Hi everyone and welcome to today's webinar. Today we'll be talking about practical tips for managing behavioral health concerns for people with diabetes. I'm Dr. Julie Gettings and I will be moderating today's webinar. We'll spend the next hour together by following the agenda on the screen. We'll be using interactive features during today's session. We'll use the chat box to send you important links throughout today's session. So please locate it on your control panel now and be sure to click on it when you see a notification pop up. We'll also be using Zoom Q&A at the end of the presentation for panel questions. So be prepared to answer questions as they pop up on the screen. And if you think of a question while our presenters are speaking today, you can use the Q&A box at any point throughout the presentation. There's no need to wait until the end. We'll address all questions that have been submitted once we get to the Q&A portion. Now I'd like to preview another upcoming ADA webinar. Join other professional members of the ADA for a live one hour panel discussion webinar, Organizing Team-Based Care for Diabetes and Primary Care on November 14th at 3 p.m. Eastern Time. In this webinar, speakers Caitlin Nass, John Broek, and Matthew Crawley will share their experiences and tips to organize team-based care for people living with diabetes in the primary care setting. Also keep an eye out for an email from ADA membership to watch the most recent hands-on webinar and earn one CE credit. This is a member-only exclusive series. One other thing to mention, earn six CE credits by completing the Innovations and Latest Treatments in Type 1 Diabetes Self-Based Program. To register for the program, visit learning.diabetes.org. And now I'd like to introduce the other panelists for today's webinar, Dr. Nancy Rennert and Dr. William Polonsky. Dr. Nancy Rennert is System Chief of Diabetes, Nuvance Health, Chief of Endocrinology for Norwalk Hospital, and Associate Clinical Professor of Medicine at Yale School of Medicine and the University of Vermont Larner College of Medicine. She has extensive experience in clinical endocrinology with special interests in equitable access to diabetes care in underserved communities. Dr. Rennert has been recognized for excellence in medical education and for clinical research and quality improvement. She currently serves on the Education Committee and also the Diversity, Equity, and Inclusion Committee at Yale School of Medicine. Dr. Rennert is passionate about improving the quality of life for people with diabetes. Next we have Dr. William Polonsky. Dr. Polonsky is the President and Co-Founder of the Behavioral Diabetes Institute, the world's first organization wholly dedicated to studying and addressing the unmet psychological needs of people with diabetes. He is also Associate Clinical Professor of Medicine at the University of California, San Diego. Dr. Polonsky received his PhD in Clinical Psychology from Yale University and has served as Senior Psychologist at the Joslin Diabetes Center in Boston. Faculty member at Harvard Medical School and Chairman of the National Certification Board for Diabetes Educators. A licensed clinical psychologist, certified diabetes care and educational specialist, and highly cited research scientist with more than 150 peer-reviewed publications in the field of behavioral diabetes. He received the American Diabetes Association's 2020 Outstanding Educator in Diabetes Award and the American Diabetes Association's 2014 Richard R. Rubin Award for distinguished contributions to behavioral medicine and psychology. Again, my name is Julie Gettings and I'm a clinical psychologist who serves as the Clinical Director of Behavioral Health in the Division of Endocrinology and Diabetes at Children's Hospital of Philadelphia. I'm also an Assistant Professor of Clinical Psychology at the University of Pennsylvania School of Medicine. I'm a member of the Motivational Interviewing Network of Trainers and have given national and international talks on the topic of motivational interviewing. I specialize in using motivational interviewing to guide people with diabetes and improving adherence to health behaviors. I also have a passionate interest in leveraging the electronic health record to improve psychosocial screening and provide equitable care. I want to thank you again for attending today's webinar. Just to give some context for today, we're really thrilled to present on practical tips for managing behavioral health concerns. Now, something we know is that people with diabetes have a higher risk for mental illness as compared to the general population. Mental illness can affect quality of life, everyday functioning, and of course diabetes outcomes as well. So as diabetes clinicians, we're well positioned to try to screen and detect these issues early and try to connect folks with interventions and mental health treatment to support them. Now, today we really acknowledge there's a lot of heterogeneity in clinics from pediatric care to older adults, different resources available for diabetes care, but also mental health care as well. So we're going to do our best today to try to give practical tips that can apply across different areas. We're going to focus more on common mental health concerns like diabetes distress, depression. We're going to talk more about how to talk to people with diabetes about their mental health and seeking help, and how to refer patients to mental health support. So I'd like to invite Bill to get us started today in talking about identifying behavioral health concerns. Thank you, Julie. I'm going to pull up some slides here. Moving on. Julie, you covered a lot of things. By the way, if we have time, I was very glad to hear that you are a Menti. So I'll have to talk about motivational interviewing more at some point, maybe even during this talk, which I hope we will. So hopefully, I hope you can see the slides. Just to get us started, just to highlight actually what Julie mentioned, why worry about these behavioral or emotional issues in our patients with diabetes? Hopefully, it's because we actually care about our patients' quality of life, not just what their glucose values or blood pressure might be. And also because we know this is critically important if we want to help our patients achieve positive cardiometabolic outcomes, because these emotional, behavioral, mental health issues can obstruct and complicate self-management. And I want to highlight something that's going to be critically important in the title of this presentation. It's really about being practical. And so you're going to hear from my colleagues go into more detail about the fact that there's all sorts of mental health issues, emotional issues that can arise. But if you're a busy provider, if you're a busy endocrinologist or whatever you might be doing, odds are pretty good your time for visits is going to be pretty limited. So if there's complicated things that come up, which are the mental health issues that you really should worry about, that you should be paying attention to, and that hopefully you can address? And to bring that to light, to illustrate that, I thought I'd start with a case. So here's Sam. Sam, when I met him, was 42. He was a school teacher. He had type 2 for about six years, like so many folks with type 2 diabetes, like so many Americans. He was significantly overweight. His BMR was 33. And his last A1C was elevated 8.4%. He'd been gaining weight since he was diagnosed. He used to be really into checking his blood glucoses with his meter, his BGs. But he stopped because he said, you know, why should I bother checking anymore? It's always high. So I said, what the heck with it? He's on multiple daily injections. He admits to frequently missing both his basal and prandial insulin shots. And he's very comfortable telling his health care provider, you know what, I'm sick and tired of all this. But, you know, I'm going to try harder, honest, I promise. But actually, since that visit, he started to skip his appointments with his doctor. So perhaps you've seen people like Sam who have become, well, disengaged from their diabetes. And what's going on? When we think about folks like this, when we think about some of the people you meet, we think about these emotional behaviors. Behaviorally, sometimes there's just major mental issues like depression, like significant anxiety, like, you know, more severe psychiatric problems that can arise. And this is going to come up later in our conversation that I know Nancy's going to talk about. Another broad category is life stresses that people are struggling with that aren't particularly diabetes specific, but they're just part of life, right? People running into financial problems or huge battles with family members and all sorts of other things that can come up that make life difficult and can make worrying about diabetes not so much of a priority because you're worried about everything else. And then there's more diabetes specific issues that come up. And I've highlighted one, which is just diabetes stress. Of course, there's others. There's worries about hypoglycemia. There's eating disorders that can be diabetes related. But we want to really focus, in the little brief period I have, to introduce this broad topic of diabetes distress. And when I talk about prevalence, you're going to see why I think it's so important. Another reason I think it's so important is because, while the first two categories are usually things where we think of, oh my goodness, who can I refer this person to? What's in my network? When we talk about diabetes distress, this really comes down to what can you as a busy healthcare provider do? And that's really because we don't have a lot of diabetes knowledgeable mental health professionals to refer to. So when we talk about diabetes distress, really what underlies that is something which I'm sure you understand when we think about this from the patient's perspective, which is that when we think about real life with diabetes, living with diabetes is tough. It's really, you know, illustrated in one image on this slide. That we know that the day you learned you had diabetes, it means the universe said, hey, I have this job for you to do. It's going to take time and it's frustrating. I know you didn't volunteer for it. By the way, there's no pay for this job. There's no vacations from this job. And I'd like you to do it for the rest of your life. And if you ever had any job like that, and being given a job like that, you can see why. Think about this idea of diabetes distress. It really comes from this. And it really involves this idea. It's the felt burden of what is living with often a tough and demanding disease. It doesn't mean that this is pathology. It doesn't mean that this is a sickness. This is in many ways to be expected, that this can drag you down. And we think about the important elements of it. We're talking about the spare and hope that people find. Perhaps you've had people say things to you like this. You know, what's the difference? This disease is going to get me no matter what I do. Often people feeling doomed that they're going to develop terrible long-term complications, or their life is going to be limited. So why bother? We know another important element is the sense of discouragement that can come up. And again, perhaps you've had your own patients say things like, you know, I hate that no matter how hard I try, I can never get the results that I want, right? I mean, look, I'm on a diet and I can't lose weight. I've been trying to take better control of my blood sugars, and they're still going up and down for no earthly reason. And we know another element is just exhaustion. Boy, I hear this a lot from, especially my patients with type one. They'll say things like this, 24 hours a day, seven days a week. I can't go 10 minutes without thinking about this damn disease. I am sick of it. And that exhaustion, that burnout really does contribute quite a lot to diabetes distress. And on top of that, think about how we talk to people about diabetes, both type one and type two. There's often this underlying sense of shame and blame and guilt. You know, no wonder our patients show up in our office and say, oh, you're not going to want to talk to me today. I've been bad. And this guilt and shame just leads to people becoming like Sam, disengaged. So the reason I wanted to talk about this and introduce this idea of diabetes distress in this conversation is because the evidence is becoming more and more clear how very common it is. I mean, we could talk about depressions being, you know, 5% maybe of our patient population with type one and type two. In some of our larger global studies, it might be up to 10, 11%. But what about how common is really high level, significant levels of diabetes distress? Well, our most recent evidence suggests it's really high. It's 60 to 70% or more. In other words, to be fed up, to have really distressed about diabetes is really common. Now, Julie's going to talk more about kids, I hope, but I really work mostly with adults and we know this is very, very common. Very common. So really, before I turn it over to Nancy, the issue is what do we do about this? And the most useful thing busy healthcare providers can do, the single most important thing is to just investigate, to ask about it, to see, to talk to your patients, and let them know that that emotional side of diabetes is something that you're willing to recognize as being real for them, even if it's not the easiest thing for you to solve and address. It's just bringing it up is respectful. And there's different ways of doing it. There's the informal method. In many ways, I think is the best, which is to just ask questions like this, you know, Mr. Smith, you know, can you tell me what's one thing about diabetes that's driving you crazy? And notice how we frame this question. It's not saying, Hey, anything bothering you? It's please tell me one thing about diabetes that's driving you crazy. And for busy healthcare providers, I always say put your finger up when you say that, because you're going to open a door here and you don't. Everything about diabetes is driving them crazy. But to open a door and say, I care enough to ask you this, tell me at least one thing and let's see how this fits into what's making managing diabetes difficult for you. And I can assure you having asked this question, as I have many of my colleagues over many decades, we still have never met anybody who said, you know, I really can't think of anything. It's all good. It opens a door to an important conversation. Now, the last thing I want to say is there are more formal ways to begin to look at and to begin to identify and open up a conversation with your patients about this issue. What's driving them nuts about diabetes to investigate diabetes distress. And this means using common self-report instruments. We've developed a lot of them over the years. The easiest way to use them and find them. Certainly the ones that we've developed, the diabetes distress scales and those that have followed are on this website at diabetes distress.org. This is freely available to anybody. The scales at this point, at least online, are only available in English and Spanish, but you can have your patients fill it out. I sometimes I'll just hand them my phone or hand them my iPad and say, could you just go through these items? Do, do, do please score yourself. And then. Automatically comes up with a graphical display of what the. And therefore leads to being a really nice conversation starter. So I just want to show you an example. I told you about Sam and how he, how he came in and was feeling distressed about fed up with his diabetes and starting the misappointments. But with my opportunity to see him, I asked him to fill out our newest diabetes distress scale, which is called the type two diabetes distress assessment scale. And he filled it out and up popped this. And these were his responses. And I'm not going to. Go and tell about this. There's what's called the core. Scale, which is what's the very top line. And his core score. If it's above 2.0. It tells us, well, he is significantly distressed. If it's above 3.0, it tells us he's very distressed. And Sam scored above 3.0, which told me he really is. Something is big, big going on for him, which you could kind of tell, but it allows us to open that conversation for me to say, boy, Sam. And everything below that are what's called the sources scales to tell us where's all this coming from and allows us to focus our conversation. And so, for example, if you look there, you can see the highest scoring scale had to do with his long-term health. And when I asked him about this, Sam was able to tell me about his sense of just hopelessness that, you know, he was sick and tired of this. He wasn't really sure what he was being asked to do really mattered. Anyway, he thought. Whether diabetes was going to get him or not, wasn't really in his hands. And he didn't really see the point of going on. If he was doomed to develop long-term complications and hit his grave early. So it allows us to understand that and begin to offer him some information you might not be aware of. So is there a time for you to do this in your setting? For some of you, maybe for others, probably not. But again, it's think of it as simply a conversation starter, not necessarily a screening instrument. So that's really all I wanted to say about this. I wanted to open this door to that. I'm going to turn this over back to Julie and to Nancy, and we're going to talk hopefully further about this. And thank you for listening. Thank you, Bill. Just one follow-up question, and then we'll have Nancy present. You know, you're absolutely right. For children and adolescents, they experience diabetes distress. I see it in my clinics. And I think we're faced with this balance of these standards of care requesting that we do depression screening. And commonly we'll use PHQ-9, PHQ-8, PHQ-2, all these standardized measures. What's your recommendation of, you know, would you say that there's better bang for your buck in using a diabetes distress scale versus a depression measure? What would you recommend? Well, there's no question. If we identify someone with this, we should try to assist them. It's an enormous concern for that individual, and we want to address that. I just want to point out the actual numbers we're talking about. If you use a PHQ-9, you know, remember, a major depressive disorder, again, is not going to be more than 5% to 7% to 8% of your population. It's important to find it, but it's kind of rare. And with a PHQ-9, remember, it's really just a screening instrument. So our best evidence suggests if you use, for example, a common PHQ-9 score of 10 or higher, you're going to have about more than a 50% false negative rate. It's not really measuring depression. It's measuring that someone's distressed about something. What are they distressed about? Well, the most likely thing to be stressed about is diabetes distress. I think the fact that this has become this common thing that we're supposed to assess depression is because our early evidence suggests that depression was very, very common, and it's just not. It's high PHQ-9 scores, but that really tends to reflect people being fed up with their diabetes. If it was up to me and I could shift all that, I think it's way smarter just to ask people, what's driving you crazy about your diabetes and go from there. That's really helpful, Bill, especially as we think about having time-limited visits and trying to get the most information when we have a short amount of time. With that in mind, I'm going to shift over to Nancy, and I'm going to share slides at this point. Nancy is going to talk a bit more about integrating behavioral health into medical care. Yeah, and thank you, Bill, for that great presentation. I really like that we have a unique terminology now for diabetes distress, as you talked about, and some way to quantitate that and pick apart its components. I am going to focus on how can we possibly do this in our 15-minute follow-up visit? How do we integrate it into our medical visits? Next slide, please. For some things to consider, there's no one answer, so I'm going to talk about things to consider and then talk about some options. I hope that that will spark something in all of our listeners to maybe think about trying one or two of these things. Our practice settings are very variable. The resources that we have in behavioral health, both within our practice settings and in the community, are also going to vary how accessible these are to our patients, whether they are affordable to our patients. Then, in addition to that, those sort of system things is to address individual challenges and barriers, especially in our vulnerable groups. We may need to tailor that support to make it more acceptable to certain groups. I would encourage us all to take the long-term view. All of us, and people with diabetes included, we have the ability to cope with different things, and that changes over time. Lots of things influence it, whatever else is going on in your life. It may be that when you address the potential for seeking behavioral health consultation, initially a patient is not going to be motivated to do that, but at some time down the road, don't give up. They may be. Then, always just keeping in mind, really just expanding on what Bill just said, the interaction of mental health and diabetes, that people with diabetes are more likely to have mental concerns, and this can lead to worse outcomes. Then, the flip side is also true, that as you address some of the mental health concerns, you can get better outcomes. It's just as important as some of the lab tests we do and some of the medications that we prescribe. Next slide, please. This just is meant to show that we all practice in different settings, and I'm going to just have a couple of remarks on these settings, because they really give us different opportunities and different care models. Some of us will work in independent medical practices, and we may have to rely completely on external referrals for behavioral health. We may not have anything directly integrated. Some of us will be in an affiliated or employed medical practice, and there may be resources in the larger group that, as a clinician, you may need to seek out, because there may also be affiliated behavioral health clinicians, but you may not really know about it. Specialty practices, sometimes you may have the opportunity to connect with, just have a group of behavioral health providers that are specifically trained or have extensive experience in diabetes, and that's really a goal, so that they can really address our patients' issues more specifically. Those who work in academic medical practice often have trainee programs, and that can also give you accessibility to psychiatry or behavioral health trainees, who can also help to to fill the gap. Diabetes centers, not always, but often, have embedded specialized behavioral health and folks who are really well experienced and knowledgeable in diabetes distress, and then, you know, we have our underserved patients under resource centers, federally qualified community health centers. Often, we can utilize other members of the team, such as community workers, who can be trained to at least identify some patients and try to bring them in. Also, there are a number of grants that sometimes these various centers can apply for to bring behavioral health to the centers. Okay, next slide, please. So, in addition to all of our practice settings being different, our patients are different, right? Everybody's an individual, so we have to be open and try to understand what our patients' attitudes are about mental health. It's going to vary based on their, these are just some of the factors, based on their culture, their religion, their family, whether there's a perceived stigma about seeking mental health help. People are also going to have different readiness for therapy, and also, maybe you don't really have an understanding of what therapy means, right? I mean, there's just a whole bunch of different modalities, and that's something that might help to bring them into it. I'm going to speak about that a little bit more specifically. I think it's really critical to listen and understand what their individual attitude is, and maybe what their barrier is, and then tailor your plan to what the people are, your patients are willing and able to do at that moment, and realize that, you know, sometimes it's going to be baby steps, right? It's not going to be, they're not going to be all in, so to speak. So, I think really, you know, attitude-wise for us as providers, some of the most important things we can do is recognize that mental health care and diabetes is, it's a care gap. It's a very big care gap, and view this as an opportunity. We can normalize mental health care. I really feel like this terminology of diabetes distress helps us to do that, because it can really be, as Bill described, just a kind of a normal reaction to a lot, right? A lot that goes along with diabetes. And then, and now I'm going to transition to talk about maybe some more workflows and models, is, you know, we really have to look towards baking mental health care into our visits, just like we always ask people or send referrals to the eye doctors, the dentist, maybe the nephrologist, and we need to add it to our checklists, to our templates, so that we remember to do it. It's an important part of our medical care. Next, please. So, I put two exclamation points next to some of our challenges, and I put this all on one slide for a reason. So, I put our challenges, and then maybe some models, models of care on the same, in the same slide. So, our biggest challenge is probably time, right? I mean, I generally have 15 minutes. Most of us don't have much more than that to do my complete medical follow-up. So, that includes me doing an overall check-in, seeing if I have any other medical issues, you know, doing a physical exam, their blood pressure, everything, you know, going over maybe some labs, their data, their CGMs, their pumps, maybe I have to change their medication doses, maybe I got to start a new medication, talk about side effects, you know, I got to order tests, I got to have referrals, and then I have to explain it all. So, it took me almost 15 minutes to go through that. So, now I also have to include behavioral health. That's a very big challenge. The other challenge for many of us is staffing. There are staffing shortages, and there's a lot of turnover. So, using our team, as I'm going to suggest, may not be as easy as it seems. The access to behavioral health for many of our patients, both acute and non-acute, may be quite limited. So, even if they're willing to try it because of their insurance, a lack of insurance, or the location of the provider, it's just not going to work. And then there's the issue of ensuring patient follow-up with behavioral health. So, now I want to move to some examples, and, you know, every setting is different, but my hope in going through some of these is that it will spark some ideas for some of you that you could think, oh, okay, maybe I could try this. Maybe this would work in my setting with my patients. So, I broke down care connections, and I think there's many ways to connect. You know, perhaps the sort of the easiest, maybe the best, is if it's actually embedded in the practice. So, you have your behavioral health clinicians on site in your office, and they sort of call that sometimes like a warm handoff, even if they're not going to necessarily have a session, a full session with your patient. At least there's an introduction and a little bit of triage, and then there's connection need, and there's more, their patients are more likely then to follow up. The other, another way to connect is remote, and remote can be either at the point of care, so that when the patient comes in for their medical visit, and you've assessed, and you, and they agree, they could do a quick tele-visit, again, making that connection, and then, and then the other one, of course, is the off-site, completely off-site, and community referral, where there really is no immediate connection that's linked to the medical visit, and that's where I, I find that we have the most drop-off from patients, and so I just want to mention some care models, because, and again, this is not meant to be sort of discrete, there, there's a spectrum here, so many times you can be fully integrated, and the advantage of being fully integrated is you can share an electronic medical record, and then your behavioral health consultants, your psychiatrist, and all of the medical and surgical teams can all be on the same page, quite literally, and can see each other's notes, and, and it's just overall more integrated, and then another care model is to have someone function in a triage, or a navigator function, can be remote, it can be at the point of care, and the idea is that that person then makes a plan for that patient based on, generally based on, you know, sort of the severity of it, or, you know, just trying to come up with what's going to work for them, and then, and then finally, there's the, the external referral, but it has to be somehow put in your electronic medical record, and just like we, we always look at our, our other consults, and our labs, and make sure that patients have completed what we, what we recommended, that has to be done for behavioral health as well, there's a tremendous amount of no-shows, lack of follow-through, and so care coordination is, is really, really important. Okay, and then next, and so just, I want to sort of leave you with some practical tips. I like screening, I know that it, it can be somewhat controversial, and I know there's a lot of things that my MAs have to do when they walk in that room, it's a lot that they have to do, but for me, I like it for a couple of reasons. One is, first of all, it can, it can, you know, highlight for me when maybe I, I need to address it more, or push a little bit harder, but also, I find that when my team members talk to patients, they often get different or more information than I do, and we share that information, and that, that can really help me when I, when I see the patients. So, I like it. So, I think it's also really important, just listen to your patient and allow them to take the lead. You know, usually, I know it's hard, because we all go into the room, and we, you know, we've already read the chart, and we're thinking, okay, yeah, I'm going to increase the cranial insulin, I'm going to do this, this, this, this, and, you know, you sort of have your whole plan, I'm going to order this test. But if you just kind of walk in the room and say, hi, and, you know, how are you, or even just hi, and stop talking, most of the time, your patients will say something. And I find that similar to how Bill described it, they'll just get to tell me how they feel. And it's often how they feel about their diabetes, or some, you know, really strong event that's occurring for them, that's having a big impact. And the things that I get is, you know, this is my fault, I haven't been good, don't look at my blood. I'm not checking it, because I don't want to see it. So, you know, and the way I think to handle that, and my recommendation is acknowledge it, validate it, and then, you know, discuss what there might be some possible options to help, and always encourage them to come back and try to be as understanding, you know, as you can, we can't, none of us can keep up with everything all the time. And then I usually will talk to my patients a little bit about the various modalities, not that it's really my area of specialty. But I think sometimes people may have some preconceptions about what therapy is, or what behavioral health is. And, you know, really, it'll help, I think, to give them an idea of the broad spectrum. And some of the things I like to emphasize, sometimes therapy can be short term, doesn't mean like you have to spend your whole life doing this thing. Sometimes, you know, medication can help. Sometimes all it takes is health behavior change. And that's actually the example that I use a lot. I say, you know, we talked about this, you're having difficulty sleeping, you know, it might be that if you could sleep better, that might really help you a lot. And we know there's a clear metabolic link between sleep and glucose metabolism. So that seems to be less threatening to patients, if you approach it that way. And then, of course, social support networks. So these are the things that I like to do. And I'm going to end by saying that I would just encourage you to think about this care gap that we have now in diabetes. And patients often come to our visits. And there's a certain expectation about what we're going to do. And it's very data oriented. And I think if you just give them a little time to talk and respond to that, then you can really have a huge impact. So I would encourage you to maybe pick one of the issues, one of the opportunities that we talked about and try to add it to your practice, I think you will find that it will just make the whole thing more satisfying and better. Thank you, Nancy. That was really helpful. And thank you for thinking about this. Go ahead, Bill. Well, I just wanted to chime in how nice that was. And to say, I think you really did a good job of distinguishing something I wish we had a lot more time to address, which is that, you know, when you think about dealing with emotional or behavioral health issues in diabetes, we really have two broad directions to go either what is it I can do with this person sitting in front of me right now with my 15 minutes, which of course is really two minutes because you've got all these other things to deal with versus this person needs something more than I can offer and how the heck can I refer this person to anybody in a way that so that they actually might go and don't even know anyone I can refer them to. And that's so much trickier, but just sort of thinking about these two broad categories, I think are, are so important. And anyway, well, hopefully we'll chance to talk more about that. Julie, that's a good point. And I want to respond. And most of the time I spend my two minutes or three minutes just trying to get their trust and get them to open up a bit. I know that in that short period of time, it's the, you know, it's a proverbial tip of the iceberg. So I try to refer everybody that is, is willing to go because I know that there's a lot that I'm not only not going to have the time to do, but I'm not going to have professional expertise to do. And so I really think I personally think ultimately this should be on our checklists. It should be on our flow sheets, just like we check. Okay. Did I, you know, did I do the yearly labs? Did they go to, did I do my A1C every, whatever it is, three to six months that I do this, did they get a mental health check? So I, I just tried to be the conduit. That's how I view it. That's fantastic. Thank you, Nancy. And just one other quick question, and then I'm happy to keep going here. How do you, how do you handle situations when patients say they don't want to go, or maybe they try therapy and it doesn't work and how do you handle those conversations? And that's a great question because that does come up a lot. And if that seems to be the barrier that they've either tried it or they don't think it's going to work, you know, I try to figure out, well, you know, more specifically in the same way that I try to figure out if someone says, no way, I'm not using insulin. I couldn't possibly do an injection. I try to figure out exactly what it is and also have them understand that maybe it was maybe a different therapist, maybe a different type of therapy. You know, try to have them give another shot at it. But also there's going to be people who are just not ready or willing or both. So I accept that. I keep the door open and I will say, obviously excluding those patients for whom we're worried about safety or substance abuse or, you know, things that we really feel need to be addressed acutely. But those things aside, I keep the door open and I also tip off my staff because I do find that my medical assistants and my nurses, you know, it's something you really think about, but somehow they seem to get people to do things more than I can. So we work as a team and I never give up on anybody and I just leave the door open. Such a great approach. I mean, there's something to be said for, you know, putting the information out there and then acknowledging people might not be ready or willing to hear it at that point, and maybe hearing it from someone else or hearing it again works. And so with that in mind, what a lovely segue. I'm going to round out our presentation here in terms of thinking about behavioral health planning with your patients. And so, you know, I really want to focus on how we talk to patients about mental health and diabetes. And I want to start with the more extreme example of thinking about, you know, in all reality here are patients with diabetes that are at a higher risk for mental health issues, including suicide or being in some psychiatric crisis. And so as we normalize mental health issues, I would encourage everyone to think about normalizing, talking about safety planning with patients. And so, especially for your patients who may be at risk for depression. You know, often I might liken thinking about suicidal thoughts or thinking about safety planning. Sometimes I talk about it, you know, similar to ketones, right? Ketones are a sign that our body needs more help or needs more urgent medical intervention. And sometimes people with diabetes understand that in a different way, that essentially suicidal thoughts or passive death wish, it's a sign that our brains and bodies need more help. And this can help take away the stigma or take away the personalization that comes with, you know, sometimes being in these crises. So in having these conversations, I encourage people to normalize this and talk about going to your local crisis center for providers to know the resources that are available and share them with patients. Recently, we have a national mental health helpline. So for those who don't know, 988 is our national mental health helpline, and anyone can call or text that number for any sort of mental health concerns. And they are connected with a mental health counselor who can help guide them through the situation. For patients, we also want to help them identify a support person who can help in these more extreme situations, who can take them to the local crisis center if needed, and who, along with the patient, is aware of mobile crisis, which can involve in certain states and cities, teams that come out to see a person and do an evaluation in person if the person isn't safe to be evaluated at a crisis center. So I'd encourage us as providers to keep this information in mind and, again, be able to normalize talking about this in a way that isn't scary or bad or stigmatizing. Now, Nancy mentioned talking to our patients about outpatient therapy, and I wanted to really highlight how important it can be for providers to know what therapy looks like. You know, some people have this idea of therapy as, you know, still laying on a couch and see what comes out, and, you know, that's not where we are in the state of therapy at this point. Certainly, some people could benefit from that. But the goal of therapy is really to be goal-oriented and time-limited, with the understanding that the idea is to focus on a specific issue. Now, the issue might be depression, it might be anxiety, it might be diabetes care. Some people, some patients find it, you know, more, you know, they're more understanding if you frame it in the context of diabetes care. I mean, certainly what we know is the more people take care of their blood sugars, the more time they have in range, generally, the better they feel physically and mentally. So sometimes it helps to talk about that as a goal potentially for therapy. Now, with therapy, we have different options at this point. With the COVID-19 pandemic, it's really opened the door for a lot of telehealth options in addition to in-person sessions. So when we think about access for our patients, this could include providers that are now out of state because of telehealth licensing agreements. So we don't just have to encourage people to look in person at this point. If they're having difficulties with access, they might find it helpful to look for a broader net of providers who can provide telehealth services as well. And then finally, I recommend finding community partners, finding therapists who you reach out to, who you know, who maybe understand more about diabetes. I love it when I get a contact from a medical provider and they give me the description of what's happening with a patient. And so we can really have optimal care coordination for that patient. Just other things to keep in mind for folks who have insurance, we want to encourage them to use their insurance, obviously, for behavioral health services and going through insurance to look into those in-person or telehealth options. For those without insurance, there are several options that I wanted to make sure folks know about. Some community clinics can have a sliding scale fee structure that can be more affordable for folks and it's based on their income. Commonly, psychology training clinics where there's doctoral students or master's level students training towards a degree can order lower cost or no cost sessions. So I'd encourage you to look into these options in your area. And then finally, I'd encourage you to think more broadly about mental health resources. Psychology Today is an excellent website that has profiles of providers and you can filter based on insurance type, the concern that you're seeking therapy for, male, female, gender of the therapist, whatever you would like to filter by to optimally find someone who may be a good fit for you. So I'd encourage folks to look at that website. For those who don't know the ADA Mental Health Provider Directory, also is a great resource on the ADA website where it has a listing of mental health professionals who've often vetted, who have shown some competence in caring for people with diabetes in the mental health context. And then finally, thinking about peer support networks that can be helpful, whether this is support groups or diabetes walks or really anything to build that sense of community can be helpful as well. So I'm going to wrap up the presentation part with just some final reflections and then we'll move on to some more questions. So things to keep in mind is behavioral health concerns are a normal part of living with diabetes and we really want to reflect that in our conversations. We as providers have an important role in validating and normalizing the concerns and screening for them in both formal and informal ways. Interventions can vary and providers can partner with patients. Really the ideal is based the ideal is based on what patients need, what's available, and really what they're willing to do at that time, whether it's therapy, medication, or as Nancy mentioned, maybe some lifestyle modifications. And then finally, we'd encourage folks to know their resources available and use them to share with patients, but also partnering with your behavioral health clinicians to really optimize care coordination. So at this point, I'm going to take a break from presenting and I'm going to invite Dr. Steve Clement. He's taking a look at our Q and A. If we have any specific questions, Steve, please feel free to share. I think you're muted, Steve. Better? Is that better now? Yeah. First of all, Bill, it's so good to see you. It's really great to hear from you. 30 years later, I'm still learning tons from you. It's really great to be a student and one of your students from the behavioral side of things. Okay. We do have a question from Dr. Rajesh Garg. Hello, Rajesh. It's great to hear from you. Question is, are there any insurance coverage challenges to get mental health support for our patients with diabetes? So we're going to go live with this. Probably the best thing is if you can send a message on the main chat group on if you have any ideas about this. And we have our panelists here, Bill, Julie, Nancy. Do you have any words of advice for Rajesh? I have just depressing things to say and hopefully my colleagues will have better things to say. I can tell you here in California, especially here where I am in San Diego, most mental health professionals who know anything about diabetes don't even take insurance anymore. Things have really become quite odd, which is an enormous problem, an enormous issue. I don't have any great solutions, but yes, I think there's big challenges with this that we're seeing in other places, not just here. I don't know, Julie, Nancy. Yes, I agree. I often will encourage folks if they can't be seen through their insurance, going through those options like community clinics or the university training clinics and seeing if there's ways to educate those folks to try to help them learn more about diabetes. I know there's coursework online through ADA and other outlets, which is some way to help. I'm sorry, I was just going to say, I'm going to focus on some positive things. I just try to balance, although I agree it's a big, big challenge. Sometimes if you have in your insurance an added network benefit and you can prepay for those folks who don't accept insurance, they will be able to give you an itemized invoice that can be submitted to your insurance, your added network benefit. Usually that'll go to your deductible first, but then over time, there is often payment for that if you do have it. In addition to that, I think, and this was maybe you pointed out how telehealth was maybe a benefit of the pandemic. In addition to that, I think many employers have various mental health resources that they didn't have before. Often they're outside vendors and they're often provided at least for some time period without charge. That might be a place for people to start. I don't know that they would find somebody who's specifically knowledgeable about diabetes per se, but perhaps it could be a starting point. Also, just as I think was mentioned, looking into sliding scale coverage. Now, sometimes a lot of these clinics will work that you have to get your primary care at that place in order to access any type of specialty care, including behavioral health care. Sometimes people, what they will do is register for primary care and that will open up the door to utilize those services often at a fee reduction, or if it's an employed behavioral health professional, then again, they usually have to go with whatever is in the system. I think where people find it most challenging is in the community, because I feel like everybody can kind of make their own rules and most of them, understandably, I suppose, from a financial perspective, choose to be self-paid and to not take insurance. Those are maybe some ways that people can can access it. I think employers are a good place to start, and maybe at least to give you some direction. Let's propose another solution, something I heard about a number of years ago that was wonderful. I was always hearing from my primary care and endocrinologist colleagues like, oh, that's so nice that there's all these issues we should deal with, Bill, but Nancy, like you said, I don't have time for this. You've got to be kidding. This is ridiculous. And so when we think about that broad category, not the major psychiatric issues, but really sort of the ways in which diabetes is driving people, and he goes, he says, Bill, you know, I gave you so much crap about how all this is impossible, and I finally figured out how to make this work. And he said it was group visits, which can be logistically a challenge for busy practices. That really helps. Number one, it gave him, as an endocrinologist, time to begin to talk about and address some of these issues in a way that he couldn't do it with these individual 15-minute appointments. And the other, of course, magical thing that we all know is probably the most important thing our patients need is each other, right? So in this group setting, people really learn from each other, realize they're not that weird. Everybody has complaints about diabetes and the solutions that they hear from each other. And I think the degree to which we can support sort of this opportunity, I think really, and by the way, that can include someone like Julie, include someone like me, you know, mental health providers in that setting. I think that's going to be a real opportunity moving forward in the future, at least I hope. That's awesome. Again, I'm still learning from you, Bill, and Nancy, and Julie. We don't have any current questions. I have just one final question, unless something comes up. I was jotting things down like crazy on everything that you're saying. Tell me about empathy. Some of the best providers that I know, they're known when you ask, what makes them good? And Bill, you're one of them, is empathy. Can you and Julie and Nancy explain all that for a little bit? I mean, you don't want to be, feel like, oh, I'm so sorry. I want to coddle you. But how, as practitioners, how should we offer empathy in a constructive way to our patients? Well, you know what Julie brought up at the beginning that she's part of the motivational interviewing network of trainers. You know, the key of what motivational interviewing is all about is this idea that how do I convince my patient and myself that we're on the same side? You can get into the nitty gritty of it, but it's really that. And we have wonderful evidence that we cite this study from the UK, from Donna Miller and her colleagues, that when patients perceive us, us as healthcare providers, as being on their side, as being someone who cares about them as human beings and are good listeners, this isn't just nice, but that we see really profound benefits moving forward in the future. So we do have evidence to support that. And again, it doesn't matter. I can spend two minutes and listen to you and look at you without looking at what I'm typing or, you know, without looking at your file and that has profound consequences. And I think there's, I know there's good research to support that. Fantastic. Julie, Nancy. Yes. I would agree. I would agree that, you know, empathy is really being able to demonstrate that you understand what the person is saying, even though it's not your lived experience. Right. And so being able to do reflections of what you hear them say of this is really hard for you and you want to stop and you know, you can't. Right. And trying to point out both sides of this is hard and I understand, and I'm here in partnership, as Bill said, to help get you through it. And so being that ally who works together is so critical. Nancy, more than the numbers. That's all. I was just going to say, I would echo that. Again, I'm the time constrained person and I've got 10 things on my head that I need to check off. So I mostly, you know, listen and I'll just try to empathize. And, you know, usually it's obviously something that's a negative that they're expressing. And I'll just say, wow, you know, that sounds like a lot. And most people react to that by thinking that at least you're, you know, understanding them and then maybe we go a little bit further. But the reality is that in my role, my particular role, I can't really completely unbox that because there's just a lot of things that I won't have time or expertise to do. But I just try to reflect back on them that really definition of empathy is, you know, can I see it from your point of view? So I try to do that in a short time period. You know, one way I think people do that, and Steve, I think you're really good at that too, have always has been. I'm always saying this to my busy healthcare provider friends, you know, when you walk into that next visit with your patient, every patient should have this little mantra that just says, remember, no one's unmotivated to live a long and healthy life. Stuff gets in the way, but this person you're about to see, no one's unmotivated to live a long and healthy life. And if you can believe that, then you are on the same side. Absolutely. Absolutely. We're out of time. Just one little thing that came to my mind when, Nancy, you were talking has nothing to do with, you know, all my great mentors as yourself in medicine is someone who's been a project engineer. And when I'm actually trying to do something outside of medicine, I'm trying to finish this project where we go from A to Z. He says, Steve, remember, particularly if you're a little too fast, he says, being slow is actually fast. And I know I was scratching my head is what is he talking about? Being slow is fast. And I totally get it now. You have to take a breath. You have to shut up, let the patient talk to you and be slow and let them work with you. And you're going to get so much more information. And obviously you guys have taught me all that too, from the bedside side standpoint. So I appreciate that. I think that's the last question. I think there was an amazing discussion. I wish we could go another 20 minutes, but we did promise to stop at four o'clock. So I'd like to thank all of you for participating and for your questions. And I'm going to hand it back to the ADA and keep in mind, we're going to try to get the PDF of these PowerPoint presentations to you. And I'd like to again, thank you for your attendance.

behavioral health

diabetes

managing

integration

diabetes distress

patient outcomes

empathy

mental health

resources

care coordination