WEBVTT 00:00:03.317 --> 00:00:06.720 Dr. Samantha Hack: I’m going to turn the Webinar over to our presenters. 00:00:06.720 --> 00:00:11.840 Dr. Dimitri Perivoliotis: Thank you so much. Thank you everybody for joining us today, 00:00:11.840 --> 00:00:17.920 we’re really pleased to be here with you all. Happy New Year – wishing you all a better year 00:00:17.920 --> 00:00:24.720 than last year. [laughter] I’m Dimitri Perivoliotis. Thank you for having us, we really look forward to 00:00:24.720 --> 00:00:32.800 our hour with you. So we’re talking today about getting recovery into the inpatient unit, 00:00:33.680 --> 00:00:37.520 inpatient mental health units of the VA. Just to give you a brief overview of the agenda, 00:00:37.520 --> 00:00:41.680 we’re going to start with, I’ll start us off with a overview of this transformation, 00:00:41.680 --> 00:00:47.280 what the research tells us. Talk a little bit about what a PRRC is and the roles of the 00:00:47.280 --> 00:00:52.320 PRRC’s in this transformation, and then we’ll move into the main crux of the talk which is 00:00:53.120 --> 00:00:58.400 the connection between training and trainees in inpatient units and recovering from inpatient on 00:00:58.400 --> 00:01:05.760 the unit. I’ll talk to you a little bit about the PSR fellowship and then my colleagues will take 00:01:05.760 --> 00:01:11.040 it over and describe the nuts and bolts of how we have integrated trainees onto out inpatient unit 00:01:11.040 --> 00:01:18.080 here in San Diego, how trainees are supervised for that purpose, and I’m very happy that we have, 00:01:19.360 --> 00:01:25.280 well actually, really, all three of my co-presenters are past PSR fellows, 00:01:25.280 --> 00:01:30.400 Dr. Tamara Rumburg is our most recent one, so I’m really happy that she’s here to talk about it from 00:01:30.400 --> 00:01:37.680 her perspective. And then reflecting on challenges that we’ve experienced in this process and lessons 00:01:37.680 --> 00:01:42.080 learned, and we hope to leave a good chunk of time at the end to answer your questions. So please, 00:01:42.080 --> 00:01:47.040 keep them coming and in the chat box and we’ll be keeping an eye on them and try to address all of 00:01:47.040 --> 00:01:54.240 them hopefully. So, um, let’s talk a little bit about the overview first about the VA’s inpatient 00:01:54.240 --> 00:01:58.960 recovery transformation. So, when you really look at that, I’m sure a lot of you are very familiar 00:01:58.960 --> 00:02:03.120 with this already, when you really look at the materials that have been released by the VA, I 00:02:03.120 --> 00:02:09.680 don’t think transformation is an exaggerated word. It really, it does, it really is a large effort 00:02:09.680 --> 00:02:15.760 that the VA has its sight's set on. Its outlined in multiple policy documents – I’ve pointed out a 00:02:15.760 --> 00:02:21.600 few of them here for you. If you aren’t familiar and you’d like to do a little bit more reading. 00:02:21.600 --> 00:02:25.600 And I have some quotes selected on the bottom there just to give you a little bit of a taste, 00:02:25.600 --> 00:02:32.400 if this is new for you, about just what the VA has in mind and to give you a sense of the magnitude 00:02:32.400 --> 00:02:39.760 of this transformation to inpatient mental health units. I just wanted to point out a few of these, 00:02:41.920 --> 00:02:46.240 uh, handbooks. At 1160.06, inpatient mental health services 00:02:46.960 --> 00:02:51.520 is a really good one if you’re looking to do this, or you’re involved with this kind of work because, 00:02:51.520 --> 00:02:56.160 you’ve probably seen it already, [laugh] but in case you haven’t, it really operationalizes really nicely 00:02:56.160 --> 00:03:02.000 what it means exactly to have a recovery-oriented inpatient unit, because a lot of times, you know, 00:03:02.000 --> 00:03:07.120 we look at it as a lofty aspirational goal, but this document really goes into some specific 00:03:07.120 --> 00:03:13.840 details about the components, like recovery plans and evidenced-based psychosocial rehab practices, 00:03:13.840 --> 00:03:19.680 and evidence-based psychotherapies and involvement with PRRC’s and so forth. So that’s a really 00:03:19.680 --> 00:03:30.080 good one. VHA directive 1163 is also great, particularly if you’re involved with a PRRC like 00:03:30.080 --> 00:03:36.240 we are because it talks about how PRRC’s and other psychosocial rehabilitation and recovery services 00:03:37.600 --> 00:03:43.920 should be run, and also, in relevance of our talk today, what they should be doing on the inpatient 00:03:43.920 --> 00:03:52.480 unit. That’s another good reason to review that document, 1163, is that it really nicely outlines 00:03:52.480 --> 00:04:00.560 how the VA sees and defines recovery and outlines the fourteen recovery domains that the VA has in 00:04:00.560 --> 00:04:07.360 mind, when they use the word recovery. And as you can see here, this is really treating the Veteran 00:04:07.360 --> 00:04:11.760 as a complete person. It’s very holistic care as you can see here, it’s not just 00:04:13.520 --> 00:04:18.400 optimizing psychiatric symptom management that third red box on the top, but it’s 00:04:18.400 --> 00:04:24.560 really everything else too from spirituality to overcoming stigma, optimism and hope and so forth. 00:04:25.120 --> 00:04:28.560 These are the things we have in mind when we talk about doing recovery. 00:04:30.320 --> 00:04:34.640 The mental health inpatient recovery services toolkit is also really useful, 00:04:34.640 --> 00:04:41.680 very practical tool that the VA developed to help sites implement recovery principals 00:04:41.680 --> 00:04:46.640 and practices on inpatient units, and it has things like a checklist where you can conduct 00:04:46.640 --> 00:04:52.000 a self-assessment of your site to see where your strengths and weaknesses are, and specific steps 00:04:52.960 --> 00:04:59.840 involved in implementing a recovery model of care on the inpatient unit. So that takes us to our 00:04:59.840 --> 00:05:05.120 first polling question. We have a series of four polling questions we will present to you today, 00:05:05.120 --> 00:05:10.400 just to get a sense of how things are going at your site. The first one here is “Do you feel, 00:05:10.400 --> 00:05:16.000 in your opinion, that the recovery model is sufficiently implemented on your inpatient unit?” 00:05:16.560 --> 00:05:22.480 And what do I mean by that? Um, you know, what I mean is, do you have psychosocial rehabilitation 00:05:22.480 --> 00:05:30.480 services, like vocational rehab, social skills training, um, illness management and recovery, 00:05:30.480 --> 00:05:35.360 these kinds of things. Are there evidenced based psychotherapies like cognitive behavior 00:05:35.360 --> 00:05:42.880 therapy? Are the Veterans asked about what they want their life to be [pause in dictation] be 00:05:42.880 --> 00:05:49.840 about beyond just their symptom relief? Is there talk of what their recovery goals are? 00:05:49.840 --> 00:05:53.120 Are their peers involved on the inpatient unit and so forth? 00:05:54.240 --> 00:05:58.720 So we’ll just give that a few seconds more. This is a really cool feature, I’ve never used before, 00:05:58.720 --> 00:06:05.040 I love this. Wow, I feel like I’m on TV [laughter] on a game show or something. So, all right, 00:06:05.040 --> 00:06:12.960 this is a very nice, thank you all for replying. This gives us a sense of where we are at. Um, I 00:06:12.960 --> 00:06:17.520 wonder how this compares to what your expectation was going in. This is actually a little bit, 00:06:17.520 --> 00:06:23.440 [inaudible; laughter] I’ll be honest, I’m very happy to see that more than half of the respondents feel like “yeah it is 00:06:23.440 --> 00:06:28.880 sufficiently implemented”, a little less than half say no, so obviously we have a ways to go so, 00:06:28.880 --> 00:06:36.880 but good to see though that it’s moving in that direction. So let’s get back on track here, 00:06:36.880 --> 00:06:43.760 all right, so what does the research tell us about this whole concept, you know, recovery is great, 00:06:43.760 --> 00:06:48.080 I think a lot of us believe in recovery, it sounds nice, getting on inpatient units, 00:06:48.080 --> 00:06:53.200 great, but what about the research? Well, the research, as you might not be surprised, 00:06:53.200 --> 00:06:58.320 first of all, it’s not a ton of it, there’s really a lot of room for growth in this area. 00:06:58.320 --> 00:07:04.480 I think this is relatively new, kind of focus of research, but what research we do have suggests 00:07:04.480 --> 00:07:10.880 that it is hard. It is easier said than done. There was a very nice 2016 review of studies 00:07:10.880 --> 00:07:16.880 where they found only eight studies looking at recovery implementation in inpatient psych units, 00:07:17.680 --> 00:07:24.960 and what they found was that the staff had varying definition and often times vague, 00:07:24.960 --> 00:07:30.000 sometimes even contradictory definitions of recovery. They described it in different 00:07:30.000 --> 00:07:34.640 ways. Many of them knew the general concept, but had a hard time articulating 00:07:35.360 --> 00:07:41.920 what it is and how to applies to their practice on the unit. A lot of them felt positive about it, 00:07:41.920 --> 00:07:48.560 but expressed difficulty applying their knowledge of recovery to everyday practice which, you know, 00:07:48.560 --> 00:07:56.320 to me was very validating because that’s exactly what we see in the real world. Um, now why should 00:07:56.320 --> 00:08:01.520 we have recovery? Other than it sounds great as far as the whole recovery movement in the United 00:08:01.520 --> 00:08:06.800 States, well, there’s actually some good research, not a ton, because there’s still a lot of work to 00:08:06.800 --> 00:08:12.480 be done in this area, but there are some very promising glimpses of the benefit that bringing 00:08:12.480 --> 00:08:20.720 recovery to inpatient units can have. For example, when recovery has been brought into the inpatient 00:08:20.720 --> 00:08:25.840 units in a number of studies, through a variety of ways that I won’t get into probably today, 00:08:27.280 --> 00:08:36.000 um, we have found things like reduced use of seclusion and restraint. Patients reported improved 00:08:36.000 --> 00:08:45.600 benefits to their recovery process and decreased re-hospitalization rate even in one study, and one 00:08:45.600 --> 00:08:54.000 study also found an increase in staff satisfaction and there was another study where they found that 00:08:54.000 --> 00:09:01.120 attitudes of the staff improved in terms of working with people in inpatient units. So 00:09:01.120 --> 00:09:08.800 some promising signs in the research that this is a good thing to do and actually leads to positive 00:09:08.800 --> 00:09:14.800 changes. So definitely, if any researchers are on the line this is a ripe area for more research. 00:09:15.840 --> 00:09:21.920 So, what about PRRC. So many of you on the call are probably well aware and familiar with PRRC’s, 00:09:22.880 --> 00:09:27.520 either psychosocial rehabilitation or recovery centers, with the program 00:09:27.520 --> 00:09:34.880 manager of our PRRC here in San Diego. Just to take a direct quote from VHA directive 1163, 00:09:34.880 --> 00:09:42.560 “PRRC’s are intensive outpatient specialty mental health transitional learning centers designed to 00:09:42.560 --> 00:09:48.000 support recovering integration into meaningful self-determined community roles for Veterans 00:09:48.000 --> 00:09:53.760 challenged with SMI and severe functional impairment.” There are a lot of key words 00:09:53.760 --> 00:10:00.960 in there, it’s a specialty mental health program really geared to specialize in Veterans with SMI. 00:10:00.960 --> 00:10:05.440 Ours in San Diego is a little unique in that we focus exclusively on psychotic disorders, 00:10:06.000 --> 00:10:11.920 but most PRRC’s are broader than that to include MDD, depression, bipolar disorder, 00:10:11.920 --> 00:10:18.560 PTSD and so forth, and we really target our care, our services to Veterans who are experiencing 00:10:18.560 --> 00:10:24.160 difficulties with their day-to-day lives, and it’s a very recovery-oriented holistic model of care. 00:10:25.360 --> 00:10:30.880 Why do we talk about PRRC’s on this call, well, they’re very specific directives from the VA about 00:10:30.880 --> 00:10:37.680 the role the PRRC’s should have on the inpatient units, specifically, we are mandated to offer, 00:10:38.880 --> 00:10:46.640 according to VHA directive 1163, PRRC Bridge Groups on inpatient units, and these are defined 00:10:46.640 --> 00:10:53.520 as psychoeducational outreach groups, and the purpose is to have a PRRC staff go to the unit 00:10:53.520 --> 00:10:58.720 and provide education about, not just the program, but about recovery in general and really kind of, 00:10:59.920 --> 00:11:03.600 you know jazz up the Veteran, help them, if they’re not already, to start thinking about 00:11:03.600 --> 00:11:09.760 what their recovery process and journey and goals might look like and how they can work toward that. 00:11:10.480 --> 00:11:17.040 And, another reason for their Bridge Group, is to facilitate referrals to the PRRCs. Hopefully 00:11:17.040 --> 00:11:21.600 get the Veterans excited about the program and also get the staff to be more aware of 00:11:21.600 --> 00:11:29.360 it so that they can refer once the Veteran is discharged from the inpatient unit. And also, 00:11:29.360 --> 00:11:36.480 another purpose of our groups is to teach about the principals and definition of recovery for the 00:11:38.480 --> 00:11:48.640 Vet. Go back to that slide here. All right, so here in San Diego ourPRRC is called the Center of Recovery Education or CORE, 00:11:49.200 --> 00:11:53.920 and we have a lot of, um, we go a little bit beyond the Bridge Group, and I want to give you 00:11:53.920 --> 00:11:58.160 a bit of a snapshot of that today. We’re going to spend most of the time talking about what 00:11:58.160 --> 00:12:03.280 are trainees do on the unit, but from a bigger picture, we do a few other things too. We provide 00:12:03.280 --> 00:12:10.080 clinical services, both to our trainees and staff. This mostly takes the shape of running therapy 00:12:10.080 --> 00:12:14.880 groups and psychosocial rehab groups, but also some assessment in psychotherapy. 00:12:16.320 --> 00:12:21.280 We try to facilitate referrals by, of course having the Bridge Group, but also bringing 00:12:21.280 --> 00:12:27.920 program brochures to the staff. We have a staff brochure and a Veteran brochure that 00:12:27.920 --> 00:12:33.600 are kind of written differently to describe the program. We have the fortune of having a 00:12:33.600 --> 00:12:39.200 vocational rehabilitation specialist embedded part-time in our PRRC, and she goes to the…, 00:12:40.240 --> 00:12:44.720 a lot of this by the way is pre-COVID. Right now we’re still struggling with getting 00:12:44.720 --> 00:12:47.840 services on the inpatient uses – I should make that disclaimer. [laugh] 00:12:48.640 --> 00:12:54.800 But when we were going to the unit, our voc rehab specialist would go there weekly and run a group 00:12:54.800 --> 00:13:01.600 to educate the Veterans about the benefits of work in terms of recovery, and also the voc rehab 00:13:01.600 --> 00:13:06.080 services including supportive employment that are available at the VA. And again, 00:13:06.080 --> 00:13:13.600 try to jazz them up to sign up for those services with the VA. And we have a lot of collaboration 00:13:13.600 --> 00:13:19.680 with multiple disciplines. We periodically will train the inpatient staff on a variety of things, 00:13:19.680 --> 00:13:25.040 like a Nurse's Education Day that we’re going to get into a little bit more in a minute. We also, 00:13:27.040 --> 00:13:32.400 um, in the past, have shared our peer support specialist would also run groups on the unit, 00:13:33.040 --> 00:13:39.920 and Dr. Gallegos Rodriguez who is on the call today, is our, is in the PRRC, but also 00:13:39.920 --> 00:13:44.640 serves as our local recovery coordinator and our director of peer support services, 00:13:44.640 --> 00:13:51.120 it’s really nice to have staff who are involved in multiple recovery focus programs like that. 00:13:54.160 --> 00:14:00.240 So that brings us to our next polling question, number two. I’m curious, we’re all curious to 00:14:00.240 --> 00:14:10.320 hear if all of you have a PRRC or some other recovery-oriented mental health service. For 00:14:10.320 --> 00:14:17.440 example, MHICM at your VA that specifically has trainees, just so that we can get a sense 00:14:17.440 --> 00:14:23.440 of how likely is it, you know, to get this kind of effort of having trainees from a recovery-oriented 00:14:23.440 --> 00:14:30.240 service onto the inpatient unit possible. Okay, this is, wow, this is amazing, so a vast majority 00:14:30.240 --> 00:14:36.880 do have such a service with trainees. That’s wonderful, that’s really, really great…let’s see 00:14:36.880 --> 00:14:45.680 82, hovering around 82% it looks like. Awesome. Thank you all. All right, going back to the slide… 00:14:54.400 --> 00:14:59.520 So I’m going to, uh, shift gears a little bit and start talking about training. So, why 00:14:59.520 --> 00:15:06.720 are trainees important? Many, many reasons. [laugh] First of all, the VA conducts the largest 00:15:06.720 --> 00:15:10.880 education and training efforts for health professionals in the United States, 00:15:11.600 --> 00:15:18.240 and it’s the largest trainer of psychologists in the county. However, obviously we don’t just 00:15:18.240 --> 00:15:24.720 train psychologists, we train social workers and psychiatry residents and so on and so forth, 00:15:25.440 --> 00:15:31.920 occupational therapy training, chaplain training, many, there’s a huge training presence in the VA. 00:15:32.720 --> 00:15:37.920 And, I’ve been involved in supervising and training trainees for a long time, 00:15:37.920 --> 00:15:45.520 and can tell you that a lot of them really come to us wanting inpatient experience. Some of them had 00:15:45.520 --> 00:15:50.720 a taste of it before they got to us and want more, others realize there’s a gap in the training. They 00:15:50.720 --> 00:15:56.560 really want this and the VA is a really great place to be able to deliver that, fill that 00:15:56.560 --> 00:16:01.840 training need for our trainees. And, the other thing to keep in mind in terms of psychology, 00:16:01.840 --> 00:16:06.160 is that as many of your have probably heard, last year our Serious Mental Illness was finally, uh, 00:16:09.360 --> 00:16:14.080 determined to be, or, accepted as an official, or designated I should say, as an official 00:16:14.720 --> 00:16:22.160 specialty of psychology. Believe it or not, it had never been. So what that means is, is I think it’s 00:16:22.160 --> 00:16:28.880 a watershed moment for the field, um, what that means is that um, the APA now recognizes that hey, 00:16:28.880 --> 00:16:34.320 this is a special kind of branch of psychology, requiring specialized skills, and specialized 00:16:34.320 --> 00:16:38.480 training that people don’t particularly get in a clinical psychology graduate program. 00:16:39.120 --> 00:16:42.880 And we’re gonna be seeing a lot of benefits coming out of this. First of all, 00:16:42.880 --> 00:16:46.960 bringing attention to Serious Mental Illness. It’s going to really, I think, 00:16:46.960 --> 00:16:51.920 improve the rigor and standardization of training for people in Serious Mental Illness, 00:16:51.920 --> 00:16:56.880 and I think alternately, we hope, it will lead to better treatment and better outcome 00:16:56.880 --> 00:17:03.520 for people with Serious Mental Illness. So, having inpatient training available 00:17:03.520 --> 00:17:11.120 is very attractive to trainees, and is also going to be of a direct relevance, particularly to 00:17:11.120 --> 00:17:15.280 psychologists who eventually want to be board certification in Serious Mental Illness. 00:17:17.360 --> 00:17:22.320 So, one example of training in Serious Mental Illness in the VA is the PSR Fellowship. So 00:17:22.320 --> 00:17:27.440 that’s the name of the fellowship on the top, it’s very long. We just call it the PSR Fellowship for 00:17:27.440 --> 00:17:31.520 short. The purpose of the fellowship is right there – really it’s to develop future mental 00:17:31.520 --> 00:17:38.160 health leaders, um, who will transform mental health care systems by emphasizing functional 00:17:38.160 --> 00:17:43.920 capability and rehabilitation and recovery, where I really like that mission, really our training 00:17:43.920 --> 00:17:48.960 future leaders, and Dr. Ehret, Dr. Gallegos Rodriguez and Dr. Rumburg, who are co-presenting 00:17:48.960 --> 00:17:54.800 with me today, I think are wonderful examples of that, and are former PSR fellows themselves. So 00:17:54.800 --> 00:18:02.480 really quickly, before I turn it over to them, the PSR Fellowship is run through the VISN 5 MIRECC, 00:18:03.520 --> 00:18:07.920 Uh, Dr. Richard Goldberg is the director, Ralf Schneider is our amazing coordinator who 00:18:07.920 --> 00:18:14.880 was probably on the call today, has six sites across the country, and we recently submitted 00:18:14.880 --> 00:18:20.080 some applications to get I think one or two more – I forget if it’s one or two. [laugh] 00:18:20.880 --> 00:18:28.160 So we’re going to be expanding by at least one more and it’s an interdisciplinary fellowship. So, 00:18:28.160 --> 00:18:34.880 we accept trainees from a lot of those disciplines that I mentioned previously. Here in San Diego we 00:18:34.880 --> 00:18:42.160 accept psychology, typically social work and voc rehab, but also some sites accept OOT, Chaplaincy, 00:18:43.520 --> 00:18:53.120 nursing, psychiatry residents and the idea here is that the, and we’re also, by the way, in our 00:18:53.120 --> 00:18:57.920 thirteenth year of training here in San Diego, we’ve trained fellow, sorry, fifteen fellows from 00:18:57.920 --> 00:19:04.800 six different disciplines, and the idea here is that the trainees train at sites, VA sites, 00:19:04.800 --> 00:19:10.640 that are involved in proving PSR, psych social rehab for Veterans with Serious Mental Illness. 00:19:12.000 --> 00:19:18.880 Um, so here in San Diego the PSR Fellowship is one of five mental health training programs that 00:19:18.880 --> 00:19:25.040 have trainees that our PRRC. We also have interns, practicum students, psychiatry residents, chaplain 00:19:25.040 --> 00:19:30.720 fellows – it’s a very rich training environment. The way we do it here in San Diego is that our 00:19:30.720 --> 00:19:37.920 fellows train primarily at the PRRC and each do a mini rotation at the inpatient unit about a 00:19:37.920 --> 00:19:43.840 day per week, although they often say that they would like more. [laugh] And their training is organized 00:19:43.840 --> 00:19:48.800 with the training plan, and a training plan is basically a living document that we create at the 00:19:48.800 --> 00:19:54.000 beginning of the training year, that outlines what they want to accomplish, what are our requirements 00:19:54.000 --> 00:20:00.880 for them to accomplish and um, and that includes what exactly they would like to do on the 00:20:00.880 --> 00:20:06.320 inpatient unit. And it helps to keep everyone on the same page so that expectations on both sides 00:20:06.320 --> 00:20:12.480 are clear. And I have to tell you, um, I’m not exaggerating when I say that universally, when 00:20:12.480 --> 00:20:16.960 I ask the fellows at the middle and at the end of the year when I check in with them formally, what 00:20:16.960 --> 00:20:24.000 do you think about the inpatient experience? I am literally always, they say, it was amazing. I’ve 00:20:24.000 --> 00:20:29.600 never seen such universal praise for any aspect of a training program before. [laugh] They say they really 00:20:29.600 --> 00:20:33.920 enjoyed it, it was a nice change of pace from the outpatient unit, and it was really important 00:20:33.920 --> 00:20:39.680 skills, they felt like a leader, and so forth. I won’t say more. I’ll allow Dr. Rumburg to tell you 00:20:39.680 --> 00:20:49.360 her experience directly So I’m going to hand it off now to Drs. Ehret and Gallegos Rodriguez, and 00:20:49.360 --> 00:20:56.160 Dr. Rumburg for the next piece, which is getting into more details about how exactly our trainees 00:20:56.160 --> 00:21:01.760 have been integrated into the inpatient unit. Dr. Blaire Ehret: Thank so much Dr. Perivoliotis 00:21:01.760 --> 00:21:08.160 for that incredible overview. Um, this is Dr. Ehret, um, I would love the opportunity to meet 00:21:08.160 --> 00:21:13.520 each and everyone of you, but we’ll have to do it virtually for now. I wanted to take us into 00:21:14.400 --> 00:21:20.560 focusing on, you know, really looking at what we have done at the San Diego VA. Uh, to give you all an 00:21:20.560 --> 00:21:26.720 example of just how we’ve integrated our trainees onto our inpatient unit. And, this is a little 00:21:26.720 --> 00:21:32.880 bit of an overview here that kind of outlines the different aspects that our trainees are involved 00:21:32.880 --> 00:21:38.400 with, and I’ll speak as well to the importance of having a consistent staff liaison to kind 00:21:38.400 --> 00:21:44.880 of facilitate the transition from trainees as they move through their rotations. But I wanted to just 00:21:44.880 --> 00:21:53.360 touch briefly, um, you know, the inpatient trainee integration took place far before I joined the 00:21:54.480 --> 00:21:59.840 program as a trainee and as a staff member, but in terms of kind of understanding how 00:22:00.400 --> 00:22:06.880 things got started, we took a look at the connection between the PRRC and the inpatient 00:22:06.880 --> 00:22:13.200 leadership. So there was a lot of collaboration in terms of understanding how our trainees could fill 00:22:13.200 --> 00:22:18.320 a need for recovery-oriented services on the inpatient unit, as well as how the inpatient 00:22:18.320 --> 00:22:24.480 unit could provide a rich and comprehensive experience for our trainees. So, there was 00:22:24.480 --> 00:22:32.560 really, um, a nice synergy I think between leadership and other PRRC stakeholders, and we were able to 00:22:32.560 --> 00:22:39.840 successfully develop a program in which integrates our PRRC trainees onto the inpatient unit as 00:22:40.560 --> 00:22:46.800 Dr. Perivoliotis mentioned. One thing that I think has been a really important aspect to 00:22:46.800 --> 00:22:53.760 not just the development, but also the maintenance and strengthening of having trainees on the unit, 00:22:53.760 --> 00:23:00.960 is having a consistent staff member of the PRRC serve as a liaison to the inpatient unit. 00:23:02.000 --> 00:23:08.640 Um, I currently serve in that position, but prior to myself one of our PRRC’s social workers, 00:23:08.640 --> 00:23:14.240 Eric Eichler was the liaison and what’s really nice about that is that that’s a consistent 00:23:14.240 --> 00:23:21.360 individual for the inpatient unit to create a relationship with, and they help to really just 00:23:21.360 --> 00:23:25.840 kind of bridge the transition between the fellows as they move through their different rotations, 00:23:25.840 --> 00:23:30.960 and so some of those responsibilities really include um, continuing to attend monthly 00:23:30.960 --> 00:23:37.440 inter-disciplinary team meetings, um, and just being available to develop different types of 00:23:38.000 --> 00:23:43.280 SOPs related to the process, meeting with the different inpatient staff as needed, and just 00:23:43.280 --> 00:23:50.160 overall being a facilitator. So, on this slide you’ll see that our fellows, not just our PSR 00:23:50.160 --> 00:23:55.680 fellows, but other trainees that we have in our PRRC are pretty active on our inpatient unit. So, 00:23:55.680 --> 00:24:02.400 as Dr. Perivoliotis mentioned, we typically will have four psychosocial rehabilitation fellows, 00:24:03.200 --> 00:24:09.280 which they will each do three months on the inpatient unit, um, and there will be a little bit 00:24:09.280 --> 00:24:14.080 of an overlap to help with the transition between the fellows, but not more than just a week or so. 00:24:15.120 --> 00:24:20.720 We have other trainees in our program outside of the PSR fellowship. We have often several 00:24:20.720 --> 00:24:26.000 psychology trainees – these can include interns and practicum students, as well as social work 00:24:26.000 --> 00:24:33.040 interns. And we also include peer support specialists. So, we have a wonderful peer on 00:24:33.040 --> 00:24:38.400 our unit, as well as we currently have a vacancy in our program for a peer support specialist, but 00:24:39.040 --> 00:24:45.040 when that position has been filled in the past, that individual has been a really important part 00:24:45.040 --> 00:24:51.520 of providing PRRC services in collaboration with our trainees and our staff on the unit. In terms 00:24:51.520 --> 00:24:55.920 of supervision, and we’ll talk a little bit more about this in a couple slides, but really, 00:24:55.920 --> 00:25:02.160 there’s a strong coordination between the PRRC supervisors as well as the unit supervisors. We 00:25:02.160 --> 00:25:07.840 are very fortunate to have a phenomenal clinical psychologist who is full-time on our inpatient 00:25:07.840 --> 00:25:14.240 unit, and that was a recent transition. Previously we had a wonderful part-time psychologist. 00:25:14.240 --> 00:25:19.280 But really connecting and collaborating with the supervisors that are on the unit that can provide 00:25:19.280 --> 00:25:25.760 those in the moment supervision opportunities is a really huge asset and I think one of the 00:25:25.760 --> 00:25:30.000 things that has made our integration of trainees on our unit really successful. 00:25:31.280 --> 00:25:39.520 As I mentioned when I talked about staff member liaison, um, we also really include our trainees onto 00:25:39.520 --> 00:25:47.200 the team the unit team, which I think is another really important element. Um, so our trainees are 00:25:47.200 --> 00:25:53.120 to, they attend morning psychiatry rounds and nursing rounds, as well as the inter-disciplinary 00:25:53.120 --> 00:25:57.280 treatment team meetings that take place throughout the year. They take, you know, 00:25:57.280 --> 00:26:01.760 they attend the rounds that they are able to attend on their respective days of their rotation. 00:26:01.760 --> 00:26:06.640 They’re not expected to attend every single day, but really just kind of when they’re expected to 00:26:06.640 --> 00:26:12.240 be on the unit. And then in terms of clinical duties, um, many of our fellows have a wide 00:26:12.240 --> 00:26:17.600 range of clinical activities that they participate in. Of course they facilitate groups. Often they 00:26:17.600 --> 00:26:24.080 will conduct intakes for the PRRCs, so if we get a referral from the unit for a Veteran to be seen 00:26:24.880 --> 00:26:32.080 by the PRRC, the intern or the fellow will complete an intake assessment on the unit. From 00:26:32.080 --> 00:26:38.160 time to time, there are psychological assessments cases that can really help with the trainee’s 00:26:39.440 --> 00:26:44.160 training plan that might fit a few assessment goals that they have, but also really help out the 00:26:44.160 --> 00:26:50.000 inpatient staff by completing a few psychological assessments. Individual therapy as well takes 00:26:50.000 --> 00:26:54.800 place. And another piece that I’ll mention is that, you know, often times we will have folks 00:26:55.360 --> 00:27:04.080 who are in the PRRC who go on to the inpatient unit and it is a really, I think, a wonderful way 00:27:04.080 --> 00:27:10.160 to bridge care when that Veteran’s recovery coach can go and visit them on the unit, and maybe even, 00:27:10.880 --> 00:27:16.960 you know, work on the recovery plan together and giving them a sense that, um, they have a plan for when 00:27:16.960 --> 00:27:22.160 they leave the unit and that, you know, they’re still very much a part of the PRRC. And then 00:27:22.160 --> 00:27:27.520 lastly, for folks who are familiar with vertical supervision, this is a really great opportunity 00:27:27.520 --> 00:27:34.080 for trainees, but also for staff as well. Um, and this gives mainly our PSR fellows an opportunity 00:27:34.080 --> 00:27:40.880 to provide some junior supervision of some of their junior training colleagues. And so, for 00:27:40.880 --> 00:27:48.240 example, we may have a fellow, um, who provides some vertical supervision of a practicum student, maybe 00:27:48.240 --> 00:27:52.960 as they facilitate one of the inpatient groups together, and it’s just another great opportunity 00:27:53.760 --> 00:28:01.920 for training. So in terms of um, you know, just kind of to bring what our trainees have contributed to 00:28:01.920 --> 00:28:08.720 life a little bit, these are a few just absolutely beautiful examples of the ways in which our 00:28:08.720 --> 00:28:14.160 trainees have integrated onto our unit, but also really been able to make meaningful contributions 00:28:14.160 --> 00:28:19.440 above and beyond kind of what we lay out in terms of the expectations for their rotations. 00:28:20.240 --> 00:28:25.520 So many of these projects are things that were, that trainees collaborated with one another, 00:28:25.520 --> 00:28:30.160 or they may have collaborated with inpatient staff, or even PRRC staff or 00:28:30.160 --> 00:28:37.680 all of the above. Um, so, for example, development of a recovery plan, a recovery workbook, which 00:28:37.680 --> 00:28:43.840 I will talk about a little bit more in detail for the inpatient, bridge to recovery group, 00:28:45.120 --> 00:28:50.880 as well as an Act group that we’ve developed. Um, again, I’ll speak to that a little bit more 00:28:50.880 --> 00:28:58.080 specifically in a couple of slides. Social skills training is a phenomenal opportunity to integrate 00:28:58.080 --> 00:29:06.320 onto the unit, and many of our trainees will facilitate those groups, and in addition to that, 00:29:06.320 --> 00:29:11.840 I’ll just highlight a couple of other areas here. Firstly, in services, are really remarkable 00:29:13.040 --> 00:29:18.400 contributions our trainees make. So, to give you some examples, um, when I was a fellow, 00:29:19.200 --> 00:29:27.600 I had a really cool opportunity to present to the psychiatry residents and the medical students 00:29:28.240 --> 00:29:34.000 on recovery-oriented care for persons with Serious Mental Illness, and it was a great 00:29:34.000 --> 00:29:38.880 opportunity not just to get to meet some of my medical colleagues, but also to have the 00:29:38.880 --> 00:29:44.240 opportunity to learn some skills of presenting to a discipline other than folks in psychology, 00:29:44.240 --> 00:29:49.840 as well as to start to spread some recovery knowledge to, um, individuals who are interacting on 00:29:49.840 --> 00:29:56.480 a daily basis with patients with Serious Mental Illness. In addition to that, our Nurse's Skills 00:29:56.480 --> 00:30:01.120 Group Day is something that started in the last couple of years, and, um, basically how this was 00:30:01.120 --> 00:30:08.480 developed was our nurse coordinator on the unit approached myself and a few of the trainees and said 00:30:08.480 --> 00:30:13.520 “We would really love to help our nurses become better at delivering some of our recovery-oriented 00:30:13.520 --> 00:30:19.920 groups”. And so now, several times a year, we put on a Nurse's Group Skills Day, where the 00:30:19.920 --> 00:30:27.520 trainees will assist in basically going through and training folks, nurses, specifically on how to 00:30:28.080 --> 00:30:32.160 be involved and help us deliver our recovery-oriented services. And it’s just, 00:30:32.160 --> 00:30:37.840 again, another opportunity to really get to know the unit staff, to integrate and, 00:30:37.840 --> 00:30:44.960 again, to really connect over recovery-oriented services. I’ll go briefly through this really, 00:30:44.960 --> 00:30:50.320 let’s see if I can get my pointer out, this like really pretty um, card here that says SHINE. 00:30:50.320 --> 00:30:56.480 This is actually developed by, um, I want to point it here, this one over here, not this one, 00:30:56.480 --> 00:31:01.920 sorry, whoa… never mind, I’m not going to use that. [laugh] Um, this really pretty card over here, 00:31:01.920 --> 00:31:08.640 was actually designed and created by a Veteran and um, I created a PRRC group called Caring Cards 00:31:08.640 --> 00:31:14.240 when I was a fellow as part of my dissemination project. And, long story short, in conversations 00:31:14.240 --> 00:31:19.600 with our occupational therapists, we decided that this could be a really great art-based 00:31:19.600 --> 00:31:24.560 activity for Veterans on the unit to actually get involved in and so, um, in coordination 00:31:24.560 --> 00:31:31.520 with them and we effectively launched a group that we had in our PRRC’s over with the OT’s 00:31:31.520 --> 00:31:37.280 facilitating, and it’s been really successful, particularly as part of weekend art-based care, 00:31:37.840 --> 00:31:43.040 and the Veterans really enjoy the opportunity to create these cards and then these cards are 00:31:43.040 --> 00:31:48.240 actually then sent to other Veterans who may be in need of some additional support in the system. 00:31:50.080 --> 00:31:55.360 Okay, so I’m gonna turn things over my colleague Dr. Gallegos Rodriguez, 00:31:55.360 --> 00:31:59.040 to go through this next slide. Dr. Yuliana Gallegos Rodriguez: 00:31:59.040 --> 00:32:03.680 Thanks you so much Dr. Ehret and Dr. Perivoliotis for your warm introduction. 00:32:04.720 --> 00:32:09.520 So I just wanted to speak about the treatment and recovery plan we have – this is kind of 00:32:09.520 --> 00:32:16.160 like a sample we have going on, and this example, um, is actually from a dissemination project from a 00:32:16.160 --> 00:32:23.280 social work fellow who eventually became staff at our PRRC, Mr. Eric Eichler. Um, in this treatment, 00:32:23.280 --> 00:32:31.040 or recovery plan, has now evolved to be used with individual in our inpatient unit, but it also has 00:32:31.040 --> 00:32:37.280 been incorporated into the unit’s treatment plan. So pieces of it have also been incorporated 00:32:37.280 --> 00:32:44.320 into the recovery workbook that we use in groups, which also another psychology fellow, Dr. 00:32:44.320 --> 00:32:50.880 Francesca Bond created while she was working with our current unit psychologist, Dr. Andrew Bismark. 00:32:51.440 --> 00:32:56.000 So, I particularly like this recovery plan because it has examples on the bottom of the 00:32:56.000 --> 00:33:02.160 prompt to guide Veterans with the type of goals they can focus on, and then eventually, 00:33:02.160 --> 00:33:08.160 obviously it breaks it down from the big picture to a smaller shorter-term goal and then further, 00:33:08.160 --> 00:33:15.600 you know, you see 1, 2, 3, so we can break it down further into steps and barriers that can um, that 00:33:15.600 --> 00:33:23.360 can come up during, um, pursuing the recovery goals. Dr. Blaire Ehret: 00:33:23.360 --> 00:33:29.760 Great. Thank you. Um, so, I had mentioned earlier when I was discussing some of the different 00:33:30.400 --> 00:33:34.000 uh, contributions that our trainees have made, that there is a recovery resource 00:33:34.000 --> 00:33:39.680 book that was developed in collaboration with one of our recent PSR fellows, Dr. Francesca Bond, 00:33:40.240 --> 00:33:46.960 and our inpatient psychologist, Dr. Andrew Bismark, and this recovery workbook is absolutely 00:33:46.960 --> 00:33:52.480 stunning. I believe that we do have this available in the files for download. If you would like to 00:33:52.480 --> 00:33:58.000 take a look, it’s titled Recovery Workbook, Final. And basically the development of this workbook 00:33:58.720 --> 00:34:04.800 was created out of a need that was being noticed by our PSR fellow, Dr. Bond, that a lot of the 00:34:04.800 --> 00:34:10.880 folks on the inpatient unit had a lot of downtime, kind of in-between their groups or on the weekends 00:34:10.880 --> 00:34:17.760 or if a group happened to be canceled for whatever reason, in addition, there might be a few Veterans 00:34:17.760 --> 00:34:22.880 who may struggle to be appropriate in groups – whether they’re, you know, getting settled on the 00:34:22.880 --> 00:34:27.520 unit, or they’ve gone through a recent medication change and it’s just made it difficult for them 00:34:27.520 --> 00:34:34.480 to sit in a room and, um, participate in a group. Dr. Bond wanted to develop something that was really 00:34:34.480 --> 00:34:40.560 an opportunity for Veterans to be able to start to do some of the recovery-oriented and skill safe 00:34:40.560 --> 00:34:46.560 learning work on their own during these downtime periods, as well as for folks who may not be able 00:34:46.560 --> 00:34:53.680 to access groups as effectively as some of the other unit members. And so this workbook is really 00:34:54.320 --> 00:34:59.440 phenomenal, and just walks through a lot of different types of skills-based learning and 00:34:59.440 --> 00:35:03.544 recovery-oriented, um, components, and has been [inaudible-recording skips] 00:35:03.544 --> 00:35:04.044 recording may have skipped as speaker 3 stops abruptly and speaker 4 begins speaking] 00:35:04.044 --> 00:35:09.280 Dr. Yuliana Gallegos Rodriguez: …. And as mentioned, according to VHA directive 1163, 00:35:09.280 --> 00:35:15.040 the PRRCs are required to provide Bridge Groups in inpatient mental health units. So here we begin 00:35:15.040 --> 00:35:20.800 helping our inpatient Veterans focus on personal life and their recovery goals, and we point out 00:35:20.800 --> 00:35:25.840 alternative definitions of what recovery means, but also beginning feeling hope and empowerment 00:35:28.400 --> 00:35:33.360 empowering them to think about their goals and their sense of purpose. So it’s a reminder that 00:35:33.360 --> 00:35:40.880 VHA directive focuses on psycho ed outreach, providing a new patient about PRRC and recovery, 00:35:41.680 --> 00:35:46.960 assist with transition to PRRC or other recovery-oriented services, 00:35:46.960 --> 00:35:52.160 and the definition and principles of recovery such as goal setting, strengths and barriers, 00:35:52.160 --> 00:35:55.840 hope, intro to community integration or inclusion 00:35:55.840 --> 00:36:02.240 and introduction to peer support. Dr. Blaire Ehret: 00:36:02.240 --> 00:36:08.560 Thank you. And another beautiful example of our trainees outstanding contributions 00:36:08.560 --> 00:36:16.640 to our inpatient services is and an Act group that was developed by, now Dr. Montague – at 00:36:16.640 --> 00:36:24.000 the time she was our psychology intern, and in collaboration with other PRRC trainees and staff, 00:36:24.880 --> 00:36:31.920 um, Dr. Montague developed what covers eight main topics of acceptance and commitment therapy, 00:36:31.920 --> 00:36:35.920 and it’s covered across sixteen unique sessions. She was really clever in the 00:36:35.920 --> 00:36:42.080 way that she developed this, such that each topic had two unique sessions that focused on the values, 00:36:42.880 --> 00:36:48.240 um, and committed action and diffusion and different variables of Act. She did this purposely because 00:36:48.240 --> 00:36:53.600 she noticed that several Veterans, although several may move through the unit quickly, 00:36:53.600 --> 00:36:59.280 there are several others who stay on the unit for a while and/or, um, come back to the unit, and so she 00:36:59.280 --> 00:37:03.600 wanted to make sure that we had enough material to keep things fresh for folks who might have already 00:37:03.600 --> 00:37:08.800 been in the Act group and might have already received that particular session. Um, again, this is 00:37:08.800 --> 00:37:15.120 something that I would be more than happy to share with folks, um, if people are interested in that, but 00:37:15.120 --> 00:37:23.200 it’s a really fantastic group, and really, uh, geared towards really the inpatient audience as well. 00:37:26.400 --> 00:37:31.680 So I mentioned a little bit earlier, um that I talked a little bit about supervision approach, 00:37:31.680 --> 00:37:36.240 because this can be often a little bit of a difficult thing to coordinate and 00:37:36.240 --> 00:37:41.760 over the years we have developed some pretty great procedures, I would say. Um, and I’m 00:37:41.760 --> 00:37:45.440 also happy that it’s not in files, I just feel like I wanna give you guys everything but, um, 00:37:46.240 --> 00:37:53.520 [laugh] I’m also happy to share our SOP, which is also kind of a living document the trainees developed 00:37:53.520 --> 00:37:58.640 and they refined kind of as the year goes on. But in the SOP, 00:37:58.640 --> 00:38:02.800 there are really clear outlines in terms of how this supervision is going to work 00:38:02.800 --> 00:38:07.120 for folks so there isn’t really kind of a second guessing of whose supervising beyond this case. 00:38:07.760 --> 00:38:12.320 So, of course I mentioned we’re incredibly fortunate that we have a full-time inpatient 00:38:12.320 --> 00:38:18.880 psychologist who absolutely loves training and has been phenomenal to work with. So a lot of the unit 00:38:18.880 --> 00:38:25.280 specific care is supervised by Dr. Bismark, which is, you know, he’s outside of the PRRC; 00:38:25.920 --> 00:38:31.520 however, when it comes to interactions with Veterans who are already a part of the PRRC 00:38:31.520 --> 00:38:35.760 and they happen to be returning to the inpatient unit or being admitted for the first time, 00:38:36.720 --> 00:38:42.400 that supervision would then be provided by the trainee’s PRRC primary or secondary supervisor, 00:38:42.400 --> 00:38:47.680 depending on whoever caseload that individual falls under when they are not on the inpatient 00:38:47.680 --> 00:38:57.520 unit. Um, we do break up the supervision of CBT for psychosis, Dr. Perivoliotis runs a fantastic 00:38:58.400 --> 00:39:03.040 peer consultation group that takes place every two weeks are part of our PSR 00:39:03.040 --> 00:39:08.160 seminars following out inter-disciplinary team meeting. So CBT for psychosis cases 00:39:08.160 --> 00:39:13.920 that take place on the inpatient unit will be provided with some peer consultation by Dr. P. 00:39:15.120 --> 00:39:20.320 In addition the vertical supervision piece to the junior trainees that I mentioned and to peers, 00:39:20.320 --> 00:39:27.120 that, in terms of who kind of supervises the supervision of that, um, will be in collaboration 00:39:27.120 --> 00:39:32.720 and determined based off of what makes the most sense. So, for example, Dr. Bismark currently 00:39:32.720 --> 00:39:39.040 supervises our Peer on the unit, and if a trainee is looking to get some supervision experience of 00:39:39.040 --> 00:39:44.720 the peer, it would make more sense for Dr. Bismark to supervise the supervision of the peer. Whereas, 00:39:44.720 --> 00:39:50.320 for example, if there was another trainee, let's say, a psychology practicum student that say Dr. 00:39:50.320 --> 00:39:55.680 Gallegos was supervising, it would make most sense for the fellow to supervise the peer, excuse me, 00:39:55.680 --> 00:39:59.920 to supervise the practicum student and have Dr. Gallegos supervise the supervision of that. So 00:39:59.920 --> 00:40:07.360 we kind of were flexible in terms of what makes the most sense for supervision as well. Um, and then 00:40:07.360 --> 00:40:12.480 supervision of groups, we’ve pretty much just kind of split it down the middle – so actually I 00:40:12.480 --> 00:40:19.360 supervise the Act group and Dr. Gallegos Rodriguez supervises our bridging and social skills groups 00:40:19.360 --> 00:40:26.160 as well. Um, we have recently in years added a third group, a CBT group that is supervised by our unit 00:40:26.160 --> 00:40:32.640 psychologist, Dr. Bismark. So, we kind of break things up accordingly to give everybody a diverse 00:40:32.640 --> 00:40:38.320 experience of supervision, but also to, you know, in real life, give the supervisors a little bit of 00:40:38.320 --> 00:40:45.120 a break as well, because supervision is hard, it’s um, part of your, you know, daily caseload, so, 00:40:45.120 --> 00:40:51.120 important to balance that out. So, I would love to turn things over to Dr. Rumburg, 00:40:51.120 --> 00:40:56.640 who, as Dr. P. mentioned um, was a, our most recent former PSR fellow, 00:40:56.640 --> 00:41:00.880 to share a little bit about her perspective. Dr. Tamara Rumburg: 00:41:00.880 --> 00:41:05.840 Thank you Dr. Ehret. Can everyone hear me okay? Dr. Blaire Ehret: Yes. 00:41:05.840 --> 00:41:10.560 Dr. Tamara Rumburg: Okay perfect. Thank you. All right, well thank you for my team 00:41:10.560 --> 00:41:15.440 for providing such great introductions to the PSR Fellowship so far and just a great overview 00:41:15.440 --> 00:41:20.480 of what trainees do on the unit. So I’m gonna share a little bit about my experience. I think 00:41:20.480 --> 00:41:24.720 the opportunity to train on the inpatient unit is such a rich learning experience. 00:41:25.520 --> 00:41:29.600 Um, so, particularly first with clinical training of course. Um, you heard a little bit about the 00:41:29.600 --> 00:41:34.080 groups that we facilitate, the Bridge to Recovery Group and the Act group are like the main ones 00:41:34.640 --> 00:41:40.240 that I facilitated when I was on the unit. We do sometimes do social skills training, um, on the 00:41:40.240 --> 00:41:46.080 unit as well, which of course was, um, ceased due to the pandemic, but hopefully that will be back on, too, 00:41:47.600 --> 00:41:55.040 soon. Um, so I think those were great opportunities. Also, delivering individual therapy. So I actually 00:41:55.040 --> 00:42:01.440 set up kind of an agreement that like every Tuesday, which was our inpatient day, I would 00:42:01.440 --> 00:42:06.640 see one person on the inpatient unit prior to running group. Um, and often times that 00:42:06.640 --> 00:42:11.360 was CBT for psychosis, sometimes it was focused on different referral questions, 00:42:11.360 --> 00:42:17.920 but it was such a great opportunity to integrate, kind of, individual therapy focused on brief intervention. 00:42:19.200 --> 00:42:25.600 Of course leadership and program development. You all saw some of the groups that some of our PSR 00:42:25.600 --> 00:42:30.240 fellows have developed in the past, as well as other clinical material. So, often times 00:42:30.800 --> 00:42:36.960 we were given the opportunity to like chose what group we were going to run, um, and really focus 00:42:36.960 --> 00:42:42.320 the interventions on the type of people we have in the unit at the time, um, you know, 00:42:42.320 --> 00:42:46.080 being able to attend rounds in the morning was a great opportunity to get the know the patients 00:42:46.080 --> 00:42:50.400 that were on the unit and what kinds of things they were coming in with so we could really tailor 00:42:50.400 --> 00:42:57.040 the group content to meet their needs, which was a really awesome opportunity. Attending those 00:42:57.040 --> 00:43:02.320 morning rounds with psychiatry and nursing staff was a great opportunity to get to know the team as 00:43:02.320 --> 00:43:07.840 well and the unit and everything that was going on because we were only on one day a week. So, 00:43:07.840 --> 00:43:12.400 going for those morning rounds were really important as a trainee. We also had the 00:43:12.400 --> 00:43:18.080 opportunity to choose Veterans for groups, so some of groups, like the Act protocol, um, isn’t 00:43:18.080 --> 00:43:23.120 really a good fit for everybody on the unit all the time. Um, sometimes people come in that, you know, 00:43:23.120 --> 00:43:28.560 are a little bit less suitable for groups – I think going to those morning rounds we got an idea 00:43:28.560 --> 00:43:33.920 of who would be a good fit for the group knowing what the group focused on, um, and then the Bridge 00:43:33.920 --> 00:43:38.640 to Recovery Group I think was like more open and really could work for anybody on the unit. Um. 00:43:40.400 --> 00:43:45.120 And then working with Peers. So, one of our Peer Support Specialists I worked with actually when 00:43:45.120 --> 00:43:49.920 I was on the unit, is on the call today, and it was such a pleasure to work with our Peer Support 00:43:49.920 --> 00:43:56.080 Specialist and have them facilitate groups with us. Um, it’s, you know, we can say all we want when 00:43:56.080 --> 00:44:00.080 we’re in groups with Veterans, but when they hear it from a Peer Support Specialist it just like 00:44:00.080 --> 00:44:06.400 really drives the message home even more, and then of course supervising junior trainees. So, 00:44:06.400 --> 00:44:12.240 I actually ran a couple of groups with some of the junior trainees that I was supervising and 00:44:12.240 --> 00:44:17.840 providing vertical supervision for, which was such a great opportunity for live supervision and um, 00:44:17.840 --> 00:44:23.120 learning to co-facilitate groups together, so, um, that was definitely one of my favorite parts. 00:44:24.800 --> 00:44:30.080 All right, let me see if I can advance this slide here – okay, hopefully that worked. Um, 00:44:30.080 --> 00:44:34.400 so I was going to talk about some challenges and lessons learned, um, while working as a trainee 00:44:34.400 --> 00:44:39.120 on the inpatient unit. I think one of the things is that it can be challenging to integrate into 00:44:39.120 --> 00:44:43.680 the team when you’re only on the unit one day a week. Um, so I have had the privilege of working 00:44:43.680 --> 00:44:48.000 on an inpatient unit five days a week when I was on internship and it does make a difference to 00:44:48.000 --> 00:44:52.000 be there every day. Um, but I do think that that means that it’s a great professional 00:44:52.000 --> 00:44:57.520 development opportunity to learn to develop your clinical voice on a team and speak up in rounds, 00:44:57.520 --> 00:45:02.400 collaborate with providers as much as possible, and really get to know the patients when you are 00:45:02.400 --> 00:45:07.680 there. So, on my inpatient days sometimes I would just like walk around the unit and poke my 00:45:07.680 --> 00:45:11.840 head into people’s rooms and chat with them and really try to get to know them as best as I could. 00:45:12.480 --> 00:45:16.480 Some of them I would only see one time, but others ended up being on there for a few weeks, 00:45:16.480 --> 00:45:21.840 or even a month or more, so…um, having that time to just kind of connect with them on the day 00:45:21.840 --> 00:45:28.640 I was there as really important. I think as a trainee we’re super tuned into issues of ethics. 00:45:29.200 --> 00:45:34.720 I often noticed Veterans mentioning things that were potentially reportable to CPS or APS, 00:45:34.720 --> 00:45:38.320 and there are a couple of times where I noticed that in a prior note from another provider, 00:45:38.320 --> 00:45:43.520 and it was hard to tell who reported it or who was responsible for reporting it. Um, so I think 00:45:43.520 --> 00:45:47.920 that really gave way to a learning opportunity for how to discuss reporting requirements with 00:45:47.920 --> 00:45:53.600 other providers, providing psychoeducation when it was necessary about what is reportable, etc. 00:45:56.000 --> 00:45:59.440 Um, and then for owning your expert role, I think particularly as a post-doc, 00:45:59.440 --> 00:46:02.960 you know, we have our doctorates, we have extensive training up until this point, 00:46:02.960 --> 00:46:07.520 but it can be easy to feel kind of like lower on the totem pole so to speak when 00:46:07.520 --> 00:46:12.240 you’re a trainee and only on the unit one day a week. Um, so I think, you know in that 00:46:12.240 --> 00:46:16.960 situation I really learned to trust myself and my clinical judgment, my supervisors, 00:46:17.760 --> 00:46:24.960 um, both of my supervisors had been former trainees as well in PSR fellowships, and so they 00:46:24.960 --> 00:46:29.680 also were on the inpatient unit and so their guidance was really helpful in this [inaudible]. Um, and 00:46:29.680 --> 00:46:34.640 just how to be an assertive member of the team so that other people knew my role and my expertise. 00:46:36.560 --> 00:46:41.360 Um, I think there are plentiful learning opportunities to be creative, develop new group sessions, 00:46:41.360 --> 00:46:46.160 I kind of touched on that already. I particularly noticed being able to be really creative as a 00:46:46.160 --> 00:46:50.960 clinician in my individual sessions – I mentioned each week I’d see someone right after rounds, 00:46:50.960 --> 00:46:55.520 I’d get a referral question like, you know, this Veteran wants to work on emotion regulation, 00:46:55.520 --> 00:47:00.560 I then have 45 minutes, if I’m lucky, with that person, to quickly establish rapport, 00:47:00.560 --> 00:47:04.960 teach them a brief skill. They learn to really review what I knew about something, chose a few 00:47:04.960 --> 00:47:09.200 brief interventions to have in the forefront of my mind when I’m going into the session, 00:47:09.200 --> 00:47:13.760 and really be flexible to pivot if something unexpected came up. I think that was such as 00:47:13.760 --> 00:47:18.480 great opportunity to think like, “Okay, if I only have one session with this person, what do I want 00:47:18.480 --> 00:47:23.080 them to walk away with? What do I want them to remember, to get the most bang for our buck.” 00:47:23.840 --> 00:47:29.360 Of course prioritizing safety is always at the forefront, and it sometimes can be challenging. 00:47:29.360 --> 00:47:34.080 As I mentioned, one of our roles as a trainee on the inpatient unit was to decide 00:47:34.080 --> 00:47:38.400 who seemed fit to come to group. Um, and that as sometimes challenging since the milieu is always 00:47:38.400 --> 00:47:44.160 changing from one week to the next. Um so I really trusted the other staff members to help me decide, 00:47:44.160 --> 00:47:49.040 you know, who was a good fit for group. Um, and sometimes people would be let into group that 00:47:49.040 --> 00:47:53.840 really weren’t a good fit, so, you kind of have to get comfortable with being uncomfortable and 00:47:53.840 --> 00:47:58.320 making sure we’re able to like have someone excused from group, or redirect some staff 00:47:58.320 --> 00:48:04.320 to please assist them into their room in order to keep everyone safe. Ethical issues – I sort 00:48:04.320 --> 00:48:08.480 of touched on that a little bit. Um, on the previous slides, and think this is something, 00:48:08.480 --> 00:48:12.400 I always think about particularly on the inpatient unit, because it does look different. So, 00:48:12.400 --> 00:48:18.240 for example, someone’s verbalizing SI or HI, it’s not like we’re calling the police or, they’re 00:48:18.240 --> 00:48:23.600 already at the highest level of care. So, it does look different. I always made sure to like loop 00:48:23.600 --> 00:48:28.160 back with my supervisor and the team, who often knew a lot more about the patient than I did. 00:48:28.160 --> 00:48:33.840 And that was really essential in deciding kind of if we were to proceed with a report or not. 00:48:33.840 --> 00:48:39.520 Dr. Blaire Ehret: [inaudible 48:33] Dr. Tamara Rumburg: Go for it, Dr. Ehret. [laughter] 00:48:39.520 --> 00:48:43.280 Dr. Blaire Ehret: Thanks, and I’m realizing that on time we’re a little crunched, so I 00:48:43.280 --> 00:48:48.800 just want to make a really quick mention about SAIL considerations, when providing PRRC-based 00:48:48.800 --> 00:48:54.720 services on the inpatient unit. Um, obviously I know that there’s a lot of, thought behind 00:48:54.720 --> 00:48:59.520 and a lot of, you know, maybe emotions behind SAIL, I know certainly on my part there are, 00:48:59.520 --> 00:49:06.320 um but with that said, I just want to keep in mind for folks that um, there are some challenges, 00:49:06.960 --> 00:49:12.880 meeting certain SAIL measures and receiving certain credits for PRRC-based measures by 00:49:12.880 --> 00:49:21.200 including inpatient encounters. Just very briefly, for example, particular measure highest 72 and 73, 00:49:22.000 --> 00:49:29.040 although they include inpatients, and outpatients who meed PRRC diagnoses in the denominator, 00:49:29.040 --> 00:49:35.120 they actually explicitly exclude inpatient encounters by PRRC from the numerator. So, 00:49:35.120 --> 00:49:40.560 you know, when you’re looking at and you're talking to your leadership about developing having more of 00:49:40.560 --> 00:49:47.440 a PRRC presence in the inpatient unit, you may just want to really consider and think about 00:49:47.440 --> 00:49:53.200 SAIL and how that may be affected. Um, so, I just wanted to put that out there for you guys. 00:49:56.640 --> 00:49:59.120 Dr. Yuliana Gallegos Rodriguez: Now I have another polling question for you guys. 00:50:08.160 --> 00:50:13.200 Do you currently have mental health trainees providing recovery-oriented psychosocial rehab 00:50:13.200 --> 00:50:18.640 services on your inpatient unit? Dr. Dimitri Perivoliotis: [clears throat] 00:50:18.640 --> 00:50:25.840 Actually, I think this is the wrong question. There should be number 4, what are the barriers? 00:50:25.840 --> 00:50:28.800 Dr. Blaire Ehret: Yes, that’s what I have also. Dr. Dimitri Perivoliotis: There you go – there 00:50:28.800 --> 00:50:30.160 it is. [laugh] Dr. Yuliana Gallegos Rodriguez : Thank you. 00:50:31.120 --> 00:50:36.320 So what are the barriers to integrating trainees on your inpatient unit or challenges you have 00:50:36.320 --> 00:50:43.680 experienced in doing so? We’ll give a few seconds because I know we’re running short on time. We’re 00:50:43.680 --> 00:50:49.920 almost wrapping up though. All right, so we have lack of leadership support, lack of staff 00:50:49.920 --> 00:50:55.840 buy in, lack of experience providing training and supervision for inpatient Serious Mental Illness 00:50:55.840 --> 00:51:03.360 for PSR services, no trainees available, lack of trainee interest and inpatient work, and other. 00:51:05.200 --> 00:51:12.720 All right, we have it looks like, we can go ahead and close the poll and from what we have, 00:51:12.720 --> 00:51:21.120 the highest recorded answers are lack of staff buy in and lack of experience providing training and 00:51:21.120 --> 00:51:28.720 supervision for inpatient Serious Mental Illness. We also have some others. I wonder if we can see 00:51:28.720 --> 00:51:46.000 the answers briefly. So quickly, I just wanted to point out the settings needed for success and 00:51:46.000 --> 00:51:53.280 after consulting with our colleague, Dr. Andrew Bismark, our inpatient psychologist, um, we thought 00:51:53.280 --> 00:51:57.920 that it was helpful to have recovery-oriented leadership who support programming and 00:51:57.920 --> 00:52:04.080 trainee integration, also to actively attend treatment rounds and presenting clinical work, 00:52:04.080 --> 00:52:09.680 or assessment results, taking an active role in unit level treatment planning meetings, 00:52:10.960 --> 00:52:14.080 to make time for direct greater hands-on experience, 00:52:14.640 --> 00:52:18.800 ownership or PSR groups and material such as the Bridge Group, SST, 00:52:20.000 --> 00:52:25.600 uh, certification, whole health, and to integrate specific training – again, like SST, social skills 00:52:25.600 --> 00:52:31.520 training certification, targeted assessment in an interpretation, as well as screening patients 00:52:31.520 --> 00:52:36.720 for transfer to our PRRC once they’re being discharged from inpatient, and facilitating that 00:52:36.720 --> 00:52:42.400 transition to care or continue to get trainee- Veteran relationship. And last, but not least, 00:52:42.400 --> 00:52:50.320 shadowing inpatient staff whenever possible. Dr. Dimitri Perivoliotis: 00:52:50.320 --> 00:52:55.040 Terrific, thank you Yuliana. We’re almost out of time. I’ll make the summary very fast. [laugh] 00:52:56.000 --> 00:53:02.320 Basically I hope that what you’ve all gotten out of today is um, you know, understanding, 00:53:02.320 --> 00:53:08.640 which I’m sure you already did, that how important and how really big this effort is to transform our 00:53:08.640 --> 00:53:13.760 inpatient mental health unit to recovery-oriented modeled care, and that there are challenges to 00:53:13.760 --> 00:53:19.200 that which I’m sure many of you are well aware. Um, but then mental health trainees really need 00:53:19.200 --> 00:53:26.720 and want that experience and can be successfully integrated onto the unit in a number of ways. 00:53:26.720 --> 00:53:33.440 Um, and I really truly believe that the arrangement is mutually beneficial. Um, you know, 00:53:33.440 --> 00:53:37.680 I’ve heard a lot of feedback, not just from the trainees about how great of a training experience 00:53:37.680 --> 00:53:42.880 it was, but from the inpatient staff telling us that they like having our trainees on the unit, 00:53:42.880 --> 00:53:50.320 it really helped them. They also learn a little bit too, and also from the Veterans as well. I’ll 00:53:50.320 --> 00:53:55.760 never forget I had nurse one time tell me that “Our Vets are just kind of calmer when you guys 00:53:55.760 --> 00:54:00.560 are here doing your groups.” [laugh] And it also gives them something else to do. You know, so, I don’t, 00:54:00.560 --> 00:54:05.360 we don’t have data on it yet from our site, but anecdotally I think it seems to be beneficial for 00:54:05.360 --> 00:54:11.040 the Veterans too, which is obviously the most important thing. So, um, some keys to success, 00:54:11.040 --> 00:54:17.040 I think Dr. Bismark’s slide really encapsulates that really well about what needs to be done 00:54:17.040 --> 00:54:21.600 to make this work, and we really appreciate you all being here and listening. I know we’ve gone 00:54:21.600 --> 00:54:27.360 almost to the very top of the hour. [laugh] I’ve been monitoring the chat and responding, I think I 00:54:27.360 --> 00:54:32.240 responded to most of the questions. There were a lot of requests for materials and I think it's best 00:54:32.240 --> 00:54:37.360 if you all E-mail me with that – I tried to paste your names, but just in case I missed anybody. [inadubile] Um, 00:54:40.560 --> 00:54:43.680 there was a very good question about “How do you advocate for having a full-time 00:54:43.680 --> 00:54:47.680 psychologist on the unit?” I mean, that’s a really good question. I’m not entirely sure, 00:54:48.480 --> 00:54:55.040 uh, but I think our chief of psychology and inpatient psychologist would know more about that so… Um, to 00:54:55.040 --> 00:55:00.320 that attendant, I will try to connect you to them and hopefully they will have some words of wisdom. 00:55:00.320 --> 00:55:07.680 “Any interest in providing brief EBP’s for PTSD on inpatient?” That’s a great question. Um, our PRRC 00:55:07.680 --> 00:55:15.200 focus is mostly on psychosis, so when we have done brief therapy it has been for, um, psychosis; however, 00:55:15.760 --> 00:55:20.480 um, I am now, I’m glad you mentioned that Mary because I am reminded now that we had a fellow 00:55:20.480 --> 00:55:26.320 once who was, uh, in our PRRC as a PSR fellow, but came to us with a lot of trauma experience, 00:55:26.960 --> 00:55:32.000 and he actually did exactly that. Yes, he delivered a brief intervention that 00:55:32.000 --> 00:55:36.080 he had developed actually as part of his dissemination project for the fellowship 00:55:37.360 --> 00:55:43.840 for trauma, and got some very compelling, good findings, too. Um, so for what it’s worth, 00:55:43.840 --> 00:55:48.480 you know, we do have some precedent there that, yeah, you can also do some 00:55:48.480 --> 00:55:54.560 good, valuable, brief PTSD work on the unit. It wasn’t really designed as a be all end all, 00:55:54.560 --> 00:56:00.000 it was more designed as a primer to continue psychotherapy once outside the unit, but he was 00:56:00.000 --> 00:56:06.907 finding some good results and presented on those actually. I think it’s a good sign. Um, so Mary I 00:56:06.907 --> 00:56:12.480 will try to connect you to him, yep, absolutely. Ralf Schneider: Thank you everyone, we are about 00:56:12.480 --> 00:56:19.600 out of time. Ralf Schneider, I would just like to remind everyone that the next presentation will be 00:56:19.600 --> 00:56:27.600 on February 9th, 12:00 Eastern Time, Dr. Donna Ames will be presenting on Prompting Recovery, 00:56:27.600 --> 00:56:35.840 Resilience and Suicide Prevention with Holistic and Spiritually Integrated Treatments: Taking Care 00:56:35.840 --> 00:56:42.240 of Our Veterans and Ourselves. So look out for that invite, and thanks again to our presenters. 00:56:42.240 --> 00:56:44.960 Dr. Dimitri Perivoliotis: Thank you everyone, thank you Ralf, take care. 00:56:44.960 --> 00:56:46.960 Multiple speakers: Thank you everyone. Bye.