24/7/365 Access: #8 Emerging Adults with Mental Illness

Proem

When I’m in trouble or have a question, I need help when I need it, preferably from a warm person, not an app or a bot. Is this even possible today? One of the health systems I use just shifted the patient portal inquiry responses to a central department, open Monday through Friday, 8 am to 5 pm. No more replies to non-emergent questions from my doctor or nurse within two days as I’m used to. Not a warm person when I need it.

I called my dear friend Dorothy Cucinelli as I planned this Emerging Adult with Mental Illness series. Dorothy, CEO of the Capital Behavioral Health Network (CBHN), sponsors COAST (Coordinated Opioid and Stimulant Treatment) 24/7/365 person-answered hotline for people in need. Kelly Lane joins Dorothy to tell us more.

Podcast intro

Welcome to Health Hats, the Podcast. I’m Danny van Leeuwen, a two-legged cisgender old white man of privilege who knows a little bit about a lot of healthcare and a lot about very little. We will listen and learn about what it takes to adjust to life’s realities in the awesome circus of healthcare. Let’s make some sense of all of this.

Access through a single number

Health Hats: Dorothy and Kelly, thank you for joining us today. I look forward to discussing the COAST program (Coordinated Opioid and Stimulant Treatment). And as we’ve talked about previously, I’m focused on young adults and their families with mental illness and the services they need and can get. So, I was very excited when Dorothy and I were just catching up to hear about the COAST program. I’m wondering if you could tell us a little about how people access COAST referrals, supportive services, young adults, and families.

Kelly Lane: Sure. It’s easy. We’ve designed this project with a single number that connects you to services anywhere in our eight-county region, south to Columbia Green County, north to Warren, and Washington.

Health Hats: In upstate New York?

Kelly Lane: Yes, the Capitol District, Warren, Washington, and Columbia Green.

Dorothy Cucinelli: For those listeners who might not know this area, the Capitol District is Albany, about three hours’ drive north of New York City. We cover the eight counties in that region, to the Massachusetts border and West, then up north to the North Country, to the Adirondacks, and south to the Catskills. It’s a big geographic area. It has quite a mix of demographics, everything from people in the cities to very rural locations. One of the challenges we’ve been able to meet successfully is establishing ways for people to access this program regardless of where they live. It’s unique in that, as Kelly said, it’s a phone line, so people can call this number twenty-four seven/three sixty-five. And they are connected immediately with a prescriber. So, someone who can write a prescription and get that person connected to medication-assisted treatment right away.

Wraparound services

A prescription goes to the pharmacy. If the person doesn’t have the means to pay for that medication, our grant program also covers that. And we can even arrange transportation to get that person’s prescription. We use the term wraparound services a lot in the mental health field. And this is a form of that because it covers a lot of different bases that individuals sometimes aren’t there. And if any of those pieces are not in place, the whole thing doesn’t work. We’re proud.

Health Hats: Wraparound is a comprehensive, strengths-based, planning process put in place to respond to a serious mental health or behavioral challenge involving children or youth. Wraparound shifts focus away from a traditional service-driven, problem-based approach to care and instead follows a strengths-based, needs-driven approach. Meaning it considers the whole people and what they need in their lives and not just the medical services.

So, does that mean it’s two in the morning, and I need some help for my son, and I can call and get a live person?

Dorothy Cucinelli: Yes, that’s precisely what it means.

Health Hats: Wow, that’s amazing. You can’t do that with Amazon, that’s for sure.

The behavioral health network collaborative

Health Hats: The little thing you told me about is that this is a collective. Tell us how it is structured and your roles in this.

Dorothy Cucinelli: Well, let me tell you a little about the network, and then I’ll toss it over to Kelly. The grant went to the Capital Behavioral Health Network. CBHN is our abbreviation, and we represent about 30 different mental health and substance abuse provider organizations in that eight-county region I described earlier. So, everything from the very large to the small providers who do clinic services, residential the whole range. CBHN brought together a subset of those major players who could best deliver this service, coordinated a program, designed it, and made this happen so that all these providers who do work together sort of on individual case-by-case basis issues. But really, they don’t typically work together on a significant project like this. So, our role was to bring them together. And to continue to coordinate. And Kelly’s role in this is a lot of that coordination. Kelly, do you want to speak about that?

Kelly Lane: So as the partners came together and identified a critical need in the community. And that’s when someone is interested in making a change and the period at which they can get help. And there’s typically a significant wait list, especially for folks who need medication-assisted therapies for opioids and stimulants. So, the partners came together and said we want to design something that meets that need to help people immediately connect folks to services and supports. I see incredible commitment and willingness to partner across counties and service types. There are ten funded partners and even more partners who aren’t funded but are part of this network of providers in this grant who came together and worked out how they would implement. And continue to meet and improve the project.

Doing something right

Dorothy Cucinelli: We know there’s a need for services of this type because of the opioid epidemic, but what surprised me is the extent to which people are accessing the line. I’m happy that they are, but we’re getting an average of about 130 calls per month on that line. People are getting connected to treatment, and many have had callers say I was on the verge of deciding whether to use another hit of a street substance versus calling. And I called you, and it has made all the difference. It’s been life-changing for a lot of people. Which is terrific. We’re very proud of that. And we hope to continue doing it.

Substance use and mental health

Health Hats: Is this a service for substance use and severe mental illness, or is this pretty much focused on substance?

Kelly Lane: It’s focused on substance use and specifically opioid and stimulant use.

Health Hats: In the years I’ve done this kind of work, it seems like having a firm line is challenging. It looks like the call might be about substance use, but you probably don’t have to scratch the surface too far to find underlying issues. People are often self-medicating because they’ve significant mental health issues, whether it’s despair or anger or voices, and then they get to addiction through self-medication. Is that part of how you decide on referrals and supportive services by what the mix is?

Dorothy Cucinelli: We do get a lot of callers who self-identify as just a mental health issue. This is not a line where we just give you a script and send you on your merry way. There’s a significant coordination component with this grant so that the person calling gets connected to services that will help them get started or continue their treatment and recovery, whatever that may be. So, it’s not just, okay, we’ll give you a script and let you go. It’s ongoing care.

Warm hand-off

Dorothy Cucinelli: The other thing is, as I said, we do get people who call with a mental health issue, who don’t have an active addiction, and those people are given that same kind of handoff to other services. So, it’s not we just give you a list and say, here you’re on your own. Call them and see who’ll take you. Here’s a list of providers. It is a referral process, and it’s what we would call a warm handoff.

Health Hats: I was just going to say that this sounds really like the warm handoff, which is just so much.

Partnership with families

Health Hats: What if a parent calls about a young adult in their household or a caring person?

Kelly Lane: One of the beauties of this program is that it brings together treatment, recovery, and prevention. Prevention programs can support that loved one or that caring person. At the same time, the individual struggling may be given information and is supported and engaged in services. But prevention services can provide that support to the family member in helping educate, helping connect. So, it truly is a great partnership that can support the individual and the folks around that person.

Residential and inpatient?

Health Hats: Does your network include residential treatment as well?

Dorothy Cucinelli: The members of CBHN are comprehensive regarding the range of services. So, it’s mental health and substance abuse providers within those two categories. It’s everything from family support services which we just talked about, to outpatient clinics and residential. We don’t have hospitals in our network, so it’s not inpatient hospital care, but everything else is included in the network.

Collaboration over competition

Health Hats: In my experience with you, Dorothy, although there was a solid collaborative streak among like providers, there was also intense competition. And I don’t know if it’s history, personalities, or whatever, but sometimes there could be fabulous collaborations and some less than successful. So, what’s been your experience with navigating the challenges of cooperation among so many organizations? Aren’t there territorial things you must deal with, or is it smooth? Are people just focused on getting the job done?

Kelly Lane: My experience has been that folk, for the most part, are willing to do whatever it takes to get the job done. Because of the large geographic area that people serve and even perhaps do a bit more coordination to serve some areas that they wouldn’t cover. And that’s welcomed because everyone’s getting their needs met, services are operating, and people are receiving help. So, our experience has been positive in that respect for the most part.

Networking coordination

Dorothy Cucinelli: I would add that beyond Project COAST, there are other things that we do as a network, and one of the things that I have found through my experience is that the network provides a forum for particularly leaders of many of these organizations to come together regularly and share ideas, share concerns, strategies whatever it may be. That has been lacking in many other areas in the region. So, we were the sort of the glue that kind of brought everybody together, and it’s been gratifying to see people are interested in just solving the problem. They want to help people. There isn’t a whole lot of territorial stuff. These are very dedicated people invested in their work. I can’t speak highly enough about them. They’re all terrific.

Emerging adult priorities

Health Hats: When I talk with a small sample of people who have been young adults, they talk about two things. One is what you were talking about, getting help when you need it, lining it up. Getting help tomorrow is not good enough. You need help when you need it. You’ve talked about that. And then they talk about how they’re treated in isolation. Meaning that they live in a world of drugs and that it’s hard to include your parents in that world talking to people you care about because it’s embarrassing. And there’s stigma, and I think I’m hearing that you get help when you need it and that it’s a comprehensive program to help deal with many of the levels of recovery. That will help people move toward recovery, which concerns young people. So, what have you learned yourselves when you’re evaluating? You get together with leaders. How about with the people that you’ve served? How do they help inform your program?

Kelly Lane: When you were talking about how young folks engage in the world with drugs and with the people they care about? Immediately I thought about peers as being that bridge: folks with lived experience who are now working to support others on the path to recovery. And one of the things that our program does well is connecting folks with Certified Recovery Peer Advocates throughout the eight-county region. And I know there’s a great organization in Green County, the Mental Health Association of Columbia Green, that does a lot of work with young adults who have been in recovery and connects them with young folks who are struggling with their challenges. And they’ve been great in connecting with folks, keeping folks connected to treatment. I think peers also play another important role: being the bridge between the individuals in recovery and the service system and helping inform the service system of what’s working and what’s not working for the people they serve because of that great relationship.

Matching resources to demand

Health Hats: So far, I’ve spoken with primary care physicians, an ED doc, a pediatrician, and somebody who’s the administrator of an adolescent psych unit. And one of the things that’s a theme is that, on the one hand, they don’t have enough capacity, and on the other that for the capacity they have trouble staffing it. Remarkably, somebody can call your number anytime and get somebody. It’s almost unheard of. How does matching resources with demand, capacity with demand, what are those struggles for you? Or are they?

Dorothy Cucinelli: I talk with various leaders from these organizations in our network and others almost every day. I hear we’ve got vacancies, and we can’t fill them due to staff shortages. It’s a national crisis. I don’t use the word crisis often, but it’s a big problem. Many people left the field during and immediately after the pandemic due to burnout, family issues, etc. There aren’t enough people coming in the pipeline to replace them. I think part of the reason is that the pay level in this field is not competitive. It’s terrible. Who will get a master’s degree in social work, spend all that time and money, and then get a job that pays less than you would get for many other professions requiring the same education level? You must be dedicated. And then deal with all the stress that comes with the job afterward. It takes a lot for people to enter this field; I don’t think many people recognize that. But it’s a very demanding field, and there just are not enough. And I’m not just talking about social workers. I include psychiatrists and peers. It’s everywhere. It’s just terrible. Can we match resources to demand? It’s an ongoing issue. It’s not just a matter of here. We’ll give you the money. Create a program. Can you find the people to staff that program? In a grant application recently, as a network, we discussed a significant drawback because the agreement required staffing that was difficult for us to meet. Everybody is struggling with that. So, I don’t have an answer. Suppose somebody threw a lot of money at these positions and magically raised the salaries, got more doctors to choose psychiatry, and increased pay levels. In that case, it would go a long way toward easing the crisis. But honestly, I don’t see this easing up anytime soon.

Maximize access

Health Hats: I imagine that if your promise is access and there isn’t the capacity to care, that’s disappointing for the carers and the people seeking care.

Kelly Lane: The project does have processes and systems in place to help maximize the availability of providers across the network. So as folks are getting referred to services, there’s a program called Matters, the referral-based platform with real-time availability of those outpatient providers. The individual can get matched with a location, referral to their community, and a provider with confirmed availability. That’s helped match people to available prescriber resources.

 After the call, I asked Dorothy to tell me more about the process. She said, Basically, our project (COAST) connects people who call the 800 number for COAST to a prescriber. The client is also connected to a COAST care manager who helps the client find follow-up and continuing care after the COAST Prescriber gives the immediate prescription. The MATTERS platform, New York State-sponsored, lists various providers all over the state, including our area. Available appointments are on the platform so a client can get signed up for care through that platform with the help of a care manager immediately instead of the client having to call the provider for an appointment- which avoids the run-around a lot of people go through. Also helps to get people immediately connected to follow-up which is important because without that hand off many people would just take the script and not follow through with additional care.

Health Hats: Young adults grow into adults. How does COAST Network maintain a pipeline of peer support as people age?

Kelly Lane: Most peers in our network are peers that serve adults. The most significant challenge is identifying peers to serve young adults and adolescents, so the challenge is on that end, not on service to adults as they age.

Kelly Lane: We didn’t touch on folks’ ability to connect by phone, in person, or via telehealth. If you are outside the Tri-County area, the Capital District and you don’t have transportation. You still need help. How do you get connected to a prescriber? Right? COAST can talk to you over the phone. For example, they can interact with you over Zoom and still get you the help you need.

Prevention

Dorothy Cucinelli: I would say there’s one other part of the program that we didn’t talk about too much, which is the prevention piece. Two programs included in this grant are called Teen Intervene, a program for teens and their parents to come together and learn strategies for better communication. And there’s Strengthening Families which has also been successful. So those are two program components we have not touched on too much.

Kelly Lane: They are valuable evidence-based programs seeing great results in the short time we’ve been funding them in this region.

Marketing programs

Dorothy Cucinelli: Also, regarding how people access this. As Kelly said, once they know about the program, they can connect in several different ways. But getting the word out on the program has been something that we’ve spent a lot of time and effort on. Because if people don’t know you have something, you might as well not have it. Marketing often gets lost, is thought of as frivolous, or we don’t have the funds, but our marketing efforts have shown us how important that is. We’ve got data on where calls originate. Not by the individual, of course, but where calls come from geographically. It helps us to pinpoint our strategy so that we’re reaching people most effectively. It’s been great.

Health Hats: Thank you. The conversation has been outstanding. Request: could you send me any links that you know? I have an international audience. People like to learn about what works even if they can’t get it because agencies struggle with this wherever they are located. And people want to hear what’s working for others. You’re onto something.

Dorothy Cucinelli: I just want to say, too, Danny, I appreciate you doing this for us because it helps to demonstrate to our grant funders at the state that we’re using innovative ways to get the word out. Yes. I don’t know that anybody’s doing a podcast interview. I just wanted to thank you for that. And the other thing is the Matters program that Kelly mentioned. Might be something that you might want to do another interview.

Health Hats: I increasingly think about how people take in information. That started with thinking about people who are hard of hearing or visually challenged. I started as a blogger, and then I went to a podcast, and I realized that there were people who read primarily, they’re people who mainly listen, and there are people who watch. I’ve been producing YouTube videos of the episodes as well. I claim no rights to any of my work, and you are free to use it. Dorothy, if you’d like me to pull specific clips so that you can use them in marketing, I’m happy to do that. Let’s think about that down the line.

Thank you so much, Dorothy. As always, I love seeing and talking to you and meeting you, Kelly, and we’ll talk again. Okay. Take care.

Reflection

You might think I am most excited about the warm handoffs in 24/7/365 live-person access. You’d be wrong. Well, actually, I do value that tremendously. But the last bit about marketing resonates most with me. Throughout my career, I’ve emphasized marketing in, for, about services, ideas, and leadership in all aspects of healthcare – governance, operations, research, quality, outcomes, and measurement. Other than surgery and drug therapy, which are core to the medical model of healthcare, everything else, culture, public health, prevention, habits, and lifestyle depend on marketing. I define marketing as knowing and listening to customers and target audiences, strategy, analytics, writing, and storytelling. I appreciate Dorothy’s emphasis on marketing. Although I emphasized marketing throughout my career, I was underwhelming everywhere at marketing marketing. So sad.

I wonder if COAST is a hyper-local solution, or can it be generalized? Certainly, collaboration over competition, live phone attendants, 24/7/365 access can be generalized. But the flavor, the infrastructure, the process, and the participants need to be local.

Lastly, although COAST does not emphasize emerging adults, its focus is adults, the service includes emerging adults, and the model can serve emerging adults. I’m grateful to Dorothy Cucinelli and Kelly Lane for sharing.

Podcast Outro

I host, write, edit, engineer, and produce Health Hats, the Podcast. Kayla Nelson provides website and social media consultation and manages dissemination. Leon van Leeuwen edits the article-grade transcript. Joey van Leeuwen supplies musical support, especially for the podcast intro and outro. I play bari sax on some episodes alone or with the Lechuga Fresca Latin Band. I’m grateful to you, who have the most critical roles as listeners, readers, and watchers. See the show notes, previous podcasts, and other resources through my website, www.health-hats.com, and YouTube channel. Please subscribe and contribute through my Patreon page patreon.com/healthhats, also listed in my show notes. If you like it, share it. See you around the block!