Nadine Wilches 0:00

Hi, welcome to Navigate with Nadine. We are here today with Ishan Arvin. He is a healthcare executive, registered nurse, behavioral health leader, and you've worked in bedside care, clinical operations, patient safety, workforce development, and really transforming the way mental health care is done. So we're excited to get into that. Your focus is on building stronger systems, improving access, shifting behavioral health care from crisis to crisis response to early intervention and prevention, which aligns very well with what we do here at Mind Arc Health. So I'm really excited to dig in a little bit today and welcome.

SPEAKER_01 0:41

Thank you, Nadine. Pleasure to be here.

Nadine Wilches 0:44

So jumping right in from nursing to executive leadership, I've done that transition from direct clinical care to administration of clinical services. What did you see when you were on the front lines that made you think about preventing mental health crises? How does that shape kind of what you're doing now in the leadership role?

SPEAKER_00 1:07

Yeah, I mean, on the front lines, by the time the patient got to us, whether it was in the ED or whether it was on the inpatient psychiatric unit, like you said, I've worked in many different places, residential psych, they were already deep into their psychiatric journey, their mental health journey, and sometimes at a place where we're just trying to really get to stabilize them. And so that really taught me or really made me think about like what is happening with these patients prior to them coming to us? What are we doing to prevent some of these things from happening? And so that kind of brought me, wanted me to get into leadership so I can be able to make those types of changes. We had extraordinary caregivers, but sometimes the systems weren't always the best. And so trying to figure out, and will we switch to trauma-informed care when the world switched to trauma-informed care and saying to like what happened to you to get you to this point in your life? So really trying to nail those things down and hone in on that kind of stuff is a lot of what I've learned in bedside going from that transition from bedside to leadership.

Nadine Wilches 2:03

Yes, very similarly, I saw those trends. And when you start to wonder about what folks are going through, you start to think about the situations, the environments, the traumatic experiences, but also just hardship and adversity that folks go through. What does their community health look like? What does their school or workplace health look like and all the things that affect them? And so it looks very different than the clinical realm of what we would typically assess and address at that level. So from this new leadership perspective, what would a truly kind of prevention first, if we were to say the biggest part of the triangle of services, if we were to say that actually health promotion, prevention, well-being is at the base, population health and crisis intervention, kind of harm reduction is at the top, what would that kind of system look like in your mind?

SPEAKER_00 2:55

So I like to say, and I think of a lot of other people say this as well. So it's not my praise, but mental health is health, right? And with any type of health care, whether it's mental health, physical, your heart, cancer, anything like that, we want early identification. And so we want to people to be talking about their mental health at their primary care appointments, talking about their mental health at home and schools and in those settings where they live their everyday lives. And so before they get into that crisis state, we want to be intervening. We want people to have access, very quick access to outpatient services. And we know that doesn't happen a lot. But the current place I'm in now, we're doing that too. I did a podcast with a local person here and we talked a lot about mental health. And someone commented on the podcast and they said, I know where you work and they do a great job, but I can't get an appointment for six months for outpatient. And so we want to make sure that people can get an appointment the next day or within that week. Because if not, things can happen in their life at home, work, or school where they're going to be in that crisis situation. And now they're at the top of that continuum and we've missed a lot of things up front.

Nadine Wilches 4:02

Yes. And we have an 11-year gap between the onset of symptoms and treatment on average. So we are really missing signs for a long time. And you're talking about those acute moments, which are really important as well. And we definitely miss those opportunities because of access issues, systems and settings of support training and all sorts of needs, because you're talking about schools and workplaces and all these areas where we need to strengthen prevention. And I feel like we're really just at the beginning of that. But when we think about those 11 years of trajectories, what are we missing? What are those big warning signs that we're missing and healthcare systems could be looking at earlier?

SPEAKER_00 4:43

You know, missing, and I was looking at the talking to someone about in like AI programs. And so we're missing things, repeated ED admissions, people that are testing positive on suicide assessment screens, reporting something to their primary care doctor. And when you're going to all these different places, people's insurance change or they don't have insurance. So they're trying to do the best they can to navigate the healthcare system, it's not connected. And so we're missing a lot of opportunity where, like you said, there's this 11-year gap, right? We're missing years of opportunity where people could have been intervened as a child before they became an adult. I was just taking care of a 19-year-old the other day that unfortunately had attacked someone, another staff, another patient, and then a staff member on our unit went and trying to get this kid's history in navigation that there was no history of things reported in the ED. And then once you started digging deeper and talking to the parents a little bit more, you're finding out, oh, five years ago this happened. And it was like five years ago that happened. So, I mean, what happened after that? And it was nothing. It was really just the kid just went on five years ago. He was probably a freshman in high school or an eighth grader in middle school, and something happened to him that was pretty traumatic in his life. And so, but there was really nothing done there. And so just trying to now this kid is at a point where he's an inpatient facility, he's attacked a patient, he's attacked a staff pretty severely. And we're backtracking, right? And we're trying to figure out how do we get this kid to this point. But now he's had this possible psychotic break or a personality disorder or whatever it may be. And we're just trying to figure those things out now. And he's an adult when he's a working adult. He lives at home still, he's 19, but he works. He has his own life and he has his own friends, and there's a lot going on with him. And all that trauma just built up and he finally couldn't handle it any longer. And so we've missed all those opportunities.

Nadine Wilches 6:28

Yeah. Absolutely. I think that it adds a layer of frustration and a bit of sadness, I think, for a lot of folks working in these spaces to see this constantly because they're seeing these stories. That's one story of all of the people that they see. And every day they're seeing that there were signs and symptoms and where we can intervene. Well, I like to say prevention needs to be early and often where we're getting involved and understanding those places that we can support. But it's super challenging. I think that we have it's easier said than done that we need to do this, but that actually getting this done and making this happen is really about changing systems, which is very difficult.

SPEAKER_00 7:08

That's the challenge for sure.

Nadine Wilches 7:10

Yeah. When we talk about trying to get this done or and we look at maybe how data and technology, I know we've you've worked on this, we're working on this too. Is it helping identify risk earlier? How so? Where can we be using some of those workflows and building in data and technology to help us better?

SPEAKER_00 7:30

Yeah, I mean, that's kind of what I was touching on a little bit earlier with the programs and new things that are coming out, especially with AI. And then I don't want to keep pushing AI, but I think it's important because it's a lot of busy work that can be done very quickly. If we put people on trying to do the things, we'd have 10 people working 40 hours a week trying to figure out what happened to this kid when he was younger. If we could use programs and technology, connecting EHR systems and different things like that, whether it's between this young man's school or the emergency department, his primary care position, if he did have some counseling when he was younger, if there was a way to connect all those things, we could have connected the dots to prevent, most likely, I would really believe that to prevent where he had this situation that got him into the situation he's currently in now, which is trying to find a forensic place or possibly be incarcerated because of the consequences of the actions that he had. Although he had a mental health disorder, he probably wasn't totally in control of his own self, his emotions, his mental state. And so it's sad to see that because that's the last thing we want to see is somebody with a mental health disorder be incarcerated or not receive the proper treatment, not be able to go back to their regular life, their job, or not have this on their record as well. And so, really anything we can do to prevent those analytics, predictive analytics, those types of things will really help us. And I think we're getting there. But like you said, it's a very slow process. It's very difficult. Large system change is difficult. As a leader, I've been a director since 2013 in the mental health world and worked at many different places, FQHCs, inpatient psych, outpatient, freestanding, for profit, nonprofit. And unfortunately, you kind of see the same thing when you're trying to change, make a change to the system, it is very difficult.

Nadine Wilches 9:06

Yeah, and I think rightfully so. We have really protected mental health patient data differently than we have for typical medical data of other types. And I think that real desire to protect that data differently has contributed a bit of the silo problems that we have in terms of data sharing and that information sharing that you're talking about. And I think that we also have to consider how the burden of technology on our workforce and our providers, because technology is so exciting and there's so many good things that we're doing with predictive analytics and trying to get information in front of primary care providers so that they can make these decisions earlier. But we know that the workflows are hard. And we also know that folks are getting burnt out. So at the primary care level, we know that they're seeing anywhere from 25 to 75% of their time is spent on mental and behavioral health issues, which don't have the same level of equippedness to deal with. I just made up that word.

SPEAKER_01 10:08

Yeah, it's not their spectral because like a psychiatrist is not going to treat you for your heart.

Nadine Wilches 10:12

So yeah. Yeah. And so I think we have to protect the workforce burden around technology, but also from burnout and their own mental health challenges. And how do you see this role in leadership overlapping and overlaying into everything else that you're doing?

SPEAKER_00 10:29

Yeah. So really just coming up through the ranks in nursing and being a bedside nurse and then seeing all those things while I'm working with it, being very frustrated, like you said, being burnt out. I have someone off today at the hospital that I am today because they're a little burnt out from a lot of the things that we have been dealing with on this last week, with the incident with the patient, with trying to find the appropriate level of care for this patient and just working way past their hours. We all have been here a little bit earlier and a little bit later on meetings with our providers and our C-suite team and very supportive of the patient and of the staff person. But we have all these extraordinary people, but we don't have the system to really get us there. And so trying to build that system is what we're really trying to do, trying to set up these new workflows. And that's what I do. I'm a consultant. And so as an interim consultant, I come in and then I try to help organizations build these things. And some of the things I recommend, they don't have money in their budget for. That's tough, like newer technology. There might be a problem with your distress buttons or things like that. And a lot of it, and I said there's newer technology out there, but obviously it costs money, right? And then you're in that really uncomfortable place where you're talking about money versus patient and staff safety when it's like, well, what does someone's life cost? And so you can't put a number on that, obviously. And so sometimes you have to bite that bullet, that financial bullet, and spend that money. They develop new systems, bring in consultants like myself. And then sometimes I have to bring in, I'm not the person that's creating the technology, so I might have to bring in someone else to do that for them. And so it's cumbersome. And I understand the burden on the executive leadership and their organizations and their financial responsibilities and also the responsibility to the community, because that is a very tough balance. But we do have to figure out ways that are fiduciary responsibility, ways to fix systems, create new systems, and use this technology that's coming out because that's really going to help us to keep our clinicians and folks from being burned out.

Nadine Wilches 12:23

Yeah, you're right. That systems change requires a lot of hands on deck and a family community approach to this. And I think this is the nice place where consultants come in because they can have their really uncomfortable conversations in a different way than when I lead my teams. We have this relationship. And when we bring in a consultant, it changes those dynamics and we can dig a little bit deeper into some of the things that we may not be able to do as well on our own. And then I think it's also our job in the community and as technology providers to prove the ROI, not only on patient well-being and mental health, mental behavioral health in the long term, but also on provider mental health and the retention of really good providers and what that means for the company's longevity and stability in organizations, organizational health and safety costs and things like that. I think that we can prove those things. And I think that it allows us to make those financial decisions a little bit easier. And I think it's our job to kind of make sure we do that well. But that was my little tangent to jump on board with what you were saying. No, definitely. Yeah. And so um jumping, jumping around a little bit here, but prevention is really sometimes we look at it as the absence. I like to think about it as if you're skiing through the trees. I don't know if you're a skier, but if you're skiing through the trees, maybe in our earlier days, but when you're skiing through the trees, my kids can do it. You're looking for the absence of something, right? So you don't hit a tree, right? You're looking for the absence that white space. And I think a lot of times prevention kind of mirrors that analogy. So I you I know you're doing some great measurement work. What does that look like? How are we measuring what's actually working to prevent some of these downstream crisis high-cost healthcare events?

SPEAKER_00 14:12

Yeah, I mean, measuring things like the screening rates, identifications to their first appointment, to their next appointment, getting their medications. And then if they, let's say they come into the ED, getting to the appropriate care at that time, if it's not a sag bed on our floor, if we don't have any open, getting to the appropriate hospital again, because it's very fresh, just had a meeting about it this morning. But getting this young man that we have here to the right level of care that's going to really help him with these issues that we did miss earlier. When I say we, I'm not saying his parents, his mom and dad are both there first day he was in, very present, talking to us and whatnot, and raising the kid to the best of their abilities. But all of us miss things, and they're not mental health professionals, so they're mom and dad. I don't know what they do for a living, but even if they were nurses, that's probably even worse.

SPEAKER_01 14:59

I had three sons and I was just like, oh, you're fine. We're not going to the ED for that.

SPEAKER_00 15:04

But uh, I do it to myself too. And so we really need to rely on the expertise of our clinicians and make sure that we're not missing these things. But again, the clinicians, like you said, with all that they're seeing, the primary care providers, 75% of their time being spent on mental health. I didn't think the statistics was that high right now. And that's it's mind blowing when you think about that. But to use some of these things and some of these systems that we're missing, to use some of that technology to catch some of those misses would be astronomical and saving time. And now the primary care doctor can focus on what they're there to focus on with the person's diabetes or whatever it may be, but they can also quickly refer them to the expert that can get them the preventative treatment they need before they end up in a crisis situation.

Nadine Wilches 15:47

Mm-hmm. Yeah. And it's really nice to think about systems and settings that need to change, both within the health system spaces, within the community spaces. And I think prevention starts to fall much more outside of the big hospital settings and much more into these community spaces. So if we were to end with maybe redesigning, what would you think would be the best place that we can start to redesign prevention where it would help people ever from reaching a crisis? Where would you start?

SPEAKER_00 16:22

Just like a big behavioral health gateway where someone can enter in and say, I need help. Whether it's an everyday stressor, a major life traumatic event that goes unaddressed for some time and then it builds up. But anything, because those everyday stressors build up too. They say stress kills. And it really does. You start to create, you start to get physical symptoms from stress. You have anxiety disorders and panic attacks and things like that. And that shit just builds up over time. You lead into depression and different things. But really just to come in to that open corridor and say, hey, I need some help. And then immediately we can use those technologies to look back and say, okay, this person never asked for help before. Have they ever been hospitalized? Were they seeing anyone? What was going on in this situation or that situation? And just have a real full chart. And then we can continue to follow that continuum of care and get them early access, increased access and early access, right? That's everywhere in medicine and especially in behavioral medicine. And so I truly believe that's kind of where we need to start. It takes a lot to get there. When I work with several companies and things like that that do these kind of things and look for those kind of opportunities, but it really starts with monitoring those things, scheduling the appointments quickly, making sure people aren't missing appointments, following up if they are, making sure they have their medications, making sure they're taking their medications and getting all that preventative care done before they end up in what we call the ICU behavior off. And that's the inpatient psych unit. And so we want to keep just like you want to keep your medical patient. I like to do that because sometimes people don't understand how serious mental health is. But we like to call the inpatient setting that's the ICU. So if you have diabetes or congestive heart failure or lung failure, different things like that, that you can live with and go to work with every day, but you might have a behavioral health issue that you can't even wake up in the morning. You don't want to get up, you don't want to get out of bed, and you sometimes don't want to be alive, unfortunately. But if we can get that preventative care done early, then we can prevent that person from being in that level of care. We're not going to prevent everybody. Sometimes there's just things going on in your brain that you have to get certain treatments for and things like that that are inevitable. But we can also treat those folks too and make sure that they don't end up back in the psychiatric hospital two weeks later or back in the ED the next day after discharge, making sure that they have those, their services, their coping skills on all those things, and making sure that all the clinicians are aware. So their primary care doctor needs to be aware. Oh, this person was just in the hospital. And it's not from the patient telling them because they might not want to tell them, right? And so you have that. So having all that technology to put everybody on the same page. And I like the point you brought up earlier about the protected information. I've always said that I'm like, it's like patients and people in the prisons, they're like the most protected class ever, sometimes rightfully so, because of the abuse that they've endured in the past. And so people do protect that information and make sure that they're not judged by that. And that's where we always try to reduce that stigma of mental health. But I really believe just getting that early care, someone says I need help, and we're addressing it right away.

Nadine Wilches 19:13

Absolutely. I love that. We're doing this look back analysis on 10 years of 11 million medical records to look at trajectories to find those little whisper signals that will allow us to intervene earlier. And I think that there's some really good initiatives beyond ours, too, like you said, with technology just being a better predictor. And then helping with communication. I think this is something we don't do, but I know a lot of tools are doing this, helping with that transfer of communication and also just basic reminders of things that are easy lift, but that we need to know about. So this is great. I think that you shared a wealth of information with our listeners today. I think that there's a lot for people to take away. So thank you for your time. It was really nice having you and look forward to staying in touch.

SPEAKER_00 19:56

It was a pleasure. I thank you for the invitation and definitely we'll stay in touch and keep working on this one patient at a time, one medical record at a time.

Nadine Wilches 20:04

Sounds good. Thanks, Sean. All right.

SPEAKER_00 20:06

Thank you, Nadine.