Rethinking Mental Health Benefits for Traditionally Under-Served Groups: How One Organization Piloted and Scaled Two Innovative Mental Health Solutions Every year, 20% of people in the United States experience a mental health disorder. Yet, fewer than half will receive any treatment. Stigma prevents many people from ever seeking care. Those who do reach out to a provider often wait unacceptably long times for an appointment. Even individuals in ongoing treatment are unlikely to have their provider systematically measure their treatment outcomes. While these issues affect everyone in the United States, under-served communities are disproportionately impacted. One such group is professional caregivers. Caregiving is a stressful, low-wage occupation, and many caregivers live in rural areas without access to behavioral health clinics. Compared to the general population, caregivers are more likely to have experienced a high number of adverse childhood experiences (ACEs). ACEs are correlated with increased lifetime risks of physical and emotional health conditions. This talk discusses how SEIU 775 Benefits Group piloted and scaled two innovative mental health benefits for caregivers. The first is a mindfulness course offered to caregivers as continuing education credit. The course has been highly successful in reducing caregivers’ anxiety and depression symptoms, while also decreasing stigma. The second is Ginger.io, a HIPAA-compliant mobile app that provides caregivers with access to emotional health coaches via in-app chat, 24 hours a day, as well as video chat appointments with licensed mental health providers. This service has dramatically reduced caregivers’ wait times for mental health appointments. This talk will touch on a number of important issues for mental health innovators. How can we design mental health solutions that meet the needs of traditionally under-served communities? How do we talk about mental health in a way that increases engagement and reduces stigma? What are the best ways to measure success? And, how do we help populations with lower digital literacy access digital solutions?

1. Rethinking Mental Health Benefits for Traditionally Under-Served Groups:
How We Piloted and Scaled Two Innovative Mental Health Solutions
Rebecca Fraynt, PhD
HXD 4/3/19

2. Understanding the National Mental
Health Crisis

3. 3©2018 SEIU 775 Benefits Group. For internal use only.
Mental Health Problems are Common and Under-Treated
43.8 million
~17.5 million
~4 million
US adults with a diagnosable
mental health condition in
2015
US adults who got ANY form
of mental health treatment
US adults who will get
adequate mental health
treatment

4. 4©2018 SEIU 775 Benefits Group. For internal use only.
Vulnerable Communities are Disproportionately Impacted
65%
The number of
rural
communities
without ANY
psychiatrists1
14.5
years
The average length of time Asian
Americans and Latinos with limited
English proficiency wait before getting
mental health treatment2
25%
Number of people in the US
reporting that they can’t
afford treatment for both
their physical and mental
health conditions3

5. SEIU 775 Benefits Group Overview
Our population is greatly impacted by mental health
disparities

6. 6©2018 SEIU 775 Benefits Group. For internal use only.
What is the SEIU 775 Benefits Group?
Taft-Hartley trust that administers health, training, and secure retirement benefits to home care workers in
Washington state
• 50,000 home care workers who are part of the SEIU 775 union
• 18,000 of these workers are enrolled in our health benefits package

7. 7©2018 SEIU 775 Benefits Group. For internal use only.
Caregiver Demographics

8. 8©2018 SEIU 775 Benefits Group. For internal use only.
Characteristics of Caregiving as a Profession
• The starting wage for a professional caregiver inWA is $15/hr
• 80% of caregivers are independent contractors (IPs) whose employer of record is their client. IPs don’t
have a main office or supervisor.
They don’t have work email or a dedicated HR department.
They work in their clients’ home.
• 58% of caregivers report that their first client was a friend or family member.

9. 9©2018 SEIU 775 Benefits Group. For internal use only.
Mental Health Need is High in our Population
Survey Type Description Results
Exposure to Adverse Childhood Events
(ACEs)1
Linear relationship between ACEs exposure
and risk for negative physiological and
psychological health outcomes
HCAs were almost 2x more likely than
members in a general population survey to
have experienced 4 or more adverse
childhood events (ACEs)
Anonymous Depression Screener Over 12,000 screeners completed as of
April 2018
1 in 5 respondents report moderate to
severe depressive symptoms
Anxiety Screening Anxiety screener administered to random
sample of caregivers
50% had screening results suggestive of
some distress caused by anxiety symptoms
(20% had a likely anxiety disorders)
Internal survey work indicates that mental health problems significantly impact our population

10. 10©2018 SEIU 775 Benefits Group. For internal use only.
Caregivers Under-utilize Behavioral Health Services and
Have Low Access to Care
Health plan partner data shows that:
• Mental health services are under-utilized
Significantly less than 1% of our health plan members initiate specialty behavioral health
care per month
• Wait times are long
Average wait of 28 days to an initial treatment appointment

11. Solving this Problem Requires New
Thinking

12. 12©2018 SEIU 775 Benefits Group. For internal use only.
BG’s Philosophy for Solving Health Problems in Our
Population
• Use claims data, customer service complaints, etc. to identify areas of opportunity
• Use a combination of literature review, qualitative methods, service design approaches, and
survey data to gain a fine-grained understanding of the problem
• Pilot solutions at small scale to test for effectiveness
• Scale the most promising pilot solutions

13. 13©2018 SEIU 775 Benefits Group. For internal use only.
Step1:Talking to Home Care Workers About Barriers to Care
Focus Groups Mental Health Navigator Informant Interviews
Project Description Focus groups about caregiver
preferences re: mental health
communications
Two-month pilot phone line to help
caregivers schedule mental health
appointments through their health
plan
Conducted qualitative interviews
with 12 caregivers about their
behavioral health experiences
Main Findings • Desire for
asynchronous/text-based
communication*
• Confusion about available
resources*
• Stigma*
• Desire for peer community*
• Desire for asynchronous/text-
based communication*
• Relationship building is very
important to help motivate
caregivers to schedule
appointments
• Systems barriers
• Caregiving is a stressor*
• Confusion about available
resources*
• Desire for peer community*
• Stigma*

14. 14©2018 SEIU 775 Benefits Group. For internal use only.
Step 2:Thinking Holistically About What it was Important to
Design for
• One size doesn’t fit all – Creating a menu of options
Options for caregivers at different levels of clinical severity
Options for caregivers who cannot travel to care, either because of distance or schedules
• Providing caregivers with care exactly when they need it
Providing human contact almost immediately
Incorporating text messaging when possible
Decreasing wait times for clinical appointments
• Addressing stigma
Both in marketing collateral and program design
• Providing options that involve contact with a live person
Important from both a navigation and relationship-building perspective

15. 15©2018 SEIU 775 Benefits Group. For internal use only.
The Solution Menu
The Solution What it Looks Like Why it’s on the Menu
Mindfulness Courses 6 week, evidence-based course that caregivers can take for continuing
education credit
Offered primarily online in English and Spanish.
(May offer in-person options in future)
Provides a prevention option for people with low clinical
severity
Low stigma
Ginger Virtual behavioral health system that caregivers can download onto
their smartphone
Caregivers have access to an emotional wellness coach via in-app text
chat in less than 1 minute
Caregivers with higher levels of clinical need can access therapists and
psychiatrists through secure video chat
Care exactly when caregivers need it
Incorporates texting
Multiple levels of care
EAP 24-hour hotline caregivers and household members can call for
emotional support. Also provides practical support around finances
and child care
Offers a phone-based solution for caregivers uncomfortable
with digital technology.
Offers support for other household members

16. Spotlight on Mindfulness
Courses and Ginger

17. 17©2018 SEIU 775 Benefits Group. For internal use only.
Mindfulness Pilot to Scale Timeline
October 2016 We compared caregiver response to in-person, 6-week Tai Chi and
mindfulness courses
August 2017 Piloted a 6-week online mindfulness course. Offered caregivers 6 CE credits
for course completion
July 2018 Made mindfulness available to all caregivers as a regular CE course offering

18. 18©2018 SEIU 775 Benefits Group. For internal use only.
Mindfulness Program Results
Enrollment: ~500
Attended 1
Class: 310
Completed
Course: 248
One a scale of 1 to 10, how
likely are you to recommend
the course to others?
9.2/10
Results show sustained decreases in
anxiety and depression scores
Behavioral Health
Measure
Pre to post
class*
3-month
follow-up**
Anxiety (BAI) ↓ 16% ↓ 39%
Depression (CES-D) ↓ 20% ↓ 33%
Insomnia Severity (ISI) ↓ 21% ↓ 35%
Perceived Stress (PSS) ↓ 16% ↓ 20%

19. 19©2018 SEIU 775 Benefits Group. For internal use only.
Ginger Pilot to Scale Timeline
September 2017 While running a mental health navigation line, we spoke with a caregiver
in crisis and were unable get an urgent appointment for them
October 2017 Escalated this issue to our board of directors, who provided the green light
for testing solutions
December 2017 Offered the Ginger solution to 50,000 caregivers as part of limited-term pilot
June 2018 Decided to offer Ginger as an ongoing benefit to our caregivers

20. 20©2018 SEIU 775 Benefits Group. For internal use only.
Ginger Program Results
Sign Ups: 568
1 Text with
Coach: 339
25 Texts
with Coach:
189
Number of HCAs Using Clinical
Services: 40
Avg.Wait to First Appointment: 5.7
days
185 HCAs
completed a
PHQ-2
Service Avg. Stars
Text Coaching
(n = 172)
4.58
Video Therapy
(n= 56) 4.58
Video Psychiatry
(n= 15)
4.54

21. 21©2018 SEIU 775 Benefits Group. For internal use only.
Ongoing Challenges with Behavioral Health Programs
• Engagement in most of our programs remains low. Driving new sign-ups often involves costly, intensive,
in-person interventions
• There is also a significant drop from initial enrollment in a program and actual utilization
• Caregivers report difficulty navigating and understanding the difference between all the services
offered (as well as differing eligibility requirements)
• Few behavioral health services are offered in languages other than English
• Many caregivers report difficulty using digital tools
• Many caregivers report social isolation and concerns that non-caregivers will not understand their
unique life situation

22. 22©2018 SEIU 775 Benefits Group. For internal use only.
Next Steps
• Partnering with our Human Centered Design to examine how technology barriers may impact engagement with our digital
behavioral programs
• Partnering with our Human Centered Design team on a multi-phase analysis of other barriers to using Ginger
Low program awareness
Misunderstandings about the service
Low perceived need/stigma
• Partnering with University of Washington to better understand barriers to engagement with mental health services in
traditionally under-served groups
• Exploring healthcare navigation services for caregivers
• Exploring mental health services in languages other than English
• Exploring peer support group models
• Building a custom mindfulness curriculum tailored to caregiver needs and increasing the number of classes offered

23. ©2018 SEIU 775 Benefits Group. For internal use only.
Thank you
Rebecca Fraynt, PhD
SEIU 775 Benefits Group