Dr. Erik Mikaitis (Host): Well, hello and welcome to our latest edition of Pulse Check, the internal podcast for Cook County health employees to know what's happening within our health system. Joining us today for a discussion on behavioral health, we have Dr. Tom Nutter, Chief Behavioral Health Officer, and Dr. Kiran Joshi, Interim COO for the Cook County Department of Public Health. Thank you both for joining us today.

Grateful to both of you for your work in the mental health space. That's where we'll be focusing for our conversation today. But before we start about our health systems' efforts, I did want to call out two resources for our internal staff, for our CCH team. As we all know, healthcare is a very challenging profession and we oftentimes face risk of burnout, compassion fatigue, stress, anxiety, loneliness. So, we do have resources available. We're able to talk to someone 24 hours a day, seven days a week by calling ComPsych, our employee assistance program. It is free and fully confidential. We have trained staff answering calls and providing support for emotional needs, for work-life balance, and financial resources. So, call ComPsych anytime, day or night. It's 1-800-890-1213. That's 1-800-890-1213. You can also access resources online at . guidanceresources.com, guidanceresources.com. Register and enter the web ID BCBSILEAP. Again, that's B-C-B-S-I-L-E-A-P. When you spend your day taking care of others, it's essential that you also listen to your own needs and make sure that you're taking care of yourself.

Okay. So with that, let's jump in. So, Dr. Joshi, let's get started with you. Could you maybe talk a little bit about our behavioral health landscape in Cook County?

Dr. Kiran Joshi: Thanks so much, Dr. Mikaitis, for pulling this together and for your support, particularly to our staff, many of whom we know have experienced trauma and other issues that could put them at risk for mental health concerns. So, just in response to your question about the current state of mental health, we know that there's a crisis. It's a countrywide crisis. And certainly, our county is not exempt for that.

Our understanding is that it's something that's been exacerbated by the pandemic, but is certainly not new. And we think multiple factors have been contributing to this. And they range from increasing need and not enough behavioral health care workers. Dr. Nutter is going to speak to that, I believe, in just a little bit. One factor I really wanted to highlight was loneliness and social isolation. These things increase one's risk for premature death by up to 29%. And to reframe that, lacking social connection can increase the risk for premature death almost as much as smoking 15 cigarettes a day. So, we really have to work on addressing all of these issues to improve behavioral health in Cook County.

Now, I wanted to offer a balanced perspective here. There is some good news to share and it's that, nationally and for the first time in really over 10 years, the number of overdose deaths is on the decline. So, that's good news. We're still waiting for the data disaggregated by race to sort of think about like where there could be disparities, but it is a little bit concerning here that the national decline that we're seeing is being driven primarily by decreasing rates of overdose among adult white people. Blacks, Hispanics, and other racial and ethnic groups are still seeing increases. We must continue to work really hard to address this. The rates are still too high, but we do have a sense of what interventions are effective and that they're working.

Host: Absolutely. And I know we'll talk about some of the things that we're doing as well at CCH and CCDPH. I also want to call out kind of the broader perspective around the work that we've done for CCH, starting with the American Rescue Plan Act, right? ARPA. And just for background, local governments received an infusion of dollars from the federal government to address the aftermath of the pandemic. And thanks to President Preckwinkle, and the Cook County Board of Commissioners, we actually received $174 million dollars to the health system to help address a lot of these needs. And, Dr. Nutter, one of the big things early last year was the Stronger Together initiative. I was hoping maybe you could tell us a little bit about that.

Dr. Tom Nutter: Happy to do so. First, a quick word of gratitude and a word of protest, maybe, if you will. The gratitude is, as you mentioned, to be able to steward these kind of resources. Thank you to the president and the commissioners and board of directors, to you and your leadership, at this moment in time when the needs are so vast, to be empowered to take action in a kind of once-in-a-generation way. It's just a fantastic privilege for me. And I know that I speak for everyone in our office and all those working in behavioral health, both those in clinical settings and those in public health in public health roles.

I mentioned the protest because I realized this particular podcast is going after the one that Dr. Fegan and Shannon Andrews did on the history of Cook County Health. For those that have not had a chance to listen to that, it makes one inspired about the place we work and the DNA of the place we work. The initial podcast is also fantastic if you need an introduction to our CEO and Dr. Mikaitis' vision for CCH. So, listen to this one first, but then go back and listen to the others.

On the topic of the Stronger Together, as you mentioned, the summit, which, believe it or not, was almost a year ago now, we pulled together community partners for what we were envisioning as a day of structured listening to see, you know, where are we, where do we need to go as we try to come in as CCH, as a convener and coordinator of services throughout Cook County, not just through CCH, but really, again, countywide. We had a few weeks to plan the summit and an email list that is I would describe as much less robust than our current list. So, we had a room of 800 and expected, "Well, if we get 400, that would be absolutely wonderful." And then, in less than two weeks, we had 700 people registered and had to actually close registration briefly because there was so much interest. And I just think the appetite for this kind of collaboration is not just within CCA, but really countywide for those working in this space for us to all come together to solve the problems that we're seeing across the county.

So, that event, I think, was huge success. And following right on the heels of that was we were able to award $44 million in in grants to 53 separate organizations serving throughout the county. We had 324 organizations that applied. Thank you to everybody who served as reviewers for that. That was no easy task. Thank you in particular to Jennifer Brothers and her team who really led that initiative from our office. And we're not just excited about the awarding of those grants, but really where they're going to go and what they're going to do. They're largely concentrated in areas that have suffered from historic disinvestment and current disinvestment areas of particularly high need. We focused about 60% of those dollars on youth and families, and are looking forward to seeing the results of those projects over the next couple of years.

Host: Absolutely. I was very exciting to be in the room for that really see the entire community come together. I really can't wait to see what that means going forward, right? To have that big of a conversation, that widespread. And it was really interesting to see how having all those different organizations and that diversity, just in terms of how people engage in the healthcare space, really all the different ways and the different pieces to the puzzle. Really, really was exciting that we were able to, as CCH, kind of bring all of those people together as a convener to have that conversation. So, kudos to you guys both for working through that and making that happen.

You touched on partnerships in kind of that discussion. It's so critical, right? Especially as we try to create that network so that there's better support in the community and better coordinated support that I think will increase access and create more touch points right throughout the county. Dr. Joshi, could you talk a little bit about those partnerships and maybe specifically spend a little time on NAMI?

Dr. Kiran Joshi: Yeah, absolutely. So first, I just want to concur and offer my kudos to Dr. Nutter and his whole team for really, I think, what's a body of work that has been created that's really impressive and really thoughtful and deliberative. So, really appreciate that and appreciate the partnership.

Our work here is focused less on sort of thinking about treatment and more about prevention and upstream factors. We've been working to connect community groups to be all kinds of behavioral health resources. Again, thanks to ARPA dollars, which were a huge resource once in a lifetime as per Dr. Nutter's prior comments. And a huge thanks to the President's Office, the Board of Commissioners and, of course, my colleagues across CCH that have worked so hard on this.

What was really wonderful to see was that we were able to build on relationships from decades of community engagement across suburban Cook County with a focus on some of our most vulnerable communities. So, we've provided grant dollars to organizations that provide programs such as social emotional learning, youth mentoring, professional development to educators and school staff, for example, by partnering with the regional offices of education, which really you can think of them as regional associations of school superintendents. We've got the potential to reach almost every single public school student in suburban Cook County. So, a lot of reach there. That grant making has consisted of $22 million in ARPA funding to 30 non-profits or organizations or schools. And again, they provide a myriad of behavioral health prevention programs, harm reductions, and other services. We managed to reach about 25,000 people across suburban Cook County in 2024 alone, and nearly 8,000 of those individuals were referred to additional support services.

Just some additional concrete ways that we've been in community are this past summer we collaborated with the village of Maywood and brought together nearly 200 educators, faith leaders, first responders, and older adults to talk about how to best respond to substance use needs in that area. The request of a community partner, the Proviso Township Youth Services Mental Wellness Task Force, we also created a report on youth suicide that was hyperlocal and focused on their community.

And then, of course, you mentioned NAMI. That's a long-standing partnership. We've worked really closely with them to expand their helpline referral list so that suburban residents and treatment providers could be included there. So, a lot of really wonderful work that's happening, and I think there's just more to come.

Host: Absolutely. Dr. Nutter, did you want to add anything about NAMI?

Dr. Tom Nutter: Well, I'm particularly excited about NAMI project, and we appreciate CCDPH's partnership in general, but particularly leadership with NAMI in this space, because given the access problems that plague-- again, these are as mentioned by Dr. Josie, these are nationwide problems, but we're certainly not immune from them locally, it's daunting to try to get into our system. Our front door-- when I say our, I'm not talking about CCH, I'm just talking for behavioral health treatment-- it's not easy to step into. And to have a centralized number that one could use regardless of geography, regardless of insurance status, regardless of which condition, whether you have a substance use disorder or depression or anxiety or whatever it is you're suffering with, to have one number that you can call and soon that you can text or chat, more news to follow on that soon, it's a huge addition to-- you know, while we still lack the access we want, at least to have somebody as a navigator at the front door is a tremendous thing, and we're excited to be able to partner with NAMI going forward.

Speaking of partnerships and partnerships with CCDPH, in October, we had a workforce symposium that really shed light into one of the biggest reasons for our access problems. And that is that we don't have enough providers and really any discipline. The estimates were that we were around to 15,000-16,000 workers short of what we would need to meet all, if everyone who needed treatment were to seek treatment today across Cook County, we would need up to 16,000 more workers.

And perhaps even more daunting was given the current rates of retirement and folks leaving the field, to meet those needs by the end of 2028, we would require over 30,000 workers. So obviously, we're doing all that we can to improve and bolster the workforce, but also to improve processes so that we can better retain the workforce we have and help them to work more efficiently and effectively, which will be a number of initiatives over the next year or two in that space. And we're excited about the chance to make a dent in that access issue.

Host: Yeah, absolutely. I think that report was very telling. You know, I think we've all known it, maybe felt it deep down that there's this shortage, but I think putting those real numbers behind it really snaps it into sharp focus, right? The issue that's there. We've also, more broadly, at the healthcare system level, across the country, we've felt these workforce shortages, but I don't know how much people have really teased out that the mental healthcare space specifically to really look at the workforce there.

And I think as we've gone through that, and I've been hearing the outputs and getting feedback from you and the teams that have come together to talk about this, it's been interesting to see just how important every member and their different kind of background and the role that they play, how important it is in the behavioral healthcare space, especially. And I know that we as a system, CCH, right, we've done a lot to try to really incorporate those behavioral health services across our system through social workers and medication for addiction treatment into all of our ACHN sites, our jail, our Cermak team is operating the only OTP-certified MAT program in the entire state of Illinois. We have the Bridge Clinic, which is a rapid walk in access for MAT services at CORE Center. So, we're positioning ourselves, right? We want to be able to care for people when they're ready to receive that care and provide as few barriers as possible.

And, Tom, I think what you just said about access is difficult, right? Figuring out the system, navigating, right? I think that's where all of the work that's been done over the last year to try to convene and create that system. So, that access is possible is just so important, right? I know we've talked and the goal is that there's no wrong door for behavioral health care when you need to access it wherever you contact the healthcare system, there's a way that access. And that includes county care, right? They've done a lot of work as well. Our county care members have access to outpatient, inpatient residential treatment at no cost. And I think that also kind of spreads out into the community. So, I'm wondering, Dr. Joshi, could you maybe tell us a little bit more about the role of community mental health and then talk a little bit maybe about trauma-informed care too.

Dr. Kiran Joshi: Yeah, I think I'll focus my comments on trauma-informed care. It's an area that is really near and dear to my heart. And the reason for that is because it's something that we were sort of tasked with advancing a couple of strategic plans ago, but really has become this wonderful experience in that it's a labor of love for a lot of really dedicated staff across CCH. So, our role is convening trauma-informed collaborative, which includes membership from across the health system. And it's just really wonderful to see, again, the dedication, the compassion, sometimes the relentlessness that our staff bring to this work.

So, just to provide some background, trauma-informed care really explores how social and emotional childhood experiences can impact our health, our well-being, and that includes our behavioral health, our mental health as adults. It really teaches approaches that avoid further traumatization of co-workers, of patients, certainly community members, and oneself.

We've made a lot of strides in a lot of different areas over the years. This includes advancing an effort to develop a really safe appropriate space for people to grieve in the physical trauma bay adjacent to the emergency room. More recently, in 2024, CCDPH trained 356 employees in the fundamentals of trauma-informed care, and that included staff, again, across the health system, with a focus on the Robbins, North Riverside, and Arlington Heights ACHN locations, and we're really looking to expand that group over the course of this year. We've got Trauma-Informed Tuesdays going, where anyone can come in and sign up and be trained. And again, this is an area of work that I could just go on and on about. But I'm going to pause here and turn it back over to you, Dr. Mikaitis.

Host: Well, thank you so much, Dr. Joshi. It's so encouraging to hear about all the work that's happening in that space. It's so deeply needed and I'm so happy to hear that, that we're focusing in that space. If we could come back around maybe to some of the addiction topics that we had talked about, specifically our naloxone initiatives, maybe Dr. Nutter, could you tell us a little bit about that work?

Dr. Tom Nutter: So, you know, imagine you have medical condition with high mortality. And you have a treatment that is free to patients, total cost is only about $18 a dose that will, in most cases, be essentially an antidote for the mortality of that condition. And a medication that has virtually no side effects. And so if accidentally ingested, no consequences, that's naloxone. Naloxone is a safe medication. It is highly effective in reversing opioid overdoses. And the more widely available we can make that drug, the more lives we can save. I think the increased availability of naloxone has to be a part of the reason for the early decline that we seem to be seeing finally. I say early because we don't have the final data yet in opioid deaths throughout Cook County in 2024. Given that now somewhere around 90% of our heroin has fentanyl in it, the fact that despite that content, we actually have a lowering of the number of deaths over the last year is, I think, largely attributable to the availability of naloxone.

And so, everything that we could do to increase the availability of naloxone, we certainly want to support. The efforts here have included not only efforts in the clinic, but also having vending machines at Stroger, at Provident, at CORE ,soon to be at the jail in conjunction with our partners at CCDPH at all Cook County courthouses and really making an effort to coordinate those efforts so that we can just saturate the community with naloxone and continue to save, I would argue, hundreds of lives each year.

Host: Wonderful. Thank you, Dr. Nutter. Dr. Joshi, did you want to add anything more about maybe the Get Naloxone Campaign?

Dr. Kiran Joshi: Yeah. So as I stated earlier, we have seen a decrease in overdose deaths in Cook County last year. We're resolved that every death is one too many, particularly given the preventable nature of these deaths. We need to continue to make naloxone readily available and saturate the community per Dr. Nutter's comment. In 2024, we distributed 13,000 Naloxone kits and this is all through partnerships with community-based organizations. It's not enough to just put naloxone out there. It needs to also be coupled with training. And so, we also trained about 5,600 people on how to use naloxone.

Following the events I mentioned earlier in the village of Maywood, we also placed 10 naloxone drop boxes with businesses and in municipal buildings across the western suburbs. And in 2024, we found that the naloxone we distributed was used in at least 21 overdose deaths. I say at least because there's no way of counting, that denominator is a little bit unclear.

In the past four years, we know that it's been used in 106 overdose events and that represents 160 doses of naloxone. So, this spring, we're going to launch a larger scale get naloxone public education campaign in the focused on the suburban ZIP codes with the highest numbers of overdoses. That campaign is going to coincide with the placement of even more naloxone drop boxes in priority ZIP codes. So again, a lot of good work that's happening here and a lot more to come. A lot of this work is happening in partnership with Dr. Nutter's office, and once again, I just wanted to express my appreciation for that.

Host: Absolutely, very, very exciting work and thank you both to you and your teams for engaging in that. And I think you've both done a wonderful job sharing just how big of a year 2024 really was in terms of advancing our behavioral health care goals. I really think we're on the precipice of making some real structural improvements in the delivery model. Thanks to the investments and thanks to both of you and your teams.

And I think this coming year, we're all very excited about some major wins that are on the way. We're opening a specialized behavioral health unit that'll focus on stabilizing patients at our Provident Hospital Emergency Department who present in crisis. I think that really offers a unique clinical environment to our community. And we're also opening our new Bronzeville Health Center. That's going to provide a new space for psychiatric services in a modern, more patient-centered setting.

So, I think we're nearing the end. Maybe Drs. Nutter and Joshi, let's close out with each of you kind of sharing any parting thoughts you might have. Dr. Nutter, maybe let's start with you.

Dr. Tom Nutter: Well, I started with gratitude. I'll end with gratitude as well. And I just want to say not only thanks for the opportunity that our office has, but with all of our teams, both those in the Office of Behavioral Health and CCDPH and our leadership teams across all clinical areas in behavioral health. It's just been such an honor to work with the folks that we've been working with over the last year and very excited about 2025.

We had to focus most of our efforts because of ARPA funding and getting certain things obligated on external processes in 2024. But in 2025, as you mentioned, Dr. Mikaitis, there were a lot of internal things that are going on that we're excited about and very much looking forward to bringing about over the coming weeks and months.

I guess, as a parting comment, as a psychiatrist, appreciate you mentioning earlier, Dr. Mikaitis, the toll that the work can take on folks. So, for those listening who are in the field, let's continue to look out for each other. We're good at taking care of those we serve, and sometimes we're not as good at taking care of each other. So, just a reminder to all to do that. And for anyone listening to this who is suffering with depression, with anxiety, with thoughts of suicide, with feeling like you can't stop using whichever substance seems to have suddenly started to dominate your life or whatever activity that's been destructive and feels like there's not an easy way out, know with 100% certainty that you are not alone. We do have some problems in our systems, but there's not a deficiency of dedication among those who want to treat you and want to be there when you reach out for help. So, please do that. Know that you're not alone and that we're here for you.

Host: Very well said. Dr. Joshi, any final thoughts?

Dr. Kiran Joshi: Yeah, I agree. That was well said. And it just reminds me how fortunate we are, again, to have this partnership. At CCDPH, we feel really strongly that behavioral health is public health with the caveat that everything we do is collaborative. We can't do our work in isolation. And again, just really fortunate to have so much support from all levels of Cook County Government and CCH leadership, such wonderful partners, both internally at CCH and across our suburban Cook County jurisdiction. And really, just, like, this superstar team within CCDPH led by Hanuk Haidt, our Director of Community Behavioral Health.

Our work in this space is really some of the most important and meaningful work that we do. This work is deeply personal for me, particularly given the number of people in my family that have been impacted by behavioral health issues. We're just sort of forecast ahead to 2025 from our side. We're really kind of interested in exploring the crisis response space, specifically looking at suburban Cook County and are planning to and looking forward to releasing a report documenting the strengths of the crisis response system, as well as the opportunities where potential resources could be devoted.

So again, so much work to follow and wanted to just close by saying thank you for the opportunity to talk about this work.

Host: Absolutely. And thank you both very much for joining me. I know we covered a lot of information, and we probably could have kept talking for another hour or two. As an aside, I want to encourage our staff consider taking the trauma informed care training that's actually available on our intranet. And of course, as I said earlier and Dr. Nutter reiterated, please make sure to take care of your own mental health. Use our EAP resources if needed. They're free and confidential. Again, I'm grateful to our team for the tremendous work you've done across our system. I'm looking forward to what 2025 is going to bring. I'm very excited.

So, I think that's going to do it for us today. Thank you again for joining us. Thank you, Dr. Nutter. Thank you, Dr. Joshi. Thanks everybody for listening. I'm Dr. Eric Mikaitis, CEO for Cook County Health, and this is Pulse Check.