Netsmart CareThreads
Netsmart CareThreads

Episode · 7 months ago

Balancing Disruption and Collaboration: Defining the Future of Mental Health

ABOUT THIS EPISODE

Some things — just a few — changed in 2020. Are those changes here to stay, or are we only having a moment?


What does the behavioral health landscape look like post-COVID?

On this episode of Netsmart CareThreads, we talked about the future of behavioral healthcare post-COVID with Dr. Ron Manderscheid, President and CEO of the National Association of County Behavioral Health and Developmental Disabilities Directors and the National Association for Rural Mental Health, and an adjunct professor in the Johns Hopkins Bloomberg School of Public Health.

Here's what we discussed with Ron:


- “Modernizing” virtual care to engages all of a person’s providers to create a more integrated care environment

- Closing the chasm between community-based and institutional care settings to create a “center” while also respecting the recovery movement

- Embracing consensus-built (not top-down) data systems

- Artificial intelligence systems that support the provider...help them decide more quickly on appropriate meds or interventions

- Better use of good apps that are evidence-based

- We have to change behavioral health training practices

- The ultimate goal is recovery and the well-being of the persons we serve

This discussion with Dr. Ron Manderscheid was taken from our show Netsmart CareThreads. If you want to hear more episodes like this one, check us out on Apple Podcasts here.

If you don’t use Apple Podcasts, you can find every episode here.

Listening on a desktop & can’t see the links? Just search for CareThreads in your favorite podcast player.

Welcomed in that smart care, threads, apodcast were human services and post tocute leaders across the healthcarecontinuum come together to discuss industry trends, challenges andopportunities. Listen is we uncover real stories about how to innovate andimpreve the quality of care to the communities we serve? Let's get intothe show, welcome to DA show. My name is Tom, Herzo, chief operiting officerhere in Netsmart. It is my pleasure to introduce our guests today, Dr RonManderschide, a national expert on mental health, INSUBTIONC SE treatmentpolicy practices, issues intrance. That manshide has also served in seniorleadership rolls at the US Department of out and Human Services for the pasteleven years. He has brought a voice of county babrel health and IDD providersto Congress as Executive Director of the National Association of CountyBehavoal Health and development, disability directors. Welcome to ourconversation today. Thank you so much for joining us and taking the time I'mreally looking forward to some of the things that we're talking about ind. Iguess I'll jump right in with that context. You know this. Last year,we've learned a lot in probably I'm learning some things as well and inmany ways it's becomean excelerant for the things that we need to be doing. Agood example is tell of health. I think you and I both know those were meat,ideas and concests. We did see a lot of adoption and then overnight, til healthbecame the thing that were focused on so I'd like to really begin today withyour thoughts, Youre thinking the things that you're dreaming about, oryou challenge us when, as we look towards the future okay, yes, thank youvery much Tom for inviting me. I always look forward to working with net smartand enjoy doing these things. So let me also set the context a little bit in twthousand and twenty. So two thousand and twenty changed our world andbehavioral health. Not only did it change, I in terms of services andchanged T in terms of epidemialogy. We went from about twenty percent of thepopulation with behaviral health conditions to forty percent of thepopulation, with Bhehevro healse conditions. The translation of that whis we move from being able to serve about fifty percent of those people toabout twenty five percent of those people. So we have a huge agenda goingforward here of how we expand our capacity to serve more people in anerror where the number of people who need services has increaseddramatically. You mentioned virtual care, it's absolutely correct. In Aprilof two thousand and twenty we went at from the beginning of the month, whereeverything was interpersonal to the end of the month, where everything wasvirtual and a normal sequence of time. That probably would have taken fiveyears to accomplish because of the press of the emergency and depressedfinancially on organizations. It was accomplished literally overnight andwe've learned a lot about that. We learned for many people. Virtual careis to be preferred actually over interpersonal care t say that again,virtual care is preferred over in ar personal care. You think about that andsay. Why is that the case? It's the case, because I think virtual careequalizes the provider and the client in a way. That's not true when theclient has to go to the providers office for some people. However, weneed to learn more, some of Oure, very serious population of people withScizaprinia people with by polar disorder. Don't always do as well undervirtual care, so we have to learn how to combine and create integrationbetween interpersonal care and support...

...and virtual care for those populations.So two thousand and twenty was a very difficult year, but it was also a veryexciting er in terms of virtuality, basically Olo, I'm gonna ask you aquestion on them on that right there and just an jump right in so when youtalk about that being preferred, do you think that's just a moment, or is thathere to say I think it's hered to stay and an my organization and others in DC.We are working very hard to make permanence the financial changes thatwere permitted as part of the emergency through Medicaid, through Medicare andalso through private insurance, and I think very much there's very muchsupport for that in the current bitand Harris Administration. I believe thatwill happen. Nitsoy makes very good. Perfect sense so that obviously, andyou've already hit on it, we go from twenty percent to a forty percentdemand out there and we were meeting- maybe fifty percent of that before andnow that's reduced to twenty five percent because of the capacity. How dowe address capacity? But I think you know that's part of the agenda for thefuture. I'd like to spend a little time talking about. I think we have tochange our training practices. We could have very long conversation about that.Simply in terms of the number of people we are producing through. OurUniversity programs need to be increased, but also we need to changethe strategy of education. Not all education needs to be interpersonal.Some of education can be virtual. For example, I teach at graduate students,Tok Charl students at University of SOTHERN, California. All of my teaching,through an entire course with those people, is virtual. Their education isvirtal which allows me then to have a classroom of people throughout theUnited States that I could convene tonight at eight o'clock and work with.So if I modernize the educational process somewhat and we train morepeople- and we add virtuality to that- I think we can make a huge difference.We also need to enfranchise some of our providers, who aren't currentlyenfranchised, for example, metal, health, consullors, marriage andfamilies. Family Therapist. Some social workers are not enfranchised to be paid,as independent practitioners were working very hard in advocacy to changethat to enroll. Im were also trying to bring on more peer supporters who canhelp us deliver, support and care virtually in all quarters of our system,whether it be in community facilities or hospitals, are even for those peoplewho are in jail. So training is a huge issue going forward and must be on theagenda of Behavioral Health in two thousand and twenty one sowhen. Youthink when we talk about training you're talking about differentmodalities of training that we need to make it more accessible. How do wecontinue to ensure the quality of that training? That's been a bigconversation point that, while you can do things virtual, there are somethings that are missed and I specifically in those areas aroundbehebe help the interpersonal, an the communication becomes a fundamental toour ability to absorb and learn. How do you do that in a virtual setting? So togive give you an example of that remember, I mentioned the possibilityof hybrid type treatment where you combine virtual treatment withinerpersonal treat well. The same thing is true of training and education. Forexample, one of my students at the University of California at San Diegoactually is doing projects where they're doing joint training ofsachiatrist and primary care physician. So this is not classroom training. Thisis actually practice training in the...

...community where they learn how to worktogether, and we don't do much of that and behavioal health, so them novellearning how to work together with providers who aren't behavioral healthproviders. We can do the same thing with what you're talking about soperson needs the conceptual training on treatment. They also need the practicetraining on treatment of actually working with a client learning. How tocommunicate learning the nonverbal, cues and so on? We can combine this andmake it work. Another example of quick jumping ahead, his education movingrapidly in two thousand and twenty from interpersonal education to virtualeducation. The whole system went virtual at every level and we'velearned re: WHERE HAS IT worked? Well, where has it worked less well, and howcan we improve that? Basically? Well, I got to pick up on that because I'vebeen in healthcare for over twenty years now the health care it side andthe integrated care has bean this. This pursuit, this goal that we've all hadand contectually. How do you make that relevant for anyone you've just takenthat to another whole level, though, because it's not about a system'sapproach, that training piece where you have medical model or primarycharateers me or O' care, we're givers, studying and working together. Thatreally is giving ahead of the curve and making it or a standard practice. Thentrying to figure out how to do that and in existing environment. Can youtramble that any so so yeah so again, working with some students? We firsthave learned that we can create integrated care virtually and that hasbeen a huge boon. We had difficulty moving into integrated care after twothousand and ten in the affordable careact, because we said well, you haveto completely change your organization and how you do business and everythingelse we've learned with virtuality. You don't need to do that. For example, oneof my students in Boston, actually at mass general, has set up a system wheremass general sochiatrist work with primary carephysicians and ruralwestern Massachusetts. All done virtually so. The client comes in theclient can work with both of those providers simultaneously in the primarycare office in Rol Massachusetts and have access to very good psychiatricare. So that's the the service side of this training side of this. It's thesame thing. You know we can actually see a client virtually and we canpractice with a client Irchley. If we had a third person here. One of UScould be the client, the other two of US could be providers. We could beworking virtually and we could have a fourth person here, an instructor whocould be watching this interaction and say well, you know, run banter. IyDidn't do very well in that interaction and so on. You know he didn't payattention to Tom's nonverbal QS. Basically, so this is not impossible.Just have to start thinking about doing this in a different way and I'm goingto call it a more modern way than we have done. Some of these things in thepast, I'm looking forward thou turning the page on some of these things andmoving the agenda, but I think in some ways this disruption is open doors tous ad, if largely been barriers, because that's the way it's always beendone and it's forcing us to do a rethink on Itd. So I think on that,let's continue down this future thought and we talk about normal. What is notnormal and I'm one of the people who believe that we are shaping what thenew normal will be. I don't think we're in that now. I don't think we're goingto go back to everything that was so as you look forward and you've got greatcontexts and land at at national level...

...and education level and at thatprovider level and you've already mentioned the first one around training.What are the other things that we need to be thinking about? So we've alreadymentioned two on Weve Beent, some training. Second, one is integratedcare, which I think now is beginning to boss them and move ahead in the veryeffective way. We can talk more about that if you like, but I think there areat least two other things that we need to have on our agenda in two thousandand twenty one. One is the whole issue of building consensus in the fieldabout where the field is going and I'm speaking, particularly about the chasmwe have between a whole set of people in our fields, who believe communitycare is very important, that everything should be community care and, on theother hand, the set of people who believe that care in institutional settings isabsolutely critical and we have to have that. We need to be building the centerin here. These two groups should be working together. Their importantpoints on both sides of that discussion, which we don't hear if we don't bringthose pieces together. Bringing those pieces together can also help us bemore effective in our adpocacy for all aspects of the field advocacy at thefederal level edvocacy, so samps gets more money than hats had historicallyadvocay for verses, so Hersa had training money for behavioral health,which it hasn't had much of historically a CDC and the work thatCDC does on the Depression and suicide and so on huge opportunity here. If wecan work together toward the center of the field a little more and stillrespect the whole recovery movement, respect, peers, respect, consumers andson. I believe we can do that in need to do that. One other thing I want tomention, which I think is very important going forward- is the wholemovement that we have to pay attention to assessing the effects of what we doad, that we actually measure outcomes that occur as a result of care andmeasure them in a way. That is practical, straightforward, useful toour providers, to counties to states and so on, which we have not done verywell historically, and I believe companies like net smart and others aregoing to play a huge rall going forward in the future of doing that in a verypractical way. For example, I'm just starting a pilot in my own organizationto run outcome and performance assessments, ind four of our stateassociations. The goal is: They have the counties in the state work together.The counties report to the State Association them State Association,reports to County and State Association, Data Nationally and Soo, building ahierarchical system, but building it on the basis it consents is not me. Comingwith the brief priseing. You know. These are the measures you absolutelyhave to have. I learned in the when I was in the federal government. topdowndata systems, don't work, consensus, build Davi Systems, work very well andthey last much longer. So in this pilot, I'm trying to build this consensus onwhat types of measures we ought to share among all the counties and statesparticipating in the pilot. What measures we don't need to share andwhat measures we might share among some of the entities depending upon theparticular work they're doing, and I'm looking forward to that, because wehave not, as coudies really done as much as we should be doing in theoutcome and assessmentare. Why is it so important? It's absolutely criticalbecause of the movement toward value base purchasing which is upon us, andif you look outside behavioral health,...

...health care actually has moved aheadmore rapidly than behaviral health in adopting value base purchasing, it isgoing to be uponust in order to do value based purchasing. We have to beable to put reasonable outcome measures on the table for our providers here sovery, very important work that needs to be done in two thousandad. Twenty oneagain. I fo part of this. I we can almost do a four part podcast here these topics, because there's so muchto discuss so you mentioned training, so we covered that a little bit. Wetalked a bit about any Greato care, your your last two there I want to hiton in I'm Gon na I'm going to. Maybe take a different approach to it. Youyou talked about the need to build consensus or I'll use. Another workaround collaboration, but then also talk about what the effects are here.The measurements are, and when I look at those too, uniquely the barriersthere are finding common ground and in there is so much diverse opinion ongetting consensus and I'll, say the dreade board at times around some typeof standards or at least impli standards, because one of the big jokesin in our world or kind of things the wlcome mock, is if Youv seen one systemyou've seen one system, because we have a tendency to want to configure to someof our Var uniqueness, whether it's local state, regional or around somedifferent thinking and then the other ones are, is Agreeng on what thoseoutcome should be. I've got to tell you in a day and age, where we have a hardtime finding agreeven on much. How can what can we do? What can I do? Howwould you challenge us for how we really get to roll up your sleeves,Conco collaboration to find commonground on these two topics? El? Ithink you know so when I was a fed many years ago. A lot of the work I did wasfinding consensus among different groups on Dayta issues. Good examplewould be finding consensus among all the disciplines in behavioral health,upon what measures we should be using for our human resourcet. I spent twentyyears as a fed, actually working on that and there's a certain culture youdevelop of doing that kind of work. You have to first build confidence of thepeople you're working with that you're, not there to take advantage of them,putwing them. Any of that. You have to be a credible, balanced, unbiasedobserver of that process. Then you have to build support from them and then youhave to start on a small scale and build outward. I think you know we'retalking about behavial health, but if I step back for a second, I think part ofthe huge agenda in the United States currently and going forward will be.How do we find the center for things? It isn't just measures or it isn't just training or whatever it'sabout almost everything. So how do we build a culture that builds out thecenter and I think, they're good examples in the field? I think titerNoras, for example, at the well being trust, is one of the people and hisendity is one of the endities thats trying to build out the center in thefield and say well. No, we all can agree that well being and the wellbeing of you, your family members me, our community is a good thing. If wecan agree on that, then don' we need to start talking about well. How do weaccomplish that, and we get some agreement on- is to find some centerand you build out from that to try to actually make this happen. Think Tyleris a good example of that in the field. I'm also doing some work with a littleconsulting firm right now, where we're thinking trough how we would doconsulting with anybody could be with you. Itcould be with me. It could be with a...

...state. How do we actually find thatcenter and begin building out from that center, because I guess we in thislittle consulting activity, see that as the huge problem of the age in theUnited States and that it pervades every single field and our disparitybetween community care and institutional care is a good example ofthat in Beabro health or could be another dimension of that andbehavioral healls might be between different disciplines and how differentdisciplines approach, treatment or how different disciplines get financedversus not financed and so on. So there are a number of these areas inbehavioral health, where we need to be building that center. What I hear is- and I've not heard itphraise this way. I agree- We got to figure out how to common ground isultimately found at the center respects. The perspectives that people bring tothe table around those things, a novel idea, listen so do a lot of listeningin the process, learning together and sharing those perspectives. I thinksometimes we find ourselves in such a position. I know technologist can be very guilty of. This is where you havean absolute mindset or something that this is the way way it has always been.Or this way it needs to be, is really pause and be willing to unlearn thosethings so that we can arrive or shift into a new paradigme is whateverw. WhatI'm hearing you saying in a very unique way, if there's good to come from thechallenge of this past year, it's open the door that we've got to get here,because our future is dependent upon it and what we need to be doing yes,absolutely and not only the future of behavioral healthcare, but the futureof the IT industry. All of this is at stake, and what we're talking abouthere, Soi I'm going to Git to a couple other questions here, but I do want torecap on these four things that you just said to make sure that we allgrasp them and I'm taking notes here, the first one, because you talked aboutthe challenges or the opportunities and and speifically around capacity, and Ithink in the goodnesses we're all in Ou. Talk specifically to mental health atthis time is we're more aware of it now, because we've seen the challenge of itin at all ages of life and at the pandemic specifically or the otherchallenges of two thousand and twenty is really brought this sense ofundersteanding and managing our well being and moving beyond just thewindsheld of physical health. If you will and the way that we need toaddress that capacity is training at all else and Thad led to that to thepart of the conversation round. antegrated car is going to become moreof a reality because of how we pursue care that, when I go seek out care, I'mgoing to look at those things and seek both of them at the same time and thengetting the third thing that you mentioned is we've got to be outcomesbased? What is the measurement in the results around us an be willing? Ithink they have the freedom to talk about what's working but also what'snot working. I think that's part of that challenge of finding consensus ofcommon ground, and that was the other one that you mentioned. Is it's goingto take a unique collaboration, probably in a very temontuous time, forus to be willing to get to that center to rethink some of these things? So Ithink, on those four things I'm going to ask you ate past question in afuture question I'll start with the past futures always good. I think whenpeople get nervous is we're going to forgive what got us here and what aresome of the things that you would say that in this pursuit to reshape relearnor evolve ourself forward that we should not forget, has we take thesenes steps? I think you know absolutely crem. Ithank you for asking that, because I think you're asking again a very, veryimportant question and if I were to...

...answer that just off my top of my head,the type of thing that comes to my mind is we absolutely should not forget thatwhat the goal here is is recovery and well being of those people we serveand that they number two that they play a huge role in achieving that recoveryand well being just as the provider does, just as the county does and so on.Just as the state does in the federal government, and we need to respect thatand keep focused on that, it's very easy for recovery to go out of focuswhen you're dealing with an acute behavioral problem of a person who hasa very severe disorder. But if you step back and say well, you know that personunder another circumstance would be very different and has huge potentialhere as huge potential that we can help realize and bring about so the vision,keeping the vision in mind of where we're trying to go, and I thinksecondly, bad vision relates to outcomes. You know you've talked aboutdifferent kinds of measures of outcomes. I personally believe where we're goingin the longer run on outcomes is toward well being and the dimensions of wellbeing as our fundamental outcomes for health and for behavial health. In fact,in my pilot I would like to test some well being measures, as opposed to someof the more traditional measures will look at some of those as well, but inaddition to some of the more traditional measures to actually seewhether we can make a goal of wellbeing measures because I believe they're ahuge part of the future here. I guess the thirdly linking this together thatwe have to be able to do these things both interpersonally and we have to beable to do them virtually and- and we have to get the virtuality and theinterpersonal to work together. We were able to do one or te other. Now we gotto get them. You know. The hybrid car is a good example. It can run on gas orcan run on a battery. We got to get our care to run on gas, ER virtuality or ona battery. You know interpersonally, so we can do that. We can make that happen.So I think the vision here goot to keep the vision in mind and not get tunnelvision where we lose sight of what we're really trying to do here and it'sa noble goal. That goal one two and three thoese goals. One two and threeare part of social justice. How do you reduce disparities and promote equityin the population, particularly for people who have behaviro healthconditions? A huge huge agenda for all of us yeah? I think very well said- andI think you know in your pursuiting challenge to us to find common groundor consensus. We can all agree on well being is a community that has ishealthy and driving is one that understands wellbeing in the pursuit ofit. That is inclusive. There is a great inclusivity and quality and equitywithin it, and those really need to be a compass for us in that pursuin andthat's the part I think, of the as we look back. We got to continue to carryforward and I guess I'll send way that into my next question that you lookforward and you look at the technologies or the opportunities thatare going to be presented to us here we are talking about. We know that a rover is landed on Mars and now le Dida runer land on Mars, but then it had a helicopter take off drone to go circleMars and the wave of innovation and technology that is coming is absolutelyamazing, and I know you have a lot of...

...thoughts on this and would love to hearas you look forward if our men is defined by what we're willing to let goof, but also by what we're willing to grab a hold of. What are the thingsthat you're thinking about that you're. Pretty excited well, there's a wholenumber, and hopefully we have time to talk about a few of them here. So Ithink first, we kind of where we are today. There is a lot of excitementabout better use of good apps that are evidence based in the delivery of care.For example, the Food and Drug Administration now will certify APS. Ifthe FDA certificing am as an evidence base practice, it can be build, forthat is a huge transition in care that we're just on the cusp of beginning andin these various apps were in the stage of research where we saying well, if Ihave thirty APPS here, how do I match these thirty APPs to three hundredpeople who need care? Ie whichap belongs with which person and willfunction more effectively for that person. So we have to get into some andwe are getting into some predictive anlitting sword to actually make thathappen. So current Erra of activity, kind of a next Eira of activity that Ithink is very exciting, is the whole issue of the use of artificialintelligence as a support to a provider. So not every provider will know ofevery med or of every particular treatment. However, if I have anartificial intelligence system working with that provider, that artificialintelligence system can actually help the provider come more quickly to anappropriate med, come more quickly, Toan appropriate intervention and thenactually infect shadow. The provider as a shetprovider delivers care to make this happen. We have an interpersonalexample of this right now. They've been apersonal example of this type of thingis the echosystem at the University of New Mexico. So if I'm, if I'm aprovider and I'm having a difficult client with depression, that I don'tknow what to do with, I can work with the echosystem and I will be put into agroup with other providers who have that particular problem and theperson leading the process from the University of New Mexico will work usthrough the difficulty I'm using a person there. I could just as easily beusing an artificial intelligence system, and we will be doing that. I wouldpredict with it within five years we're going to have primitive systems that dothat and going forward ten to fifteen years, we're going to have more advence,much more advance systems. Thot. Do that so that's kind of a second example.A third example is it's overly simplified to call it this, but to callit a bio feedback system. For example, I can write now wear a smart watch thatwill monitor my blood pressure. It will tell me what my heart rate is. It willalso tell me what my galvanic skin response is. So if I'm getting stressedmy govanic skin response changes, so I can pick up a number of biomarkerssimply by wearing a smart watch. If I link that Smart Watch to assist of themonitors well, yeah Bron Mandershids biomarkers are getting. You know, hisheart rate is going up, is gelfanic skin response says Chan something's,going on with Ron Mandershide this afternoon at four o'clock. Then I can intervace. I can either havean interpersonal intervention with ron manner. Someone calls me and say wellwhat's going on this afternoon, or I...

...can have a artificial intelligenceintervention. I could receive a message and say they have a message AF here inmy computer. You know you seem to be having some difficulty, this aften, somixing biomarkers, with artificial intelligence systems and with providersI think, has again huge huge possibilities and in the in the limit,some the more extreme examples of this. For example, years ago I did some workwith Darpa the Defense Adens Research Project Agency. When I worked in theprivate sector already fifteen years ago, Darpa had the capacity of havingpeople wear helmets and fly an aerplane or drive a truck or run a ship withoutever touching the ship or the aerplane or the truck. Now with that PA. Takethat capacity. That's externally, acting on the environment, take thehelmet and make it internal. Potentially, we could use that kind oftechnology to be self corrective of people who are developing mental healthsymptoms. Symptoms is Gensoprena, for example, we just we just are not farenough along. So there are many wonderful dimensions of this that aregoing to come along again. Companies like Netsmart in the future, ten orfifteen years from now, are going to be playing in this world. So in diction toyou know, collecting data and processing data on services and onpayments, and so on. You will be playing some kind of a role, a parallelrole in this artificial intelligence world, where you will be an anchor forthis you'll, be supporting this you'll, be measuring this y you're going to beplaying in this world, so your world is going to change dramatically as well,and this the whole area of artificial intelligence is accelerating right nowI have more and more students who do work in that area yeah and I'm seeingmuch more literature about that. For example, I probably s seen half a dozenarticles just in the last week or so unartificial intelligence and itsapplication in the healthcare field. We're go oing there. Basically! Well, Ithink it's Funn, I mean you sit here and you share and express all this, andI think for many of us. This is what it's been all about. I mean, if we'recandid, the last many years has been about the digitization of a system,capturing data. If you will, and if we're candiate were transparrent honestabout it, it hasn't always been. The best experience for that in us arespecifically Teplinishen, because it's always been about what can the conitiondo for the system rather than what can the system do for the clonitionThatsexaan, and what I'm most excited about is we're now shifting into thatnext Erea, now that we played this digitization groundword, the thingsthat you're talking about are no longer dreams, they've become reality. Some ofthe things that we're doing whit, Ai Right now is my blowing. I am soexcited around getting to the practial applications of those things, becauseit's going to Empowerin a quit whether it''s a clenition, someone in anoperation or financial al to say. Have you considered these possibilities notto take decision making away? I think sometimes that gets lost in thetranslation, but is to be able to compile all that information in a in aconteptual relevant way, so that, as a connitions meeting with someone like meand saying everything that you just talk about hey ton based on yourbioparkers and base fon these kind of patterns, we gave you a call becausewe're concerned and we're- I think, for the in my kids in the generationsbehind us we're going to move away from this episode of Gara that we onlyarrived to a place when we had a crisis...

...to a preventative era. To say: Hey,we've got enough data, I know dums up, I am with you and in Thet. That term isright in front of us, but in saying that doctor I know there's a lot ofpeople out there. That's nervous! That's a significant amount of change.What role do I play? Can I play so? I guess for my last Question Year: Howwould you encourage that person who's listening to you right now saying youknow what that sounds really excited, but I it makes me anxious around thosesayings. How would you challenge or coach us to press into these thingsrather than see them? As you know what it may be too much sheat for me, and Idon't know what role I have in it. So I think you know you put your finger onit in your last comment. It's very important for the person to know whatrole they have in it. For example, when I was doing work onintegrated care shortly after the affordable charact, and I would go outand give talks about integrated care. I learned very quickly. I couldn't talkabout integrated care until I could reassure people number one. Youknow your position is not going to disappear. You know you're going to have a job inthe future and behavioral health. Your organization isn't going to disappear.I may change hits name or may be integrated or something, but it's stillgoing to be there in some form. If you don't assure people of their role insomething, then they won't hear anything else. You have to say so it'svery very important when you start these things that it's very clear thatyou explain what role that person is going to have in this change, it'sagain building from the center building a consensus with the person not comingand telling them that you're going to be doing something here. So I thinkagain, you know to go to your point. It's there's a huge opportunity ofdoing that and moving ahead fairly quickly, and I think, as we get changedin our field, the baby boomers retire more millennials come into the field,people that are the age of your son who's. Seventeen who, within you knowfive or six years, could be in the field. Your son who's. Seventeen is an aviduser of technology, he's not scared of technology. He knows what his role isin technology you're, going to get more and more people who have thatexperience. So I think they're going to be less people who are fearful oftechnology and more who actually understand the positive impact. Thetechnology can have disparities and equity. For example,the one of the huge benefits of the Internet is it equalizes people yeahand on the Internet, I'm equal to the president of the United States, becausewe both can. I can send an email to the president of the United States. Are thepresident, United States Consendeng. So to me, the Internet, equalizes Ology,also equalizes, and we need to bring people along and, as you say, they needto understand what their role is in the process and I think that that's doablejust as we talked about training earlier, it's do well in many ways inwhy I know we don't have time to dive into this. Topic is you're speaking tothe social determinance of health, education, access technology and really,I think, that's. I think the world needs to change it's. No. It will nolonger be social determence of ealth because that's almost a retrospectivelook, it needs to be social determinative care, and what can we doto bring those equalizers that impact are helth everywhere? So, let's land onthis tougt conversation? This is great you'vegiven us a lot here. I've got two pages...

...of notes now and I guess I would askyou is as we began looking forward, we probably come off he one of the hardestyears. Most people have ever experienced and we've all learned somethings over last year about ourselves. I know introspectively, it's been agood time to often maybe some arteredges in my own life become betterpursue better. What things have you learned or you would encourage orchallenge us as we go forward, so you know I probably have had verysimilar experiences to you learning things you know. I give Givean exampleof that I've learned that you know if I walk down my street and I look atthings I can see a tree or a flower or a little dog or whatever a neighborthat I never did before. I drove in Park my car in the garage, and it'scaused me to be much more open to the environment and things around mebecause my whole environment became smaller. My environment used to be likethe United States. I woas now my environment is much more. Myneighborhood the office, I'm sitting in right now. My House, my family and soon, so I think we've learned to have greater appreciation of the realityright around us that we kind of lost in this broaderworld where we were everywhere, but in effect not really anywhere as stronglyand having an emotional connection to that environment. So I think that'sbeen a huge learning that I've had my wife has had, and I think a lot ofpeople have had that. Another basic point is to appreciate the very simple things very you know wwe used to take for granted think nothing of going out to dinner on aFriday night. Well, O you haven't done that that that's just ethe, mostfundamental and simple thing. We haven't done that yeah and greaterappreciation for those simple things that we took too much for grantedbefore, and I guess the third point. My finalpoint that we've learned that we can be resilient in this process here that weneed to recognize. We know there are consequences if you quarantine. Youknow there are consequences if your children are home from school, workingon computers at home, Eah, etcee, etceter, and that you need to besomewhat flexible and adaptable and resilient and kind of go with the flowof those changes. You know you aren't going to have the wholehouse toyourself if Yore Otin er there, those kind of things, so I think there'vebeen a lot of learnings that are very positive here in this hugely negativeenvironment. Where now we're beyond five hundred and fifty thousand peopledying and now we're in an upswing again, and so on and vaccinations, we need toimprove and get them out there faster and so on. So I think, there's a lot ofpositive in effect behind the negative, and weneed to see both sides of it and I think it's healthy to see both sides ofit yeah. Well, what I I mean myg treat take away from which you just said,which are absolutely beautiful, be present when you're present could agreewith you more and I you know. I shudder to think of the Times that, while I mayhave been in a place, I wasn't really there. The second one is to be grateful.I started a gratitude journal through this process and ith's been really good.O Help me focus my mindset and your resiliency remarket couldn't agree.More is Adatan. Pivot somethings find us some. We find we always chooseforward and we can get better from them. So, Dr, I want to thank you for today,but also want to thank you for your vision, your passion, your compassionand what you do to impact, not only...

...providers that ar healthcare systems,but every individual. I know I am personally impacted by your work and weare grateful for all the things you're doing. Thank you for taking the time tospeak to us today. I hope you will join us again. I've gotten a lot from this. I knowthat I know our audience and listeners will get a lot from this as well andI'm looking forward to the next time. Thank you, sir. Thank you so much forinviting me good luck to you. Thank you very much. Thank you at net smart. Weunderstand the challenges facing provider organizations. Our team willhelp you navigate changing value, based care models with solutions and servicesthat make person centerd care or reality will equip you with technologyand services that provide holistic, real time. Uws Of Care Histories thatinform better decision. They CEN and better outcomes visit us today atNtstcom netmark serving you. So you can serve others thanks for listening tothe net smart care, threads podcast through collaboration and conversation,we can work together to make healthcare more connected than ever before andbetter support the communities we serve to ensure you never miss an episode.Please subscribe to the show in your favorite podcast player, if you useapple, podcast, we'd love for you to give us a quick rating for the show.Just have the number of stars that you think the podcast deserves until nexttime.

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