 Okay, we're going to keep going here, and the next session that we're going to have is around exploring policy solutions to the topic that we've been discussing today, and so I'll invite the next panel is over here, my goodness, and I'll thank everybody on the workplace platform as well if they're still there, but thank them. They're gone. Okay, good. Nice to have you guys here. Okay, now then. Let me bring the next panel up, come on, Daniel. And I will introduce them serially as we go. So the next session we have really some terrific experts in the field, Dr. John Wiesman, Secretary of Health for the Washington State Department of Health, John Auerbach, President and Chief Executive Officer of the Trust for America's Health, and Nathaniel Counts, Associate Vice President for Policy for Mental Health America. I will, I was deciding, I have a page and a half of introductory notes, so I'm going to do them in little pieces instead of all at once, because I think that's a better way to do it. So Dr. Wiesman is going to go first. He was appointed Secretary of Health by Governor Jay Inslee and joined the State Department of Health in April of 2013 and accomplished transformational leader with more than 22 years of local public health experience and focuses on whole systems approaches to improving health, services as a clinical professor at the University of Washington School of Public Health, Department of Health Services, and has held an adjunct faculty appointment at the, this place is supposed to be great, the Evergreen State College, I hear awesome things about that school in particular, but also earned Doctor of Public Health in Public Health Executive Leadership from the home of the Tar Heels, University of North Carolina Chapel Hill, and his Master's in Public Health and Chronic Disease Epidemiology from Yale University. So Dr. Wiesman, you're up. Thank you. Yeah. Okay. Great. Good afternoon, everyone. Let's try that again. Good afternoon, everyone. Good afternoon. All right. Great. It's approaching afternoon in my time zone in Washington State, maybe. So it's good to be here with you all, and I want to thank everyone who's here. It's amazing to be in this room of experts and who are doing such great work and to have folks from Kaiser joining us as well. As a Kaiser member, I want to thank you all for the care you do provide me and the amazing research you do and the work in policy. As a Secretary of Health, I must say I'm often envious of the work that Kaiser does in terms of your thrive kinds of health promotion work. I'm like, oh, I wish I had that kind of advertising budget. So anyway, as Secretary of Health, I do want to say that the best part of my job is being able to talk about work that others have done. And really, in this space, I want to thank all those folks in Washington State who have been working in the area of suicide prevention and policy. I'm going to give you a quick background of the situation in Washington very quickly, indeed. And then talk a little bit about leadership and public health and suicide prevention. And then go into a couple of policy areas around schools and health care provider training and lethal means reduction. So in Washington State, we're very much like the rest of the country, except that our suicide rate is about 22 percent higher than the rest of the country. That is also very similar for the Intermountain West States and the Pacific Northwest. Our state population is about 7.5 million, and every day we have about 3.5 suicides a day in our state. Three and a half deaths every day in our state. In terms of the opioid crisis, we lose about two a day in our state. And I think it's kind of interesting that the resources that we, I think, appropriately have put into opioids in that response is certainly important and something we should do. Someday, I would love to see us put the same kind of resources into suicide prevention that we are in that effort. Like much of the rest of the country, we do have higher rates in males, young adults, older adults, American Indians, Alaskan natives in our rural communities and our LGBT populations and especially in the youth in that population. Firearms really have been strongly connected to our suicide prevention work for this reason and the reason on the next slide, which is that half of our suicide deaths are by firearm, which is much like the rest of the country, as you can see. And if you look at all of the firearm deaths in Washington state, 75 percent of those are suicide deaths, which makes it, I think, really important to that from a public health perspective. We think about that and that is exactly what our Governor Jay Inslee did. So historically, Washington has really focused on preventing suicide among young people ages 10 to 24 years. And then the legislature in 2014 passed House Bill 2315, which asked the Department of Health to actually write a suicide prevention plan, essentially across the lifespan. And then that plan was published in January of 2016. Now as this plan was being written, the Governor was very interested in addressing firearm injuries and deaths. There were a number of mass shootings around the country and getting much attention. And so we gladly worked with the Governor around this and said, Governor, if we're going to take a data-driven approach to this, we need to understand the role that suicide has here. And that as being sort of the major issue that we need to focus on. So he issued an executive order in January of 2016, which really focused primarily on three things. One was to begin implementing the suicide prevention plan. A second was to look at a gap analysis in looking at the sharing of mandated information between agencies for background check information. We had a past in our state in November of 2014 initiative 594, which closed the background check loopholes for all gun sales, including those at gun shows and on the internet. And so this was an effort to say, hey, where is some of that information that comes from multiple state agencies not getting clearly communicated in terms of those background checks? And then the third was asking the Attorney General to look at gaps in enforcing laws when people who are prohibited from purchasing or possessing firearms actually attempt to do so. And what are we doing about that? So that executive order also had us form an action alliance for suicide prevention, much like the national one that you saw. That was actually our model. So Colleen, thanks for your great work. And it was really developed to help ensure accountability of this plan to ensure progress is accelerated. And when we pulled together this group, I came at it from a place of three sort of common agreements. One was that owning a firearm is a personal choice and a personal choice that we know is there and want to protect. Secondly, that we all want our families to be safe and protected. We all want our families safe and protected and the people we care about. And that together we want to prevent harm and do that together. And that if we found that common ground, we could work together. So Washington did develop, as I said, the suicide prevention plan, which you can find on our website. That plan focused on four strategic directions, which you can see here around families and communities, clinical and community preventative services around treatment and around data and surveillance. Each of those have goals and recommendations that go with those. And they led us to a place where one of the leadership issues that we did is say how as a state across agencies, whether it's the Veterans Department, School of Superintendent of Public Instruction, children, youth and families, all of our state agencies. How do we come together and actually put together a core around suicide prevention? And because, frankly, this isn't well funded. And we get a few dollars from CDC, but they don't go nearly far enough. And each agency has maybe little dollars here and there. So we put together a decision package, as we call it, to say as state agencies and as state universities, let's come together and think what would be a core. And that core, we said, would be an education campaign to both raise awareness as well as reduce stigma, to have crisis hotlines that are funded and resources for people that are there when they need them, to have some specialists in these areas around veterans and other high-risk populations, and to have local resources in communities that we know can actually do good work. We put forward that plan. It was many millions dollars more than was going to be funded. And so we're going to keep working on that over multiple years. On the policy side, though, in addition to policy, we've focused on higher education. And back in 2011, there was a bill implemented and passed to have a work group on preventing bullying, intimidation and harassment, and increased students' knowledge of mental health and use suicide through the learning standards in the curriculum. So really starting to take, again, this policy and systems approach in our education settings. And it also had colleges compiling this information as well. That went on to increasing capacity for training for professionals in schools to make sure they had mental health training that they could help our students in crisis. And you can see a whole laundry list of things that have happened since then. I do want to mention that it's important to have champions and important to acknowledge them. One of the champions in our state is Jen Stuber, who's a professor at the University of Washington. And she is a survivor of her husband's suicide. And has been one who said, we need to go beyond awareness and think about policy and systems approach changes to restore hope. And she has really done that in this work in helping move along some of these policies, along with representative Tina Orwell. It's always important to have those champions for us. And that sort of education that started with school professionals then moved into other education requirements, continuing education requirements for health professionals, starting with mental health professionals about being able to do suicide assessments, referrals, understand the imminent risk, and access to lethal means and how to help protect people. And that then really started a cascade of bills of expanding the continuing education requirements that my agency actually puts forth. Then we focused a great deal, as you can see as well, on reducing lethal means, as I said from the earlier data. So in 2016, the legislature created the Safer Homes Task Force. This task force was to put together suicide awareness and prevention strategies with firearm dealers, firearm ranges, with hunter and safety and pharmacies. So it was taking an approach of safe, essentially, storage and homes for both firearms and medications. And really putting those two together to again talk about creating safe environments for our folks. This led, as you can see, to other policy issues. The state did also voters past initiative 594 requiring background checks and allowing the temporary transfer of those firearms to others to protect people who might be at risk for suicide. And has then led to actual funding of the Safer Homes Suicide Aware Program. And one of the unique things I think about this is that this effort is co-chaired by Jen Stuber, who I mentioned earlier, Dr. Stuber. And then Alan Gottlieb, who is with the Second Amendment Foundation. We said if we are gonna come together on this and find common ground and work with folks who own firearms and who hunt and use firearms for safety reasons, we need to be on common ground. We need to come together. And that's really important to us. Some people have been critical of us that we would partner with the Second Amendment Foundation, given that on the other policy sides, we don't always see eye to eye on those. But I think it's important to work on common ground when we can. And in Washington State, many of these other policies have been passed through initiative because those were also things that wouldn't get through the legislature. So in wrapping up, since I'm well over time, the other initiatives we're working on is looking at the agriculture industry and suicide risk there, which is the agriculture industry is large in Washington State. And it's important for us to understand how to best work and prevent suicide there. So I know we'll have time for a question and answer later and further discussion of any of these. But I'll just leave you with one of the things we do on our Action Day during the legislature is outside the state capital put out on our Action Day tombstones representing all of the suicides in Washington State. They are color coded by those that died by firearm, those by suffocation, those by poisoning, thus the different colors. And yellow ribbons are put on those for veterans. And this last year, they put backpacks on the ones for young people. So advocacy is incredibly important when we're in the public policy making area. So thank you very much. Thanks, it's amazingly creative and thoughtful work, particularly the gun work that's been going on. We have seen the need to find a way to change the dialogue and it's that kind of leadership that I think is really helping us move in other directions. So thank you. Next up is John Auerbach. He's the President and CEO of the Trust for America's Health. Non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. Former Associate Director for Policy and the Acting Director of the Office for State, Tribal, Local, and Territorial Support. I always have to read that very carefully because there's many words in that. At the Centers for Disease Control and Prevention and a Distinguished Professor of Practice and Health Sciences and the Director of the Institute on Urban Health Research and Practice at Northeastern University in Boston from 2012 to 2014. John, thanks for being with us. Thank you very much. Good afternoon, everyone. I would also add that part of what I've done over the course of my career was I was a city health commissioner for a decade in Boston. And for several years, I was the Massachusetts Health Commissioner and so had the pleasure of working with Dr. Weisman on many of the policies that he's implementing in Washington state we also looked at in Massachusetts. So my emphasis in terms of the talk today would be to suggest that in order to effectively reduce suicide, we have to work in coalitions and collaboration with each other. And all too often, the sectors that we represent are in silos and not working with each other in an effective way. This pyramid illustrates some of why we need cross-sector work. It's a pyramid that's been used frequently in public health that illustrates that at the top of the pyramid it's the work that we do on a one-to-one basis with a patient to try to screen that patient for risk as we've been talking about, counsel that patient and then maybe refer them to specialized services. It is smallest on the top because that work is done one by one and it's very resource-intensive because it means you have to work with a single person often with a single clinician or multiple clinicians. At the bottom of the pyramid, on the other hand, is changing the conditions, broadly changing the conditions in people's lives, addressing the social determinants like racism, like poverty, that create additional stress and additional pressures that make people more vulnerable for suicide. So the trick is not to try to do everything in the sector that you're in but to understand that to be effective we've got to be at the same table and there have to be people from all those different sectors that are working in sync. Kaiser Permanente, I think, is a perfect example of the recognition of that because Kaiser Permanente, in addition to providing excellent clinical care, works in a variety of ways in different sectors. Its philanthropic work, for example, pays for affordable housing and pays for looking at both city and state policies and I'll give you a couple of examples of those. We're working in Washington to focus on a certain aspect of that work in coalition that often is neglected and that's what gets referred to as primary prevention or sometimes primordial prevention and that idea is really working even before we're thinking of working in the schools with terrific programs like the Good Behavior Game that build resiliency to trauma and resiliency to difficult circumstances kids have gone into. Instead to think about how can we eliminate those conditions from ever occurring in the families and with children and adults that may make them later in life at elevated risk. Now, that may seem like too idealistic. Where do you begin? How do you begin to think about those kinds of policies, particularly if you're an individual clinician or working in a small practice, even if you're in a large health system? Sometimes those larger social issues can seem beyond your control. Part of what we do at Trust for America's Health is we look at the evidence base for those broader policies and we try to gather that in a helpful way so that that can become a resource for you about what are those policies, what are those laws, what are those regulations that would make a difference. We now have a coalition by the way called the Well-Being Working Group funded by the Well-Being Trust, a philanthropy on the West Coast that brings together 25 different national organizations to think about how can we across sector work on some of these upstream approaches? And that means beginning to think about such policies as insurance coverage. You know, we're talking about what happens in terms of good clinical care this morning, but we're still struggling to make sure that every person in the country has access to comprehensive health insurance, high quality comprehensive health insurance with parity. That's key. We can't lose sight of that. That's a policy we need to pay attention to. We also need to pay attention to some of the more controversial policies like gun control, not because it's a cause in and of itself, but because if we're looking at the science base, the evidence base, and there's certain policies that will be effective in terms of reducing suicides by limiting guns worth considering. Even looking at policies related to discrimination is incredibly important here. That includes such things as looking at the policies around immigration, looking at policies against particular populations like the gay, lesbian, bisexual, transgender populations, and looking at where we see racism and discrimination creating conditions in people's lives that elevate their risk significantly. Now, I'm going to skip over in the interest of time and focus on the question that people may have the most often is, what, how do you do this? So I'll give you some concrete examples. Communities across the nation are developing the concept of trauma-informed agencies and institutions. Many school systems at the school superintendent level, sometimes at the county level or the state level, are embracing the idea of trauma-informed schools. These are schools where the notion is if we find that children have behavior problems in the schools or if something's going on, there's chronic absenteeism, instead of thinking, what's wrong with that child? That the approach is, what has happened in that child's life that we can help to address? These are just two school systems out of many that I've happened to visit. There's not enormous resources. They're not necessarily in the most progressive political communities, but they have embraced this approach completely. In Bethlehem, for example, 1,000 people moved to Bethlehem. It's only 70,000 from Puerto Rico after the hurricanes that took place last year. And they integrated hundreds of kids through the schools where they noted those kids were experiencing trauma and working with them realized part of that was the parents needed help in terms of finding jobs, relocating to stable housing. And the whole county got involved in working on addressing those issues as part of the notion of reducing elevated risk. This is also related to the overall efforts in the country that are anti-racist efforts, anti-discriminatory efforts, where we know that also contributing to elevated risk for suicide is when people have a sense of hopelessness or don't see a positive future because of limited educational opportunities or economic opportunities. This has gotten a lot of attention in the last couple of years with regard to the rural communities, but it's true over a wider segment of the population. So paying attention to things like economic opportunities, who's not having those? Why aren't kids graduating from high school? What can we do to help them succeed? Is actually part of an anti-suicide approach. We've tried to collect these, as I said, in some useful documents. This document, promoting health and cost control in states, was actually funded in part by Kaiser Permanente. And what it did is we searched 1,500 policies that had an evidence base looking for the ones that had the strongest evidence base for if they could be adopted as laws at the state level would result in a relatively short time in improved health and cost reduction. Much of the improved health is related to some of the risk factors associated with suicide. We came up with 13 of those policies that look at everything from income, housing, and safety. So I'd encourage you to take a look at that. You can Google it. P-H-A-C-C-S is how we refer to it, are facts. Kaiser Permanente also supports a city version of this that's known as city health, which promotes nine policies that are evidence-based at the city level that, if implemented, will create conditions which reduce those stressors that are more likely to put people at elevated risk for suicide. And the CDC also has another example of that. Again, as a resource to help you that's known as high five or health impact in five years or less, it summarizes the evidence and presents policies with language that can be used at multiple levels, city, county, local. And if put in place, has the advantage of reaching large segments of the population and really working at that primordial or primary population level. This is just a couple of examples of what those policies are that have been shown to have a strong connection to reducing the risk factors. Our earned income tax credits, for example, by reducing the impact of poverty, has actually been shown in a relatively short amount of time to have a positive impact on overall health and can contribute to the work that's being done in multiple sectors around suicide prevention. And similarly, fair hiring practices. This one highlights the policy known as ban the box. Eliminating the discrimination that can come where people are coming out of correctional facilities and can't find jobs is part of this overall approach that looks at the underlying factors or primordial factors. So in conclusion, I would just say, again, where I started, this is too big a problem to try to solve in one location. It's too big of a problem for clinicians to have on their shoulders. We have to think about excellent clinical care, the screening, the referrals that we heard of earlier. But we also have to think about how do we create helpful communities where people are connected to each other in positive ways, where we work against discrimination, we work against bullying, and we try to eliminate some of the conditions like poverty and racism, which can significantly increase the risk factors. Thanks. John, thank you. It's always a pleasure to have a public health leader like John join us on an event like this. I get a side bit of my work is to do some public health work with the Public Health Institute and other organizations. And when I told a couple of my colleagues there that John would be joining us on this forum, they were very excited for me. So thank you for being here. Our next presenter is Nathaniel Counts. Nathaniel is actually a mainstay of our mental health forums that we've had here at the Center for Total Health. I think you've been at all of the forums that we've had here and a frequent participant and excellent contributor. So thanks again, Nathaniel, for being here. Nathaniel is Associate Vice President of Policy for Mental Health America, works on innovative federal and state policy solutions for problems in behavioral health, focuses on issues in incentive alignment and sustainable financing in behavioral health care and issues on population health. Recent publication, I won't get into. You might talk about that. Don't hold it against him or any of the rest of us who are trained as lawyers. But he's a graduate of the Harvard Law School where he was a Petrie-Flam Center for Health Law Policy student fellow and got your bachelor's degree in biology from Johns Hopkins. So welcome. Thanks. Great to have you. Thanks so much, Tony. OK. Where's my little clicker guy? Oh, this guy. The big green button, I think. Ah, that makes sense. OK, wonderful. And so collusion is a hot topic in DC at the moment. And John and I colluded a little bit on our presentations. So while he did social tournaments of health and context matters and here's state and city solutions, mine's going to focus what can we here in DC, sometimes hundreds or thousands of miles away from the people we're trying to help with federal policy solutions to affect these social contexts. And in doing so, I don't want to say health care reform isn't important. Health care reform is clearly important. I put up a lazy list of examples of things we could definitely do tomorrow for any kind of behavior trying to incentivize around suicide risk prevention, like safety plan, assessment and screening and completion. We can make that a quality measure and begin measuring and capturing and promoting it. We could have value-based payment models that look at things we care about. We could use the vast machinery of CMS that has these quality improvement organizations and qualified entities to push on better outcomes for people around depression and mental health. Just like an easy example, if you guys have looked at the NCQA HEDIS database, one of the measures is follow-up after hospitalization for initial mental illness. The national rate is about 40% successful follow-up. That's not great if that's a major risk factor. So we could push on that. Another example in the Medicare serious savings program, the median rate of depression remission at 12 months for ACOs reporting in is 8.7%. The median rate of random remission for depression at 12 months is 53%. So a lot of work should be done within health care to get these numbers to line up. But what I really want to focus on is the opportunities to stop it from getting that far and the sort of social context that we know matters. And the thing I want to start with is the single most obvious solution is to start in health care and screen people for social terms of health and refer out. Just, I think, two months ago in American Journal of Public Health, CommunityRx, which is, I think, probably the largest and most well-developed study of social needs screening and referral, just completed its evaluation. It was like a many million dollar CMI project. And so what it did was it looked at every intake you filled out a social needs questionnaire and it had a database of all the different community-based organizations in the community. It would give you a personalized referral database so you could go meet your social needs. And they found that at the three-month follow-up, people's knowledge of community resources doubled. And about 50% of people told their friends about community resources. They really were genuinely internalizing the resources. There was no statistically significant effect size on health-related quality of life, either mental or physical. And if you look a little bit deeper at the data, it actually trended negative. People seem slightly worse off in the intervention group. The conclusion, and it could be there's a bunch of problems, like maybe three months isn't enough time and you need more time to follow up, or something else happened. But the conclusion from the authors was that we likely need a higher intensity intervention. And we need to make sure that the resources meet needs. And what I really want to touch on today is that to make a really meaningful impact in people's lives, we should probably focus on the institutions that govern people's social lives outside of health care and make sure that those are equipped and fully capacitated to meet people's needs, rather than hoping that through health care referrals alone, we can address all the social context for people. Part of that, too, is how many of people are you familiar with, and I guess you can kind of raise your hands if you know, the White Hall study, like the original social determinants of health study. Yeah, so we've got some public health folks. So in the social needs world, often we screen for and refer to discrete social determinants of health, like housing and food and whatever kinds of other needs we have. What the White Hall study found was for the people, civil servants in England, UK, even though they all had roughly the same access to high quality health care, and they also all had this huge benefits package, people's health still almost perfectly correlated with their income. And unpacking that over decades, what they found was a major determinant, wasn't absolute resource access or deprivation, it was your perceived sense of social control. And apparently in replications, and don't quote me on this, they found, I think it was like the Grammy award winner lived statistically longer than the Grammy runner-up or something like that. Apparently in replications, you actually find this in very fine green, too. And I think perceived sense of control affects our immune system, affects our health-related behaviors. So I think part of our strategy has to be not only making sure we're meeting these discrete needs, but also the norm change interventions that leads to building everyone's perceived sense of control and value as well. So what I wanted to touch on is often the social context for suicide feels incredibly nebulous and how on earth do we affect that. And there actually are major laws in every single area of social determinant that I think do both affect people's absolute access to resources, but also the norms that govern their lives. And that we as health care stakeholders can and should lobby on this. And just to put it a little bit finer point, I think our dalliances into other sectors of health and social needs are pretty effective, because health care is actually one of the strongest lobbies in the United States. If you look at it, it's like US Chamber of Commerce, the National Realtors Association, then a list of health care entities. And so I think when we combine efforts and it's trying to work on the health care pie itself, but trying to work on social terms of health, I think we can be hugely impactful. And for me, I spend all my time in energy and commerce and finance and everything, and this is a call for all of us to wander over to the other committees and see how they're doing as well. OK, so I just wanted to touch on some case studies and just four examples. The first one is the easiest, which is school. We've heard about good behavior game. We've heard about trauma-formed schools. We're already headed in the right direction on that one. So our three major authorizing statutes are elementary and secondary education act, which is Title I's funding for low-income schools and Title IV funding for professional development dollars, all these sort of things that drive federal resources into under-resourced schools. Then we have Individual Disabilities Education Act, which governs individualized education programs, all the sort of web of needs for children that require additional help. And then Higher Education Act, which actually is both the conditions for college students, but also the training that teachers receive when they go into schools. So there's kind of two levers there. And increasingly, for the Elementary and Secondary Education Act, there's a focus on the non-academic indicators and non-academic grant programs. And so with the most recent bill, Every Student Succeeds Act, it was sort of like the first foray into non-academic things and not just having like strictly reading math accountability. And I think when the next authorization is up, which is next year, I think, we could continue to press on that to make sure that schools have what they need to implement effective mental health, social-emotional learning interventions, good behavior game system-wide. Then Workplace. So this was actually new to me. I was reading section 29 of the US Code for the first time, which is all the labor laws. And so we actually, and you kind of think in your head, you're like, I don't think there's a big federal role for labor here, because we kind of hear about often that. But we do have labor standards. We have ERISA, which governs benefits. We have Occupational Safety and Health. And we have this Workforce Innovation Opportunity Act, which is all the job training programs. And I think one of the biggest difference between when a lot of these bills were passed and today was these were all sort of forged in the fires of the labor movement versus the robber barons and protecting the rights of individuals. Today, though, I think we've kind of taken, at least increasingly, taking on a different viewpoint that mental health and productivity are related and that the interests of both employees and employers are aligned. And I think that shifting empirical science underlying mental health, suicide, workplace productivity allows for new kinds of policies to be co-developed among the stakeholders if we work together to integrate that empirical science. Then for occupational safety and health, that was designed to stop people from being exposed to chemicals or dangerous machinery. But imagine if we added in psychological safety and well-being as a key function of occupational safety and health. I think it would fundamentally transform the way we view workplace, suicide, adult health. And for Workforce Innovation Opportunity Act, one of the biggest problems is job loss is a major predictor of suicide. And it's viewed not only as a financial and security issue, but also as a personal failing that makes you feel like you have no more options. And so I think one of the opportunities there is to better press on connecting people leaving jobs with immediate retraining and making it kind of normative to get retrained and reengaged rather than getting fired, having to hunt down your unemployment benefits, having to hunt down, eventually, a job training program, and the kind of log slog towards reintegration. I think there's chances to tinker with all of these to change the norms around labor, reemployment, everything around mental health. Then this sort of combines two ideas. So this is both community development, so the macro level of financing, what does low income housing tax credits look like, and the kind of subtle behind the scenes levers that shape the built environment around us, but then also consumer protection. So we have all the Elizabeth Warren's big consumer finance protection bureau and the protections that came after the financial crisis. And the opportunity is there. And I think just an easy example is right now the Housing and Community Development Act and the Community Renewal Tax Relief Act, which are each billions of dollars for community development projects, are only tied to low income and economic prosperity, but don't consider the mental health and suicide prevention aspects of it. And I think that by mainstreaming the considerations around mental health, suicide prevention into these kind of built environment interventions, we could more fundamentally transform the conditions of people's lives. OK, so this is, to me, seems the most intractable from an initial past, which is like family relationships, social isolation. We know that relationship problems are at serious determinant. What on earth are we to do from the federal perspective? Weirdly enough, the Deficit Reduction and Claims Resolution Acts both contained huge marriage programs. And so health systems across America, the Gathe's Grants, are running free marriage counseling programs, basically. And they have pretty good effects, but they're not widespread or even slightly normative. But they do show good effects on reducing intimate partner violence. And I think probably you could find they reduce suicide. Then Family Violence Prevention and Services Act is the domestic violence clinics that are all across America, which unquestionably reduce thousands of suicide by giving people options. And the Preventive Health Amendments, which is part of what develops the Injury Prevention Center at CDC, which does intimate partner violence, and then child maltreatment, and all the other sorts of parts. And I think my big point would be, these are great starts. These are clearly not the final answer, though. We have a handful of challenging to reach relationship interventions, and none of them get to the larger context of social inclusion belonging community, and only intervene in certain kinds of normative relationships that are cognizable failures, like upcoming divorce, but not the more malleable parts of modern life. And so I think part of what we could do is press on new approaches that build norms around social inclusion, make it more normal to seek social opportunities, and admit that you're lonely, and all of that. And the UK has started going down this route. It's mostly older adults focus, but I think part of what this all of the research shows that it's cross-cutting across all ages. And I am way over time, but I think I would just say we can and should address social terms of health using federal legislation. And as health care stakeholders, we have opportunities. It just takes abnormal amounts of creativity to figure out how to translate this onto the ground. Thanks so much. OK. So we have about 20 minutes for some discussion and questions. So I will ask anyone who has thoughts and questions to step up to the microphone. And I know many of you, Nathaniel did give us the tour de force of every possible federal intervention. And so if anybody has a favorite, they should step up and vote for that. One of the things that I think I was hearing as a theme through all of your conversations really has to do with resourcing and how under-resourced it seems like this problem is at every level. So I don't know if, you know, at thinking about it, there's a local level, a state level, or a federal level. Are there things that we should be focusing on to try to tap into some of the resources that do exist and can be turned in this direction a little bit better? I don't know if that's a helpful way to start the conversation. Maybe I'd start in that. I think that we've really emphasized the critical importance of the health care system. I would say that equally important in terms of addressing this issue is the public health system. But the public health system exemplified by John and people in every local community and the states, it doesn't have any specialized resources, for the most part, to deal with the complicated issues that we're addressing. Public health can be the glue, importantly, that brings together health care with these other sectors, we say so, are important from the faith community to other governmental sectors, transportation, job opportunity, education, get them at the table, make sure the data is presented, present the evidence, and then get people working together. So what we've done at Trust for America's Health is we now have a proposal before Congress and with the administration that would get every state health department a unit that could work on these kind of activities in collaboration with the large health care providers and the other sectors that are key. You can't do that without resources. Somebody's got to really work hard to get folks at the table and to get them the resources they need. Yeah, that's helpful. I would just echo that. And I think that's one of the things we're attempting to do without additional funds with the Action Alliance is pull together the various state agencies with business and others and take a look at what resources we can actually maybe think about using in a different way. Whether that's the Department of Commerce as well, Department of Children, Youth, and Families and what are those opportunities that are out there. But core funding for this sort of basic convening work and policy development work really is something that many states are working on. We have an approach that we're calling foundational public health services where we're trying to fund essentially those really core pieces that are not funded because people fund a grant to do X, Y, and Z. And I would say one of the critical things too is getting aggressive and unified about the economics of human development so we can better understand and reinvest savings. Like the good behavior game is estimated it's like return investments like 35 to one or something. If that was a bond, it would be like we would all invest in that, right? But I mean, so you guys have the Washington State and State of Republic policy. Most everyone else has nothing, unfortunately. So I think getting, figuring out and mainstreaming that math would help a lot with the investment. You know, Nathaniel, one of the things that you mentioned and I'm gonna ask this because it presses on some of our plans as an organization, it's viewed as a progressive and stretching kind of activity to do work, to screen and try to link people to the social services that are available. You made the point, or John, maybe you made the point, that that's great but it doesn't really get into the underneath and there's questions about the effectiveness and I'm wondering if that's about the capacity of the system itself to actually perform at that need or if it's something else because as we go down this road we wanna make sure that we're providing the appropriate support to the system as well as it's trying to meet needs. I didn't know if there was more to amplify about that. And to be honest until I saw that study I thought for sure that was gonna work. So I don't think it's intuitive at all that that wasn't going to work and I think it's a kind of like touch with reality moment where we need to figure out because the conclusion of the study wasn't even necessarily that the referrals weren't effective it was like the process of linkaging was stressing people out. So it seems like we just need to keep iterating on the linkaging system and there's probably, I mean for sure there's also like strong start at the big perinatal health intervention found that the enhanced social screening increased rates of free-term birth which can't be good. But and part of the reason was they made calls and they found out that women were being put on like seven year housing wait lists. So there's definitely problems with the capacity of the system but I think there's also we just need to do additional work iterating on the linkages. Well, but I would say that we need the experience from Kaiser Permanente and other providers that in the screening are identifying what would help because some of it is clearly referral to an appropriate clinician but some of it is people might say, you know, my housing situation is really a major problem now that's contributing to the stress that's making me more likely to think of, have suicidal ideas or other mental health issues or substance abuse issues. If we have the data from that that could say, well we've identified a shortfall in, you know, let's say Washington D.C. of 5,000 units, affordable units from the data, then that's a plan that can be used for planning purposes but there's no getting around. We have to think about supply and not just need because if we're identifying need and it stops there then it frustrates the clinician as well as the patient. We've got to pay attention to that and that isn't being a paid attention to now. One of the things I'll be interested in looking at is with the healthcare transformation work and the CMI Innovation Grants, sort of where some of these accountable community of health structures are able to get, where we're really bringing together healthcare delivery system with housing, with employment, with social service agencies to see if we really can get to this upper stream social determinants of health. The reality is we do need some core funding to do this work but in lieu of that we're also needing to come together and figure out how we work differently across our sectors and I think healthcare folks are as frustrated as we are with the lack of these kind of resources and effective systems so I'll be curious to see what the results show from the, actually the many experiments that are out there across the state or across the country. That's great, that's helpful. I think we do have a question, actually. Hi, John Rich from Drexel University in Philadelphia. I just want to thank you for, this is one of the most thoughtful and actually practical conversations about the social determinants of health from a policy perspective that I've heard. I do want to, and I appreciate the discussion about firearms because certainly with regard to suicide we know that's a, is a critical area and recognizing that the second amendment is what it is but doesn't constrain us to regulate. Do you have ideas about which of the, of the panoply of possible regulatory strategies around suicide which you believe might be the most effective? And I realize that often is an uncomfortable question. I feel a bit uncomfortable asking it for reasons that are partly about the intimidation that come from it but if not that then how do we, are there opportunities to better understand that if we don't know it's given the constraints about research? Well, I think, you know, there's some common sense approaches out there that I think if you do the public polling shows that the public thinks makes sense, whether it is about restricting access to firearms for those who have domestic violence histories or mental health or in crisis. And I think what we've seen in Washington state is our citizens are saying those common sense things need to become law and, you know, they're making it happen through the initiative process because, you know, even if you consider Washington a blue state which I'd say it's actually much more purple than people realize, you know, we weren't able to get those things through the legislature. So I would look to those things that I think, you know, even firearm owners say makes sense. You know, I'd say from an evidence-based perspective, fewer firearms lead to fewer firearm related injuries intentional or unintentional. So just from an evidence-based perspective, not talking about politics, if there are laws that are in place which make guns less available to people, you will have fewer suicides from firearms. That's obviously politically not always possible, but I think it's important for us as people who are engaged in the sciences to really talk about the science and the science would say fewer means less availability. Now, if that's not a possibility, thinking about the ways of restricting it by certain populations certainly makes sense. Thinking about restricting certain types of weapons makes sense and thinking about the kind of protective lock and counseling that we heard earlier this morning makes sense, but the bottom line is when it comes to opioids, when we're thinking about appropriate prescribing practices we're talking about fewer opioids being circulated in the public and available to the public, we're not telling people get as many opioids, just lock them up and use them wisely. We realize that doesn't work that way. You really have to think about the availability of the, what is used as the tool to that results in suicide. Another question. I just wanted to say thank you because I thought this panel was amazing and I feel like I learned a lot. I wish it was like another hour long, but it's not. But my question has to do with this real practical opportunity, just like you were saying with the practical, another major opportunity has to do with extending the mental health workforce. There aren't enough mental health providers and not everyone's receptive to a mental health provider. So thinking about peer navigation models such as Keita Franklin was talking about with the VA, like in the VA system, they can implement these innovative things like that. And even though the billing for these providers may not be totally worked out, they can play a massive role in supporting patients and helping them connect with services, practical services in their community, firearm safety counseling, from more of a peer, not like the top down type approach, like I'm your doctor and I'm telling you what to do. And so this type of peer to peer model hasn't been broadly disseminated, but for suicide prevention, it makes a lot of sense. And in connecting the dots for these patients, they can't do it on their own. And so I think we should also be thinking about that type of approach in adding that to our toolbox, so to speak. I fully agree with that and thank you for bringing that up. And I think two things come to my mind in this area. One is thankfully where we are going with health transformation work and sort of paying for outcomes rather than specific sort of individual services allows an environment where we can bring in sort of more creative kinds of workforce and have them paid, whether those are in bundled payment kinds of things or just different payment schemes so that it isn't about needing to have a scope of practice that is approved by the legislature and that you can actually bill for. So I think that's a positive thing moving forward. And as an agency, John, I think, did you regulate health professions in Massachusetts? Yeah. So as the secretary of health, I've really learned a whole lot about health professions and regulating them. But we're stuck with things that we have to figure out as well like background checks and like really what should be something that would disqualify someone. We're looking for lived experience folks. And so sometimes with lived experience comes history. That our current systems basically say, eh, you can't get that license. I think we have to really think through how we better do that and how we work with organizations who are employing folks that might have a criminal background history of theft or other substance use histories than that allows us to make sure we get a workforce that actually has lived experience and is safe at the same time. I'd also add that another advantage to the model you were just mentioning is it has greater likelihood that the people being trained would reflect the racial, ethnic, and linguistic composition of the communities. And that right now, they're real barriers to people getting services because they may not speak the same language as the clinicians who are available to see patients. And so we need them to overcome some of those barriers while at the same time we should be training at all levels a more diverse workforce in the interim. This is important, I think, of not losing whole segments of the population that otherwise wouldn't have access. And peer support is just added as a supplemental benefit in Medicare Advantage and pending with ways and means as a policy proposal to add peers to traditional Medicare. So come join us in that fight. I mean, that's a great point. I think, Nathaniel, you'll agree with me that the various sessions that we've had, particularly around mental health, this topic has come up intensively in every single one of those meetings, that it's not just around suicide prevention. It's about access to mental health services. It's about the right types of services being available. It's about the limitations on payment of what therapists, what social workers can do in schools as opposed to being freely available to the environment in those schools. So I think that's a really important question and something where I think there's a lot of work for us to try to do together in that space. Hi, Bill Arnone with the Natural Academy of Social Insurance. My question is for Dr. Weisman. The state of Washington has been a leader in promoting policies to support caregiving and caregivers, Paid Family Leave being one of them. Did you see any correlation between the stresses of caregiving and suicide rates and was that a driver in the promotion of caregiving policies? I don't think that was a driver in those policies. It was really, I think, more about what we thought was doing right. I think all the benefits that might be there include that, but we've really, I think, tried to move in this case of Paid Family Leave and other policies that we think make for a good economy and make for sort of healthier populations altogether sort of just come for good health. So there are many reasons to do these things. Pavin? Do we have time for another question? We absolutely do. Fire away. Yeah, so first of all, just a quick comment. The state of Washington's suicide prevention plan is amazing, and even though it's not yet funded, it's a guidebook for us to follow what to do in primary care and special behavioral health care. So I just encourage everyone, if you get a chance to read through it, it's not short. I was curious about, you know, we all know that we need to have more mental health providers not creating enough. I will say that today I've spent about twice the amount of time learning about suicide than I did in training as a psychiatry resident. And so we can, I guess, create more mental health providers, but I wonder if there's a role in making sure that all providers have a core competency. How can we do that and make sure that our providers know about suicide prevention so that when our providers come in Northwest Permanente, we spend a day training them on it with stuff that they haven't learned before. Well, that really was the driver for the legislation in Washington, which mandated this continuing education requirement for the health care providers that were noted and that we've been expanding. It started out just sort of requiring training, and then we basically had to certify like that the training was like decent training. And I think over time, we'll keep looking to build on that with more in-depth training that really gives providers the tools, I think, truly that they need, whether it's DBT or other kinds of training for particular categories of health professionals. But to hear you say that is like just shocking, isn't it? Right? Because it's like, wow, really? A psychiatrist with little training in suicide? It really suggests that part of what we should, the work we should be doing at the national level, as well as in states, is talking to the medical schools, the nursing schools, social work schools to make sure the curricula have components that are offered to all the students that help them to better understand how to screen for and address the issues. And my sense of the policy implications of accrediting bodies is if you can throw out a little bit of grant dollars to get a certain number of medical schools up to speed on training, then that gives the board the accrediting body enough coverage to say that at least now enough schools are doing it that they can change the accreditation standards and then everyone else follows suit and there's a whole dance, I think, in there to do. And I think it is better now, but it's still not good enough. I graduated 10 years ago, so it wasn't on the forefront of people's minds then. Well, Don and I will take this up with the leadership of our new medical school soon to see what we can do ourselves to try to lead the way there. Well, I hope all of you will join me in thanking the panel. This has been terrific. Thank you, guys.