic syndrome which then can lead to the chronic diseases that (Elsie) was talking about, diabetes, heart disease and so on.

You have the situation where the mental health system actually encouraged smoking at one time. Smoking use to be part of token economies in the mental health system so we may have been partly the cause of more people who are mental health consumers becoming smokers and smoking is a known factor in mortality. If you smoke for 30 or more years I can predict almost with certainty that it will kill you. Lifestyle factors.

So after 1980 with the institutionalization because we did not build the community mental health system we created a huge homeless population who lives out under bridges. If you live under a bridge in the winter in the Northeastern part of the United States this is not going to be good for your health. So there’s a whole host of things that have changed in essence over the last 20 years.

Elsie Freeman: And that’s the other things that I think you’ve changed also though are that the general population is getting access to better care for chronic conditions, better healthcare and so their lifespan has also increased in that period. So I think it’s partly the population is doing worse and partly it’s doing worse in relation to a population that’s doing better.

Ron Manderscheid: I would agree with that because we spend 75 cents out of every healthcare dollar on people with chronic diseases. So, that I agree with, the concept of access here.

Jane Tobler: Excellent thank you very much. Operator if we could have our next question please.

Coordinator: Okay, next question is from Jerry. Your line is open sir.

Jerry Stork: Hi Ron this is Jerry Stork from Minnesota.

Ron Manderscheid: Jerry how are you?

Jerry Stork: Good how are you?

Ron Manderscheid: Good.

Jerry Stork: We are having 10x10 project in Minnesota and we’re working with some health plans. The focus though is more on people with adults with schizophrenia and bipolar disorders. Now I think what you’re talking - and that’s with a 10x10 research is based on that information. Are you focused on broadening your focus or do you think are we focusing too much on our population on - is it like the first step that was working on that population as a focus.

Ron Manderscheid: Let me start and maybe Elsie and Meghan can add to this. I think it’s okay to start where you’re starting because that is the population that’s its highest risk of what we’re talking about here. I think what health reform will do is gradually broaden this population out. And Jerry I know you were around when we used to talk about the population with severe and persistence mental illness.

Well, that population represents about 3% of adults. Then we broaden this out to talk about the adult population with serious mental illness. That’s about 6% of the adult population.

And, I think what healthcare reform is going to do, is add additional people to that group through Medicaid who have mental health conditions but also have other chronic physical conditions as Elsie was talking about. And we haven’t yet thought our way through of how we’re going to work out from the group you’re starting with to this third group that’s going to be brought to us through health reform.

Again I think this is an urgent call for the field to begin thinking about that issue and say how will the addition of this new group to Medicaid change our approach to the kind of problem we’re talking about here of premature mortality.

Elsie Freeman: Well I have sort of a slightly different take which is that - and that’s why I think I sort of would encourage you and Minnesota has a great research program. The data on the healthcare side and supported by BRFSS is that your mortality, if you’re somebody with heart disease in the general population and you have depression, you are four times more likely to be dead in a the next two years than if you have the heart condition and no depression.

Garden variety depression, this is not the stuff that gets you to a hospital. It’s not the stuff that gets you all that functionally impaired. You are symptomatic, you go to your primary care doctor, maybe you get some meds, maybe you don’t stay on your meds but that is actually ultimately affecting one in five in any population. And when they get their chronic diseases, they do a whole lot less good with them.

So I think that there is something to be said, not – I mean, the 10x10 campaign sits where it does, but I think it’s taking this message to your healthcare leadership, that the things you care about unless you pay attention to mental health, at the same time you’re not going to get the outcomes you want for your – for taking care of diabetes or heart disease. Because there’s lots of data that out there in general population, mental health matters.

Jane Tobler: Thank you. This question is for Meghan. Meghan, this is a question we received via email. A mainly disregarded aspect of early mortality is metabolic syndrome caused by many popular described mood stabilizers, atypical anti-psychotic medications.

Many of the illnesses commonly attributed to smoking, nutrition and activity level, even socioeconomic class actually are due to the profound long-term side effects of these medications. Research or work is being done looking at non-drug alternatives to wellness. And Meghan you had a couple of really good sites on wellness, could you answer that please.

Meghan if you’re speaking you need to star 6 because we cannot hear your lovely voice or your good answer. Meghan, we still can’t hear you, we might have lost Meghan, star 6 to unmute.

Meghan Caughey: Can you hear me yet?

Jane Tobler: Yes, Meghan, welcome.

Meghan Caughey: I’ve been pressing star 6 and nothing has been happening. But finally I’m through. I think the - these comments really describe what the situation is and it is not going to be simply fixed by – by us either not taking medication or having alternatives. But everything is interrelated. And for those of us that take medications, we need medications that don’t have these terrible side effect profiles and we do need alternatives to medications.

And some of us who take medications need to also need to be using alternative practices and our public systems must support and encourage alternative practices to help support us with our lifestyle.

We need to have more emphasis on learning about nutrition and making that available, making good nutrition available to the consumer-survivor community. We need to be utilizing all kinds of nuanced treatments like some of the Eastern ways of treatment from the oriental cultures.

A lot of things have been found to be helpful and I used the medication we’re just kind of touching on one very small, very well – well it’s kind of like a double sword, it helps in some ways and then it could really create a lot of problems at the same times.

So I think here are a lot of non-toxic things that we can do that will help us become more well and our public systems are so far are really dragging their feet when it comes to – to bringing these into wide view in supporting this in wide use.

Jane Tobler: Thank you. Operator, next question please.

Coordinator: Next question is from Laurie. Your line is open.

Laurie: Yes I work at a psychiatric rehab and last year was the first time I heard about the 10x10. At the same time our county put out for RSP and I put it in for a wellness center.

And we’ve been using cooking and nutrition from a local farm. We get the produce so people are – they get to learn how to use that produce that they might not otherwise use, or even purchase from the stores. But my question is, is I’m trying to collect data now. I’ve got a number of people who have diabetes. The number of people who are obese is astronomical in our area. We’re a big Amish area, so it’s a lot of heavy foods.

And I guess my question is in the beginning you talked about some of the places to get existing data so that I might even add my data to that. What would be the best way to go about doing that?

Elsie Freeman: I assume that’s for (Elsie), for me. I do think local, I mean I don’t know the organization of public health in your county or your state. But it - public health agencies, those things that are funded largely through the national CDC, with which we are pretty disconnected as a system, are a huge resource for data on things like obesity, food security, physical activity and that’s a lot of the places where you can – can find what’s going on.

You can even get them to over sample your population possibly. But I don’t know whether you’re a county public health organization or a state-based public organization. It’s probably best to start with your county and find out what’s your local public health resource.

Laurie: Okay, okay thank you.

Jane Tobler: Okay we have time for one more question. So, Operator, pick the best one we have.

Coordinator: All right, well, our next question comes from Katherine. Your line is open.

Katherine: Thank you so much. I’m a, a consumer. Also a master’s level health educator and professional grants consultant who’s worked with both federally qualified health centers and mental health agencies trying to get them together to work on this issue in particular.

And I guess I have kind of a two-fold question one for Meghan about how you get started trying to get these two kind of agencies together. And also just wanting to make a plug for non-drug related evidence and form practice funding, and also new and continuing funding for both kinds of agencies that are tied to performance, reporting and outcome, because they seem to be in such different places, in silos.

For example, in HRSA and other places so that they don’t see much incentive to work together. Any comments would be appreciated.

Meghan Caughey: Can you hear me?

Jane Tobler: Yes, Meghan, thank you.

Meghan Caughey: Okay great so how do we get the silos down so that there’s more seamless care is kind of what I hear you asking about. On the peer level, yeah I’m very fortunate because my program exists in the context of a federally qualified health center. But even within this health center we are coming from a time when mental health was on one side and primary care was on another side and there was really no communication between primary care, mental health and then this other entity called public health.

And so the peer program that I designed and that I’m part of is playing part of a very important vetting process. Because with our clients, you know, we’re located in public health and we’re working with a lot of mental health clients that have physical problems and our peer specialists are crossing from mental health and working with data through the electronic medical records so we know what’s happening with people physically.

A lot of our clients do have very serious problems and we have to work with the physicians. The physical primary care people that help support our – our clients. So I think peer-delivered services can really play a bridging role in helping integrate care and I do agree that we need some alternative to just giving people drugs.

And I think some of the, you know, role of peer support is huge because peer support and peer support we can really take the time needed to listen and go out in the community and support people where they are. Leading their lives and it’s not just something done at the clinic or at the health center. It’s done in a more holistic way.

Ron Manderscheid: Can I also add I want to say something, just a brief comment about HRSA.

Jane Tobler: Sure.

Ron Manderscheid: We have a very good friend at HRSA in the person of Dr. Mary Wakefield who is the new administrator of HRSA. This is not the HRSA of old who was difficult to work with. This is the HRSA that wants to partner with us and wants to work with behavioral health care. So again my encouragement would be open the door, reach out to Mary Wakefield, reach out to the staff of HRSA, they want to work with us in a way they never did previously.

Jane Tobler: Excellent thank you Ron for sharing that.

Elsie Freeman: I have actually something to tell the group, though, which is bad news if you will, which is my–my state Medicaid Medical Director, we actually have a great relationship and that’s why I know as much as I do about Medicaid, just sent me this announcement which I am just going to tell people on the group.

There is a state Medicaid program on Thursday and it is a combination of CMS and ARHQ final recommendations for the initial core quality measures for adults in Medicaid as required under the Affordable Care Act. We’re tuning into this. It’s this Thursday 1:00 to 2:30 and I can give you the conference phone number is 8665015502, the conference I.D. is 18698110. There are not a lot of mental health measures in the core set.

Ron Manderscheid: So to Elsie’s point here this is a very good area to begin doing some pushing on the data that I was talking about earlier.

Elsie Freeman: You might want to get your state mental health folks to get onto this call or people, everybody who can get on this call and comment on this final recommendation for the quality measures and it’s speaking to the last – last caller who said well what about outcome and quality measures.

Jane Tobler: Right, right those are great resources to share Ron and Elsie. We have come to the end of our call today. If you have more questions or would like to follow-up you may email the SAMHSA 10x10 wellness campaign at 10x10@samhsa.hhs.gov.

Or you may contact the speakers directly via their contact information on Slide 51. Dr. Freeman, Meghan and Ron thank you so much for your work on this important subject and for sharing your insights and experiences today.

Also, I want to thank all of our listeners for caring about this topic and taking time out of your afternoon to learn more today. This conference has been recorded and the audio recording and transcription will be available mid-November on the SAMHSA 10x10 campaign Web site.

Later this week you will receive an email request to participate in a short, anonymous online survey about today’s training. It will take about five minutes to complete.

Please take the survey and share your feedback with us. This information will be used to help determine what resources, topic areas need to be addressed by future training events. Thanks every - thanks again, everyone for joining us and I want to thank you in advance for filling out the survey. Have a great afternoon.

Coordinator: Thank you for participating in today’s conference, you may disconnect at this time.

END