And now it's my turn, right? Yes. Okay. Thank you. Well, I'm grateful. I think we have 20 plus individuals on the call, so thank you so much for caring about this and caring about the people that come to us for care. And when we look at the evolution of telehealth for behavioral health care, just as I had absolutely nothing to do with that quiz at the beginning, but it was a wonderful idea because it brings, as you'll see as we go forward, that telehealth has been practiced for decades and decades, and it has been evidence-based as SAMHSA defines evidence-based, which is very well-vetted research for at least three decades, okay? Obviously it's increased since COVID, but so we'll look at the evolution, just a little bit of the history, some of the research, and then what has happened post-COVID. So all of us in the opioid treatment field, all of you, anyone that said anything to do with it, you've had a remarkable, remarkable, remarkable, successful, creative, and courageous response to the COVID-19 epidemic and the fear that we all had, the deep-seated unknown, the fear of the unknown around COVID. We did a wonderful job in our response to keep our patients safe. We call the people patients in Rhode Island a lot of times. Everybody's different, but the folks, the peer recovery group prefers to be recognized as patients here, so that's what we continue to do. So that the risk mitigation activities that we all did, I think were actually brilliant, and we'll talk a little bit more, well, I'll talk about them now. I know that many of us within, it was February 2020, right? The first week of March 2020, that is when the sky fell. And all of us, all of the OTPs immediately looked at how we could keep our patients safe, our clients safe, and we did across the board, nationally even, curbside dosing, various delivery systems to keep people isolated, to keep people in terms of risk mitigation. We did a huge, huge, we created a huge influx of medicine into the community because we, I think it was 500%, that was the increase in take-homes, which really set this, because we did it so well, you did it so well, it set the stage now for SAMHSA and Dr. Olson to be able to say, okay, DEA, CSAT, we're opening the take-home medications, the entire piece there. So everybody did a great job, and telehealth became immediate, it had to be, right? And then the problem was that we did it, because we had to do it, we did it in two weeks. Everybody looked back, remember, that's what we did. We started moving within two weeks, 10 business, well, 14, everybody was working weekends then. And so telehealth was adopted wholesale because we had to, to keep people safe, and we didn't have a plan. There was no strategic plan, you know, there was no systems change 101, you know, or science to service initiative from the ATTC, none of that. We just jumped in. Now, some of these things that I'm talking about on this slide are, now contribute to what some of the barriers have been around a continued adoption or retention of the utilization of this modality. And, you know, when we jumped in, you know, our regulatory entities and us, our culture was saying, oh, this is going to be scary, oh, this isn't going to be safe, despite the decades, literally decades of evidence-based, of evidence that telehealth was safe and telehealth was effective. And we actually are proving that now with continued research. And am I moving these or are you? I'm moving them, so you can just let me know when you're ready to move on. Oh, okay, Gretchen, thank you. Let me get rid of this then. Okay, please, next slide, please. No, not that, that's good, thank you. So this just gives you a little bit of background, okay? 13.5% moved to 17.5% of all services increased across the country, mostly in rural areas from 2016 to 2019. And then we look at the Medicare mental health visits. And Medicare mental health visits means generally aging population and those that have some pretty significant diagnoses, correct? And between 2010 and 2017, telehealth was already picking up steam, 425% increase, right? Now those two demographics, those two populations, the primary barrier to access was geographic limitations. So this probably, we didn't feel this much on the East Coast because we don't have that same, not like mid-country, the same limitations. And then we look, March 11th through April 22nd of 2020, how long is that? Five weeks? It jumped 556%. And again, I think we all need to be proud of that. And it's continued, it continued to rise during COVID. Next slide, please. So again, just keep in the back of your mind what we're looking at here, what are the barriers you're facing now to having staff be excited about this wonderful gift that we can give patients and our providers to be able to connect in a more effective and efficient way. So I don't know if you guys, you know, Deming, I just use Deming because he was the very first person to talk about systems change. He was over in Japan and he was working with some kind of Japanese technology. So you find something that needs to be done or fixed, you plan, you do the plan, you check the plan, and you check your matrix, you do all the things you need to do, and then you act, and then you check and act and check and act, you know, we had five weeks to do this, and we were not doing a Deming project, we were not doing systems change 101. And again, we're paying for that now, because even we, you know, well, we'll talk about a little later. So next slide, please. So what we know, this is what we did, you know, and we did it haphazard because we had to do it haphazard. We were literally, I believe we saved people's lives by really making sure that we mitigated the risk of transmission. So this is exciting because we improved population health, right, improved the quality of life, mental health, depression management, and satisfaction compared to in-person treatment. And there are so many research articles on this, by the way, I, we gave you some, there's some in the, at the end of this presentation, but, you know, my suggestion would be just to go into SAMHSA and look for it. But, you know, my suggestion would be just to go into SAMHSA and look for them because there's so many, and we can really use these to kind of sell this to a patient or to staff that we're onboarding to sell this to staff that's been around for several years and have the cultural barriers. And the improved population health is also clearly, clearly recorded for substance use disorder, reduces alcohol use, boost tobacco cessation, and improves opioid treatment, engagement, and retention. Next slide, please. Okay. Provider. This is, this is a good one when we're talking to staff. Okay. When it's been researched and it's been researched nationally. Let me see. I kind of want to lose track of myself. Provider experience has been, they love the increase in flexibility and scheduling. It improves coordination of care. You get, you know, you can do a conference call and have an introduction and you can be there to keep, you know, individuals safe, feeling safe. For us, we have spent a lot of dollars and utilized a lot of resources in creating liaison positions where if one of the individuals that come to us for care are getting primary care for the first time or going to treatment for a more severe mental health issue, whatever it is, whatever it happens to be, we actually paid liaisons to go and meet the patient at the doctor's office because our patient's history has been such that they are, they are, they were and remain stigmatized because you know, this country stigmatizes poverty. I mean, it's, it's across the board. We stigmatize poverty. We have, when we serve 93% of the folks that many of us that we serve are Medicaid patients. So, you know, in addition to all of the other institutional stigmatizations, they, poverty in general is one. And so, so we would spend money to do that. Now you can just do it. You can do a conference call, you can make sure that individuals are following through and the three of the, the provider, the referral source, the referral, and the client or patient can all come together and not have to spend the time driving, taking a bus or walking. And these are what has come out of these various, various, I'm sorry, I just had a blank there. These variance research projects helps to reduce stress from workforce shortages because the time is so much better used. It reduces provider burnout. And again, these are like 20 years old. This isn't like new stuff. And individuals, individual providers and providers, by the way, here in this presentation are anybody that provides service. So it's not just a doctor or prescriber, it's a therapist, a counselor, clinician. So this is provider experience. Increased ability to assess psychologically and environmentally, having a sense of where someone is, their, their living, their living condition, their living arrangement. And that's one of the biggest barriers when we hear people say that they don't like, or they don't want to do telehealth is because, you know, oh, I need to, you know, it's so important for me to be able to assess them person to person. And hundreds and hundreds, probably thousands of therapists, counselors, clinicians, doctors that have been interviewed have said that it increased the ability to, to access, assess, because the access issues were heard. And of course, reduced wait time connecting to crisis services. If any of these didn't make sense to you, ask in a chat or give us a, let us know. So next, yeah. And the financial benefits have been, this, this is amazing. Increased utilization is really important because we can go for it. So, and we saw, and I'll show you, have a graph for you here later, the increased utilization of counseling sessions of medical contacts, it, the increase was tremendous. And we saw the increased revenue. Now this is still, this increased revenue is results in pushback from our third party payers that some, like in some states, some counties, depending on your state, individual third party payers are not, you know, oh, you know, it has, it can't be audio only. Well, how many of our patients don't have full access in their contracts with their iPhones, right? They don't, they don't have FaceTime. So we have to be able to use audio. That's one of the biggest, that was one of the biggest fights in Rhode Island. And it's really not still resolved, but across, across the country, you know, a lot of the third party payers have, have really put up barriers to decrease the amount of money they're going to have to spend to pay us back for the services we're doing and reduce staffing costs. Of course, that works well, right? Next, please. So, you just saw, providers have loved this, and organizationally, providers have loved this. So why hasn't this transition been simple? And a lot of it has to do with, you know, and I said it in the title and I'm going to keep, I'm going to be redundant about using the word culture. The culture of OUD treatment has been driven by punitive and paralegal regulation. The DEA is the Drug Enforcement Agency. In the 50s, it was a paralegal, just like a police department, a paralegal, I mean paramilitary, a paramilitary structure and the regulation was as such. So when individuals have been in the field for three decades, two decades, even into one decade, this culture exists because it moves by, you know, those that have been senior, teaching those that are coming in for the first time to provide services. And there's so many aspects to this one. In addition, we didn't have a well-defined or vetted strategic plan. We didn't. So we were doing it and then creating the plan. We're getting better. But policies and procedures were created and then changed and revised during implementation. And so when you have policy and procedure, generally, we love to use that because we would love to use policy and procedure because some, we, you know, even during orientation, if this happens, here's the policy and procedure. You go to that first. If this doesn't work, you go to your supervisor. Policy and procedure creates practice and practice guidelines that we want our staff to use. And so when these policy and procedures are mixed up, they're not clear, then our staff aren't clear and, you know, lack of clarity results in anxiety. And then also, you know, we also, we had a lack of alignment and clarity among formal regulatory language across the board. CSAT, various accreditation agencies, DEA, your state regulatory agent, BSAS in Massachusetts. And so none of that, none of that, what was written was anachronistic. What was amended was quickly done and contradictory. And then there was so much that was verbally approved and didn't even get written anywhere that that also caused anxiety. Correct? So there's all of this bubbling in the background of this is what happened in 2020. And of course, the resistance of third party payers. Next slide, please. Okay. The internal environmental variables. Okay. Again, opioid treatment. I'm being redundant about this because we really need to address it with folks. Internal, the internal environmental variables are, you know, the stigma. And stigma has been over-regulation under compensation for 100 years. It continues to be, but it is much better now. And again, I'm so grateful to the last year and what CSAT has done. They have done a remarkable job in assisting us with these guidelines. And under recognition of treatment success. Everybody's so afraid of the disease that they don't recognize. It's not publicly recognized that treatment is successful. It's not recognized now. Now it's, it's, it's a new sort of conflict that is emerging or has emerged that, you know, you know, treatment is, well, you know, in mass, Markey's saying that we're, what is that cartel? We're a cartel. And we're only in it for the money and all of that nonsense, but that it was easy for him to sell that because history allowed it. And so that's where we are right this moment. And that's also an important internal variable. We created truly a fear-based system of care for the patients and for the staff. And if you would like to change the movement, thank you. So this is all the history, you know, we know it works. We know we have stigmatized regulation and we know that it's now 2020 and we've just turned the snow globe upside down and we don't know where everything's going to land. So Kodak and others, but we knew out the gate that we were going to have problems with our third party payers. So, and that's really why we did this. We created a telehealth survey with Brown University, 106 patients responded. These areas are important. Satisfaction, convenience, therapeutic relationship, substance use recovery, and general feedback. And we examined both patient and counselor experiences with these same five. What's interesting here, and I'm just going to talk to you a little bit about it and then I'll skip this next slide, is that we measured what they call balances, but, you know, are patients happy with it? Is it positive? Or are patients negative with it? And we measured it through these five pieces. But what happened with the folks that were the primary researchers in our research project were that on the positive side, you had to be positive in all five areas. If someone answered and said the therapeutic relationship, convenience, satisfaction, all that was great. I happened to relapse because I was scared. Then that went to the negative side. So can you hear how that balances? It had to be all five in order to be positive. And you'll see that even as with all five being positive, it was still, please, next slide. It was still 78% positive. So that was a positive balance. So these are all the pieces, the qualitative overview of what was measured. I don't need to get into this. You can look at it if you would like to. But everything is positive on the therapeutic relationship factor. A few people had mentioned impersonal experience. And then on the personal factors, it was all positive. And some people were indifferent. So I think you can feel from here, and I'm hoping that you can, that this was current and this was real. And it is a good example of how positive, how positive can you be when you have a therapeutic relationship? And this was real. And it is a good example of how positive, how effective and how efficient telehealth is. And we used it not just with counseling, but with case management, with medical case management, with doctor's appointments. I'm sure that Laura and Jess will talk about their mobile units. We use telehealth to connect to docs when we're out doing mobile health. So this was good. This was strong. Next slide, please. Okay. And these, I'm just really giving you some of the direct responses. And so we don't, you don't need to read through those. You can read through them at your leisure. We can go to the next slide. But individuals really liked the relationship, the communication. They really liked the convenience. Lines, don't have to bring my kids out. And, you know, and it assisted them. And this is important. The one that says keeps me from getting COVID-19. That sounds like a very simple phrase, but it has a lot of therapeutic value because what we heard from people is you heard our fears and you are responding to them. You really heard me. I was afraid and you didn't make me come in and you gave me better service. That's critical. Next, please. Thank you. And then these are the negative aspects. And for me, the top two feels like they were far more individual than about the process. Not sure. And the bottom one actually ended up being positive anyway. So there you have it. Next. Okay. Yeah, this is the one. I really, I enjoyed that. I enjoyed hearing that. I thought it was important. And you got to figure this is well over 78% of 160 people. So it's a pretty consistent response. Next, please. So, we are missing one, huh? Okay. Look at what happened here. 2024 was the first quarter. A year ago, I had asked. I wanted to know where we were with telehealth because I wasn't getting as many requests. There weren't many laptops being utilized. There was something because I'm the CEO. I'm so far removed. I really don't have good knowledge. And I asked our IT department, our QA folks, to show me this and look what we saw. So, that to me, this really shows me that, you know, again, we know what we have to do. We taught, we bought the technology, we taught the technology, we created it, and now we have it. We created policy and procedure. We did all of the things that we were supposed to do that would have a strong outcome of sustained performance in providing telehealth, right? But to sustain it, you have to review and review and review. And please, please know that this is a cultural change for individuals. They're afraid of confidentiality issues because second to the DEA, we are afraid of 42 CFR. And again, it's very fear-based for many of us. We used to get a lot of litigation around 42 CFR. So, confidentiality is huge, you know. And then most importantly, you know, I've had many experiences where people have lost jobs because someone found out they were on methadone. People have lost their health insurance because they were on methadone. So, 42 CFR really provided wonderful protection. And what we're happy about now is that that has, you know, we've figured out a way to have those protections and still can have strong, good communication to provide coordination of care. So, what did we do? Okay. What did we do about this? We went back in and showed the evidence through supervision, through trainings. And we made sure that our clients, our patients, and our staff knew how to use the technology. And then we made it very clear through surveys with our patients, through asking people to ask their clients to, from the people we serve, that they were motivated to participate in telehealth. You know, it was almost like at this point, you know, when people started coming back into the offices in 21 and 22, it's like, well, I came back, so the patients come back and we'll get everything back to normal. And that is not what we wanted to have happen. And here I am, like, I'm out there talking about telehealth and fighting with insurance companies on a national level and doing all this stuff. And my own backyard just started to go down and down and down. So, it was, we have to, in order to retain any new service, any new modality, we need to review it over and over and over in training and supervision. And, you know, as much as they sometimes get tired and you might get tired of, you know, why does CAR for JCO, or not the joint, the Joint Commission, you know, why do we have to do this every year? And, but it's good to do it every year. So many things need to be reviewed and so many things get updated. So, but the client stakeholders, we went back to, we did go back to the beginning, remind the staff that patients are motivated, they want telehealth, and when we give it to them, they feel heard and the relationship becomes more solidified. Next. Okay. Again, organizational stakeholders, we need to have staff and clients with telehealth technology, they need laptops. We got laptops. We just got funding to get, we have a fair amount of those that are unhoused. So we got iPhones and we're, you know, we have to continually find dollars for iPhones and, and then we continually have to get help for us to provide the minimal service for allowing people to have connections and linkages in the community for safety and for their care. And ensure, this is big, ensure ongoing IT support, and then training over and over and over. And to maintain competence, there has to be regular clinical supervision that focuses on telehealth issues. You know, the kind of conversations that people are afraid of, that, you know, I don't know, how do I address when people walk through the door into the room where my client is having the exchange with me with their IT equipment? You know, how do I address, you know, I mean, a lot of times, you know, it's, we ask people to perhaps not just climb out of the shower in a towel to speak to me, but like, you know, get yourself ready, get dressed like you're going to go out to see us, and have that kind of, you know, and I, I mean, I could talk on all of these things for the next six hours, but it's those kind of role plays as part of clinical supervision, it is necessary for people to get comfortable believing that they are, that, that they are participating in a modality that is effective. So get comfortable with how you make it effective. And of course, if you can, or if your, your entity, your organizational entity can advocate for policies that support us, because reimbursement, again, I did, I gave you that little piece about the struggle of having iPhones and then the communication program that they can at least have audio communication with us through various, I don't know, Verizon, Cox, whatever it might happen to be. Next please. Okay. Again, providers, stakeholders, what we need to do for them is continuously review evidence. This is good. If you're, if you are not feeling that it is not good, then let's work on it. Because for most people, it is good. And nothing is good for everybody, right? It's really important. I should have, when I was talking about who providers were, I should have qualified it in the beginning. Telehealth is not good for every single person. It isn't. Okay. That makes good sense. There needs to be, you know, your initial assessment, now that we're no longer in crisis, an initial assessment, and then you have training for the counselor and training for the patient or the client about the utilization, basic, you know, actually it's checklists. And there are a number of them out there, APA, SAMHSA, and I'm happy to give you some of them. If you want them, you can email me or email Gretchen or Melissa, right? And this is, this is, I can't say it enough. Acknowledge the biases from embedded cultural beliefs. You know, we, I hear, and I have heard from the clinical director here, you know, how can I be present? How can I be, you know, and present meaning, you know, allow myself to be open and allow the patient or client to know that I'm open. People feel like in order to be present, they need to be within three feet of someone. And I mean, we, you know, we can all do this. We, on Zoom, if any of you have taught on Zoom, you can tell when somebody is present to what you are trying to provide. And when someone else is not, you know, you can feel it. You see it, you know. So again, it's practice, but the idea that presence, presence is very much possible in telehealth. Absolutely. And, you know, and I would, I would often suggest, you know, ask somebody to think about when you were with somebody in person and they weren't present, you know, yes, no, okay. Well, you know, you know when somebody is present or not in a relationship. And I'm going on and on about this because I have heard that it is a critical piece in the lack of understanding of the possibility of efficiency. And I think I'm running out of my 40 minutes. So next one, please. Okay, because this is big. This is the next big one. Another barrier is adherence to confidentiality. So again, I had said this before, right, that, you know, it's to prevent stigma and discrimination and legal regulatory clients. All that is great. It protects our patients, our clients. However, confidentiality is not a reason to say, oh, well, you know, we don't know who's in the house. So we can't maintain their confidentiality. That's part of the checklist. That's part of the assessment. That's part of the training. Look, if you don't want to come in, you know, and you don't have to, then we can do it this way. So how are you, you know, give the client, okay, the responsibility to maintain their own confidentiality. That's further valuing. So, you know, so it's just ongoing supervision, practice reviews, et cetera. But if you're going to get three, take three things from this, and I don't have a slide on it. I will next time. Confidentiality, presence, and observation. Those are what people say are barriers to doing good care through telehealth, and they are inaccurate for most people. But you will hear it a lot. Next, please. Okay. Again, this is just the systems change policy and procedure. Please have informed consent and policy development, because that's part of the training for your staff and their client to be able to move forward into telehealth. And we have some. But again, also the APA, there's a couple of, I wrote it down for you because I always forget the acronyms. But if you chat a question, I'll be able to give you a couple areas that you can find really good templates. All right. Next, please. So, oh, this is so nice. You did this for me. Thank you. It's a proven modality, evidence-based, satisfied. Technology does enhance client-centered care. The concepts of being present, the concepts of confidentiality, and the concepts of needed observation are very often misunderstood and end up being a barrier for this care. And systems of change, improving technology literacy and challenging outdated treatment beliefs. Thank you. And person-centered care. And this, next to the last bullet, please hear this. Can you go back just a, there it is. Opioid treatment programming, it's showing that opioid treatment programming is responsive to current community needs, because our community has said that this is what they need. And that is the bottom line. Okay. Thank you. Next. Are we done? Yay, there's all these references. But there are tons and tons more. There is so, so much. Thank you, Linda. I'm, these slides will be sent out, so you can check out those resources. But we do have time to open this up for questions. I did put a prompt in the chat to see if there were any questions that folks had. But I will stop talking to see if anyone would like to raise their virtual hand. If not, our team has some questions. That we would like to ask Linda. That was a really good, we didn't even mean to have that mind meld in the beginning with the quiz. So that was fun. That was lovely. I'm glad you got it right. So, so our team had some questions. I don't know if anyone else, feel free to soak it in while we have Linda here. And raise your hand if you do have questions. But Linda, what, what would you, or how would you ensure equity when trying to increase access and distributing technology to patients, knowing that access to technology can be a barrier? Well, I know that, I mean, I'm not going to get into policy and procedure relative to equity, etc. But the bottom line is, everybody that comes to us for care needs to have the opportunity for telehealth if it's going to be effective for them. Right? So that's the assessment process. And at that point, we assure that every person has at a minimum, every person has at a minimum, a iPhone. And that iPhone has the capacity for audio. And occasionally, you know, somebody, a carrier will be kind and say, oh, we'll give you six months of face, you know, FaceTime too. But at a minimum, and that way we know that they are linked to safety if they need it. And at the same time, they have a link to us. And we have a link to them. And I know that's a simplistic answer. But it's everybody that comes to us for care has that. It is simple, but that is how we live our lives now. I mean, you can't successfully live without your phone these days and have that connection. You really can't. And it's complicated because, you know, many of the folks that come to us for care, and I'm sure the rest of you, you know, that are on that work in OTPs, many of them are unhoused and their life is in upheaval and stuff gets stolen, stuff gets lost. Somebody might have three phones throughout the course of the year. You know what? If I have them, you have them. I mean, that's just what has to happen, you know? So you talked about presence and the importance of presence. I totally understand. Like, I understand what you mean with that. But do you have any or I guess I'll ask you first, but I would also open it up to others. Examples of what you've done to, like, what you can do to create that presence or to establish that feeling of presence. I don't think that there is a physical piece to that. I mean, when we look at, okay, how do you establish this? You know, you have your consent and you have your training for both. And now, you know, you move forward and you work for a while around making sure that there is a place relatively quiet and private for the client to be able to speak with you through telehealth and receive the modality. And then it's the relationship. I mean, it's all about the relationship. I mean, we could, you know, we could do another training on supervision around this if you want. I think it's fascinating. But, you know, it's first it's the groundwork because nobody can be present if they have two kids under the age of two and a dog and a television on at the same time. We can make sure they're safe and have that conversation about being safe. But we, you know, it's not going to be that kind of a conversation that counselors often refer to as being present. You know, if I'm making sure you're safe, I'm present in that, you know, and you are too. But it's really defining presence. And understanding what that is and then understanding probably through experience, I would say, that telehealth is a modality that will support presence. And and you're like with supervision. That could be something that is supported and modeled, I guess. Yeah, role playing is so good. That's really important to do with this. And it doesn't take much. You know, once people get comfortable with it, it doesn't because it's good. So it doesn't take much when somebody has an understanding. And when we don't have an understanding, we get scared. Some people are afraid. It's OK. Nobody else has any questions? Don't worry, Linda. There are historically a very quiet group. OK, but we are at time. So I think it we do have time at the end for more questions. And Linda is planning on staying through the end. So if something comes.

telehealth

behavioral health

COVID-19 pandemic

opioid treatment

regulatory resistance

rural areas

cultural barriers

provider flexibility