Inspiring & Expanding the Psychiatric Workforce in Texas DRAFT - WHITE PAPER

ABOUT THIS WHITE PAPER This paper is intended to capture a high-level summary of the discussions, findings and recommendations generated by meeting participants during the interactive event, Inspiring and Expanding the Psychiatric Workforce in Texas. It is not intended to be fully descriptive of all the important conversations held by participants during the event. It is understood that the role of medical and psychiatric residency training programs in shaping the psychiatric workforce in Texas will be iterative and evolving, as the needs of patients and communities across the state change over time. ACKNOWLEDGEMENTS The development of this paper would not have been possible without the assembly of Texas educators who shared their valuable time, expertise, experience and recommendations for improving medical and residency training in Texas. (For a full list of participants see Appendix A to this paper.) A special thanks to UT Southwestern Medical Center Department of Psychiatry, Dr. Lindsey Pershern and Dr. Lia Thomas, for facilitating and hosting this event. A special thanks to the Meadows Mental Health Policy Institute for their financial support, leadership and guidance. A special thanks to the American Association of Community Psychiatrists for their group facilitation and sharing of their content expertise.

The following individuals contributed to the writing and editing of this white paper: Christie A. Cline, MD, MBA, Founder & President, ZiaPartners, Inc.; Director of Collective Impact, Meadows Mental Health Policy Institute Michael Flaum, MD, President, American Association of Community Psychiatrists; Clinical Professor of Psychiatry, University of Iowa. Kenneth Minkoff, MD, Senior System Consultant, ZiaPartners, Inc.; Director of System Integration, Meadows Mental Health Policy Institute; Clinical Assistant Professor of Psychiatry, Harvard University Lindsey Pershern, MD, Assistant Professor of Psychiatry, UT Southwestern Medical Center Lia Thomas, MD, Associate Professor of Psychiatry, UT Southwestern Medical Center Stephanie Smit-Dillard, LCSW, Project Manager, American Association of Community Psychiatrists

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Inspiring & Expanding the Psychiatric Workforce in Texas DRAFT - WHITE PAPER

CONTENTS Introduction ........................................................................................................................................... 3 Organization of the Meeting ............................................................................................................ 3 Meeting Participants ........................................................................................................................... 4 Summary of Findings and Recommendations ................................................................................. 5 Common Opportunities Identified ......................................................................................................... 5 Common Barriers Identified .................................................................................................................... 5

Summary of Small-Group Discussions .............................................................................................. 6 Creating Education Experiences for Medical Students and Residents ........................................... 6 Teaching Public Health, Population Management, and Performance Improvement .................... 8 Teaching Integrated Practice – Primary Care and Behavioral Health ....................................... 10 Strategies in Promoting Psychiatric Training Experiences with Underserved Populations....... 11 System-based Practice: Teamwork and Technology Skills ............................................................ 12

Action Plan ......................................................................................................................................... 13 Concluding Remarks ......................................................................................................................... 15 Appendix A ....................................................................................................................................... 16

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Introduction While psychiatric training programs have increased in size in Texas, the supply of mental health professionals is still not keeping pace with the state’s growing and diverse population. In 2014, 206 of Texas’ 254 counties were designated as mental health professional shortage areas, with fewer than one mental health clinician per 30,000 individuals. In 2013, 10.5 percent of the Texan population lived in counties with no psychiatrist. These shortages are compounded by the fact that the psychiatric workforce in Texas is aging, with 24 percent of active psychiatrists aged 65 or older. 1 Psychiatric medical education and residency training have clear roles to play in addressing the psychiatric workforce shortage in Texas by exposing students and residents to diverse, rewarding and sustainable training opportunities in psychiatry. Curriculum that emphasizes innovative models of care, including team-based and integrative practice that focuses on providing care to individuals in the context of their communities, will attract new students into the field and inspire residents to remain as practitioners in Texas. Residents who take part in care provision along the acuity spectrum, serving patients both where and when it is needed, will be exposed to a field of practice that is current and meaningful, while affording a high quality of life for the practitioner. When we promote these kinds of training opportunities, medical students and residents will be incentivized to make Texas their long-term home. This interactive event provided an opportunity for leaders in psychiatry education, policy and training from state and local systems across Texas to network and share ideas for aligning psychiatric medical education with community need, and creating a system of training that promotes growth in the state’s psychiatric workforce. With guidance from national experts of the American Association of Community Psychiatrists (AACP), and the American Psychiatric Association (APA), discussants identified innovative approaches along with a set of recommendations for furthering community psychiatric education in Texas to meet the needs of Texans, particularly those who need help the most.

Organization of the Meeting This meeting was organized through a joint effort by the UT Southwestern Medical Center Department of Psychiatry (UTSW), Meadows Mental Health Policy Institute (MMHPI) and the American Association of Community Psychiatrists (AACP). The goal of organizers was to convene an assembly of Texas educators that represented the full diversity of Texas public mental health services and Texas medical schools. The organizers were determined that this resulting white paper would be the product of a “grassroots” effort by Texans from every geographic region and healthcare system. The meeting was facilitated by Drs. Lindsey Pershern and Lia Thomas of UT Southwestern Medical Center and consisted of a series of targeted small-group discussions centered around topics that had been pre-

Department of State Health Services. (2014). The Mental Health Workforce Shortage in Texas: As Required by House Bill 1023, 83rd Legislature, Regular Session 1

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Inspiring & Expanding the Psychiatric Workforce in Texas DRAFT - WHITE PAPER

selected by Texas education and training leaders. Meeting attendees participated in the small group discussion of their choice. Discussions were facilitated by an AACP national leader. Topics covered in small group discussion were as follows: Creating educational experiences for medical students and residents Strategies in promoting psychiatric training experiences with underserved populations Teaching integrated practice: primary health and behavioral health Teaching public health, population management, and performance improvement System-based practice: teamwork and technology skills Small groups discussants were invited to consider these topic areas within their own institution or program, as well as within the broader local or state context, using the lens of a SWOT analysis (Strengths, Weaknesses, Opportunities, Threats). Discussants were prompted to make recommendations on actionable goals and concrete next steps for their respective topic area. Findings from each group were shared with the broader group for comments, questions and larger discussion.

Meeting Participants There were 76 meeting participants from public psychiatric training programs; hospital programs; community psychiatry programs; and government, policy and advocacy programs from across the state and nationally. The following Texas organizations/programs were represented: • • • • • • • • • • • • • • • • •

Areté Community Psychiatry Solutions Baylor College of Medicine Community Healthcore Dell Medical School, UT Austin The Harris Center for Mental Health and IDD Hogg Foundation for Mental Health Humana Behavioral Health John Peter Smith Health Network McGovern Medical School, UT Houston Meadows Mental Health Policy Institute Metrocare Services National Alliance on Mental Illness, Dallas Texas A&M College of Medicine Texas Health and Human Services Commission Texas Tech University Health Science Center, Lubbock and El Paso University of Texas Health Northeast University of Texas Health Science Center, San Antonio

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•

University of Texas Rio Grande Valley School of Medicine

For a full list of meeting participants see Appendix A.

Summary of Findings and Recommendations The following opportunities for and barriers against the advancement of psychiatric education were consistently identified by meeting participants across all small group topic areas. Note: Throughout this paper, we will discuss opportunities in undergraduate medical education and graduate medical education. Where applicable, we will use the terms “resident” and “medical student” specifically, but intend to highlight opportunities and strategies that may impact any level of learner. COMMON OPPORTUNITIES IDENTIFIED Create a system for partnership, collaboration and sharing between psychiatric educators across the state through achieving the following goals:   

Create regular meeting opportunities (in-person and/or virtual) for program directors, clerkship directors and other psychiatry education leaders. Be a platform to identify existing, shareable resources across the state. Develop cross-cutting community-oriented psychiatric curriculum for the state of Texas.

Increase resident and medical student engagement with diverse training opportunities that align with community health needs, to include training opportunities in:      

Community psychiatry Administration and leadership Primary care integration Population health State hospitals Forensic programs

Increase longitudinal learning experiences that emphasize ongoing relationships with patients as they move within and between systems, and allow students and residents to interact with patients along the acuity spectrum. Teach outcome-focused and measurement-based care that uses data about individuals and communities to drive care decisions. COMMON BARRIERS IDENTIFIED

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Financial barriers that impede the development of innovative residency placements: 

There are financial incentives for inpatient settings to retain their residency placements: residents act as additional members of the workforce.  In contrast, there is limited financial viability of residency placements in community-based and other settings—the current funding model for residency positions in all specialties is based on support from Centers for Medicare & Medicaid Services (CMS), which is strongly targeted to hospitals. This points to a need for innovative strategies for developing sustainable funding streams for community-based residency training.  There is an emphasis on revenue generation that has the effect of eroding the teaching mission, as clinical staff are pressed to find dedicated teaching time. Inconsistent resident exposure to practicing psychiatry leaders who model and reinforce excitement and inspiration in public and community psychiatry settings, along with inconsistent evidence of strong professional quality of life practicing in these settings. Funding structures which create relatively low compensation for psychiatrists, particularly those working in public settings, compared to other specialties. Relative lack of psychiatrist leadership in government agencies responsible for health, behavioral health, and human services which makes it harder for needed changes identified on the front line to be addressed at the policy level.

Summary of Small-Group Discussions The following descriptions of needs and opportunities in the advancement of psychiatric education were identified by meeting participants within their respective small-group topic areas. CREATING EDUCATION EXPERIENCES FOR MEDICAL STUDENTS AND RESIDENTS The current balance of clinical experience for trainees weighs heavily towards acute inpatient hospital units. This is in part a historical remnant of an era in which hospitals were indeed the primary locus of care for a significant portion of the most seriously mentally ill, but it no longer reflects where most of psychiatry really takes place today, and likely even less so in the future. It also perpetuates and reinforces a problem-based vs. strength-based view. Students considering career choices and residents just starting out spend most of their time with psychiatric patients who are in crisis or doing the most poorly. As a result, they get relatively few opportunities to see what good outcomes look like, even among the most severely ill. Early trainees should be spending more of their formative time in settings in which recovery-oriented mental health care is incorporated as a part of other services, including primary care, addiction, criminal justice, housing and employment services.

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Moving from standard inpatient experiences and office-based medication management and psychotherapy to community-based, population health, and team-based care in a variety of practice settings:        

Primary care Crisis stabilization/mobile crisis programs Homeless shelters and supported housing programs Jail or criminal justice systems High system utilizer programs First-episode programs State psychiatric hospital system VA system

Promote longitudinal clinical experiences in recovery-oriented practice with individuals along the spectrum of acuity, emphasizing to trainees that inpatient hospital stays occur at a time of crisis for patients and are not reflective of how they live in the community. Longitudinal experiences with people who have serious mental illnesses and/or substance use disorders will also allow trainees to develop trusting and engaging therapeutic relationships with patients who are most in need of ongoing psychiatric care. Develop/gather evidence showing that physicians who have more community involvement in medical school and residency take jobs in community organizational settings. Support a shift in philosophy and practice such that trainees are primarily treated as learners, and not simply as an expansion of an agency/ program’s workforce:   

Consider documentation time demand placed on residents and challenges with electronic medical records directing trainees’ attention away from patients during clinical interviews. Consider the balance of education with clinical responsibilities. Consider limiting the number of patients that residents see so they can have designated time for reflection and learning from their patients such that patient well-being is maximized.

Support policy changes that allow for more flexible training placements both in hospitals and in community settings. This may include time spent in mobile crisis/treatment teams, home visits for homebound patients, time spent in community-based not-for-profit behavioral health programs, and other systems in the community that provide behavioral health care, such as the criminal justice system and veterans system, and providing home visits for homebound patients. Support ongoing faculty development and training, including protected time for teaching, to provide current, relevant learning experiences which will help trainees to receive enhanced supervision in systems based practice and recovery oriented care .

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Existing curricula (e.g., Recovery to Practice 2) can be developed as cross-cutting statewide materials, along with experiences, and resources (e.g., Recovery Library 3) that are easily accessible to residents and medical students. Given the limited availability of community psychiatry experts, teams of multidisciplinary educational consultants can be used statewide to enhance learning content, promote teamwork and align roles. Enhanced partnership with other mental health disciplines (e.g., physician assistants, nurse practitioners, social workers) can be leveraged to promote resident participation and leadership in multi-disciplinary teams, and to create integrative learning and work experiences that create complementarity in roles and responsibilities. Consider use of innovative roles (e.g., medical scribes) to balance trainees’ administrative responsibilities by freeing up time to provide direct patient care. Leverage psychiatric residency training expertise to teach primary care physicians, and vice versa, and create opportunities for mutual learning about integrated care. Residents and medical students can learn from faculty role-modeling on how to coach patients, and teaching the psychiatrist’s role in the community. This type of exposure to psychiatry can and should start early—beginning with medical students. TEACHING PUBLIC HEALTH, POPULATION MANAGEMENT, AND PERFORMANCE IMPROVEMENT An essential feature of psychiatric/medical training is thinking at a systems level, learning to examine the health of communities and various populations to identify and find solutions to public health needs and broadly improve health outcomes. To serve this purpose, students, residents and junior faculty need exposure to the strategies and tools used to support decision-making at a systems level. Many important areas of study and experience need to be incorporated into a modern education, such as epidemiology, population management and continuous quality improvement, with its associated use of data that informs change processes. As well, the systems approach to healthcare requires “hands-on” experience to truly understand public health strategies and to learn how to use the various tools that are available. While there are some opportunities for students and trainees to learn and participate in this arena of healthcare, these are limited and not a matter of course for all. This should become a standard part of training in psychiatry and across all primary care fields. American Psychiatric Association, Recovery-Oriented Care in Psychiatry Curriculum: https://www.psychiatry.org/psychiatrists/practice/professional-interests/recovery-oriented-care/recovery-oriented-care-inpsychiatry-curriculum 3 Pat Deegan, PhD & Associates, LLC, Recovery Library: https://recoverylibrary.com/ 2

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Encourage more opportunities for residents to observe, shadow, and work in administrative settings and with key policy leaders and within the public health system, and health payer organizations. Support resident and medical student participation in existing quality improvement initiatives and committees in hospital, community and government settings. Expand development of curricula materials to include:      

Social determinants of health Structural inequities Improvement science (IS) Service funding and service prioritization processes Data and statistics related to process and performance improvement (distinct from statistics for clinical research) Community and population health

Advocate for these curriculum materials to be reflected in the standards set by credentialing bodies and in assessment processes. Increase the number of qualified or interested faculty and medical leadership within this area by demonstrating that population health is a sustainable area of practice. Expand faculty to include other health system providers, payers and administrators. Support enhanced faculty development, especially in public health, population health, and IS.

There are existing ACGME Requirements for all residents to learn about quality improvement and improvement sciences, and an opportunity for this to be pursued more consistently in Texas. There is availability of research time in most residencies and medical student training programs and resources for population-based and systems research that could benefit residents, medical students and the institution. Outcomes data and socioeconomic data are already available in many systems. Access to these data could enhance resident learning experiences and tune them in systems-based thinking. Residents can engage with existing QI committees at agencies/hospitals. There should be a psychiatry resident representative on each behavioral health related QI committee. There are opportunities to work with the LMHAs, Hospital Districts, and MCOs (or similar organizations) that are managing the care and funding within state regions. These could provide valuable learning opportunities in population health and public health.

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There are existing systems that are more organized around certain populations (e.g., VA, Medicaid health plans) that could also be good training settings. These may also include mobile outreach teams and other community-based services, corrections and schools. TEACHING INTEGRATED PRACTICE – PRIMARY CARE AND BEHAVIORAL HEALTH Residents and medical students across disciplines need training experiences that include an integrated behavioral health/primary care model. This model emphasizes interdisciplinary teamwork, community collaboration, coordination of services and recovery-oriented care. These skills can be acquired through use of bi-directional integrated care experiences that partner the expertise of primary care and psychiatric practitioners. This integrated learning should take place throughout the course of training programs.

Create a consistent requirement across the state that all residency programs provide an integrated primary care/behavioral health care (PCBH) experience. Advocate that this be a bidirectional training requirement (i.e., primary care practitioners also complete psychiatry rotations). Create ongoing opportunities for primary care, psychiatry, internal medicine and other medical disciplines to learn and work together during their respective residencies. Employ team-based care to address workforce shortages that result when residents leave an inpatient unit for the community, creating fewer disincentives for promoting community-based placements. Promote “behavioral health” approach to psych-residencies in primary care practices, in response to the recent trend of primary care residency review committees towards removing specialized psychiatry training from their programs, in favor of behavioral-health-focused training. Promote faculty development in teaching and supervision of PCBH.

There is appetite to pursue partnerships with federally qualified health centers. Medicaid (1115) waivers can be leveraged to expand PCBH competency among trainees. Partnerships with VA primary care clinics, the justice system, community care organizations, patient safety organizations, pediatrics and government agencies can be explored. Primary care practitioners can be promoted as expert consultants in behavioral health residencies, and vice versa. There are existing examples of creative placement experiences that can be compiled and shared statewide.

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There is existing evidence showing improved outcomes related to PCBH integration that can be collected and disseminated. STRATEGIES IN PROMOTING PSYCHIATRIC TRAINING EXPERIENCES WITH UNDERSERVED POPULATIONS Developing exciting and rewarding training experiences in underserved areas, both rural and urban, is a critical priority for helping to attract psychiatrists to the settings in which they are most needed. Many of those strategies are aligned with efforts that are identified in other areas of this report: create recoveryoriented experiences, embed training in primary health settings, focus on teamwork, and expand exposure to tele-psychiatry. However, there are some areas of emphasis that are recommended to assist in addressing the most challenging workforce shortages. The value of team and community relationships is even stronger in the areas in which community psychiatrists are most isolated. In addition, projecting the positive presence of the academic center of excellence is particularly vital in the most underserved areas.

Promote stronger incentives for trainees and practitioners to practice in rural areas (financial, social, cultural). Develop meaningful opportunities for trainees to be embedded in communities and work as members of a team, to provide high-quality clinical care for patients (i.e., beyond 15-minute med checks). Promote tele-psychiatry as a core skill-set in residency training, and leverage this to engage remote and underserved areas. Promote ongoing statewide support for professional development and investment in learning for rural community psychiatrists to address potential sources of burnout that may be more common in this practice setting, such as relatively increased caseloads, generalist practice that may detract from specialization, relatively fewer psychiatry peers in the practice setting, increased challenges with maintaining patient confidentiality and privacy. Address resource shortages and fewer service options for psychiatrists practicing in rural areas through teamwork and telehealth. Promote the development of stronger physician leaders in community mental health centers in rural areas.

Marketing of rural placements can be enhanced by highlighting the following unique opportunities they afford residents: 

Rural placements serve communities of highest need—appealing to residents’ commitment to social justice and advocacy.

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   

Rural placements offer generalist training opportunities. Rural placements offer strong diversity in clinical population. Rural placements offer many opportunities to participate in and lead multi-disciplinary teams. Rural placements allow for a greater population health perspective.

Tuition repayment plans and other financial incentives, such as a lower cost of living, can be leveraged to grow placements in rural psychiatry practice. For example, Senate Bill 239 (SB 239), which passed in the 84th Texas Legislative Session, created a program that provides up to five years of student loan repayment assistance to mental health providers working in Mental Health Professional Shortage Areas (MHPSAs). Data on the relative efficacy of these types of financial incentives should be collected and disseminated. Academic partnerships that leverage the branding, expertise and supervisory resources of academic medical centers/institutions can be explored to promote rural/underserved sites as destinations for professional learning and growth. Specifically, a hybrid model in which academic medical centers supervise community clinics can be explored. Existing resources and trainings in best practices in the provision of tele-psychiatry can be leveraged, along with partnerships with national leaders, to grow tele-psychiatry as a core skillset for rural-practicing residents. Use of multi-disciplinary teams can be leveraged to effectively distribute the tasks of casemanagement between team members. SYSTEM-BASED PRACTICE: TEAMWORK AND TECHNOLOGY SKILLS Future psychiatrists will need skills working both in interdisciplinary teams and inter-professional collaborations. Intra-agency collaboration and resource management are key to the provision of care across wide arenas. Telehealth technology is likely to take an ever-expanding role in the delivery of mental health care; residents need to be supported to learn evolving technological innovations in care.

Adopt tele-psychiatry as a core skill set in all residency training programs. Utilize tele-psychiatry technology to facilitate team participation as well as direct service provision. Promote a more consistent understanding of the roles and responsibilities of members of the care team, and how risk can be shared across the team. Enhance training in team concepts/team dynamics and how to function as a member of a multidisciplinary team, as well as how lead such a team most effectively and efficiently.

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Working in a team is a teachable skill that can be addressed through residency and medical student training opportunities. Make use of existing models: tele-psychiatry, mobile crisis units, ACT teams. Employ the current lack of resources as a rationale for the imperative of expanded technology use, and working in multi-disciplinary teams. Complementary roles and responsibilities mean that psychiatrists, who are the most expensive members of the team, will be used in an efficient and effective way.

Action Plan Incorporating the themes and discussions above, the following action plan was developed, including concrete, actionable next steps in promoting the advancement of the psychiatric workforce in Texas. 1. Identify and enhance partnerships in Texas psychiatric medical education

Short term (i.e., within 1 year): Create a list-serve for ongoing communications between meeting participants from Inspiring and Expanding the Psychiatric Workforce in Texas. Seek ongoing consultation and guidance from the Texas Psychiatry Chairs Group. Create a network of medical leaders and medical directors working in community mental health settings. Develop list of current and additional partners and collaborators, and a plan for how they can be engaged on an ongoing basis, e.g.:        

National residency review committee Texas Psychiatry Chairs Group Texas Medical Association Texas Association of Psychiatric Physicians Texas Association of Community Health Plans Texas Council of Community Centers Texas Hospital Association Meadows Mental Health Policy Institute

Intermediate term (i.e., within 1-3 years): Convene a regular meeting of statewide residency training directors and psychiatry medical educators. Page 13

Inspiring & Expanding the Psychiatric Workforce in Texas DRAFT - WHITE PAPER

2. Develop enhancements in psychiatric medical education, as follows: Short term (i.e., within 1 year): Survey residency programs across Texas on the availability and quality of existing training programs and supervision experiences for medical students and junior (1 st and 2nd year) psychiatry residents that offer learning opportunities in the topic areas reviewed in this consultation. Compile results. Develop a listing and description of these placement opportunities and disseminate this to the Texas Chairs group and to the statewide psychiatric educators group. Identify at least one faculty member in each training program to take the lead of promoting training and supervision/mentorship opportunities in each of the four topic areas identified. Intermediate term (i.e., within 1-3 years): Based on survey results, identify the qualities of each placement that contribute to its viability and attractiveness. (i.e., what experiences/settings are found to be most useful, inspiring, interesting etc. by trainees?). Distribute results to the Texas Chairs group and to the statewide psychiatric educators group. Based on survey results, begin to develop a modifiable/flexible set of curriculum, resources and tools for each of the four topic areas available for use by psychiatric residency programs across the state. Support each medical school to adapt or develop at least one new placement opportunity in each of the four identified topic areas for medical students and/or junior residents, incorporating lessons learned from the quality evaluation. Identify at least one mechanism in each program for expanding provision of community psychiatry mentorship, supervision, consultation experience and teamwork experience both directly and through telecommunication. Identify methodology for evaluating and improving the quality and outcome of these placements. Long term (i.e., > 4 years): Expand the number of residency placements across the state, specifically those that enhance learning in the four topic areas identified. Finalize a statewide toolkit and curriculum for all training programs across the four topic areas. Promote additional contract incentives for practice settings (LMHAs and FQHCs) to dedicate resources to trainees interested in placements that enhance learning in the four topic areas.

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Develop a methodology for regular reporting on program success in achieving targets for trainee and faculty involvement in community-based psychiatry training. Shift the balance of early psychiatric training exposure so that inpatient is less heavily weighted relative to various community-based, population health, and integrated care experiences.

Concluding Remarks The findings of this white paper attest to the power of partnership and collaboration amongst medical and residency training programs in addressing the psychiatric workforce shortage in Texas. While regional variations in community need mean there can be no one-size-fits-all approach, it seems clear that there is an opportunity for training programs to learn from each others’ strengths, successes and failures and to share resources towards the common goal of building a psychiatric workforce that meets the needs of Texans across the state. The expertise, passion and commitment exists to make Texas a leader in psychiatric education nationally, and to attract skilled trainees and residents from across the country.

For questions about the content of this White Paper, please contact:

Lindsey Pershern, MD Assistant Professor of Psychiatry, UT Southwestern Medical Center: [email protected] Lia Thomas, MD, Associate Professor of Psychiatry, UT Southwestern Medical Center: [email protected]

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Appendix A Leaders in psychiatry education and training in Texas: Osman Ali, MD, Assistant Professor of Psychiatry, UT Southwestern Medical Center James Baker, MD, MBA, Associate Chair of Clinical Integration and Services, Associate Professor Psychiatry UT Austin, Dell Medical School Sarah Baker, Psychiatry Resident, UT Southwestern Medical Center Adam Brenner, MD, Associate Professor of Psychiatry, Distinguished Teaching Professor, and Vice Chair for Education in Psychiatry, UT Southwestern Medical Center Ushimbra Buford, MD, Assistant Professor/Associate Program Director General Psychiatry Program, University of Texas Health Science Center at Tyler John Burruss, MD, Chief Executive Officer, Metrocare Services Pushpi Chaudhary, MD, Associate Professor of Psychiatry, UT Southwestern Medical Center Sherry Cusumano, MS, RN, LCDC, President, National Alliance on Mental Illness, Dallas Gabriel A. de Erausquin, MD, PhD, MSc, Professor and Founding Chair Department of Psychiatry and Neurology Director of the Division of Neurosciences, University of Texas Rio Grande Valley School of Medicine Cecilia De Vargas, MD, Associate Professor, Director for the Child and Adolescent Fellowship Program, Director for the Child and Adolescent Inpatient Unit, El Paso Psychiatric Center, Texas Tech University Health Sciences Center Arden Dingle, MD, Psychiatry Residency Program Director, Professor of Psychiatry, University of Texas Rio Grande Valley School of Medicine Michael Escamilla, MD, PhD, Scientific Director Professor, Department of Psychiatry, Texas Tech University Health Sciences Center Dina Hooshyar, MD, Assistant Professor, UT Southwestern Medical Center Hisham Ibrahim, MD, Associate Professor of Psychiatry, UT Southwestern Medical Center Iram Kazimi, MD, Assistant Professor, Department of Psychiatry and Behavioral Sciences, Residency Training Director, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas, Houston Daryl Knox MD, Medical Director, The Harris Center for Mental Health and IDD, Houston Jessica Koenig, MD, Psychiatry Resident, UT Austin, Dell Medical School Octavio N Martinez, MD, Executive Director, Hogg Foundation for Mental Health, UT Austin

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Gregory R. Montoya, MD, Psychiatrist, Community Healthcore, Texarkana Nina Jo Muse, MD, Medical Director for Behavioral Health, Texas Health and Human Services Sylvia I. Muzquiz-Drummond, MD, Clinical Assistant Professor of Psychiatry & Behavioral Sciences, Baylor College of Medicine Jessica Nelson, MD, Assistant Professor of Psychiatry, Texas Tech University Health Sciences Center Lubbock Carol North, MD, Professor of Psychiatry, UT Southwestern Medical Center Kehinde Ogundipe MD, Assistant Professor of Psychiatry, UT Southwestern Medical Center John M. Oldham, MD, MS, Professor and Interim Chair of the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine Lindsey Pershern, MD, Assistant Professor of Psychiatry, UT Southwestern Medical Center Alan L. Podawiltz, DO, MS, FAPA, Chair of Psychiatry, JPS Health Network Carolyn Rekerdes, MD, Community Psychiatrist, Areté Community Psychiatry Solutions Jane Ripperger-Suhler, MD, Assistant Professor of Psychiatry, UT Austin, Dell Medical School Dr. Rafael Ruiz, MD, Regional Mental Health Medical Director, Texas Tech University Health Sciences Center, Correctional Managed Health Care Rachel Russo, MD, Assistant Professor of Psychiatry, UT Southwestern Medical Center Cynthia Santos, MD, Director, Child & Adolescent Psychiatry Fellowship Program; Clinical Professor, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas, Houston Jason Schillerstrom, MD, Director of Psychiatry Residency Training, Associate Professor, The University of Texas Health Science Center at San Antonio Michael Schwartz, MD, Clinical Professor, Psychiatry and Joint Professor, Humanities in Medicine, Texas A&M College of Medicine Asim Shah, MD, Professor & Vice Chair for Community Psychiatry, Menninger Department of Psychiatry, Baylor College of Medicine Rie Sharky, MD, Psychiatry Resident, UT Southwestern Medical Center Andrea Stolar, MD, Director of Residency Education, Associate Professor Psychiatry & Behavioral Sciences, Baylor College of Medicine Lia Thomas, MD, Associate Professor of Psychiatry, UT Southwestern Medical Center

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Dawn Velligan, PhD, Chief, Community Recovery Research and Training (CRRT), Professor of Psychiatry, University of Texas Health Science Center San Antonio Sidarth Wakhlu, MD, Associate Professor of Psychiatry, UT Southwestern Medical Center Jeffrey Matthews, MD, Associate Professor and Chair, Residency Training Director, Psychiatry and Behavioral Health, UT Health Northeast

Participants from Meadows Mental Health Policy Institute Andrew Keller, PhD, President & Chief Executive Officer, Meadows Mental Health Policy Institute John P. Petrila, JD, LLM, Vice President of Adult Mental Health Policy, Meadows MH Policy Institute Phil Ritter, JD, MPA, Chief Operating Officer, Meadows Mental Health Policy Institute Jacqualene Stevens, PhD, Director of Systems Transformation, Meadows Mental Health Policy Institute

Facilitators from Meadows Mental Health Policy Institute & the American Association of Community Psychiatry Christie Cline, MD, MBA, Founder & President, ZiaPartners Inc.; Director of Collective Impact, Meadows Mental Health Policy Institute Kenneth Minkoff, MD, Senior System Consultant, ZiaPartners, Inc.; Director of System Integration, Meadows Mental Health Policy Institute; Clinical Assistant Professor of Psychiatry, Harvard University Consultants from the American Association of Community Psychiatry Curtis Adams, MD, Professor of Psychiatry, University of Maryland Medical Center Margie Balfour, MD, Chief Clinical Officer, Crisis Response Center; VP for Clinical Innovation and Quality, Connections AZ; Assistant Professor of Psychiatry, University of Arizona Maggie Bennington-Davis, MD, Chief Medical Officer, Health Share of Oregon Anthony Carino, MD, Medical Director for Psychiatry, Project for Psychiatric Outreach to the Homeless, Janian Medical Care Peter Chien, MD, Medical Director, Acute Recovery Center, Edward Hines, Jr. Veterans Affairs Hospital; Assistant Professor, Department of Psychiatry and Behavioral Neurosciences, Loyola University Michael Flaum, MD, President, AACP; Clinical Professor of Psychiatry, University of Iowa

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Inspiring & Expanding the Psychiatric Workforce in Texas DRAFT - WHITE PAPER

Liz Frye, MD, Director of Psychiatry and Street Medicine at an FQHC in Atlanta Stephanie Le Melle, MD, Co-Director of Public Psychiatry Education; Associate Clinical Professor, Department of Psychiatry, Columbia University/NY State Psychiatric Institute Paula Panzer, MD, Chief Clinical and Medical Officer, The Jewish Board, Health and Human Services for all New Yorkers David Pollack, MD, Professor for Public Policy, Oregon Health and Science University Lori Raney, MD, Principal, Health Management Associates; Editor, The Psychiatrist’s Guide to Integrated Care: Working at the Interface of Primary Care and Behavioral Health John Santopietro, MD, Chief Clinical Officer & Chair of the Department of Psychiatry , Carolinas HealthCare System; Adjunct Professor of Psychiatry, UNC School of Medicine Wes Sowers, MD, Clinical Professor of Psychiatry, University of Pittsburgh Medical Center; Director, Center for Public Service Psychiatry, Western Psychiatric Institute and Clinic Ken Thompson, MD, Chief Medical Director, Pennsylvania Psychiatric Leadership Council; President of American Association for Social Psychiatry William C. Torrey, MD, Professor and Vice Chair of Clinical Services, Dartmouth’s Geisel School of Medicine Sarah Vinson, MD, Assistant Professor of Psychiatry and Pediatrics, Morehouse School of Medicine; Adjunct Faculty, Emory School of Medicine Rachel Zinns, MD, Medical Director of ePsychiatry and Chief of Outpatient Behavioral Health, Westchester Medical Center, Assistant Professor of Psychiatry, New York Medical College.

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