Netsmart CareThreads
Netsmart CareThreads

Episode · 4 months ago

5 Key Elements Driving the Delivery of Behavioral Health Services


Recent history has impacted many foundational elements of the behavioral health care delivery system as we know it. To make the most of the opportunities before us, we need to understand five key elements that are driving the delivery of behavioral health services.

In this episode, I speak with Bob Sheehan, CEO at Co mmunity Mental Health Association of Michigan, about the complex factors influencing the behavioral health services delivery system today and in the future.

Join Bob and me as we discuss these five key elements:

  • Growth of managed care and risk management
  • Adequate funding
  • Integration with primary care
  • Role of public and private sector and service delivery
  • Changing community expectations
  • Bonus: Bob’s optimism and encouragement about the future of behavioral health services

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Welcome to net smart care threads,a podcast where human services and post acute leaders across the healthcare continuum come togetherto discuss industry trends, challenges and opportunities. Listen as we uncover real stories abouthow to innovate and improve the quality of care for the communities we serve. Let's get into the show. Hello, my name is Tom Herzog and I'myour host today. I serve as a chief operating officer here and ThattSmartin. Is My privilege to introduce our guests today, Bob she and.Bob is a chief executive officer of the Community Male Health Association of Michigan.The Association represents the state's public community health providers and centers, public prepaid inpatient health plans, public health plans formed and governed by the CMHC's and theproviders within the C mhcs in the P I hp provider networks. Bob Isalso the current share of the National Association of County Behavioral Health and disabilities directors. Before being named Michigan's association CEO. In two thousand and fifteen, bobserve of eighteen years as a CEO of the Community Mental Health Authority of Clinton, Eden and Ingram counties. During his tenure, this comprehensive mental health treatmentservices providers served over eleven thousand persons annually in its three county area. BobWas instrumental in the formation of a twenty one county prepaid inpatient health plan thatled to increase efficiency and uniformularity of services while roteining a locally driven system ofcare. I'm really excited about our conversations. I've had many people share with mesome of the talks and presentations that Bob is given recently and said,you know what, we really need to connect on that. So here's whatwe thought we do. The topic of our episode today is understanding the focuson the delivery of behavioral health services in today's world, really focusing on bykey elements impacting those efforts. Where in the time, I think all ofus would agree, when disruption is challenging and creating more change than I knowI've ever seen in my lifetime. It's impacting many foundational elements of the BehavioralHealthcare Delivery System as we know it and as we've all used the term.We're looking for what that new normal will be. There will be a newnormal that comes. I don't think we're there yet. I think there's goingto be some things that we're going to learn on, learn and relearn inthat process. I think if you really look at the ecosystem today, we'reconstantly evolving in all aspects, clinically, operationally, financially, politically and regulatory. We know that the influences are challenging us for what is true option schoolsand what are the opportunities before us? So we're going to dive into thetopics and as Bob helps his members navigated...

...within his own community and Nashley,which want an opportunity to learn and share what some of those top of minethoughts are best practices? Maybe some of those things that we're not going todo anymore as we look forward. So let's get started. Key Element numberone. Bob, you ready, I should ask you right time and commentand against. Thanks for hosting this. Yeah, no, I'm looking forwardto it and I think this is these five things that we have out there, I think are the top of my topics and people are going to lookforward to this discussion today. So key element number one, the growth ofmanaged care and risk management. So in the past several years, behavioral healthis seen a shift from fee for service to value based payments based on theoutcomes. No question to gain changing by product of this emergence of managed careand risk management. So my first question to you is how is this impactingthe landscape for providers and those they serve? You know, it's a key,key question, Tom because impacts are providers across the country, financially andclinically. The biggest change for folks is to get used to a model thatis not volume based. You know, fee for services volume in the morecontext I have with clients, to be blunt, whether they need it ornot, the more revenue I bring in, and sometimes the revenues. By theway, the rates are so low per unit that you need to seea lot of units. As it moves to more of either a case rateor a capitation where it's more quality based, population base, which is capitation orcase client based, clinicians receive greater flexibility. They can actually make acall. WHAT IS JAN or John? Need they need five contexts or canthey do with one, or do they need twenty? And allows them tomake those those adjustments. It also allows them to do things that aim issocial determinants. They may have done before. So, for example, if I'man outpatient therapist and I'm getting paid for the session, we may betalking about homelessness or job laws or divorce, but I'm dealing with the psychotherapy rightin the room. If I'm paid a case rate or capitation, Ican now actually call the landlord, I can drive with him off to seethe landlord, to the employer, the spouse, the family and work onthe things that act you're impacting their mental health. So I urge folks inthe fee for service world none not to fear risk based contracts. In fact, if they understand the volume of services they do now, if they havea rough sense of the cost, I think we spend too much time makingpeople panicky about you better know your cost. Will actually most providers know their cost. I mean I tell people it is simply guys, your budget dividedby your units. You use that. You got good rule of thumb.So, rather making into rocket science, just take your clinical knowledge, aimthe services at what people need as opposed to what the volume used to driveand revenues and adjust to a risk based environment. And I think the riskis no greater than it isn't a fear for service environment. Getting people toknow that is it is key, I think. Yeah, I think youhit on the key topic. I know in the conversations I've had it's thecost. And what is it going is... going to drastically going to impactor our organization in a way that we can't provide those services? And Iguess I'd ask you that is I think this is a learning time and Iknow I've seen willingness to adjust and edit those things and I'm curious are youseeing that as well, or is it just set in stone and no one'sgoing to move off of that? No, I'm glad to set it so.In Michigan we provide almost a perfect laboratory and the public system, thePublic Cmh, is the cutinal health centers went to capitation in ninety seven,so twenty, you know, five years ago. But parallel to that westill had a fee for service system. That those CMH's, if they arepurchasers in Michigan, the s images are purchaser and and providers. They're purchasingout a fee for service basis. So we can actually study the the twoside by side. Those CMH has made the conversion in ninety seven pretty seamless. They really got it. They embraced it because in the major driver wasit gave him greater clinical flexibility. So make up a number. If I'mgetting thousand dollars a month for a certain case as a case rate, Ican use that thousand dollars in all kinds of ways, ways that wouldn't betypically billable under a fee for service system. And that's when clinicians realize that theyhad the ability to improve quality of life, to improve recovery, sobrietyof its substance, abuse or full functioning at the tidd without having to worryabout do I have to get every widget accounted for it it has to bein some clinical setting. So I think that once people saw it that waytime they were liberated and I think that's how people need to really embrace it. So I would urge providers actually to post their payers to move to acase rader subcapitation rate system. Well, I think that's great suggestion because Iknow it's that apprehension or fear and your encouragement as a press in and we'rereally begin helping shape the system to work best for those we serve in yourorganization and have those conversations, and I would tell you I've seen the samething. I've seen more collaboration on those things versus kind of the binary aspectthat everyone was concerned about. And we all know the concerns that people havewhen you go to an outcomes based model and how can we each evolve andlearn together on it. So I guess last follow up on this is whatdo you see is the next fundamental shift on the horizon on this topic?Well, I think we're seeing more and more states in the Medicaid side andcommercial insures are pushing risk down to their providers, either providers as a groupor as individuals, and I think providers, I mean that's where we're heading now. It's going slow, I should tell you. On the Medicaid side, it's you now, commercial side states. It didn't do it during our era, late S, early two thousand. There's some resistance. Were seen,to be somewhat frank, not only providers are used to fee for service, but payers are are two and so a lot of payers say, Idon't want to shift the risk, I want to hold the risk here because, to be somewhat blunt, pairs and also keep the savings right. Yeah, whereas if you push the risk down, the provider then is instead of eyesto do things more officially, because...

...he or she can, if they'rea public body, reinvest those savings into services. If their private body,they can, if they choose, take them out in terms of profits.And I think that's where I must tell you that more and more I'm findpayers are more resistant than providers are. Providers have gotten their heads around alternativepayment methods, the APMs, but some payers, I'm not being critical ofthem, I understand they're they've understood the've had this model since the S,but changing from a fear for service to a more risk based capitation or caserate is a big mindset change. But you know, you can see ithappening more than yeah, the big shift for all people involved and I thinkwe're going to add it and involved through it, and I echo and agreeeverything you're saying. Well, let's move on to the next topic and andreally this one is going to be around the adequate funding. And so we'veseen covid nineteen, relief from legislation is imfused billions of dollars in grants andunder another funding for behavioral health providers. How do you frame this recent fundingand the context of the long time lack of funding that health to briders have, that behavior health providers have been challenged with? So the last part ofyour question is the key. You're talking about thirty or forty years of underfundingand I would say, I would say, by the way, that's true onthe public side and the private side. Well, the public side Medicaid andState General Fund dollars at Fun Service to the Boor. That's always beenas skinnying down. If you made a political hierarchy map right, people ofmental health conditions are towards the bottom of that. Only recently has their politicalpower began to be exercised. And so because of that and because, tobe blunt, some people don't still don't get the fact that mental health conditionsare real. I mean you'll hear in fact, you like you see mediicatedbut just go up for physical health care, but you won't see that from theair health care. So I think we're starting to beat the drawing.A lot of people are just say you've got to close the gap. Infact, covids making that happen. A lot of the money that's coming downto states and counties is our mental health dollars. One of the concerns ofthe publics that, I should say, is most of the money is reliefmoney or stimulus money, so it's shortlived, and yet the problems we're talking aboutare not shortlived. I I understand the rational behind it to say there'sjust a cute set of anxieties and depressions happening throughout the country because of Covidbut a lot of those were embedded already in our system. I mean anxietyand depression, psychosis, substitutes disorders, family disillusion, academic failure, we'reall we're all there, all of which, you have their roots and mental healthissues. So we're doing a lot of work to urge federal and statefunders to recognize those new added dollars will give them hopefully, we think,a new normal, not a shortlived a shot in the arm. If Icould, Tom could talk about the private side of been if you don't mind, absolutely, and I was going to hit on that here coming up atplease do yes. So I on the private side. There's been an underfundingto I mean most people who have commercial insurance or they purchase it on theexchange or they get it from their employer. Don't pay attention to beavoral healthcare benefituntil they need it and then they...

...realize most of those benefits cover whatI called A and Z, not a through Z, a and Z meaninga outpatient psychotherapy or primary care providers giving psychotropic medical mental health medications, orthe other end in patient care. But over the last forty years the publicsystem has built all kinds of interventions in between that, from residential to dropin centers, to peer supports, to homebase care, to employment supports andhousing supports. I mean the whole range of services. But rarely are thoseservices covered on the private side, and so what you have is a herehealthcare benefit that's thinly funded by private insurance, and that means by employers. Manytimes they needs to be broad and a lot of people, you knowthis and the commercial side, end up in the hospital or end up droppingout of work of dropping out of school because those intermediate modalities, which areproven, they've been around for decades, are and being used by the commercialside. So I would I would applaud any insurers who are willing to rethinkthe re here healthcare benefit that often comes from employers and payers. By theway, you know, the customer says, I think I need yes, actthis act team thing or this drop in team thing that I saw myMedicaid Gabor have. How them? I can't get that well and I thinkyou know you hit on and I can speak at it from an employer standpoint. It's number one thing that we're focused on every year is the evolution ofthat and you know, I think the goodness is is I look out inthe broader community, we're now having these conversations that we just didn't have fiveyears ago. So the campaigns around awareness and defeating stigma have worked, butnow that we've kind of moved into the next magnitude of the next challenge,and it's really twofold there on the funding piece that you hit on that I'mworried about and one you just hit on the private side. And how dowe who are providing benefits continue to adapt in a line that we know provideproven treatments towards outcomes that are incredibly desired, that are not just a medical modelor physical model of care, and have that become part of the naturalevolution around these things. But then the other one you hit on. Ithink the biggest thing. I'm right about the funding is the surge is nice, but it was really addressed a gap that was already there before the pandemic, if we're candid about it. And yes, we were able to addresssome things across our communities. But when that goes away, I hope wewere ready to add it and evolve, because that gaps going to be thereagain unless we've done something different with the nail on the head time. Infact, the metaphor for me is the infrastructure built right. I mean we'veignored our bridges and roads and water systems for fifty years and now we areinjecting trillions of dollars into to sell them. Those will be spent over the nexttwenty years. Well, we need take take the same view of mentalhealthcare is part of the infrastructure. I mean it really is, and webring Nordon for this long. We know that we thrive as families, asemployees, as students when we have strong mental health, and so we needto make sure that the infrastructor there.

Well, Bob, I just gotI've been on a Mental Health Task Force Committee here locally in our community becausethere was a desire to rethink how we as a community. If we havethe notion is to have a healthy and thriving community, it doesn't just happenthrough fancy campaign slogans. There's got to be intentionality and there both in theservices that are offered, how we offer them, how we connect even downgoing down to co responders, and how we engage in when there is atime of crisis. So, on the positive I'm seeing it happened your connectionto the infrastructure piece. I think there's a bigger conversation that we have tohave as a society and that is how are we going to fund these thingsif we want the outcomes around healthy and thriving communities, which is obvious,exactly right, exactly. Let's move on to I think you and I couldtalk a long time about that when I'm going to move on to the nextone, which is around integration with primary care. So, and we hiton a little bit around modalities are outspanding. Opportunities for providers are expanding order they'rebeing asked to expand. So another key element an impacting the delivery ofour behavioral healthcare services is the focus on whole person care, integrated carew there'sa lot of different words or buzz words that we use around that, butessentially addressing a person's mental health, substance abuse issues or potential substance of bucieissues. Also throw a social determinants of health within that makes and physical healthneeds. Now, you and I've grown up in a medical model, physicalmodel, these others are there now. So I got to know what areyour views on the integration with primary care? What works, what doesn't work andwhat needs improvement? Great Question. It's really fundamental to our evolving healthcaresystems. I always start with the premise of we have to define integration fromthe client or patience perspective first, really, because it's he or she is saying, if my care was integrated, it would look like x. Nowit turns out it's very different for people. Right. Here's what it doesn't mean. This is where we have a debate going out across the country.It doesn't mean there's a single pair meaning, and I could I hear people saythat if my insurance company was paying for physical and behavioral man would itbe integrated? And I ask most people who have commercially courage is that whatyou see in your own world? Really, are you finding your behavior healthcare provideris talking to your primary care provider or your primary care adjunct specialist?No, and yeah, you have a single payer. So the reason Isay that is it's on the ground as a term we use on the ground, where the patient or client is served, and some of the models that workreally well, and again this is driven by the client or patient,and colocation models work right now. Some people think co location is not sufficient. However, if my therapist is down the hall from my Primary Care Doc, my chance of walking down the hall upon referral is a lot greater.Yeah, if my doctor says here the phone number. In fact, Idon't know if you've seen some of the data, the take up rate.If my primary care doc says you seem to press to me, Bob,here's a phone number. Whyn't you call the outpatient clinic, the take uprate for that is almost zero. I...

...mean, most people they lose thething or they forget about it or that anxiety they felt was relieved a littlebit by having a phone number they don't fallow up on or they're embarrassed byit. If I could just walk down the hall of my Primary Care Providerand get it under the guys a primary care I'm not worried about bout stigma. It's true. The other way too, colocating primary care providers in mental healthsettings that are meant for supere people with serious mental health conditions. Sowe're, for example, of iy have schizophrenia. Actually, my health hohoneis my metal health provider. Yeah, or or Vive Down Syndrome. Myhealth phone is that provider. I might want my primary care provider there soI can see them there. I don't want to have to go to aprimary care site. Now I shouldn't. That's not true for everyone. Forsome people integration just means please share clinical records. So that's another model thatwe use a lot. So, yeah, I don't really watch in the samebuilding effect my primary care provider. I want to be at a changethat one or my mental health one, and I don't want to have tolose that that link. So please link your clinical records. The third onewe see a lot is high utilizers. So there's some people in our communitywho use a lot of mental health care, a lot of physical healthcare. Ambulanceruns Eres and fine with a molocol. Complex Care Management. If some adultcomes alongside me and says hey, Bob, I see you go intothe R A lot. What's going on? You know the old story is sometimesthe person says, well, I'm lonely or I'm cold or I coulduse a meal, but those are the social determiness could be sold very easilywithout an expensive ear run. Or the person might say I keep losing mymedications, and so we realize I got to make sure I get to yourmental health meds every day. I'm going to drop off for every week orevery month. So it's that kind of when I say integration, it's whatthe client or patient needs specifically. And those three models the ones who seemost often. Colocation, Mr Ehr link, and or how utilizers and even howutilizers are driven by data. Right. People need to know where are thehigh number of encounters in the cost encounters happen? Well, I meanI've seen all models now and we and in my vocational role I serve allmodels and I think you hit. You know, the one that I've seenworks so well is the more we can make that immediate connection, the betterand for the for the clinician and the care providers. That contextual relevance iscritical and it can't be how do I go get this other information? Andthe more we can quite candidly untether people from technology and really use technology toempower them so that, whether you're a working on physical health, you havethat contextual relevance around the social determinants or the behavioral health or, on theopposite, that if you're a purely focused on placement, on a vocational roleor addressing homelessness, that you have that other context available too. So Ithink the goodness is those things are happening now. You're seeing everyone get innovativearound the models. Yes, in your point around for you're seeing that partnershipor collaboration. I think you don't always have to solve it within your ownorganization. You can go work with someone... just editing involved from there.And biggest challenge I get asked you know, hey, what are your thoughts orwhat do you see in the community you serve? I say start withsomething and and are it won't be perfect. There's going to be something that workreally well and there's going to be some things. You know what weknow and what not to do now and I think it will evolve in abig way. So exact. I'm glad you said that because it's interesting thing. When this movement started about fifteen years ago, there was this insistence onperfection. Right, unless you're using the high end Samson model, you aren'tdoing it, and so people stayed away from it. They said I can'tafford it or can't find a partner. I agree with you. At leastcozy up to it. In fact, it's pretty organic. Right. Onceit starts, the relationships get better. I'm going to echo something else thatyou said. I know this may be longer than we hope, but thisis you is perfect. It's good. It's good your your points a goodone and that you don't have to invent it. For example, I'm abig believer invest in breed. So if I'm a really good providers, kidsare trying to recovery services, I don't have to open my own behavior primarycare clinic. There's one down the street or there's net you. We seedown the street. I can partner with them and they say I don't neednow open a service that's really great at treating people with schizophrenia. I canactually party with Bob, who's that therapist. So I'm seeing more of those woventogether. What it's called rated funding. It's braided clinical work. You've braidthat clinical work and then the client, the pace is getting the best ofboth special tapes. Well, I then maybe a follow up discussion weneed to have, because I think people are interested in those models, butthere's not necessarily a playbook on how to go make them work, and there'salso some lessons learns that we've shared and I think when you're each trying tobe each other, those models almost never work. But if you appreciate theeach there, what you bring to the table and you can compliment, man, some amazing things can happen. It's stunning in fact, because then you'realso both keeping up on your own fields latest you know, and that doesn'thappen when someone tried to be an Omnibal provider. Are just seen it.They become a really good at one thing and they're using something that's fifty yearsold in the other, and then our clients and patiences are better than that. I A hundred percent agree. Well, I'm going to I'm going to comeback to you. Talked about private and public so our next topic isthe roll of public and private sector and the service delivery. You know you'vebeen a leader and an advocate for public health services in Michigan and nationwide.What are your thoughts, if you can expand a little more on this andregards to how public can providers can work together to achieve the best synergy?You you touched on a little bit out and a couple questions before, butthis is which I hear a concern out there. You know you you're seeinginvestment come in from the investment firms and and the people who've been serving thisin a nonprofit. where. What does that mean to me and where doesthat go? Let's hit on this one because I love for you to shareyour thoughts on you know, my belief is less fear and how can weplay offense together in this area better? We agree completely. So I havesort of a territory map in my head, mean a public and private responsibility oneand the private side. What I would...

...say where the private sector is hasan obligation. Also really good is in the commercial insurance market, either exchangeor when the employers paying it. Secondly, there's a lot of great private providersand so I think those two things are really good. And the privateproviders, by the way, can play in the private market and the publicone. So just keep that in mind if you don't mind. The privateproviders can play both. The private payers can play and I would prefer whenI look across the country, where they work best is in the commercial market. For the public side plays is in the public payer for the Medicaid benefit, or what I called the public patient. You know, people without any insuranceworth Medicaid and this doesn't always go well. But I've seen in stateswhere they've given that payer roll to a private sector firm. It looks alot like a commercial benefit and in the commercial benefit people forget insurance model isright. I want to make sure I can withhold enough money from service deliveryto pay a profit. Well, that's not what happens in the public pairworld, the public payer world. I'm gonna send all the money out,only keeping enough to have enough reserves to cover risk. There's no profit tobe taken on fact that salaries even of the public sector payers are far lessthan the private sector. So their admiraate is lower, and I think that'strue of the what I call the organizer End. So all the providers onthe ground don't have to be public providers, and I can, as I said, sorry, best partnerships are public providers and private ones partnering up.But there's an organizer role in every community. What a check call is safety netorganizer role. That says if you're a medicated rolling or if you're aperson in poverty without health insurance, you should be able to rely on apublic utility like body who organizes that care, whether it's a private sector provider poolor a public one. And that's a rule that can't be played bythe private as well, because there they don't have the same legal obligations ormoral ones. I'm not faulting them. They have a market driven one andthat's appropriate, but it's not appropriate talking the most vulnerable and the most orsome of our poorest members in our community. They need to be served by thatpublic sector who days no dog in the fight of related to profit.They have a dog in the fight relates of quality and coverage. So soI think that that's how it can play and some of the best partnerships somewere trying to build across the country. Bring a private sector health insurance companywho understands physical health management really well to it with the beheral healthcare firm andthey form a joint venture where they share in the savings and the risk.But what the behaval healthcare side brings to the table is this what you mentioned, the social determinant focus, this whole person focus, and what the hellplan and it's primary care network brings to the table is how the physical healthwork, and I think those are the ones that we're going to be seeingmore and more. So in your map. Isn't fair to say there's enough roomfor both entities to exist. And while there's some similarities in the missions, there are some differences within the missions that I think you know, andthey'll be some overlap. I don't think there's any question about that. Ithink there they will be an evolution that comes from that and I'm as metransparent. One of the things I know my non non nonprofit friends are worriedabout is great, they'll take two things...

...that work really well and they'll leaveus with the things that don't, continuing to squeeze and burdens. How wouldyou answer that, because it's probably the number one thing that I hear frompeople around but I'm yeah, and so there's a metaphor for and I'm notsure everyone wants to hear this, but the metaphor it is the one timeyou had a single thing called the postal service, right the post office,and it was your only package and letter carrier and it carried to everybody frompeople who you know, and it was like eight or n or nine cents. was always below the actual constant. I'm not sure that was appropriate,by the way. But then you had fedex and ups come in and saywe can actually take that market. Of course what they're taking is the mostlucrative market. They don't serve every little borrow and and Berg across the country. That's not to the postal service. And you have people say the postalservices going broke. Yeah, because you you creamed right, you you cherrypicked, and that's and that works and I have no problem that. Thepartnership would have worked and could work if we, as a public then said, well, what would it take then to fund that Safety Net Public PostalService? Let's Fund it right. So it may be the S and itmight not be all stamp driven. By the way. I may pay thepostage. I'll make up a number of a buck and a half to senda package, but it turns out the feds or paying the other buck anda half because it costs three bucks. And the reason I say that isthat isn't mismanagement by the postal service. That's all the good clients or customersand markets are taken away by the private sector. So I have nothing wrongwith that. If we admit that to say we don't mind that, that'sa good partnership. However, then we as public need to fund the safetynet rule, and the Postal Service serms is the same safety net that Ithink the Public Mel Health System serves, and in ours it might be crisisservices or, as you said, mobile teams going out with the police.Those are all public goods the public expects, and so let's fund them because thosearen't lucrative. You know, no one will get into that the privatemarket, but public good that people expect. Well, in your seguating into mynext question in the last one here, and this has been great and you'vegot my mind spending on a bunch of different sub topics I would loveto get into and I you know I agree with you, and that is, you know, in the way I say it is we're funding those things, whether we want to be candid about it or not. They're just notalways in the most optimal way, whether it's in an optimal outcome in regardsto how we may engage in a crisis in the community or around the efficiency. So I believe, you know, that the we got to have thatconversation as a society, that the safety net is essential to our quality oflife, to the opportunity, accessibility, affordability, and we need to bevery pragmatic around those things and help people who have raised their hand and steppedinto these roles that are very essential to our life and give them the resources, tools and funding to do the amazing things. And that's really the segueon the last one that I have here, which is changing community expectations. Sowe know that the engagement you and I've just talked about in mental healthand substance views issues continues to increase and...

I think that's through a lot ofthe efforts. We're seeing that happen. You know, mental health, FIRsaid, is a good example, that wasn't even a word many years agoand now it's a phrase that people understand, that how we connect in help aperson in need is different than person in a physical crisis. This isdriving the expectations in the opportunities for expanded services as you just talked about,such as mental programs, not just in the traditional setting but also in schools, in creative programs, law enforcement in our justice system. So I wouldask you how does this impact your members and other providers around the country?You know, I think that you and I talked about some of the threatsand cocouragements in our system, but this is one of hope. I thinkmore and more people expect to get access to mental healthcare. In fact,they're more and more expecting to talk about it. I mean, I've beendone in the last twenty years. People wouldn't have mentioned depression or antidepressants everright in in a session or if they were joking about it. Right nowpeople talk about it because it's real and I've been impressed at that. Howoften people talk about depression and anxiety and sums use disorders and recovery as ifwe're talking about getting over physical health. Health conditions. So I think it'sreally encouraging. I think because of that, though, they're expecting us to performright. They want the system then to could you help help me recover, you know, and it's a little bit different than physical healthcare. Peoplekind of forget that with physical healthcare you could often get a shot or geta bone set right and even if, even if you're a non compliant patient, unless that's true for everything, but if your noncompliant patient, your codewill go away if you just take the medicine. But with mental healthcare youhave to also do something almost beyond that. So if I'm taking medication for Antidepression, they might also say, you know, be good if you exercise, Bob, or if you hung out with friends or if you got areligious life or if you ate better or slept better. So I have tosort of take on a wholee prison orientation myself. I think people are gettingthat. They're saying I willing to do that. So I think that's key. You mentioned a couple other expectations and that's why we've seen the really hugegrowth in what are called treatment courts. Right substanct his. Course, mentalhealth cores MESSIC violent courts. People are saying we shouldn't just be locking peopleup because almost always, we remind people, that person's life gets a whole lotworse. And by the way, sometimes there are family members or victimslives to get worse, and so we're not only paying an economic price buta social price, sometimes a physical price. So I mean people are saying,let's intervene early, let's in lieu of being arrested, let's have crisisteams be out with law enforcement, let's train law enforcement officers, let's trainemts. I'm going to health condition. Let's train teachers. Across the country, including Michigan, there's been a lot of support across the aisle ours andthe D's putting money into school based mental health. They're realizing if we cando that in a non stigmatized setting, that kids academic performance can go throughthe ceiling again or maybe for the first time, because we're addressing his orher mental health needs or substance abuse or their parents. So I think theexpectations are high. And my last one...

...time is people do want crisis support. I always joke that no one knows about the crisis system for mental healthtill they need it and it takes some days to find it. By timethey get it, it's not funded sufficiently. So, I've said, people expectthat, whether they know it or not. And if they could,if we could help people understand there are tax dollars needed to support a ubiquitouscrisis system that's available seven whenever you need it, I think everyone's lives wouldrun a hole. Last mother, because a little bit of crisis invention earlyon selves a problem that can't be solved in an ear or in a policestation. Well, and I think you, you know you as you began.There's opportunities here for providers out there, and that because there's new open mindsetto venues of care, types of care they didn't exist even just afew years ago, and so I think that creates an opportunity not only toexpand modalities but services and where you offer those services. And Yeah, whileyou're existing, kind of how how things were operating for you will have changed. I do believe, and I tend to be an optimists, that newones are opening up that can that can augment any change within those organization.That's exactly the right time. In fact, the big one we saw over thelast two years is tell a health we've formed, to tell a healthresource center here to push it and holy smokes, folks have really gotten it. Not only audio video, but audio all the we've had a lot offolks who said I like talking to my therapist in the phone on my psychiatrist. Actually I don't want them seeing inside my house, you know. Yeah, and that makes a lot of sense. Some people do better with audio andvideo, some do a facetoface, and so it's two more tools inthe clinicians toolbox. Right, I can talk to you on the phone andmore and more payers are paying for it. Now we're hoping they'll continue beyond thepandemic because actually we just we just finish a research project that showed providersand clients like it a lot when it's used as one tool, not theonly tool, that audio and audio plus video are a nice adjunct to facetoface. Well, Bob, I'm going to bring us in for a landing hereand I want to first just thank you for the conversation today. I'm goingto ask you a question, just for a word or a statement or athought. And a time when people have dealt with more challenge more headwinds,more it burst city, more uncertainty than ever. I love for you tojust give your encouragement. What would the optimism has you spoke about that weneed to be focused on as we navigate forward in this closing minute. SoI think I would give forward. Sorry, time I couldn't do it to one. But one is community, that we're all in listening together, andthe second is Grit, a strength that put up with tough, tough,tough, and grow from it. There is resilience, the actual growth partof Grit, and the fourth is hope, and so I think we keep thosefour things in mind. Not only the pandemic unemployment and strife and povertycan be overcome with those fourths. And so community, Grit, resiliency andhope. And that is why, to our listeners, many of you suggestedthat we talked to Bob and then have...

...this conversation, because as we allare navigating some of the unique things to us, we are more alike thannot in our pursuits and helping other people, serving our community with great passion andmaking it different. Bob, thanks for sharing your insights on these verykey topics during this very rapidly changing time and to our listeners. If youenjoyed this podcast, please take a moment continue to give us your thoughts.Bob Is on here today because someone suggested that. We talked about. Thewhole intent that we have around these is connection and collaboration, and we believethe more we can work together, the more we can pursue the things thatfind us more alike, the better chance that we have to make a difference. And exactly as Bob said, around community resiliency, hop and grit,those are the things that will bind us together to make a difference. Thankyou all. Looking forward to our next conversation, Bob. Thank you andappreciate the time. Thanks, Tom. Really appreciated that. Net Smart,we understand the challenges facing provider organizations. Our team will help you navigate changingvalue based care models with solutions and services that make person centered care a reality. Will equip you with technology and services that provide holistic, real time viewsof care histories that inform better decisionmaking and better outcomes. visit us today atintstcom. Net smart serving you so you can serve others. Thanks for listeningto the net smart care threads podcast. Through collaboration and conversation. We canwork together to make healthcare more connected than ever before and better support the communitieswe serve. To ensure you never miss an episode, please subscribe to theshow in your favorite podcast player, if you use apple podcast. We'd lovefor you to give us a quick rating for the show. Just have thenumber of stars that you think the podcast deserves. Until next time,.

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