okay so why don't we just move ahead
and it's my pleasure to introduce Deb
Pinals. Deb is the Medical Director of
Behavioral Health and Forensic Programs
for the Michigan Department of Health
and Human Services
she's also a clinical professor of
psychiatry at the University of Michigan
Medical School
and a clinical adjunct professor at the
University of Michigan Law School
Deb is the chair of the NASMHPD
medical directors division
she has written and consulted
extensively for NASMHPD
today at this session she's going to
talk about
crisis services addressing the needs
across diverse populations
we are pleased to welcome Dr. Pinals Deb
do you want to go ahead
okay great yep I don't know what was
going on but yeah so what
I love the lineup that
Brian and Megan and others put together
on this
conference and listening to the prior
presentations is really inspiring
and I think this what I'm going to be
talking about now
is really kind of diving into what does
it mean
to have crisis services that really
address the needs
across diverse populations and
we heard before from Dr. Hoover in her
excellent presentation
about okay great sorry I was doing
that I thought I had already shared it
all right so here we are and this will
feed into what Dr. Hoover was talking
about before in terms of the
the children's services but as I said
you know yesterday
I spoke about from from the perspective
of the umbrella
issue which is how do we move our
systems into this world of crisis
services and you're going to see a lot of
papers coming out of NASMHPD that look
at specific aspects and specific
population
issues substance use disorder homeless
populations we heard about the the child
and adolescent services
and what this this part of the
presentation is really about is thinking
about
what does it mean to serve a diverse
population in accordance with the ma...
you know the ideals of building out
a crisis service
and I just want to acknowledge Dr.
Matthew Edwards who's a resident in
psychiatry at Stanford University who's
been working with me
to develop the themes in this paper 
he's been a terrific partner in this
and again just to remind everybody what
we already know and you've heard many
many times this before-COVID release of
the National Guidelines for Behavioral
Health Crisis Care the Best Practice
Toolkit
and in that toolkit is this concept of
services
for anyone anywhere and anytime
but anyone just basically also means
everyone and so
one of the things that struck me at the
end of Dr. Hoover's presentation
is you know if you're going to be
serving everyone are you a generalist or
are you a specialist
and certainly for children services you
know
deeper dive into children's services we
we value the expertise of child and
adolescent services
you know I'm a forensic psychiatrist I
work in I have addiction medicine
certification
you know so in some ways I'm sub special
I've sub-specialized but if we really want
crisis services to serve
anyone and everyone we have to have a
level of ability
within those crisis services to really
be able to meet anyone who comes in and
walks in the door
or makes a phone call and what's stated
in the guidelines in the toolkit is that
this idea of assessing the adequacy of
system capacity
and it talks about care for all
populations through
the life span and that includes
capacity to address the needs of rural
and urban communities that could be
experiencing mental health, substance use,
intellectual, developmental disability,
and co-occurring medical problems by
accepting all
at the front door and again that means
offering crisis services for children,
adolescents, adults,
and an aging population that each have
their own unique set
of needs in each community and that's a
pretty tall order for crisis services
although frankly that is
pretty much the order the tall order
that we've been putting
on our emergency departments to this
day so in this paper that we're writing
about looking at diverse populations
we wanted to sort of drill down a little
bit in terms of what that looks like so you
could start by looking at what the
toolkit talks about
which is these age cohorts as the first...
as the first way to parse this out and
without repeating Dr. Hoover's
excellent presentation
what that means is that a crisis system
would really have different kind of
referral you know
you'd want to think about where are the
referrals coming in from
and that's going to include schools
which perhaps as we build out our
ability to have schools almost service
as crisis hubs there still will be
referrals
to some array of services or some phone
call system and some 988 numbers
using schools as a referral both
a referral an entryway point
families themselves, juvenile justice
will be another
point of referral as well as child
welfare settings
and that means that we have to think
about what are going to be the capacity
for our services and our if we have hubs
that are bricks and mortar
to have a child and adolescent friendly
location and again that doesn't need to
be an entire unit it could be having
a mobile cart that could be utilized with
toys and coloring books and
things like that it could be a room
that's designed
more to be child friendly and then it's
going to need that next step
and every time we talk about a crisis
service we have to think about
you know once the crisis is resolved
what is going to be the next place that
the person is going to need to be
referred to
and is it going to be a place or a
person in terms of services
and for kids that's going to raise a
whole host of issues about consent
issues and in a
particular jurisdiction who refers and
who consents to that referral
what about SUD services what about
trauma issues I loved what Dr. Hoover
said about
ACEs really important we don't want to
just screen for trauma we want to be
able to
understand how trauma impacts
individuals and then
what sorts of treatments do people need
going forward
and then how do we think about youth-
guided and family-driven care which many
states are
operating under and then switching gears
if we look at the other side of the age
spectrum
there's a lot to be done I'm actually
just
involved in a project that NASMHPD is
going to be helping with which is really
looking at
an interface that has been largely
ignored which is
the older adult population and the
criminal justice system
it's not ignored for state hospitals
that are often dealing with older adults
in the state hospital that have been
kind of sent there as the pathway
via forensic processes but now we want
to talk about moving upstream
and thinking about helping older adults
who might be coming into crisis care
through assisted living for nursing
homes
probably you've been involved in some of
these discussions even in terms of
managing
COVID-19 right now and the interface with
behavioral health
but a family's home as well as law
enforcement who
are often the first point of contact for
an older adult who might be wandering in
the streets
might be driving erratically might have
engaged in some behavior related to
brain deterioration or neurocognitive
decline
unfortunately we see a lot of people
in the forensic system who've engaged in
sexual behaviors
probably related to disinhibiting
disinhibition that happens with
with some of the neurocognitive
conditions and dementias
or even aggression even up to including
murder that we see
in older adults who had no prior history
really with the system
at all but
might get involved with law enforcement and
so how is law enforcement gonna know
where to refer people in crisis
if there is a crisis and so with that
if we have crisis hubs as the point of
contact
or phone calls that need to be made
again what is the
what is that going to look like in terms
of triaging
the settings um just like for children
and adolescents if you were to build
your ideal
unit for example or your ideal wing of a
of a crisis hub
that's perfect for kids you would
similarly want to think about what would
the ideal
hub look like for older adults there's a
lot going on right now in the world of
architectural design for nursing homes
and for assisted living
and settings that are really more
appropriate for
understanding the needs of
individuals who might have
neurocognitive decline in terms of
not making an environment that's over
stimulating
using you know larger signs for people
that might be visually impaired
having supports for people that might be
hearing impaired and really thinking
about the settings
in a way that really accommodates some
of the older adult
needs that might be happening in
addition in terms of services and
linkages
it goes to the same thing we were
talking about with kids you know do you
need geriatric specialists on-site or at
least do you need geriatric specialists
who are
able to help inform how care is designed
and then ultimately delivered
so that the generalists who are the
greeters to all comers
really understand what they're... what
they're doing in a different way
than just treating everybody sort of the
same
and that requires some workforce
development in terms of understanding
complex presentations and co-occurring
medical conditions
we have older adults who may be
well-versed in the behavioral health
system because they may be people with
schizophrenia
who grew up in that system and became
older adults if they were lucky enough
to live long enough
to become older adults
versus those that become
new service utilizers and
you know working very often in emergency
departments myself
it's not uncommon to see people
coming from nursing homes
who engaged in in new behaviors or from
families who engaged in new behaviors
and suddenly are on the behavioral
health side of the ledger
and then we can't forget the importance
of substance use disorders in older
adults as well as suicide risk assessments we
know that older adults
are at high risk for suicide themselves
and so as we think
about what those suicide
risk assessments look like for the older
adult population
and suicide prevention we really do have
to think about
that across the age spectrum and that
means
also looking at what kind of social
psychosocial supports are in place
are these older adults that are living
alone and have no supports what supports
can be brought to bear
what about decision-making challenges
for people with
mild cognitive impairment that might be
you know they may still have decision
making that allows them to
make independent decisions but they
might be on a downhill slide
where they might need more supported
decision-making tools
and there's a lot of work going on in
advocacy
looking at what can be put in place
short of guardianship
to help people with decision-making
support
and then of course abuse and neglect
issues that our workforce
working in crisis services needs to be
savvy about because these are such big
issues for the older adult population
now of course we've been hearing a lot
about race and
and ethnicity and you know one slide
certainly does not do justice to this
issue
but we know of course that there's
historic and current barriers to access
and disparities and outcomes some of
that relates to diagnostic issues and
that can
really start at the front door within
a crisis system we know that
there's data that shows that in
with regard to diagnosis that very often
black men will be more likely to be
triaged to criminal justice settings as
opposed to behavioral health settings
um some pretty scary statistics that we
we already know are true
that we have to figure out and how to
overcome
for kids black youth are 2.5 times or
once this one study showed 2.5 times
more likely to be diagnosed with conduct
disorder
than adjustment disorder and ADHD which
again puts them more likely
more at risk for juvenile justice
involvement and there's a lot of data
looking at the DMC ratios the
disproportionate minority contact ratios
for kids involved in the juvenile
justice system
also barriers to access are
relevant in terms of individuals
feeling less likely to use professional
mental health services
probably largely related to the sense of
distrust in the system and the actual
reasons for that and the legacy of abuse
and exploitation which has contributed
to that distrust
and the historical trauma upon which
this whole
problem rests and so the role of
cultural differences,
stigma, religion, coping styles, trauma,
and familial influence with regard to
the sense of trust in the system so as
we're thinking about building a crisis
continuum that really is for anyone at
any time
we have to figure out these ways and
intentionally look at how the crisis
service system is built
to make it a welcoming system for anyone
to really meet people where they're at in
terms of cultural and racial
issues and thinking about how to
meet meet those needs
another type of
population that would access and does
access emergency
services today and that will continue to
access those services
and will need to be accommodated for in
the
crisis continuum of tomorrow
is the immigrant and undocumented
population
and obviously there's a lot that goes
into what
their experiences were as they came
into this country and then get to the
point where they need emergency
mental health uh services unfortunately
our our data shows that that their
experience of treatment that they
receive
really varies in um across ethnicity and
citizenship
in terms of the kind of clinical
approaches that are offered if
any for those individuals
coming into care it's a big deal to
access care
because for the most part
they will be having lots of their own
issues of
if they are kind of outed
if you will they may have fears of being
deported
there may be social and political
stressors that they're facing
and then fears of other legal
consequences for them or even their families
and that includes the fear of being
criminalized and so
these undocumented individuals which
are increased risk for having affective
disorders
and trauma histories and trauma
experiences are going
to have some reluctance or
great reluctance to access these
these services and so and especially
to access these services prior to a
crisis so we're going to see these
individuals and again we already do see
them after the crisis has already
bubbled up
which then once the crisis has bubbled
up and the crisis service is trying to
address their needs
raises another set of questions that
that our systems are going to need to
respond to which includes where do we
go after the crisis because as you all
know as state mental health leaders the
funding for this population is really
limited
and so their ability to access ongoing
mental health supports can be a huge
um a huge barrier for them
and the lack of benefits although some
are available through the CHIP
reauthorization act some of the benefits
are going to be very limited
and so to manage a crisis services
that's really suitable for all comers we
have to understand
and learn more about immigration
policies
and what supports might be available in
particular communities
to help individuals who might have
behavioral health challenges
and the family systems from which they
come and similarly we have the issues of
language
non-english speaking populations now
we're again
fortunate that as many things are
unfortunate we also have to count our
blessings that we have technology on our
side in terms of interpreter services there
are now some amazing
amazing abilities to get interpreters
on you know available through
technological means
and that's going to be very helpful but
as we all know interpreter services are
complicated when we're talking about
working
with behavioral health population
who's coming in for care lots of work
needs to be done for the providers that are
doing the actual clinical service to
work with interpreters who sometimes
will not understand somebody for example
with thought disorder
or somebody who's hearing voices and the
interpreters will sometimes
try to not just translate the language
but actually try and
make sense of language and that makes it
very difficult for somebody
like me as a psychiatrist or any type of
clinician
who wants to get an accurate assessment
of what's going on with an individual
to really be able to do so also
non-english speaking populations also
represent
culturally diverse populations and our
providers are not as culturally diverse
for sure and so we'll want to be
thinking about how do we extend our
cultural diversity
within our provider population and at
the very least
extend provider cultural understanding
so that it's not just language but also
understanding the cultures that people
are coming from
we'll also have to be thinking about
what we're calling experiential
minorities such as the LGBTQIA
community and we are
really just at the infancy of doing
better by this population
and many would say we have not we're
not even at the infancy stage
there's language that needs to be
basically our workforce needs training
on language and terminology which is an
evolving
lexicon the service providers need to
gain confidence related to this and
understanding the impact of
marginalization
and really developing crisis services
that are warm and welcoming
to all communities including these
communities
there also has to be an understanding
of the risk level variance the high
rates of suicide in this population
compared to the general population
and then also um really understanding
person-centered approaches and you know
in the behavioral health system
you know we're gonna have to really
be thinking about
when people need levels of care and we
really are now talking about
you know making that care really
person-centered
some of our old ways of thinking you
know male beds
female beds all of that really needs to
be rethought so that we really try and
meet the person where they're at
in terms of their own identities
so that's another population that crisis
services are going to have to be
adept at serving in 2017 we produced a
paper on the vital role of specialized
approaches for persons with intellectual
and developmental disabilities
in the mental health system and NASMHPD
has been partnering with NASDIs
a great deal and I think the COVID-19
context has really highlighted some of
these challenges
as well but our systems
often see people with intellectual and
developmental
disorders though certainly the emergency
department boarding problem has
identified that persons with IDD
are often the ones that are going to be
stuck for longer periods finding
placement and that it can include for
individuals with
autism spectrum disorder or intellectual
disabilities or a combination of both
or other types of intellectual or
developmental disabilities
and again these are not just a
one category of individuals we're
talking about
kids and we're talking about adults and
we're talking about older adults
and so the crisis services that
we're gonna be offering
have to be equipped to help this
population
and again this might include
making environmental
changes if we're talking
about having these individuals served
in crisis hubs that are bricks and
mortar or helping people who are
answering
phones for individuals with IDD
who may have articulation issues may
have hearing issues
you know proper services and
accommodations for those
individuals are going to be important
and then linkages to
other partners again
there's language distinctions um as we
you know if you're in the IDD world
there's a lot of different terminology
that's used that's not as
commonly used in the mental health
system we certainly see the crossover
into other systems
in forensics in criminal justice in
juvenile justice
and in child welfare and so the partners
are broad
the funding for services can be distinct
unless you're in one of those
few states like Michigan which has a
combined state agency for developmental
disability services and mental health
services in most states those agencies
have split off
and have a whole different way of
looking at funding services and
long-term supports
and so those organizational differences
can make
or break how crisis services are built
and again thinking about dealing with
that crisis as well as dealing with
the referral from the point of crisis to
the next stage
then we have the medically complex
individual
we've done a lot of work around making
sure that emergency departments aren't
going to be utilized for all comers
and only those who really need a medical
clearance that's at a hospital level of
care
need to go to the hospital but that
doesn't mean that you're not going to
see
medically complex individuals in
non-medically
built crisis services many states are
working on medical clearance guidelines
in their
you know through their emergency
departments to help define
some shared understanding between the
sending facility and the receiving
psychiatric unit
what does medical clearance actually
look like and what is
sufficient medical clearance because we
know that there's a lot of delays of
getting people into care related to you
know
was this lab test done was this uh blood
pressure checked enough was you know was
there sufficient medical clearance
and you can get into just long delays
based on disagreement about what does
sufficient medical clearance
mean so that's going to be an important
ongoing conversation
and again if people are going to be
using services that are outside of a
medical model of emergency departments
you also don't want to miss somebody
who's got a medically complex condition
who then needs to go to those emergency
departments so we are talking
about diverting people away
from emergency departments but I think
we also have to recognize
that some people will
need to be diverted
to emergency departments so just like
with all of the
you know the thinking about diversion is
we want to get
the right people in the right door at
the right time for the right reason
and so we don't want to just divorce
ourselves from emergency departments as
we build out crisis services
and then cut off our nose despite our
faith in terms of relationships
with those more intensive medical
services and so that's going to be
something that's going to require
the crisis systems to have as part of
the pathways that people go down
and relationships that are built of
course with COVID-19
which is our current infectious disease
sadly enough
we'll probably see others that will
come but we've learned
a lot from COVID-19 and
we've learned a lot about video capacity
we've learned a lot about crisis
services
and PPE utilization and need although I
would say there's
probably a lot more that needs to be
done again in non-medically
even in the best of medically trained
environments the user
proper use of PPE is really hard
to keep up with and of course now
with the PPE limitations
you know fit cloth masks and you know
are being used in ways that if we
weren't in this current situation
you know certainly when I trained in
medicine and when I moved into U of M
and I got my fit testing for my PPE
for my n95 mask
I mean what we're doing with mass
utilization now is very different than
what the
you know sort of the real infectious
disease specialist
taught years ago but even with the best
of medical care and services and the most
available, highest
protective n95 masks it's hard to use
it correctly
and so now we're asking in our crisis
services we're going to be asking our
our staff to use PPE in a way that's the
safest possible
and so kind of doing training for the
behavioral health population around PPE use
helping people understand testing and
what testing does and of course this is
such an evolving
area of conversation we're hearing about
a vaccine that Pfizer's just gotten a
contract to to push out a vaccine
we're going to have to understand what
that's going to look like through crisis
services because that will be the point
of the first point of contact for many
of these
populations and then of course
maintaining adequate staffing
even under COVID-19 conditions to manage
the crisis that people are seeing
now of course I can't give a talk
without talking about the criminal legal
involved and that is a really important part of
the crisis dialogue
what is this going to look like
going forward
if law enforcement is going to be
defunded and things shift to the behavioral
health crisis response
are we prepared for what that really
should look like there are
some incredible models of success
where more behavioral health response
the behavioral health response to a
crisis a mobile crisis
is more robust where the partnerships
and the policies with law enforcement
are really well laid out
you know CIT the mantra behind CIT
is that it is more than just a training
and it really does involve having drop
off
sites or drop off relationships where
where the law enforcement
might address an urgent situation but
then be able to turn the
you know through a warm handoff be able
to have the individuals crisis managed
by more appropriate behavioral health
specialists but there's
a lot of work that needs to be
done there's nationally
not every police department has the CIT
not every police department even is
appropriate
for CIT as it's designed because it's
really was designed for a volunteer
model of officers
20 percent of the workforce trained in CIT
now we see communities adopting the CIT
training
broadly but not necessarily with
the partnerships and with the policies
with the behavioral health system this
idea of co-response
also really important co-response can
mean
a couple of different things generally
speaking it can mean
having the police hire social workers or
some kind of behavioral health
specialist
to work within the police department and
ride in the squad car
or it can mean having a medicaid-funded
mobile crisis service that goes to the
theme together
or other funded services that
are allowed to
respond or designed to respond to a
behavioral health crisis
where they sort of share a radio and go
out to a scene
at the same time there is a lot of data
that shows that where behavioral health
comes to a scene
with law enforcement that you can reduce
the likelihood
of an arrest or criminal charges being
filed but are there enough behavioral
health clinicians to go around to
respond to all the crises
that police currently respond to even if we
say just the non-violent ones
do we have enough of a workforce to
really
be ready for a complete shift or do we
need to build this bridge
as we're walking on it
and you know then that involves
also making sure that our
partners again are thinking about these
broader populations like those with
substance use disorder
like those with intellectual and
developmental disabilities and all those
other populations that I mentioned
before and it really means that there's
got to be the crisis system has to
partner with law enforcement
the correctional system meaning the
jails and the prisons with juvenile
justice
with the courts themselves who are
issuing pickup orders
through commitments and as we see
states building out AOT
and you know somebody who's not adherent
creating the need for law enforcement to
go do a pickup order
in a non potentially non-crisis
situation but that
you know where those kind of things
might escalate um
also probation parole that might ask for
a revocation
you know these are things that we have
to look along the sequential intercept model
and really along the civil even the civil
commitment pathways to understand
where does a peace officer and a police
officer play a role in our community
and where do crisis services come into
play and so how do we think about these
alternative pathways
and then of course as we build the
system of crisis response
and we want to divert from justice
involvement
or criminal legal or juvenile legal
involvement
if you don't believe in the word justice
then what are we diverting
to what is the service that people will receive
as the next step and is the
service system prepared to receive those
individuals
and that requires I think us to really
examine our behavioral health system
I give a lot of talks about how do we
learn to love the population that we're starting
that we have to serve because
what we've seen is that
the criminal legal system really doesn't
embrace the mental health population
but the mental health service system
doesn't really embrace
the justice involved population
they might deal with them but it's
not a population
that's completely embraced or understood
or really looked at
as a general rule as a population
that may have a lot of issues that
kind of led them to
that individual to be just as involved
and I say that
coming from looking at things from the
forensic lens where there's a lot of
stigma attached to those labels
and so in conclusion I just want to sort
of bring this
point home about how do we look at
crisis services
to address diverse populations and
basically what we're going to need to do
is secure and leverage
varied funding and very broad
partnerships
well beyond what we've been doing
currently
and it involves partnerships across
numerous systems
not just the criminal legal system but
you know the immigration system the
housing system that you know a whole
host of other types of partners
the veteran system that many
states have already started to build but
a whole host of other partners
building systems a systems-based
approach
for early identification of youth at
risk and I think where Dr. Hoover talked
about prevention... 
prevention strategies really part of
that continuum
we're going to get from intercept 0 to
intercept minus 1 and  minus 2 as we really
look at prevention and that gets back to
what I talked about yesterday
which was the mental health as part of
public health
but also consider multiple medical
physical and psychiatric co-morbidities
in all population served and having our
crisis services be able to
think about those issues geriatric
populations must
must receive appropriate care and
coordination with older adult services
recommendation five enhanced cultural
capability
the awareness of historical trauma in
racial ethnic and experiential minority
populations
and the encouragement in our crisis
continuum
of staff being able to engage people in
their personal narrative
and listen with the from the perspective
of that individual
without immediately rushing to judgment
or using our own cultural standards
to assign diagnosis or to assign
an answer to what the individual's
issues are
foster a welcoming and supportive
environment for persons from
historically marginalized communities
that's going to be very key to serving
the anyone
and everyone recommendation six consider
mental health
and substance use stigma in communities
of color
while identifying and addressing
barriers to psychiatric care for
racially and ethnically oppressed persons
looking at developing knowledge about
immigration policies and promoting
the health of undocumented persons with
mental illness including addressing
their fears consider sexual and gender
identity as part of the biopsychosocial
assessment
in order to provide equitable treatment
for this diverse population
consider how clinical examinations could
include a broad assessment of
individuals' functional strengths
and limitations to provide
individualized and person-centered
treatment
consider how staff and physical
environments may provide
healing for persons with
intellectual and developmental
disabilities and again
utilizing a broader biopsychosocial
assessment perspective
collaborating with community
stakeholders to ensure early
interventions to
divert emergency department visits focus
on preventive care
and build alliances with other
stakeholders
re-examine all of our COOP planning and
ongoing needs with regards to crisis
services
related to COVID-19, PPE, testing, vaccines,
housing, and transitions in care supports
because this virus while it's here
really
doesn't you know we are needing to
identify those
those supports for individuals with
behavioral health concerns who do appear
in crisis services
where we're seeing barriers to next
steps
because of COVID-19 issues not getting
the PPE, not getting the testing, not
getting
the housing or transition and care
supports that are needed
and then really thinking about again our
crisis services
as part of a continuum of care partnered
with all
other aspects of the continuum to help
persons access the best
next door that's appropriate to their
level of need
so the crisis services you know that's
that's the boat to build to help people
navigate the waves
and I think we have a lot of work to do
in workforce development and policy
development
as well as funding and I'll leave you
with those thoughts about
how we can address the needs of these
the anyone and everyone who shows up in
the crisis continuum
thank you Deb uh that was excellent
great review
we have time for I think one or two
questions
one question that we have
is you mentioned boarding
and sometimes we know that nursing homes
drop individuals off at emergency rooms
and then refuse to take them back
and that's similar to what other
residential programs do with
whether it's IDD or mental health
what happens if we change
the location for that so that
now it's going to be a crisis program
how does the crisis program deal with
that type of an issue
well I mean I think this is where I think
some of the partnerships have to be
worked out every state has an older
adult services division I think this is
not just a behavioral health
problem I think it's something that's
going to require
at a state level those kind of partnerships
I think EMTALA comes into play
that we might need to leverage and
also on the ground memorandum of
understanding I think where you can
build trust if you have
you know one of the things that we
learned in discharging difficult
quote-unquote patients that were
difficult to manage in the hospital
to places like nursing homes or
was to kind of provide technical
assistance to them
and say you know we're not just
discharging and quote unquote dumping
we're actually transitioning this
person's care
and we will support your needs and I
think as you build trust
again not to be a Pollyanna because
it's much harder to do than to
and then I'm probably describing but
if that crisis hub becomes a really well-
respected place for the local service
you know so that they know that you know
we'll support you if you turn if this
person comes back to your system
and you're again finding yourself in crisis
then that may be a way to ensure that they
do bring people back into their care but
those are the barriers
that I mean have to
be dealt with kind of at the top through
the funding
through leveraging and then building in
relationships
and you know trying to
develop some some perhaps MOUs 
between systems
to continue to serve them
okay thank you very much and thank you
for an excellent presentation
why don't we take a break for a couple
of minutes and then start at two o'clock
with Dr. McCance-Katz thank you
thank you Deb
great yep thanks all
