Announcer: Thanks for joining the Re-Think and Re-Tool podcast
with Mehul Mankad, MD where we take a look at the people side
of healthcare and new ideas about enhancing overall
wellbeing. So welcome, the doctor is in the house.
Mehul Mankad: Welcome to Re-Think and Re-Tool sponsored
by Alliance Health. This is my home on cod psychiatrist and
Chief Medical Officer for Alliance. You know, something
we've all learned in the past few years is that the emergency
room is not the only place or even the best place for people
who are suffering from a mental health crisis to find support.
When folks are not yet engaged in mental health care, or if
they can't reach their mental health provider between visits,
where can they turn? Today, I'm fortunate to get the opportunity
to speak with Dr. Chuck Browning, Chief Medical Officer
of RI International, from crisis phone calls to crisis
facilities, nobody knows this stuff better than Dr. Chuck. Dr.
Chuck Browning. Hey, good to see you. So, you know, I wish these
were face to face because I feel like you know, now that people
are out and about, it would be nice to record in person. But we
will we will do the best we can virtually. But very much
appreciate you joining us today. You know, I was thinking, as I
was preparing for our time together, that I would share a
little story with you. And then you tell me how things are
different these days. So as my teenage daughter likes to say, I
was trained in the last century. And so I did, I did a fair
amount of my medical and psychiatric training in the 90s.
And at that time, if somebody had a crisis, whether it was a
behavioral health crisis or a physical one, there was
essentially two things they could do. They could call their
doctor's office if they had a doctor and try to get some help
after hours. And if that didn't pan out, which it often didn't,
their only option was to go to the emergency room. Now, my
understanding is times have changed a lot. And so what would
it be like for somebody these days?
Chuck Browning: That's a great question. And I'm gonna give you
a couple of different answers. One of them is that,
unfortunately, across our country, and I do this a lot
talking about crisis systems consulting with multiple
different country of countries and states around our country in
looking at crisis care. And unfortunately, right now, in so
many parts of our country, that's still the go to option.
It's to call 911 or go to the emergency room. Unfortunately,
that is still the place that we're in. But the good news is
there is a lot of development of a better system for emergency,
psychiatric and substance use substance use, supports being
developed and working really well and showing both good
outcomes in a business case and a clinical case in different
states. And there's more momentum hold than there's ever
been before coming through the pandemic, and different
movements related to social justice, justice, and the
involvement of mental health and law enforcement in the community
that has produced this momentous occasion that we've never had
before to really push forward a change in our emergency medical
system for behavioral health. And so that's really exciting.
Mehul Mankad: So I'm yeah, I'm excited to hear about that as
well. And I'd love for you to unpack some of that you shared a
lot with us. And so you kind of described it as a system, rather
than kind of a one stop shop being the er What do you mean by
a system for crisis?
Chuck Browning: Well, the best way for me to describe it and
hopefully in the short term that makes sense for the listeners is
to compare about the system that we have, if you had chest pain,
you know, you can call 911 and if the 911 Caller see certain
things that you can handle safely at your home, then then
they'll help you do that. But if you need someone to come to you
then they activate with GPS technology and things like that
a paramedic or EMS to come to you. And then they have
equipment infrastructure to assess you on site. And if
you're stable based on like your EKG there and the parameters of
what's going on. On, they may let you, you know, help you stay
in the community and connect with follow up. But if you need
more than you can go to the emergency department. And once
you get to Emergency Department, there are standards of care
based on, you know, years and years of studying how this is
done across the country. And the beauty of this system is that it
doesn't matter whether you're insured or not insured, what
your race or age, or demographics are, that you're
gonna get access to care, that's pretty standard across the whole
country. And we don't have that for mental health and substance
use. The other piece is that we those three pillars are there in
our emergency medical system. But also if you have chest pain,
if you go to the hospital, you don't just either go home, or go
to the ICU and have a you know, full on cardiac operation.
There's lots of layers of continuum in between that are
offered to you based on what your needs are, you might have a
step down unit, you might go to an outpatient rehab, there might
be a more cardiac intensive care unit, you might do it and get to
a stent if you need that level. So I mean, there's so many
different pieces that are there. And they're all driven on data
and studies, what works, what doesn't work. And it's kind of
publicized, and people follow that. And so we're decades
behind that in behavioral health in emergency response systems.
But there are states where we're seeing that level of change
occurring. And then nationally, there's really cool movement
called 988, which is the installation of a number. That's
the equivalent of 911, for emergency behavioral health
calls, that's going to be implemented nationwide in July
of 2022. And as that unfolds and moves forward, there's gonna be
growing pains as there was when they activated 911. But it
offers finally a really a real big opportunity to create a
system where somebody can call and get specific supports for
behavioral health crisis. And then if they need an another
layer of care, having local support teams that can come out
anywhere in the community and see people and hopefully
destabilize, excuse me to not destabilize, de escalate,
whatever they need to stabilize, and then be able to stay in the
community. And then if they need help, then there are places that
people can go to that are specifically designed to handle
emergency medical care. And ri as the chief medical officer
there, that's what we specialize in is that crisis receiving
center in North Carolina, some people call it facility based
crisis.
Mehul Mankad: Wow. So that what you're describing to me is this
brave new world that some parts of the US have already adopted.
And then other parts of the US, I'm hoping are looking at where,
right now, someone might call 911. And at some point, it'll be
988. And then there will be kind of layers and nuance in terms of
what is available and what the outcome will be. And not just
this one dimensional model of law enforcement, sometimes
picking people up, and then dropping them off in an
emergency room. So you had mentioned mobile crisis, you'd
mentioned facility based crisis. I've also heard of something
called behavioral health, urgent care. Could you tell us a little
bit about these, these kind of these different levels that
you're talking about? You're?
Chuck Browning: Sure. So the principal pillars, if you look
at SAMHSA's, national toolkit for crisis care are that you do
have the basics of the equality and parity to emergency medical
services. So a crisis call on and that will be 988, that you
would have mobile support teams, which is the equivalent of EMS
and paramedics, and then crisis receiving centers, which are the
equivalent to an ED, but specialized in those things.
Then, having a certain level of essential crisis care principles
that layer into that. So safer, Zero Suicide or Zero Suicide
principles use heavy significant use of peer support, recovery
oriented principles and trauma informed care principles that
are built into that have in coordination with law
enforcement and emergency medical services in all those
three lanes, and then being able to maintain safety for the
guests and the staff, because that's a big deal during crisis
situations for some certain psychiatric and substance use
situation situations that come up. However, when you look at
the whole continuum model, just like in medical care, it's
important to have other layers to see if you have those basic
pillars. In an ideal system, you would continue to have
otherwise. So behavior health, urgent care, would be like going
to an urgent care for medical things instead of going to the
emergency room. So if you're have you know, strep throat and
you don't want emergency room and you don't have a primary
care that can get you and you can go to a Minute Clinic, have
that test done and find out yes or no and get a prescription for
antibiotics. And that's been shown to kind of fit the model
that many people like that to get served in that way. And so
there are definitely situations where people have run out of
their med occasions, but they're not having an intense crisis
that they would need to be, you know, definitely in a
hospitalized or things like that. And so there's lots of
situations where having layers like that are great, having
different ranges of care for different levels of substance
use severity, intensive outpatient programs, MAT
programs and things like that offer lots of routines and
alternatives. And the other thing that often gets missed in
crisis is how much social determinants play a part in
people's presentation and needs. So housing issues, you know,
food, being able to obtain access to medication,
transportation, different things like that can have big impacts
on folks that we see oftentimes come to our crisis centers over
and over again. And it's not just about finding the right
medication or having a follow up appointment. There's, there's
things in their life that are basic needs that are driving a
huge amount of stress or things that are going on.
Mehul Mankad: Wow. So one of the things you'd mentioned that I
don't automatically think about when I think about crisis, is an
orientation towards long term recovery, and not just a crisis
that's right in your face. And I'd love for us to come back
after the break and hear some more thoughts about that,
because that's really a different way of thinking about
crisis than I think a lot of people do. So, I do want to warn
people, though, when we do come back from the break, Dr. Chuck
is going to share one of his guilty pleasures, we will, oh
gosh.
Unknown: At Alliance, we see health care differently than
some. Every day we walk alongside the people we serve on
their chosen path to recovery and self determination. We
believe in health care that concentrates on the whole
person, including support that promotes physical, social,
emotional, and financial well being and housing security,
helping people live healthier, more satisfying lives. That's
the Alliance way.
Mehul Mankad: All right. Dr. Chuck, you ready to tell us what
is that thing that people don't know about you that they might
be interested in?
Chuck Browning: By the admitting this, I'm a very lack luster,
lead singer of a garage band of folks that are much more
talented than me. In the band in my neighborhood, we play up in
the attic and call ourselves three floors up. And we do we do
play gigs for people in our neighborhood are willing to put
up with listening to us. Every once in a while, we've seen a
variety of like 70s, 80s, 90s, sometimes a couple of current
songs that even kids at our neighborhood that are of those
families will come and participate. Sometimes it's fun,
it gives us something to do some nights together to practice and
keep together and a lot of camaraderie. And we try to
engage other people in neighborhood to play like
tambourine or we had a lady play a flute for one of the songs. It
was great.
Mehul Mankad: That's awesome. So three floors up to tell me
something that's on your setlist for three floors up?
Chuck Browning: Oh my goodness, some of it would definitely be
what your daughter was accusing you of during your times in the
90s. We we tend to do really well with certain all rock songs
like in Red Hot Chili Peppers. Audio Slave, even some of those
tight groups Foo Fighters that stuff. But we do a variety, a
lot of different things.
Mehul Mankad: That's awesome. That's awesome. I did not know
that about you. And just you know, you've got to you got your
own layers, like an onion never seen in public. And yeah, we may
have to book Three Floors Up for like the Psychiatry Association
meeting or something. No. Maybe not. So, so coming back to our
topic, you were mentioning that one of the approaches that
you're fond of, with working with individuals in crisis is a
recovery orientation. I think I know what that means. But could
you help unpack that and just kind of lay it all out there as
to what a recovery orientation is? And how would that be
relevant to crisis? Because I gotta tell you, when when I've
taken care of people in crisis in like an emergency room
setting. It's really just about what can we do for you in the
next hour? Not anything beyond that?
Chuck Browning: That's such a great question. Well, it's one
of the reasons I love working at ri, which stands for, you know,
the former name was recovery innovations. And it originally
was started by a group of folks decades ago who were out in
Arizona who were extremely interested in the involvement
and use of peer support. In this crisis care continuum and
spectrum. And so I have been so fortunate over the years of
working with ara to really be able to have the experience of
seeing the power of what these recovery oriented approaches
bring to crisis care, as well as a person's longer term work as
well. And we talk about what we call pure power practices, as
part one of our keys that are on our way of what we do. And we
label those in certain approaches. And they're very big
parts of recovery oriented care. And by the way, when you look at
SAMHSA's national toolkit for all layers of care, whether it's
crisis call on or mobile support, or crisis receiving
centers, it is a recovery oriented approach. And so our
peer power practices include strengths based, which means
focusing on what people's strengths are, instead of their
weakness in their crisis. It involves looking at the whole
person's health. So it's not just about their illness and
their diagnosis, which is a psychiatrist, we get trained to
do that all the time. It's also about looking at what is matters
to them and their life, their meaning and their purpose, their
family and connections and support systems and where they
are. So it's really about not just focusing on this person has
schizophrenia, this person who has depression, is looking at
what is going on your life that brought you to this crisis, and
what are the meaningful things in the big picture that you can
control that we can help empower you and support you to work on
that. And you just would be amazed at how often that is such
a huge part in a crisis situation of helping someone
improve quickly, and having more feelings of hope about their
situation by being able to connect into these humanistic
things. And I really believe and I'm participating with things
that we're doing Ri and studying this is when you when people
come into a crisis situation, and they feel cared for by the
team, that that has an impact in your crisis improvement, that
just this concept of feeling cared for has been studied in
the hospital systems a lot as to what creates success. And that's
usually the number one measurement that that guests or
patients talk about is do I feel cared for. That's the number is
not hospital food might be a complaint. But what really
matters is do I feel cared for. And so that's such an important
piece that we try to instill in all of our staff. But it's not
easy to do, because there's so many different staff members,
crisis work is really hard. You see people going through really
tough times who might on their worst day be really irritable or
angry about situations that can be violent, even. So it can be
scary to work in that environment, if you're not
feeling trained, and having the tools and the resources to do
it. And so it takes a lot of work and infrastructure to have
that kind of customer service angle where you can do that.
Having peers as part of our treatment team is and giving
them voice and value in the whole treatment team also makes
a big impact. I think the whole and creating that recovery
approach, because I can't tell you how many times I've had a
peer support person work with someone who's I've walked in
your shoes, I've been where you've been. And here's where I
am now. And it just creates this lane of engagement, that makes
it so much easier. And then for them to say, hey, you can trust
talking to Dr. Chuck, he is gonna listen to you, He cares
about you getting better and working on this thing. So tell
him what you told me, you don't want to really feel about it.
And it just opens up this lane of engagement, that oftentimes
you don't get because of past contexts that people bring into
their situation. And that's that trauma informed care piece,
which is another one of our pure power practices is spin in time
from a recovery perspective, trying to understand what people
are going through. And instead of it, how it's impacting you,
as a staff member working in crisis, thinking about what
they're bringing to you and your situation, understanding that
and having empathy so that then you have a better chance of
engaging with them and help them partner with them in a
collaborative way. And that's, that's our fourth pure power
prices, collaboration. So when you partner with people, they
take stake in what they're doing. And so many times in
hospital settings, you're a piece of the puzzle of getting
processed. And so we really talk about, we want to partner not
process do with and not do too, and it's really easy in crisis
to not do that. Because your time pressured, there's
parameters of business rules and things like that. And they're
all together in this ball of tension that you have to pull
out. But when you take the time to do that, you usually end up
getting much better outcomes and much better customer service
experience.
Mehul Mankad: The idea of using peers and including people with
authentic lived experience has been around in mental health for
a while. I just I'm so impressed that you're passionate about
introducing it from the moment that people hit the door with a
mental health crisis.
Chuck Browning: It is we call it peer first peer last. You see
one for First and last. So our peers are not prescribing
medications. They're not making diagnoses. They're not doing
certain licensed clinical roles. But they're, we're, they're
indispensable in what they do for the milieu for our teams for
helping the rest of our staff use peerpower practices as well
not just the peers, it makes a big impact. So I think am I
doing?
Mehul Mankad: Yeah, yeah, I think I know the answer to this
question, Dr. Chuck, but I'm gonna ask it. What gets you out
of the bed in the morning? Why do you do what you do? Because
you have options, you are a doctor, you can do all kinds of
other stuff. Why do you do this?
Chuck Browning: That's a great question. And thatcalls that
calls for some self analysis. I did that during residency
training, to my therapy, I gotta go go, deep. No, I mean, really
just basic human things of having significance. So being
able to be a part of a movement that potentially is changing the
country's way of how we support a group that for so long, has
been disenfranchised, marginalized, not treated
equally, and having a lot of stigma. And especially when you
look at minorities and minority populations, and how they get
treated in crisis situations compared to the other
demographics, it's an it's a chance to have a big impact on
the way our system operates. And so that's one thing. The second
thing is like I described as just when I started working over
10 years ago, with Ri and being a part of what they do with this
recovery oriented approach in this peer care and seeing how it
works. And then Larry, on top of it, seeing that we had an option
in North Carolina in the areas where we're operating for people
not to be handcuffed to a gurney in an emergency room for five
days waiting to go to an inpatient stay for seven days,
that's three hours away, away from their family and support
and those types of things and having people and friends call
me and say I need some help with these suicidal thoughts. But I
am not going to the emergency room, they will lock me up and
I'm not going to happen. And being able to see people have a
better experience that's meaningful. And so it's, it's
really cool to be a part of it on a day by day level here in
North Carolina, but also on a national and international.
Mehul Mankad: level. Well, Dr. Chuck Browning, thank you for
doing what you do and for being our guest. We appreciate it.
Unknown: Mehul it so much fun. Thank you.
Announcer: The Re-Think and Re-Tool, Healthcare in the New
Era podcast is produced by Alliance Health, a North
Carolina public managed care organization. This show was
produced by Brandon Alexander our associate producer is Denise
Dirks and executive producer is Doug fuller. View our show notes
and hear other episodes at AllianceHealthPlan.org/ podcast.
Thanks for tuning in.