Putting it All Together Building a Roadmap for Success – Part 2
Good. Afternoon to those of you on the East Coast and good morning to those of you that are joining us from the west coast my, name is Angie how's Orson I'm with apt associates and, I'm a part of the be his project, for Samsa, we, will be starting, our webinar in one minute we do still have a few folks joining, us so we will pause here allow, our remaining attendees, to join us and then we will get started with our presentation. At this time you will hear silence until we begin. I. Want. To thank everyone for joining us today for building, a road map part two innovative, and integrated treatment, models, increasing. Impact of opioid treatment programs, through care coordination, good. Afternoon to those of you on the East Coast and again good morning to those to those of you joining us from the West, we. Are here today we are going to discuss integrated. And innovative, treatment models and we're, excited that you're back with us hopefully for part two this is the, fourth in our webinar. Series addressing, care coordination and OTPs, before. We begin a few, housekeeping announcements. Our webinar is being recorded and, will be posted to SAMHSA's, YouTube page we. Will provide participants with the PDFs of the webinar powerpoint slide at. This time all lines are muted I would. Like to ask that all comments, or questions be, submitted, via the chat box on your GoToWebinar, toolbar. At, the conclusion, of our session we. Will have a brief Q&A session, and we, will facilitate. Those questions for our panelists. Again, welcome to the care coordination, for OTP, series this with SAMHSA's five part series we. Have been holding these webinars, for, monthly. Over the last three, months this is number four we, will have one more webinar, that will conclude our series that will take place in August of 2018. Again. All sessions are recorded and we have posted, our previous, sessions to the SAMHSA's YouTube page our next. Session held August 9th will. Be action steps for implementation and, our goal for that webinar is to wrap everything up that we've been discussing over the previous four webinars and it, deliver a set of action steps for implementing, care coordination, for OTPs, the, webinar will be held from 1:00 to 2:30 p.m. Eastern, time, we. Will send out a registration link via the health IT webinars, listserv, two, weeks prior, to the webinar please. Email health, IT webinars, at ABT, associates comm. To, be added to our list. On. The screen here you see our agenda, so. We will begin with using, technology to, improve care to presentation. By rate Tomasi from Gosnold on the Cape we, will follow that with three models of care coordination, by, Linda heard Lee CEO. Codec and then, we will have closed with open discussion, and comments and final. Information about our last webinar to be held in August. At. This time I'd like to introduce you to raid Tomas he's the president and founder of Gosnold, innovation center Gosnold. On Cape Cod he's. Going to be talking about the technology, to improve care and I. Hope that you enjoy his presentation, the information, he has to share with you is incredibly, fascinating, and, obviously, very relevant in our technology-based, age right, I'd like to turn it over to you. Thanks very much Angie. I'm happy, to be here today it's a, nice, day in New. Jersey where, I am actually doing this from but also, on Cape Cod, by. Way of background, I. Have, worked, in this field for, over, 40 years. 25. Of those years as, president.
And CEO Gosnold. On Cape Cod which, is a multi-component. Behavioral. Health organization. With prevention. Treatment and recovery services. And. Following. A transition. And succession, planning I have. Instituted. What we, identifies, the Gosnell Innovation, Center and I spend a lot of my time now working with folks who. Are thinking about new ways to approach care, to. Organize systems, of care and to deliver that in the in, the new age of. Addiction. Treatment in healthcare, so. Just. To touch on, some. Of the points that we want to try to cover in my time today I. Want. To give a little bit of context, for this discussion, and talk. About what I see as some trends, in the addiction treatment field. And because, it is a rapidly, changing field, and. Then, what is the role, of Technology and. That, new. System. Or of paradigm, and how. It can technology. Be better used to coordinate care across across, the spectrum, I. Will. Give you some examples, of some options. Technology. Options that we've use that we've tested and. How. They have impacted our, ability to, think about. Coordinated. Care and also how they've impacted the, some, of the. Philosophical. Frames. That people have existed, in for many years in our in our field and finally. What. I believe, are some barriers to implementation some, of which I've. Encountered, personally. Through our own initiatives. And others through, talking. With folks that are doing similar types of activity so I hope this is useful, and, certainly. This is a snapshot, of. How. We. See technology's. Role many. Of you who are listening to, this today are, doing, your own thing and. Figuring. That out so I hope this expands. A little, bit your thinking, and helps. You make better decisions, in the future because this is a, an. Issue that is here to stay. So. I'm accept that and let's just put a little context. On, this. Certainly. The. Opioid. Crisis. Has. Really. Driven interest, as you all know in our field the current, state of activity, is very broad across, multiple. Sectors. It. Has done a few things in terms of helping. Us understand, and helping us have. Society, understand, so I think we're, seeing an increased, understanding of, the chronicity, of SU DS this. This historical. Frame, of. Kind. Of like go, get some help and then that should do it and you should be flying which is contribute, to great. Misunderstanding. I think that's changing I think. We've seen a general. Dissatisfaction. Without. And even changes, in how we define, outcomes, and, I think that controversy, is still, going on, we're. Talking more now about periods, of remission and, can proof functionality. And the idea that someone. Would never. Use substance, of the game and that essentially. Would define success or. Failure, I think, that's a changed. Concept, certainly absence, abuses, are objective. But. Recovery, and being, seen as more and the idea of lifetime, management, of a chronic illness, is. Becoming. More apparent also, and. I also think that we we, have had, some, changes. In our field but for the most part, we've. Had a static, model of treatment. Essentially. Defined, by inpatient, care primarily, and then, hopefully, a transition. To an outpatient. Service. But I think that, as. We move toward, a broader. Accommodation. Of population. Health. Alternative. Payment models, as systems. Begin to recognize, that costs. To. Them and risk, the. Risk that they're assuming, in some. Of these contracts, the incredible. Comorbidity. Costs with both. Mental health and addiction, is forcing. The. Healthcare, system. To think about this in a more comprehensive, way so. What. We see and what we've experienced. Is a, move, toward, application. Of interventions. And ideas, around the chronic care model with. Early, intervention prevention. Integration. With, primary. Care and specialty care, of, practices. Hospital's. Emergency, rooms, these. Are things designed, along. The lines of how one would manage chronic disease so you try to identify earlier. Do interventions earlier, and hopefully have better outcomes, on. The other side in terms of reductions. And readmission, we're seeing extended, patient engagement recovery.
Coaching, Is widespread. I. Hold. Family involvement something, that we've all done, but I think but, that would be dead or better defined, by talking about whole community. Involvement, so that understanding. That, the social determinants. That impact. Outcomes. In, this way this disease, are significant. And so with respect to coordinating, care will, be talking, awful. Lot about coordinating, care in an, internal, organization. But, certainly, the future is to coordinate that care with. Similar. Entities, in the community, that contribute, to the. Health of other patients that we serve. You know medication. Is as medication. Is and, the. Controversies. Will. Subside. But. We won't touch on that and awful I know Linda's going to talk a good deal about that certainly. Much of what we're seeing is being driven by alternative, payment models, the, need to begin to think about taking on risk, about. Collaborating. With larger, entities, about, looking, at bundled payments, all of these things that. Take us away from the fee-for-service environment. And. The, episodic, delivery. Of care will, force. Us to think about ways to stay engaged, over. Time to. Help our patients stay. In remission and I think that's the place, where. Technology has, great potential and so technology. Both, in both in terms of intervening, and assessing, treatment. Monitoring. These. Are all very. Real, things. That we can no longer pretend. That will, not change, our field they will definitely change, our field that's. What we're up against, and then, you. Know if I would I bet. If this is a sort, of repeated, much of what I just said but I wanted to put it on because it's important. To. Mention the surgeon general's report and, if you haven't, read it you must. Read it because it is in fact I think a blueprint, for the future of treatment, prevention, and recovery, and, there are references, throughout that to the need, for coordination. Of, care, for. Full, spectrum. Addressing, the problems, for. Connecting, and collaborating with. Other, entities, you can see in the middle of that. Leveraging. Technologies. Whether. It's patient portal, or health information exchanges. Treatments. Assessment. They, should monitoring, all of those things when themselves. Very. Very sufficiently, to technology. So it's. A long report you don't have to read it in one setting, but it is a something. That should all, geared overtime because it is very. Very relevant to, what we're doing today I. Often. Go outside, of the behavioral. Health field to look for ideas and. Generally. A new idea but I I wanted, to just sort, of refresh our thinking. About care coordination and. And, particularly. Point and to. Some key words that I think are, relevant. To, our field and I think we go down this list very quickly, the. Key words here, one. Is continuous. And I think continuous. Is, you, know versus, what we have historically, looked at as. Siloed. Episodic. Care. Element. The. Continuous, nature of our need to stay connected. Sort. Of defines, the chronicity, of the. Disease that we treat. Customization. Customized. Service. Delivery. Elements. And I think this is very much sort, of patient matching, patient-centered. Not, the historic. One-size-fits-all. Idea. That has been prevalent in, our field for many many years the, idea that the patient, begins to, be. The source of control. So. Bringing. The patient much more actively, into decision-making. Around. Their care the, direction, of their care as opposed. To a more prescriptive. Approach. And tick, technology. Actually, plays, a very big part, in that because, the, patient, has the device, in their hand and, and.
They In fact are, making. The decisions, about when to use it how to use it and how. That information, gets shared. Shared, knowledge free flow that sort, of inherent. In the concept. Of coordinating, chair but, it does run against what has been the historical, sort of vertical hierarchy of. Thinking. And precision making, and information, that. Also. I think been tantamount, to how we have delivered, care in the past in other words we've. Got the idea here's what you do you do this and you know things will be better, hopefully. Evidence-based. I asked a word that's tossed, around. But. I think it's, certainly. Important. To talk about that and to incorporate that, kind of thinking, into all the decisions, that we make anecdotal. Experience. Sort of academic readings. Have to be, poor. Put to the side and we need to do things that FN demonstrated, to to, work. The. Other point I'd like to make on, this slide is actually the anticipation. Of me I think what. We're talking about here, also. Has. To do in some. Way with the idea of predictive. Decision-making. Can we begin to have, a, way, to. Anticipate. When. Patients, are going to need interventions, well before, the. Crisis, emerges. And then that that intervention, has to happen in the, moments, coming so I think historically, we've had more of a retrospective view, of things but. The idea of anticipating. Predicting, it's another place we'll see where we've. Tried out some ideas, and technology. That that. Can help us do, that and head, off, crises. Or limit, the damage, when. People have regressions. Or relapses. And finally. Collaboration. I think this is easily, said, but sometimes, difficult to do because historically. There. Has been sort, of the ownership of the patient, if you will what, we're talking about now to really, affect better outcomes, is, not. Only cooperating. But collaborating. Across the spectrum both internally. And that's sometimes that is easier to sound and. Externally. With, with the community, resources that, our patient, need. And utilized so, this. Is obviously it says from cancer care but all of these things are very very applicable to what. We're doing and terribly. Important, in. Linking. With technology. So. You. Know, just. What. Are we facing and, why why technology, other, than the fact that it sort of exists, there's. Some really startling, pieces, of data that I would refer you to, the. Most, critical I think and the one I got me very interested in in technology. Where the where the projections, about works for, shortages, I don't tell any of you that, getting, good qualified. People to, work. In, your organization is. Not an easy thing the HR, person is now one of the most important, people in our organization.
But. Put some context. Around this the projection. You. Could go to the. November. 2016. National. Center for work force, strategy, document. Projecting. About a. $225,000. Person. Yeah by the year 2025. Those. Gaps seventy-five. Thousand mental health or. Addiction. Social. Workers and counselors. An. Equivalent, number of school counselors, schooled, clinical, psychologists, so we haven't a workforce. Shortage that in my view we, will never be able to hire a way out of. The. Same goes for psychiatry. It's you, know that many of you know this but to. Refresh you. 60%, of the United, States. Like. I--it rest' and. This. Was actually surprised, to me but I third. Of all of the psychiatrists, providing. Care in 2015. Were, from a foreign medical school, immigration. Is terribly, important, for our field. That. You may want to go to something, called a new American, economy it's, from an October, 2017. Publication. So. We need, to figure out a better way to. Deliver, care, and. We know that in our experience the technology. Can improve access in, hard-to-reach areas particularly rural areas, we, have a clinic. On the island Evan Tucket which is a great. Place to go at least for 10 weeks during, the summer on that let, me tell you and Daniel in February, not, exactly, a destination. But. That certainly can help at particularly, in areas that don't have, qualified. Face-to-face. Opportunities. The, whole idea, of. Extending. The relationship. With patients and engaging with them between. Face-to-face. Sessions, what I call a digital Luke, you. Will see how some of that has. Affected. Some of the things that we've done again. We've talked about locus, of control the. Other issue, here with technology. Is that we do have a capacity. Through, some instruments. And tools. Technological. Tools that. Will that. Have the potential, to improve, access to care by giving clinicians. And an additional. Tool. To. Help them complement, face-to-face, sessions, so that you are doing things in, between sessions. Either. Where, the patient, is and you're, able to see what they're doing and you're able to engage or, communicate. With them through. Technology. Is it, possible. That instead of seeing that patient every two weeks you can see them every three weeks because they have something that if they Oren you're involved with them in, between sessions and those that open up more access, for people, we believe that it has the potential to do that the. Other thing in terms of convenience is. That technology. Reduces a burden people. Have trouble getting to clinics they have trouble with family, issues and the idea that they could engage with. A, clinician. Or engage with a device, that is guiding. Them and helping. Them, opens. Up great possibility. And that not, a man least of all of course everybody's. On their phone anyway, so why not just join the club and do, something, that on the phone so. We have a lot of potential. With. Technology. To overcome some of the some, of the real difficulties, I think, we presently, have in our field so. There. Are a number of things some. Of the examples I'm going to go into in a few moments they're going to touch on these but just as it's gonna need to really read these but as the screen shows these are some, of the. Functional. Roles. That, technology. Can play both in delivering, care and making assessments in. Tracking. Patient, both progress, and, day-to-day, activity. GPS. Tools. With reviews, with some success and helping patients. Identify. And avoid high-risk locations, I. Won't. Talk too much about wearable. Devices but, I know if, you have a Fitbit.
On I keep. Losing them so I've stopped trying to do, that one but they're. Great I think there's future, there's, a lot of work being done you. And then, of course text-based. Reminders, I'm sure most many of you are doing that you, may want to reference it because I don't have this in the reference list at the end I just happen to come across it the other day as a interesting. Piece in The Washington Post. It's called from apps to avatars, new tools for taking control of your mental health, which. Does a pretty good job of addressing, this, issue and, identifies some of the tools that are being used right now so this. Is what some, of this is certain with all this is presently being done but I think we've only begun to touch the surface, of this so. Trying. To get the next screen here. No. Not. Moving. Here. There, we go okay. This. Is surprising. Too well a little bit surprising, to me this is a study that was done in Philadelphia. And. We talked about that, Oh. Sometimes, we hear well people really don't want to do stuff on the phone they want to talk, to a they. Want to talk to a clinician, they, want to have, a face-to-face yes they do but, look at this. The striking thing here, for me was that this was a study done among. Individuals. Who, had annual incomes, of less than, $10,000. So I mean. Initially. I mean. 94%. Of all have a mobile, phone. Almost. Three-quarters. Said they'd rather use an app on the phone as. A relapse, prevention tool. And. Half. Actually. Have is talking about, allowing. Clinicians, monitored. Their progress, from social, media, to. A phone so we, have a, population. Not, just a, young, population. Also. I, think one, things I saw recently that I think, 72, percent. Of, the. 18. And 44, year old. Demographic. Would. Prefer, to engage. In telehealth. Sessions. Rather than seeing a. Counselor. Directly, and. Even amongst the over 45, group that was about 43%, so, so. We have a.
Environment. That is right we. Have a population, that is willing. And. We. Are at, a place where we're, ready to we. Should be ready to do something so what I'm gonna go, through our four, five. Technology. Devices, their. Approaches. That we have used so talk a little bit about them I'm. Not gonna say much about telemental, health and, many of you are doing that we're. Certainly doing that but. I want to talk about some of these other things, include a, clinical. Progress tracking. Engagement. Through apps the, delivery, of treatment. Measuring. Outcomes and. Then contingency, measures so, basically. Five different areas, progress, tracking. Recovery. Management. Actual. CBT. Delivery. Systems. And then. A, outcome. App and, then. A contingency, management app, that we'll, talk a little bit about so. We've. Been. We've. Been involved, with this product. Called tritium now I'm going to be referencing the five specific. Product. That we've been using they. Are products. That we use there are others that. Do, similar things, the. Point here is really to talk about what. They do and. How they can help in the coordination of care so. Tritium. Is actually, a tool. Used to measure progress. For, patients, who are already receiving. Who are receiving treatment primarily, in an outpatient, setting and so, the idea here was and, thinking about this was. Can. We come up with something that will, complement. Clinician. Subjective. Subjective. View it's something, that, objective. And, comes. Out of a reliable, instrument. So that we compared, those two to make better decisions, about, how. To deliver, care the, frequency, the intensity of the care as well, as the step-down, potential. Of some, of these at, these instruments so basically, a patient. Completes. An assessment, online it, takes them through a series. Of screens, it, ends up creating, a bhi, or behavioral, health index, now that index, is.
Individualized. For the patient, but. The the, system then and because, it has millions of data. Point then it's been around for a long time has. Essentially. Was, able to take that profile, and create. An expected, progress trajectory. Over time over a period of three to six months and, then. What the patients. Of bhi. Against. That trajectory so, the clinician, can actually look at so, they do this every time they come in, the. Clinician. Reviews, it with the patient and, the patient can see where they are relative, to, the expected. Progress. They can also see, where they are relative. Issues. That emerge as part of the assessment. Screen, all, of the clinical, team members have access to this data the, doc Liat and the supervisor, and and. And, anything. That sort, of goes, into third of the red area and, get alerts. To all the alerts go to all the cornices it also goes a supervisor, and so, then hopefully there's an intervention, and kirk's that, can occur, in. A timely way to. All, to, set off. Or. Know to avoid, crisis. So. There's. Also an analytic, part of this that label, you to aggregate, data can. Aggregate, data you can look at. PH, eyes and, progress, trajectories. By site you, can look at them by diagnostic. Group by clinician. We. Used, it in some ways to look at they take a patient, all, the patients, that are being treated for depression, we. Can. Segregate that, information. Against, a by, clinician, and you, can start to see whether some, clinicians. Seem. To be having better success, or better results. If you will with patients. Who have depression versus. Patients who have anxiety you. Can then talk. To those clinicians. About. What approach they're, using, that might be useful to other clinicians or you can begin begin, to direct patients. To clinicians who, have demonstrated. Particular. Expertise. Or, results. With. Specialties. So it gives you an opportunity. Who. Did. You know any of this data can be sliced. And diced until, you're you know out of your mind I guess but so. But, it's, a very very I think interesting cool. To do his progress tracking, so something. To for, you to think about. Many. Of you or some of you may be using this HS, called, HS tap it stands. For addiction. Comprehensive. Health enhancement, support, system, so you know why they call it HS, this. Is a monitoring. Tool. Was developed at, the University of Wisconsin. We were involved in the very very early stages, of their. Prototypes. With this app it has some. Very interesting features. Around. Patient. Linkages. And. Coordination. You. Can do online support, groups patients, can do they can tie in to testimonial. Talk the A&A meetings, online, there. Are all sorts of recovery. Aids. That they can do. With. Meditation. What, we like about this, is they do a weekly survey. You can see that the, scale there we've, set thresholds. Anything above a five get. An, alert get sent to the coordinator, that is managing. This and then, we can operate, on. The basis of that information to, reach out to a patient, there's, a little beacon. A light at the bottom, there is a, essentially. A panic. Button someone, hits that it, will go to next. Screen says would you like to talk to your counselor, the. Other thing about that is that alert, also goes to the coordinator, so we know that someone, is hitting it there in crisis, that's, a GPS, feature that, allows, the patient to load. In high-risk, locations, we. Actually do this we. Load this app on the patients. That are receptive, to it while, they're in an inpatient setting, we. Do a group that explains, how to use it and then there's a point. Person that manages. That. Population. It's. Actually, been. You. Know it's like a lot of other things where the pain you know you have to sometimes. Prompt. People get. Involved to stay involved but. It is another. Another. Device, that we have used. To create and close that digital, loop. HS. This. Is a full. Pair, PE AR therapeutic. This is actually online treatment. App. We. Did an. Interesting, approach. This company, has taken it's actually the first fda-approved. App. Was, approved, I think about six or eight months ago, it's. We've. Done two, pilots. With this app and we're now in the process of discussing the next stage of.
Implementation. And application. This, delivers. A CBT. Series. Of CBT modules. That the patient, and the clinician. Determine. Together. As, to how it will complement, the sessions. That they have it also includes, some. Self-monitoring. Features, you, can't see, it because it's blurred but over on the way on the right that little that. Little phone. App has a, series. Of things where someone. Raped how they're doing, in these areas basically. It's the halt hungry. Angry lonely tired. Social. Pressures, pain, they, rate themselves and. And. This information is sort, of has a both, a patient, facing in, a, in a, clinician. Facing. Screen, the. Which. Exists. Here so, the patient, has access, to a number, of CBT modules. I'll show you what, some of those are in the next and, the next slide, there's. A contingency. Management feature. To this so that successful. Completion, of a module. Will. Result, in an opportunity, to win a gift card that, so, that sort, of hopefully, will keep people, coming. Back and engaged on the, on the physician. Or therapist, side, we. Can see. What. Modules the, patient, has completed. We can see, how, long it's taken, them to, complete, there, are little tests, associated, with each of the modules you, always, pass the test, but if you get the wrong answer it, takes you back and refreshes, your knowledge. Base about that issue. Whether it's trigger craving. Relapse, whatever. Good. Clinician, can see, the. Graphic. Representation, of, the cravings, and triggers scale, and you, can also see, whether or not, appointments. Have, been kept whether drug tests, have been passed or not passed, and. All all the team. Has access to this information so, again the idea here can, we both. Deliver, care and, influence. And intervene with with, progress. Limitations. Or progress, setbacks. These. Are just, a handful, there are there are like 60. Some. Modules. If, the. Sampling. Will some of those are. PE, AR. Treatment. And education so, very. Interesting, very. Interesting. Potential. For this particular. Technology. I'm. Gonna have to step, up a little bit now recovery, track we're, not going to show this video you can go to youtube. Put. In recovery, track that. Centers for innovation, and you, will see, about. A three or four minute video will tell you about this, we've. Used this primarily. In our recovery coaching, program, and what. It basically, we. Have patients. That there are a number of, ratings. And feedback, potentials. And this and this app we. Have been using this for about three years and, we. Are able to every. Two weeks our coaches. Initiate. A patient, responds. To these, feedback. Questions, we actually, measure sort. Of measuring outcomes in, progress in about twenty different domain. Those. Those. Results. Are graphically. Represented. And then. Our coaches, essentially, sicker patients. And review. Them look, at trends, look. At up and down to end patient can see over time how, they're, doing. It has a very interesting. This. Is an example, of how one of the ways in which we've used this, because. You can you can correlate, a two. Or three different domains this. Is an example, of a situation, where you can see that the. Dotted, line is, patient. Perception, of risk the. Solid, line is there a report. On attendance, itself held meetings you. Can see the obvious things, here, but the of the, more obvious things, the thing, is that well, we have the potential, to do or what you could do if you had something like this is you could do. Something well before, those. Two lines intersected. And and. Hopefully head off and intervene, in. A situation, that was going to be problematic, for the, patient so this is another. Device, that is connected. Both to the, coach the. Counsellor as well. As the prescriber, if, there's, a prescriber, of. Okay. So this is really to do with connecting the. Internal. Team, I'm. Going to run, quickly through this because I'm going to get to the barriers, and I have only have a few minutes left, dynamic. Air we're presently of. Two pilots. Were presently. In the middle of are just starting a night. Of research, projects, with this act this, is also similar, we're using, in. This, case however. We're. Used in contingency, management in, a very big way so. That of, appointment. Adherence. Medication. Adherence. AAA. Or n/a time. In time out difference, is, is. Results. In a reward, tell you about that in a second, it, also has, the additional, potential, to do a breathalyzer or, and or video, breathalyzers. Pencil, IVA test. Random. Alerts go out basically. You need to test. Right now we equip, them with saliva, kit and. Every time they do one, they, get it you can actually see the result immediately and. They. They get a reward. So then actually has, been very well received a little skeptical, about that part of it but it's been very well received by, patients the.
Rewards. Go. Into, a controlled. Debit, card which. Can only be used in, limited. Setting, and also, the spending. Patterns, are tracked, by the. System. So we can see whether someone, has made efforts to use it at ATM, machine whether. They have done cults, of spending, somewhere and again. This is another. Device. That's connected, internally. Both, to EMR. Clinicians. And see. What's going on as well, as UI the coaching, staff or, to, the prescribers. There. Are a lot of other. Things. Out there these are some of them but you go on I, mean there's just tons of these and I think one of the challenges is how do you decide, what. To use some of you may be using some. Of these and. With. Success, so lots. Of lots of opportunities. Out there I want to touch on I think I have a couple, of minutes here to. Yeah. To. Just, touch on these because I think there are some significant, barriers. Not. The least of which I'm. Surprisingly. It's. Really, the reluctance. That I've seen on the part of many to adopt some I mean adoption, is always difficult changes. Of challenge, but, it. Has been a challenge. I think to convince, both. Clinical, and support staff that some, of these things are not there to sort of replace you they're, there to help you in compliment, no technology, is going to open that we eliminate the need I wouldn't. I would hope for human, engagement but. It's. Been a little bit I think sort. Of the silo mentality even, in our own organization. We have multiple, multiple levels, of care getting. Those silos, to be sort. Of broken down and connected, and linked has been a long long process and, it, has to be continually, reinforced. From leadership at, the top, of. Course we won't, much about reimbursement, but quit that yeah that's always impediment. We've. Had the good. Fortune, of having philanthropic. Support, for, some of the efforts, that we've been able to try, that have not had. Reimbursement. And methods, you. Know 42cfr. You, want to look at some of the new. Regular. Toward the changes, with that with respect to how, that may impact your. Ability to use technology. And share information we've. Been talking about internal. Sharing. There. Are also pretty. Significant. Challenges, with, interoperability. And, sharing. Information across, systems, outside. Of your, own systems, but these are the. Challenges. Yes. They are but they will be overcome, because they have to be overcome there. Are additional, analytic. Requirements. That, are required, and being, able to best. Utilize. This information and. Then use. It to be a decision, making cool I think the. Idea that we all talk about how we're making data-driven. Decisions. But, the when. The rubber hits the road there's. Still a lot of sort of instinctual, response, to things and, sort. Of going the way things, have always gone. Someone, has to be, willing. And able to look at the data analyze. The data and feedback the data at the clinical, set we have had a couple of different runs effect. Supervisors. Have, been, okay, in the beginning of that but have been able to sustain it our, best results, have been when. We've had, a. Coordinator. To looking, at the analytics, and then treating, back information to, patients. And, one last thing I wanted to point out an, incident an, incident, but something. That happened, with us some. Time ago and this gets to the sharing, of information part. Where, we had a patient that was being seen by Councillor, and had, a recovery coach had. A psychiatrist, and also had another, care. Giver, involved, in their care, and. The, patient having to share something with a clinician, about. An. Incident, that had occurred but, said you, know and. When that information. Was, learned, by her. Recovery. Coach she. Was very, very incensed, that, somebody. Had broken, her confidence.
In Fact the, clinician, was concerned, that her, her, relationship. With the patient had been compromised, well that because it. Was no longer, something. That she, and the patient, were exclusively. Privileged. To had so. To begin thinking about a care, team and I mean, I actually met with that patient because, they were that, upset when. I was a CEO and and. I realized that we were to start to talk to patients about a care team in. A way that we haven't been and I think that's, because. There isn't really ownership. I'm patient, here it's, individual. Ownership of a compiled in ition when. We begin to share information and. Use, these tools to do it it's, important, that everybody be on board and so. And finally, of course you've got to get people who, who. Want, to use technology. I bet, years, four, or five years ago that was an issue that. Has not been anything for us now patients, have, been much more ready, to adopt some of these things particularly. As they see them. Augmenting. Complementing. And supporting. Don't care so, with. That. There. Are a number of references here which, will. Take you a little deeper, on some of these and I would particularly. Point. Out of the work of Lisa March, at Dartmouth, and Kathleen, Carroll at Yale. Particularly. Advanced. And looking, at been look they've been looking at this for a long time they've done some really great work and they can be very informative, pieces. For. You to go to so I hope, that has given you a bit, of a snapshot of at. Least how one organization, sees. The, future a little bit and some, of the ideas that we've been able to apply and, practice and. How, all of these things are. Going to make it much. Much more, productive, for us in terms, of taking care of patients, helping. Them manage their disease over, their life and, using. Tools, that don't, overburden, and stretch out our staff that is really, sort of at the end of it anyway so, and. With that I will turn it back. Great. Way thank you so much a wonderful. Presentation, we're gonna move right into our next presenter. At this time I would, like to introduce to, you Linda Hurley, Linda, is the president, and CEO.
Of. The, Kodak behavioral healthcare based out of Rhode Island she's going to talk to us today about the financial, and regulatory considerations. In, three. Models of care coordination, Linda. It's great to have you back when Linda has presented for us two, previous webinars, and. She's building on the information that she has. Previously. Presented to, us so we're, excited to share where we go with our financial and regulatory considerations. Today, and how to overcome, some of the barriers facing. Our providers, in these two areas Linda. Of each. Of the. Three. Initiatives. That we've been discussing through, the course of this webinar series and, then. I'll move right into, really. Talking, about the challenges, and the lessons learned this. Is a from, our perspective, it's a was. Very practical learning and. So as, we begin here. Okay. There. We go all right so sorry for the delay there, the, first initiative, that. I'm going to be talking about is an initiative, in Rhode Island that was the first of its kind in the country and it, was enhanced. Medication, assisted, treatment at, the Rhode Island Department of, Corrections. Kodak. Was fortunate, enough to have a. Long. And, extended. Or expansive, I guess, relationship. With the Department of Corrections, in Rhode Island this. Particular, picture, I really. Just enjoy it because the. Andrew. Joseph was writing, for the Boston, Globe and, spoke. To the. Effectiveness. And almost. Like the I. Would, say ethical, imperative, to. Provide medication. Assisted, treatment for. The disease of opioid, use disorder, to, those who have been incarcerated just. Like we continue, to provide. Medication. For cardiac considerations. When someone is incarcerated. So. The goal of the program was, to decrease. Mortality and, we. Were going to decrease mortality. Defining. Decrease mortality as. The. Mortality, component. For this population, in Rhode Island was in 2015. 21. To 24, percent of those who died from opioid, overdose. Death. Had. Recently, been incarcerated so. Almost a full quarter, of those who died from, opioid, overdose, in, 2015. Were, this highly, vulnerable population. Who, had been recently incarcerated, and. For those of you that are, in. The field and working, in opioid treatment programs. It's probably, quite clear, why. That would be a vulnerable population so. We all we needed to do to do that was identify. Those in need, initiate. M80 for those defined, as in need and increase, retention and, treatment, post release, which. We did to. The point that the. Most recent data has been published, that there has been a 61, percent, decrease, in, opioid. Overdose death in this population, since. 2015. With, this program, the, program itself, was the only one in the country. Until. Very recently, Rikers, has added, some. Medications. And the New Jersey Department of Health has added, medications, so they are also, also. Providing. Methadone. Buprenorphine, products. And naltrexone products. In addition, to using the three approved medications. We have a co-located, opioid. Treatment program, CSAT. Approved, DEA. Registered. Which begins. To speak to some of the regulatory issues we faced in doing this. The. Other piece that is somewhat different is that we, are providing. This to all patients, in need not, just those that are coming in already maintained, also. Those that we're doing it for people pre-release, if they feel that they're going to be at risk. So. Let's move to financial, considerations. I'm going, to try to keep. Us on time here the, first financial, consideration. For, those of you that do grant-writing might, know the term soft cost contingency. Line-item. To. Have to try to create a budget that is, fluid, for. An evolving, program, in an environment, that we have not been in before it was really a challenge, one. Example of that challenge is. That we scheduled, our ACM, physicians, for. Assessments. Eight hours a day for, three days. Which. If if, you're looking, at a community, OTP, that would be a very normal thing to do. We really wanted the expertise, in the beginning of the program because we were setting up and vetting, protocols, and we need also needed to be. Seen. As legitimate, and. That's. Very important, when you're going into a setting. That is quite different and doesn't isn't, primarily, rehabilitation. So. In. A non correctional, OTP, make, good sense what, we found at the prison, at the very very most we. Could use 50% of, an eight-hour, day of physician, time for direct care. Due. To the lack of availability, of the inmates and we, learned to term as we initiated, this with our partners, at the Department of Corrections, which I'm going to start to use do. See at this point and. That was locked down and, it means that all inmates must, be in their cells it's about safety and security so, that's very often scheduled. But sometimes, not scheduled. If for example correctional.
Officers, Needed to be elsewhere, so. With security, always being primary, we. Would end up within scheduled. Time with, inmates, / patients, but, they would be unavailable. So, we were wasting, expensive, doctor time. Another. Challenge. That we found was. That. Recognizing. That that, Kodak as an OTP, as a vendor, in the correctional, system was, a guest and. We. Were a new guest and not everybody, had invited us so as. With any organizational. Change there were serious challenges. Not all departments, buildings. Leadership, or staff were supportive, of m80 in the first place, and. Some actually, saw our presence. In providing, this air as a threat to security in, terms, of, diversion, of medication. And medication. Line security, and make, flow. Issues. So. We found that in, this in, in, this environment, where. We. There was a full range 180. Degrees, of support, for the rehabilitation services, we were providing, that. The requirements. For all staff, all staff. Needed. To the. Individuals, needed, to have experience. Hopefully. In a correction, setting, really. Strong interpersonal, skills and the ability to act as in the ambassador, in addition. To holding the skills of their professions, this. Is not a program that can support, entry-level, staff, unlike, our OTP, staffing, configurations. So our, learning here, was, it wasn't just wasted, dr. time but also we needed it you know the HR, cost was. Much larger than we anticipated. Because of the level of skill and experience required. And. One. Of the third major, financial. Considerations. We found was that. Integrating. The missions, and goals of, multiple. Groups and, agendas. Resulting. Agendas of multiple, groups was time and staff intensive. And that. Really resulted. In delays. Couldn't. Give you two examples that, ended. Up being quite costly, one. Was the Union, for the DLC nursing, staff was concerned, about. Maintaining. Positions, were, there nurses, this. Resulted. The resolution. For this resulted. In a, delay, in, in. Optimizing. Those, positions we had hired and, we. Ended up over staffing. For a period of time because having a vendor come in to do nursing tasks was, perceived, as a threat as, I, say here to, the optimization, of work, availability. For union members the, nurses, and, that's the mission of the Union it was fine, but, we we, ended up paying for expensive, our end time because. For six months, because that's how long it took to resolve the union issue totally. Unanticipated. Another. Was the actual, placement, of the dispensary, which took much longer than, anticipated due. To logistical and. Safety concerns. Changes. In staffing. Also. What I would refer to not. In a demeaning way in any way but turf. Issues people, were concerned, if they gave up space that might be space, would need in the in the future and when I say people I'm talking, departments. Buildings. Staff. So. We, ended up being caught in the middle a little bit around the Department of Corrections, middle management directions. And. Executive. Leadership, directives. These. Delays. Resulted. In some serious, and costly. Issues. As. I. Say in the last bullet there for those of you that have opened, an OTP. We. Actually ended up having to have the, safe delivered, twice because the. Positioning. Of the dispensary, was changed, due to all of these things and. Frankly. The cost of the safe is is. Is. Expensive. But, half of the third, of that cost is the delivery. So. So, how did we how did we address, the financial considerations. The three that I had just talked to you about there's. Some basic principles one, is communicated. Which we talked about before, communication. Communication. Communication. With. Leadership and, stakeholders. All of the stakeholders. And all the multiple groups and we have to focus on a media see an, immediate. Reconciliation. When possible, also. This, this, soft. Contingency. Or unanticipated. Cost. We. Needed some some. Redundancy. For the grant funding, and you, have to work very closely with. A contractor. We had to work very closely with the contractor, to be very clear, about what those needs were, we. Needed to utilize care coordination, to optimize, dollars, an example, of that is as we expanded. We needed more doctor time so, we collaborated, with the do see and work. Towards training, some of the do see Doc's not just our Kodak or vendor, doctors, so. That those, do see doctors, could assess and write orders and, those. Could then be. Acted. Upon as long. As the Kodak, physician. Or a medical director, had approved, that order so, it you know it cut. By. At least 90% and. We, were able to expand, services, that way so that was one innovative, way and why I keep going back to communication.
And Relationship, as, long as there is regular. Communication. With those. In decision-making, places. We. We were able to work through these challenges at. A time effective, way and, the. Last two bullets it. Is just absolutely important. To promote ourselves I'll, say this three more times throughout the course here that. We. Have to publicly, publicly. Self promote. Talking. About the need how, we're meaning it and what the outcomes, are so that the community, understands. The effectiveness, of importance, of the work. In. Terms of physician, time this was just a very practical. Piece. We just hadn't thought about it. So working, with it with our, own Kodak, physicians, we expanded. The number of days present, and decreased. The amount of hours that way they could be there when we had the best shot at, having, inmates. Available. For, assessment. And, treatment. Also. We needed to become more proactive and understanding. What's important, to the environment, in which we were entering, so, you, know Cleary clearing, and orienting, our physicians, through the Department, of Corrections, so that they could provide, services. There there, were times that this orientation. Process would, be delayed maybe six or eight weeks so we would be paying for a physician again. Over staffing, that, could, not enter, the, correctional. Facility because. They hadn't been cleared and oriented, yet so it's various. And. I would I believe that each system is probably different if you're looking, at. Co-locating. And OTP, ER providing, services, mhe services, in a jail or prison I, would. Imagine that, there, are as many systems. As there are jails and prisons each one has its own personality its own interpretation. So my, suggestion, here and, what we learned is that we did not understand. That well enough going in, and that's where a great deal of waste occurred, as well as noise anxiety. So. And. The, other piece that we but, that we are, now working on is, securing, CSAT waivers, for mid-level practitioners to. Provide a full range of m80, a full. Range not just beautiful nor pain. Increasing. Redundancy, and decreasing, cost in, terms. Of the HR, costs, of staff, overall. That. Was that was a real challenge particularly. When in least in New England we, have a and, I, believe are a reference to the real workforce, crisis, we, chose to mitigate risk and enhance services, by offering, these positions, to. Folks who had already demonstrated, the, needed skills in the. Community, Kodak OTPs, you. Know it created, an imbalance and, the staffing, configuration. Relative, to experience, in our other sites. And. That was just the cost of doing that, the other piece factor, relationship, and communication, is being able to. Look. At contracts, and have, a relationship that allows the kind of trust trust to allow, amendments. To. Meet. The. Unanticipated costs. Associated. With delays. When. Hiring staff as I. Had said before such. As an on-site dispensary. Staff or our nursing care managers, now, any, do, C position new, or existing we've. Expanded the job description. With a flexible, start, date at the prison, and added. A description of work at the community, OTP. So we can utilize the hired staff prior. To their access, to the do C we won't be in that same. Over. Staffing. Waist. Position, that we were before. And. Also. We, are, learning with. In terms of delays, that. You. Know what we believed was being proactive and, timely, and this, particular, tape case was being a bit rash so we exercise. More caution and pay, a great, deal of, attention. Knowing, and respecting, all the lines of authority for. Decision, making at, this highly. Complex. Hierarchy. Regularly. Regulatory. Considerations. And. I'm moving pretty quickly here, I know these are dense slides but I didn't want to miss anything for, you the, regulatory, considerations. On. This slide are twofold one, is generally, all of our state licensing. Regulations, are designed to support, a physical, environment that's. Going to engage and, provide patient-centered. System. Of care they. Are not designed, to support, a prison system so, in Rhode Island where the regulations, are fairly prescriptive. It, was simply not possible. For. All those regulations, to, be followed. Within the context, of the prison such as, numbers. And types of clinical, content. Different. Types of documentation. Toxicology. Requirements. So, this is this is another example of, challenge, to integrating, mission's. Systems.
Regulations. At the prison, support. Safety and security, they always, always they, have to supersede. Rehabilitation. Regulation, so, again that's why it's extremely important, to involve your state agencies, as you're. Developing the, program, and then, when we move into accreditation. We found that karf Joint Commission CoA standards. Plus. The survey process were, not congruent. With the correctional, environment. And system, here in Rhode Island so. We learned, always. Bring DEA state, agencies, your SSA, is your sodas, into the conversation. As the project, is developing, one. Of the things we we, bumped into was we had to ask the DEA to come in twice. To, approve security, because of what I referenced, earlier in terms of. The. Space for the dispensary. Itself, being moved. And. That impacts, your DEA relationship. I, would also suggest and, we will do this moving, forward is knowing which state regulations. Are. Not going to be able to be met and know, what you need waivers, for provide, the ration upfront if. You put it right out in front of folks it really, saves a lot of time and. What. We also found was we could choose an accreditation, entity. That did. Have, Rekha. Excuse. Me that. Did have standards, congruent. With Corrections, environment, and also has CSAT approval, and that is, the National Commission on correctional. Health the, NCHC. As, one of the six that have. The NAD. NCHS, sorry, National. Commission, on correctional, health care, is. One of the six, approved. OTP. Accrediting, bodies, that has been approved by stamps that was done in 2004. The. Second, edition of the standards. Amount. In, 2015. What's, important, to know about the. Move. Forward through, this a little bit quickly what's, important, to know about the NCHC. Is that. It is it. Is an organization. That is really, committed and, very supportive, of expanding. M80 in the correctional, setting, they. Provide technical, assistance and, we're hoping that that's going to help us to further integrate m80 into. The mission and organizational culture, of, the Rhode Island EOC, I. Included. The website, on the proof on the previous. Slide. Very. Easy to, maneuver, the, standards, themselves are, very easy the, whole book is only about 170.
Page And as. I said they're. Very committed to providing the technical assistance, and, increasing. The number of, OTP. Is providing, m80 in correctional, settings, and I'm just adding a bullet to again thank the leadership at the Rhode Island Department of, Corrections, and the oak brunette leadership, of Rhode Island and supporting, the program, the. Second initiative which. Will not take me as, long. To describe is the, Rhode Island opioid, treatment program. Health home. Rhode. Island's health home was the first the. First the second, I'm sorry health um OTP. Health um in the treat and. Kodak. Was actually, the first to be approved by carp, in. The country first, OTP, health home the. Goal thank, you very. Very common goals you know them if you know CMS, hospital, admissions, emergency, room visits nursing, facility, admissions, and, need. To decrease, and, you. Need to have and. Use, the noms measurements. And how are we going to do that here's. A list I'm, not going to read it to you but it's a focus, on a fully, supported. Recovery, oriented system, of care that's, going, to enable the system to. Meet the above goals and. Provide. Optimum, health for. Those, coming to us for m80. The. Financial, considerations. These were brand new services, in Rhode Island they, had to be defined they had to be reimbursed so. It. Was you know we needed to build an outcome measures what would the cost be there were unknown utilization. Rates we. Had no idea how many services, the patients would want to use we had no idea how, much time, it was going to take from, the. Health home team members so, the, configuration of. Time. For different team members pharmacists. Doc's our ins counselors, case managers, medical, liaisons, all. Of that was an unknown okay we, needed to establish rates. And codes, and, the other major. Financial, consideration. With new rates and codes because this was a Medicaid, program we were very concerned about the reimbursement confidence. Of our. Managed. Care organizations. Their national, organizations. And you have something new it, takes, time it's another, turning, of the Titanic. There. Was also cost of accreditation because. Now we had. The. Accrediting, bodies, had. Created, new standards, for this program, as, a separate, program, so. How did we address them one of the major things, that we, did which I have, to say Rhode Island I'm hoping. Continues, to take pride in is that, all of Rhode Island's OTP, is worked. Together, to create consistent. Programming. So. We, pulled. Funds, for a coordinator. That would be responsive. To state. And CMS. Requirements. Reporting. And, outcomes. We. Pulled funds for the development of a database and the. Payment, for these things, was. A very was a unique and successful collaboration. Within. All, these these organizations. That, is. It we're usually driven, by marketplace, competition. I'm sure that many of you listening, are aware. Of that so, we simply based it on the number of Health and patient serviced in each OTP. Because, this information is, gathered. By our state agency, and that's, how we divided, the cost and this has been successful, for the last four years.
Another. Way that we addressed the financial concerns was working. With state medicaid and, Department. Of Behavioral Health, developmental. Disabilities, and hospitals, they, allowed us input, into. The design and to. The cost of the services, provided and, that's what this what, this slide, is. Referencing. And it, allowed us to, also learn some of the constraints, the very last bullet on this slide we, recognized, how important, it was to work within an existing payment. Structure, because. Otherwise we would be delaying, the, start of, a new program, by, anywhere from six months to a year. When. We were addressing the unknown, patient, utilization. Of service one way that we did that and it was very helpful was, in surveying, eligible, patients to ascertain, wanted, services. One. Of the mistakes that I know in, the years or decades actually, that I've been in the field is that, we often look at our. Own perception. Of consumer. Need as opposed to listening to the consumers, and that's. Really, if you want to look at projecting, utilization, it has to come from consumer. Perception. We. Found we, had overestimated ours. And, we. Worked needed. Hours and we worked with state agencies to submit needed, shifts and staffing, configuration. And, it, worked again, regular, communication. With those that are in decision-making, positions. We, also. Learned. A hard. Lesson I, believe in. Addressing. Third party payors and that is that we, really need to bring them on as well as soon as possible, so, that they're part of the process and there aren't delays in payment we had delays in payment between six and nine months at one point and, the. Last thing was. Aggressive. Community, promotion, for. Referral, optimization, so that we could. Refer. Our patients to. Specialty, physicians in, the community so, that they would be comfortable, referring back to us for those with opioid use disorder, and. Again. Promotion, promotion and, enlisting. State departments, for that help. So. Basic. Principles, again. Begin. With all those who are critical to the legitimacy, of the goal once, the goal is determined, to be obtainable, include. All stakeholders. And use. Your lessons learned. I'm. Gonna try to move through this in about a minute yeah, the, last innovative. Program, that I have here is our newest health, home started, in. 2014. The, Centers for excellence we. Rhode. Island senator of excellence for treatment of opioid use, disorder, Kodak. Was the first in Rhode Island we, became certified in August, of 2015. The, CEO a this center, of excellence, I believe this is a pretty. Clear definition, it's, a hub-and-spoke model, with. Some differences to those of our northern, neighbors. The. Financial, cost we found. That. We were concerned about increased, costs, in, reflecting. Services, of the medical, team. How. Would third-party, payers accept, this on the heels of the health home model again. We need an establishment. Of code, reeds and the biggest, one was how to manage insufficient, fee-for-service reimbursement. Rates. Following a six months, of center, of excellence services. So. The center of excellence. Center. Of excellence as a hub-and-spoke model only. Allows, the individual. To be participating. With, the OTP center, of excellence for, six months at that point it is expected that the individual, has the internal and external resources. To, return. To the community or to be connected, to the community and at, that point a bundled rate goes away and we move into a fee-for-service model. Which, again, until, rates are readjusted. Here in Rhode Island are insufficient. To cover service, so, that's remains, a financial, consideration for us and we're, watching it closely many, many, patients don't. Want to leave and. We're not going to make that and, then. We built on the existing. Expertise. Through the utilization of services of, the health home coordinator, and just, really, aggressively, got out there and talked to third-party payers, and engaged community providers. We're, still in the process of, that. Examples. Of that would be that. The director. Of the Department, of Health has invited us, regularly. To. Provider, meetings. And. We take, our show on the road, the, regulatory considerations, were. Somewhat minimal. There. Were certification. Standards, that have been. Created. Here by our, Rhode Island state agency. There. Are no accreditation, national. Accreditation standards. Yet developed, as. We know accreditation. Standards, really do help us assure effectiveness. But they also always, involve, cost. So. Again, building on existing expertise. Building, on existing, relationships. Closely. Monitoring, what. To find outcome, measures there are. As. Well. As cost Center variables, because we don't have a lot of direction, yet about, what outcome, variables. We're. Going to be looking at or outcome, measures, we're. Measuring as much as we possibly can.
Because We've learned and. I think anyone, listening probably, knows that trying, to do retroactive. Data collection, is. Ineffective. And. A nightmare, so. So. Some conclusions and, I I will, do this quickly all, three programs as I mentioned, last time required, culture, and, systems. Change also, required, an acceptance, of the science. That supports that process. Systems. Integration, is required, and, we need to work together, with. All stakeholder. Input input, in. Order, to. Address. This epidemic, and. We need to recognize, that we as otps, are the experts, in the treatment of this disease we. Need to change our own self-perception, that's, the biggest culture, change we, need to move from a history of invisibility, as a goal, and. We move need to move to a position, of being very, visible, as experts. In the treatment of opioid use, disorder which, we all are. So. Just. Recognize, we are indeed the experts, and you can see I'm since being redundant, because it's so important, we, need to learn how to self promote as, a medical, specialty, with decades, of providing. Evidence-based. Care and that's, going to help us impact, public policy, regulation. And corresponding. Budgets, because in order, to enhance care, there's, a there's, a cost attached to it and we. Are in the middle of an epidemic so. Thank you I, really, appreciate your time and I hope this was helpful. And they'll. Thank you so much we greatly appreciate your time today as well we, do have a couple of questions and we have just, a few minutes to address those so. I'm going to throw them out here the. First one is for Rey Rey can you tell us how receptive, are, pairs of behavioral. Health services, technology. Based applications. Our. Experience, in that it's been I, think there's a, tooth, or two pieces to that one is. They've. Been. Interested, in seeing some of the outcomes that we've been able to generate. Incorporating. Technology. But also other things into. Into. Into care, where. That conversation starts. To get a little bit. Stretched. Out as when you begin talking about. Sustainability. And financial, sustainability and, reimbursement. We. Have we have had. Small. Successes. In that. But. You. Know as, with so many other, sort. Of negotiations. With payers. Once. You get the bean counters in the room. They. See some, of these additional, costs it's, hard for them to see value I think, alternative. Payment models, ultimately. Provide, the best hope for incorporating. These and other, approaches, into the care delivery, and an outcome. Outcome. Improvement, but, that has been that challenging. Great. Thank you. Another. Question for you right in the context, of the recovery, track apps that you mentioned are, there any studies that look at the recovery durability. Using technology. Versus, in person or, group based support. You. Know I don