 So we're here to lift up the best ideas. We focused this day particularly on solutions, on policy solutions, on care delivery solutions, on community solutions very intentionally because we think there are solutions out there. We hope that out of this day like-minded people like all of us can link arms to get to work on this. And of course there are people working on this right now and in fact as a segue that allows me to introduce our next speaker, Kita Franklin, who has been working on this for many years. Dr. Franklin is the Executive Director of Suicide Prevention for the U.S. Department of Veterans Affairs Office of Mental Health and Suicide Prevention. She serves as principal advisor to the VA leadership for all matters pertaining to suicide prevention. She leads a team of experts engaged in research, program evaluation, innovation, data and surveillance and partnership. Before joining the VA, she served as Director of the Defense Suicide Prevention Office where she was responsible for policy and oversight of the U.S. Department of Defense Suicide Prevention programs. And we know if anybody is concerned about this issue, it is the Department of Defense and Veterans Affairs. She is a licensed social worker who specializes in children and families. Yay, a family, a fellow children and families person. Kita Franklin. Thank you, thank you. Okay, is somebody gonna do the slides back there? Okay, good morning everyone. I'm happy to be here and thank you to Kaiser Permanente for your leadership on this important issue. And I just appreciate the fact that I'm here this morning with so many unfamiliar faces. In part, I talk at a lot of events and we bring a lot of forms together to talk and to advance suicide prevention initiatives. And it's often the same people in the room. And all of us are doing really good work, but it's good when we can advance this across other sectors with the partners that maybe we haven't engaged with yet. So again, thank you to Kaiser Permanente for your leadership. And I appreciate the opportunity to be here this morning as well because I was just with the Veteran Affairs, the Veteran Administration Health Affairs leadership alongside colleagues from the Substance Abuse and Mental Health Services Administration and the NIMH where we were able to address this issue of suicide before the United States Congress just this week, Monday night. It was a late hearing, I don't know if any of you are better in the evening, but I'm not one of them. So it was a seven to 10 p.m. engagement, but we were able to talk about quite a bit, quite a bit of the things that I'm gonna talk to you about this morning. This slideshow and the content comes directly from that work. And it was just a reminder of the vitally important role that policymakers are to this issue of suicide prevention and truly how we can make a difference by using policy as a form of intervention to save lives. So I will talk with you this morning about what we're doing inside the VA. I'm hoping that it will spark some ideas on things that you can do within your own organizations and either independently on behalf of veterans issues or also with the larger population writ large, not just veterans, just across the nation trying to get after this issue. Inside the VA we have adopted a national public health approach, which you heard in the opening comments a couple of gold nuggets about that approach, but I'll dig deeper into explaining what we believe that is. But our secretary has noted just as Kaiser Permanente that suicide is our top priority. It's our top clinical priority. And I think that as a nation we could move the needle if every agency that engaged with veterans and with people in this space identified it as their top priority and then had a series of strategic actions that they were doing to get after this. So I wanna jump into a couple of our important figures just to do some framing so people know what's sort of what's going on within the veteran's suicide space and what our data looks like. In part because that's what defines our approach. And so this is, you'll begin to learn why we're doing some of the things we're doing if you had a little bit of context about our approach. You hear a lot in the media about the fact that there are 20 veterans that end their life by suicide every day, 20 veterans. And you may have heard in the past the number 22 and if you're one of those people that's wondering is it 22, is it 20, it's 20. And so in past there was some analysis done on a handful of states and we generalized it years back across the entire US population and the analysis has progressed and it's a 20 a day figure. You should know in that figure that that also includes active duty. About one of those out of the 20 are currently serving in the military. And you should know that about three of them are people that we refer to as never federally activated former guard and reserves members. And if people wanna talk to me more about what that means cause it's a mouthful, please come see me. But these are our service members that get activated at the state level and they might help with things like fires in California and state level contingencies. And then they come out of those roles and down the road and their life by suicide. And we believe they're a unique population because they are not covered by VA healthcare. There may be a myth also that I think is important to clear up when we're talking about our veteran data. Not all veterans access healthcare through our healthcare organization. So I wanna make sure folks know that actually there are 20 million veterans in the nation and about 30% of them get their healthcare through the VA. And when I talk to the average public about this they sometimes think every veteran automatically can come to the VA and it's just not the case. So I never wanna miss an opportunity to share that. Also back to the data when we look at our rates and this is I think something that you're seeing true with the CDC and I know I have some CDC colleagues here in the room today this morning as well. We're seeing an increase in our 18 to 34 year old populations that are ending their life by suicide. And so when you look at the CDC's data and you're seeing an increase with youth, 18 to 34 I know it's a bit of a stretch but it's I think traveling in a similar direction when we see our highest rates with that group. We're also seeing our highest raw numbers with men over the age of 55. That's a similar statistic with our CDC counterparts as well where they're, you will hear them talking about men in the middle years. And this is a phenomenon whereby we're trying to study what's going on in the context of phase of life issues for men when they reach the age of 55 and older and tending to their needs over time. The reason that we believe of course we have a lot more in the 55 and older group is because we have more of them. We have more Vietnam era veterans that fall in this age group. I also want to talk with you about female veterans. We have an increased rate when we compare our female veterans with non-veterans. Our rate is one point times higher than the non-veteran rate. And this is concerning to us because typically you hear for years those of you that have worked in the suicide field you hear how women attempt more and women use less lethal means and men complete more and use very lethal means like my colleague spoke about firearms and I'm gonna talk more about firearms. But with our veteran data with female veterans completing more than their non-veteran counterpart we are particularly concerned about this population and making sure that we're tending to them in the proper way in the context of perhaps if they have access to firearms in the way that their non-veteran counterpart may not or familiarity with firearms and also any other wartime experiences that may have contributed to their struggles after service. I also want to talk with you about the fact of how our veterans and their life by suicide. You see here on the slide 69% to it with a privately owned firearm. And we have the other data by other methods but this is our primary method and so you can imagine in our strategy we have a unique line of effort tied to protecting the environment which is one of our questions on our safety plans which truly gets after making sure that veterans are keeping their firearms stored properly and safely. And for all of us in the mental health field or behavioral health you may struggle with how to talk about this but this is something we definitely need to talk about and we can't avoid the conversation and we have to find creative ways to make sure that it doesn't get into the political space when we discuss it because it is truly about safety and making sure that we put time and distance between people at risk and any means with which they may harm themselves whether that's medication or anything. So the way that we've laid out our approach inside the VA is to model it off of the National Academies of Medicine's approach for prevention. And so we have an effort and I'm thinking many of you in the room might know this approach I'll skim through it rather quickly but we have an effort underway to make sure we're preventing suicide amongst all 20 million veterans in the nation. And that involves a comprehensive lift to make sure we're tapping into a number of entities where they might live, work and thrive. So we work with veterans with key messages and I'll explain more some of the examples of that. But then we're also trying to work with those veterans that fall in that select group that have an increased level of risk based on what our data tells us. And I already talked to you about some of them. Women, I would also mention that we have a strategic focus on veterans that are in rural areas. If there was somebody standing here with me that were responsible for suicide prevention outside the veteran community, they would probably also be talking with you about rural struggles and access to care in rural areas and access to broadband and bringing in creative IT technologies to rural areas and the host of things that happen. But equally so in that category, falls people that are struggling with mental health issues at the group level, substance abuse issues, people that are known to us at risk based on what our data tells us. I talked to you about the Never Federally Activated Group of Garden Reserve, they're in that group. And then our indicated work which is working with veterans when they come to us in our hospital settings, which I believe is a bit of our bread and butter and we're doing quite well. We have a number of evidence-based practices that we have a clinical practice guideline that we develop in partnership with DOD and this is a standardized tool on how we do our therapies when people come into our medical settings and how we treat them. And I brought a number of other examples with me as well if we wanna advance the slides. Just to get your thinking going in the context of with your own organizations and what you're doing across these three buckets. Are you tending to your universal population and are you tending to those that you know are at risk based on your data? And then are you doing your regular work when they come to you at the individual level? And these are a few examples on the slide. I offer to you just to highlight this year in the VA. We've made significant strides trying to do universal screening outside of mental health care. And so traditionally in times past we were definitely doing good work. We would screen for mental health and suicide risk, I'm sorry, when they showed up in our mental health clinics. And we just, you know, this is great work. They show up for mental health care and we assess them for suicide risk. But what you see in the data is that people that end their life by suicide have touched a host of other clinics on the days and months leading up to their death. And we think of those as missed opportunities for engagements if we don't fully understand their risk level. So we've spent a significant amount of time in the last year making sure all of our specialty clinics and especially primary care doctors are trained in how to assess risk. And we have a sort of a three step model and it's available online. I can share it with folks if you're interested. And I know many in the room might do a similar methodology already, but know that it's a very simple, single question followed by the result of that question, a more comprehensive six or seven question followed by a very specific safety plan. So this I affectionately refer to it at work in our policy environment as this one, two, three punch, which is make sure we're following all three entities. And then we're collecting data across all three. How many screened positive on the first question? And then as the results of that, how many still screened positive on the comprehensive scale and then what were our safety plans and what was our follow through like related to those safety plans? And then I would also share with you that this year we've also made significant efforts to implement an aftercare model. So much about suicide prevention I think over the years is complicated and complex. You know, there's never one reason that somebody ends their life. There's never 13 reasons. There's never, and so we do need bundled strategies and that's what public health is all about. And we've spent significant time implementing a simple strategy as complex as it is a simple strategy called caring outreach. Maybe some of you have heard of it whereby we're making phone calls to people after they leave our emergency room. You're telling me to use the clicker or say next slide. Okay, I got it. Very well, thank you. We're making aftercare phone calls when people leave our emergency rooms when they have elevated risk and it's a simple intervention like that calling them the following morning and calling them the third day and within the first week a number of times and making sure that they've made those connections after they've left our ER to sustain their healthcare in the out weeks. It's an important approach and we studied that out through one of our MIRAKS and then implemented it enterprise wide. So we'll go ahead to the next slide, please. Okay, I also would be remiss if I didn't tell you about this new work that's going on in the context of getting after suicide according to the data. We are working in this falls in the universal bucket with something called the mayors and governors challenge work. And this is where we put out a call to local mayors and governors and we asked them to partner with us in the VA and we looked at high burden areas. Where do veterans live? What are the high population density areas? And then where do we have high burdens of suicide? And then we brought those teams in, we asked them to come to DC in collaboration with SAMHSA and we held the policy academy and we taught them a number of the skills that I'm talking about right in this brief this morning. We taught them about the importance of transitions in and out of care. We're teaching them about safe messaging, about peer support, which I wanna talk to you more about, about using their data locally to define their actions and activities and about putting pen to paper on a local plan. If you live in Houston, Texas, you know that firearms are readily available and you're in Houston. What is your local plan for preventing suicide and how can we at the national office help you implement that local plan? And so we're working with 24 mayors in their teams and seven governors in their teams and in collaboration with a technical assistance arm that's offered through SAMHSA. So this is new work. It's only started in the last year, but we're expecting these local teams to catapult their local hospital systems and prepare those hospital systems for engaging with veterans in a way that keeps veterans safe and prevents suicide. And at the heart of this model is also another capability called SAVE. If you're not familiar with it, I have the website here. There's a nonprofit called Sake Armor that partnered with us to develop a very interactive, it is not death by PowerPoint or dry clinician talking on a screen. It's very interactive and it's actually one of our own employees, Megan McCarthy, but talking about suicide risk and really explaining the ways to protect against it and what you can do. It's training for everyday people, not just medical providers. And we have a campaign and I think the nation needs a campaign. May is Mental Health Awareness Month and part of our suicide prevention campaign is just this, again, simple strategy on being there for veterans. It's called hashtag be there. And this year you'll see our campaign roll out to these sub-population groups that are at risk. For example, if we know rural veterans at risk, we're really trying to crawl all over rural America with our be there campaign. And how can you be there for veterans that live in rural areas? Five million of our 20 veterans live right in rural America. And so the way that you deliver healthcare in rural America might be different. And how are you able to be there for somebody with a mental health problem? What are the simple strategies we as a nation can take? One of our key messages inside the VA around this is really that everyday acts of kindness can save lives and small acts. And one of the big principles around this for veterans is just asking them have they worn the uniform? Have you served or what was your service like? And share with me more about that. And creating that type of culture of respect and of being humble on all that we don't know for, on what it means to deploy or operate in a war zone is definitely something that we can do to advance the cause when it comes to getting to know veterans and saving lives. We can go ahead to the next slide right onto the next one on ReachVet. I wanna talk to you a little bit more about a capability that we deploy inside our hospital system and you might have something similar in your capabilities in your organizations as well. We do have a capability called ReachVet that is a predictive analytic tool and this is a tool that assesses healthcare risk and it looks at I think 136 variables across people's healthcare records and it really puts those variables into an algorithm and then provides us a risk value so that we can understand our healthcare population writ large and how at risk they are. Are they missing appointments? Have they been diagnosed with an opioid use disorder? Are they struggling with alcohol? There's a host of variables that go into this capability. But the most important part of the capability I believe is that the risk value is then followed by action. So there's caring outreach that occurs with veterans whereby our own employees are making calls and talking about risk with veterans proactively and trying to re-engage them into healthcare. And so this, we have a whole set of data on what we're learning about risk values and getting people back into care and what we know is that when we are able to touch base with them afterward and through this caring outreach and we look at just the dependent variable of death, any cause of death, not just suicide so like an all cause mortality review, those that have been reached through our ReachVet program and capability are more likely to live. They have increased longevity by those that we're not able to catch and re-engage into healthcare which I think is a little bit intuitive as well. Like get healthcare, take care of yourself, increase your lifespan but suicide is also part of that mortality risk so. I also want people to know that if you have clinicians that are engaging with veterans in your own facilities and you're unsure what to do where you're executing an evidence-based practice and you're stuck or you're struggling, we have a suicide risk management consultation program out of one of our MyRx and this is a program that will take calls from anybody and help walk them through a part of the treatment or the therapy that they might be struggling with and so it's an important part of our portfolio because we believe that veterans are being seen outside the VA and I should have started the talk with that figure, I talked to you about 20. Six of the 20 veterans that end their life per day have seen the VA in the last 24 months leading up to their death and 14 have not. And so we also do have an approach which is there's no wrong door for care and like I said before, we're trying to meet veterans where they work, live and thrive, not just where they get healthcare in our organization. So if they're getting healthcare in any organization in America, we want these capabilities to be available for them. Safety screening, risk protocols, a suicide consultation program, all of this we make publicly available through our website. So we'll go ahead with the next slide. I said earlier, as did my colleague from Kaiser that we can't talk about suicide without talking about firearms and I want you to know we do have a number of capabilities and pilots going on underway about firearms. The first is we have, if you've not heard of this organization, write it down, the National Shooting and Sports Rifle Foundation. This is an organization that is focused on firearm safety as well as a number of other things but we have a partnership with them. We've went into a memorandum of agreement with them whereby they're helping us educate firearm dealers and retail people on the signs and symptoms of suicide risk and it's in its early stages but this builds on some good work that has occurred in New Hampshire and Colorado where they've done similar models and we believe that that contributes to a bundled set of practices to save lives. So again, I'm not proposing that educating firearm dealers about suicide risk singularly results in life saves, although you don't know but it's this bundled set of practices over time that we believe is the most beneficial. We also hand out gun locks in all of our healthcare settings. We don't hand them out in a way where veterans have to ask for them but we have them nearby in baskets and veterans can just pick one up and take them and on the gun lock we have the phone number to our crisis line. And of course, crisis line capabilities are also at the heart of every and all suicide prevention bundled practices. We do have, if you've not heard the veteran crisis line, we offer everybody to put that number into their cell phone and we have all of our leaders across the VA and at the White House and in the Congress, we never miss an opportunity to tell leaders put the veteran crisis line number in your phone. Our under secretary did it at the hearing this week, asked the Congress to pause and enter the number right during his oral testimony. So that is an important part of our strategy. But know that it's not our only approach and I think that that's where we could have done better over the years is to think through more upstream interventions. Crisis line alone catches people when they're at such high risk and with such complex sort of situations. So gun locks, partnerships, training, training firearm people. As well, I want you to know that we have an online training where we train our own clinicians on how to ask questions about lethal means. I myself have engaged in a number of conversations with the NRA over the years about this issue, this notion of bringing your partners close and trying to understand all that you don't know about a particular community is important. And I was pleasantly surprised, I suppose I could say, by all that I didn't know about firearms as a clinical social worker. And the fact that we might turn people off using the wrong words at the wrong time and I could give you just a small example when I was with the Department of Defense, it was not uncommon for us to have practices in our settings that were called lethal means restriction. And that would be a title of a policy. Lethal means restriction with a group of service members that need their firearms and that, you know, think of their firearms quite fondly, if you will. So we really underwent an effort at the time to just think through our language and our terms. It's not really about lethal means restriction and maybe it's about safety and how do we talk about things and is there a difference between the word gun and weapon and firearm? There is. And I didn't know that had I not, you know, engaged with these types of partnerships. And so it's a small, small steps and every little piece of it is important when you're trying to pull together this common thread for saving lives. So we'll go ahead to the next slide. I appreciate the talk this morning also about safe messaging. And this is, again, it's part of the bundled approach. If you can kind of think through all that we're talking about this morning about making sure we're doing our best work in healthcare settings and that we're, you know, we're screening everywhere and we're doing evidence-based therapy and we're monitoring that with tight quality controls in the best possible way that we can. And we're working with lethal means. This is just another strategy in the bundled approach and it's making sure that we're talking about suicide appropriately. And we do have some work to do in this space, I believe. I've been at a number of very official forums with very senior leaders that continue to use the word commit. And I just sort of shrink in my chair because we know we're not supposed to use that word. But we know they don't mean any harm. You know, they're just learning about it too. And there's as complicated as this field is we live and breathe it every day, others don't. And so it's important that we continue to push and educate people on unsafe messaging. And I will also share that I'm quite concerned when I see headlines, particularly about veterans around suicide and especially when we see glamorizing headlines or headlines that show a veteran in distress that's just sort of like, and the headline will say, veteran hangs himself on parents' front porch and it's, those are the type of headlines that could potentially cause harm. When other veterans see those headlines and think, and they'll read the story and they'll see a veteran who's struggling with pain management, financial issues, relationship issues, legal issues, recently had a DUI. I mean, and another veteran reads that and thinks, I have that same set of circumstances. And I also deployed three times like that fellow and that was an okay solution for him. Perhaps it's an okay solution for me. And so we worry about that. And I also, as a administrator of programming inside a large organization, that is a large healthcare organization that's sometimes a hard story to sell because people believe that we can solve suicide with healthcare solutions alone. And if we just had better therapy and if we just had a better magic wand, we could just do better work with this. But I tell you that it does call for bundled approaches and part of the bundled approaches are talking about it appropriately and the media doing their part to not glamorize. And had it not been for the good work of other researchers, I probably wouldn't believe that messaging mattered myself. I'm a clinician by training as well, but Maddie Gould out of Columbia does quite a bit of this work. And there are published studies that speak to the importance of this messaging. And then the nation has pushed out. I have Liz Nealy here with me in the front and she's worked with Colleen Carr, who's also here from the National Action Alliance. And the nation has pushed out under their leadership a guide for safe messaging. And so this is something you should have handy as well if you're engaging with the media or trying to do your own training on these subjects. Cause it is tricky and we can make mistakes if we're not careful. Hand in hand with the next slide on talking and communicating with the media. Now, I think a 2019 or probably it should have been maybe a 2010 conversation is social media and the role of social media on suicide prevention. And maybe some of you have seen this come out on the horizon where Facebook is getting more engaged and maybe one back, I might have had you go too far in the slides, I'm sorry. And maybe there's not a specific slide on social media but know that I wanna share with you for a minute about social media. A couple of things about social media. The first is that people are putting their risks online. So you should know that and think through your own approaches. People are using coded language and if you're interested in studying this more pull up the work of Craig Bryant, a retired Air Force officer who's studied this out of the University of Utah. People are writing coded language. They might not write online things like I want to end myself, I want to end my life right now but they are writing that they want the pain to go away. They're writing that they wish they could go to sleep and not wake up. And so these are serious issues and it's not attention seeking based on what we know so far. The first time I took a brief about this I will tell you I was in California and we had paid for a study and I was receiving the results and all I could think about was my own social media and things that I had seen. People that were at risk based on what I was learning on the brief. I mean that night I made an important phone call to somebody that was at risk that I hadn't spoke to myself in over 20 years based on what I saw on some posts. So know that it is very serious issue. Also, I see the field is trying to get after this with artificial intelligence. I'm not an artificial intelligence expert but they're trying to look at words that appear on pages and match solutions and bring the crisis line number to the side and advertisements and all of that is probably helpful and needed and will probably continue as mental health professionals to engage in the artificial intelligence space in the out years I suspect. Equally so, Facebook has an effort under wages to teach others if you're worried about a post they have this actionable technique which shows where by if you see a post and you're worried about it you can click a button and it says I'm worried about this post for the following reasons and one of those reasons is harm to self. And so then Facebook will generate another pop up message for you that will say here's what you do about it. Here's the crisis line, here's how to talk to your friend at risk. Every conversation I know everybody in this room knows that when we're talking to people at risk we must have them leave or not leave us with some sign of hope. And so Facebook really works with some experts on designing what that language should be so that there's some dialogue around hope. Recovery is possible. I am here for you, can I connect with you? At the heart of this is human connection when we're trying to save lives. Certainly evidence-based practices, medication, therapy and all of that but at the heart of it is building clients capacity for maintaining healthy social connections that carry them through life and make them feel less isolated and less like a burden on society and more like they have a sense of purpose, mission, belongingness and meaning in their life. And this is why this work is so difficult I believe for veterans, although my colleagues that work outside the veteran space would be here giving the same talk on why it's so difficult for any of us. But veterans who have served for over four years or 20 years and they've been in very important roles for the nation's security. And they've deployed and they've done missions and they've had leadership positions that some of us you would be surprised when you see these young O3 captains that are managing 200 troops and they're about 24 year olds themselves and they're leading like none other and then they get out of the military and they have a job that's less important to them. They have less meaning and less purpose and so this is a hard thing to balance. We're studying across the departments right now this notion of what it means to no longer wear the uniform socially. Like we prepare people for leaving the military making sure they transition well and they have a job and they know how to interview and they know how to buy a suit and dress for success, they even call it. But do they know how to tend to their social aspects of no longer wearing the uniform? That's a question to be determined and their identity and how they fit in in life in the out years for that. So I just tell you that we also have a social media toolkit and it's also on our website and if any of it is helpful to you I offer that you use it as your own. That is when we'll be doing good work when we can just further advance these tools to get them everywhere in any place that touches veterans. So we can go to the system slides and I'll cover it quickly. We believe that suicide is never the result of any one single person and I have very good colleague at SAMHSA who always says, you know I have to give him credit. Richard McHugh and I always also say his name wrong. Richard talks about the fact that when somebody ends their life by suicide it's, even when somebody's life is saved it's never the miraculous result of a single therapist and even though I wish it was. It's Julie that their system was working well and we all have a system and so who's in their ecosystem? Is it their school, their church, their family, their neighborhood, their work? If there are gaps in their system and their system isn't working well then that's when we see struggles and we need to bolster their system and so this is part of our approach whereby we're trying to tend across systems and tending across systems from the vantage point of a healthcare system is not easy because there's this tendency to think that I will tend to people's healthcare, their biological system and maybe their aftercare if they've been to me but really we're thinking through and wanting to advance this model that says tend to their life system which is a little bit different than are their organs operating properly and do they have help for their wheelchair when they leave or things like that like more broadly their system. So we do have a national strategy for preventing suicide prevention it's strategically named that, the nation strategy because we know we can't prevent suicide inside the VA alone. I shared with all of you in this room this morning that only six of the 20 that die by day touch our VA system only 30% of the 20 million veterans in the nation touch our healthcare system. So we have a strategy on the next slide I think it might be slide 16, there we go that says it's our 10 year plan and it really takes the national strategy that was written by the Action Alliance again under the leadership of Colleen Carr who's here in this room if you wanna talk with her in a green sweater and this national strategy we VAI's did if you will we took it and we made it relevant for veterans and so when you see it you'll see that it looks quite familiar but there are 14 goals and 43 objectives that are largely come from what I just described this morning there's a goal on social media a goal on safe reporting a goal on lethal means work a goal on healthcare systems and transitions in and around and between healthcare there's a goal on peer support I mean much of what I've talked about this morning and it's designed in such a way that we think anybody can take it and take action and so if you from where you sit if you touch veterans based on what we know about I should tell you based on what we know about the date on veteran suicide I said 20 a day 123 people die by day by suicide 10th leading cause of death in the nation and it's even higher you heard from my colleague for youth second leading cause if we were pushing out these strategies in a community in a hospital setting to get after veteran suicide you would likely get after all suicide I just offer you that but the idea behind the strategy is pick it up and think through what of it could you implement from where you sit anybody so this is an important piece of our call to action and you can go ahead and keep moving with some of the slides I think I described them you'll see the goals the big push in the VA right now is a goal towards working with communities and that's why I highlighted our governor's work and our mayor's work and our outside our hospital system work that's our thinking now how do we prevent suicide outside the four walls of our VA system in such a way that we're engaging with veterans where they work live and thrive not just where they come when they're in a time of crisis or have a mental health appointment I have a short video that's under 90 seconds that I would like to show you that kind of gives a bit of an overview of everything that I've just talked about as well as a number of other resources that are in the slide deck because I think they're available to you and then we'll participate in a Q and A and I'll share with you anything else that's on your mind about this topic I think we'll go ahead and put the slide on the resources just so it's up in case people want to write anything down about that and we can also start Q and A if that's okay with you do you want me to stay up here Okay, very well Thank you Okay So, thank you very much Dr. Franklin, that was incredible So right now I'd like to encourage folks if you have questions for Dr. Franklin if you could go to one of the microphones but I will kick us off Okay You talked a little bit about stigma and I know Dr. Mordecai also mentioned stigma and in the sort of veteran and active duty population it would seem that stigma is a major barrier to overcome not just for suicide prevention but just to address other mental health issues as well Can you talk a little bit about how stigma is being addressed? Yes, this is an important issue and I'm glad that you asked the question so we can talk a little bit more about it because it is a unique issue with the military and veteran culture particularly tied to this notion where I think also over 10 to 18 plus years of war there's been this emphasis on pull yourself up from your brute straps and even outside the military culture I think there's a stigma tied to receiving mental health care and one of the best ways that I see that we've made progress in this space has been when people with lived experience are willing to come forward and share their stories and not only everyday people which are critically important come forward but when leaders come forward so when we see people like Patrick Kennedy come forward and talk about his struggle with substance use years back or when we see military leaders come forward and talk about the fact that they've been in family therapy and that they've struggled with parenting and after deployment when they were diagnosed with post-traumatic stress that they were worried about how that impacted their children and I have seen it where there's a room full of Marines and you can just see their eyes light up whereby they recognize that okay maybe if this general is talking about this maybe I can talk about it too and I can come forward and share my story so I think lived experience is helpful I think language is helpful as well we've made great strides trying to use paid media and social media campaigns where we've said things like it's okay if you're not okay and you can't just say it you have to mean it and so when veterans and troops work in populations where they're struggling with their security clearance and they're worried that if they come forward with a mental health issue that it will impact their job that makes this whole stigma conversation very complicated I try myself to push the focus to getting help early intervention and also successful stories of recovery to help move the needle on it but some of the room might have more to share about that too so. Dr. Mordechai. Thank you for your comments I thought you beautifully illustrated what we're trying to do today which is policy solutions, community solutions care delivery solutions. I had a question about is it is it reach vet? Yes. So we're also interested in predictive analytics and reaching out to people who are at high risk we're a little concerned about what their reactions might be so what kind of reactions have you seen when you reach out to people who maybe didn't know that you were doing predictive analytics on them and came up that they were at risk? Right, this is an important part of the model and I'm happy to share it with you if you'd like because it involved designing a very carefully written script and the protocol must be followed carefully because you can imagine on the receiving end of a phone call you're assessing my risk you put my weight into your variable and your little predictive algorithm I didn't know you all were doing that but thank you and we can turn people off particularly veterans who I think have a predisposition towards thinking that big brother is sort of watching them and things like that too. So we did have to be very careful and put it into our protocols on the front end for informed consent and then also the language and the way that the caring outreach is done is very particular and I'm happy to share it with you. Thank you. Yes, thanks. Well, good morning, thank you so much a terrific presentation. I'm John Auerbach from Trust for America's Health and have been a public health person at local, state and federal levels and appreciate your characterization of the work as being public health related. Increasingly in public health though we're recognizing that a key part of our work needs to be paying particular attention to what gets referred to as the social determinants of health but things related to economic opportunities housing opportunities, efforts to combat racism and discrimination of different types. I suspect that those issues are issues that arise when you're reaching out to veterans in crises and I wonder how are you incorporating the attention to those kinds of issues and needs in the work that you're doing? Yeah, it's an important question and you're absolutely right. These social determinants of health play a big and important part. They're almost at the hub of the wheel of any public health approach and one of the most important factors, economic, when you look at suicide risk across the board everybody in the room should know that the economic factors play an important role and I believe that's even more important with our veterans because in some cases their economic factors are tied to their time in service and do they have a disability and are they receiving monthly compensation tied to that or are they in the workforce and we do have veterans that got out of the military after only four years and veterans that served for 20 plus years and the whole gamut in between and so you can imagine those sort of phase of life issues and there's been a number of studies that have tracked employment and economic factors across our nation's suicide rates and saw where the variables travel in the same direction over time when we've reached critical economic points in our nation you start to see increase in suicide rates and you'll even see areas there's been some data that's published or a couple I'll tell you about like in Puerto Rico after they've had a national tragedy whereby the suicide rates went up. You'll see where the call center volume goes up and areas that have been crushed by economic issues and it's not just economic and so one of the things that we've done or tried to address here this is very, very recently and I don't know some of you may be familiar the current administration, the White House has called for an executive order to come out and they're calling it, it did come out a whole of society approach to suicide prevention whereby they're bringing in agencies like the Department of Labor people that might not have traditionally known that they're social determinant if you will has such an impact on suicide. People that work in department labor might think that they're getting people jobs but from where I sit they need to get people meaningful jobs where they contribute and careers that matter to them and so maybe I need to have more of those conversations with the Department of Labor this executive order will call for all of government every cabinet member to come to the table with the White House and our secretary to take this whole of nation approach agriculture, department of energy who knew that department of energy sitting on a treasure trove of data that we can tap into in a more strategic way so I think that in the future we could see better outcomes when we bring in a whole of society approach to the table on recognizing the role of their social determinant as it applies to work that's most important to me and us but yes. This room. I wanna thank you Dr. Franklin for an amazing job and yes we got the little signs, we got the sign and thank you for the questions. Thank you guys. I'll be here all morning. Thank you. This is good. Thank you so much. Thank you.