Good morning, early Saturday morning, everyone. How's everyone feeling? I don't believe you. How's everyone feeling? Who's excited to talk about health disparities at 8 a.m. on Saturday? We're really pleased to be here. My name is Madhuri Jha. I am the director of the Kennedy Satcher Center for Mental Health Equity at Morehouse School of Medicine. It's a pleasure to be with you. I'm going to let my esteemed colleagues also introduce themselves, and we'll talk you through what we're going to present to you today. Good morning. I'm excited to be here, and it's good to see each of you. I'm Dr. Dawn Tyas, the director and principal investigator of the African American Behavioral Health Center of Excellence at Morehouse School of Medicine. Good morning. I'm sure I don't need the mic, but I'm going to. I am Mary Rory. Dr. Mary Rory, I am the director of the Office of Behavioral Health Equity at SAMHSA. Good morning. Welcome. And my name is Sosamolo Shoinka. I'm chief medical officer for the Department of Behavioral Health and Intellectual Disability Services. That's the county mental health authority for the city of Philadelphia. I'm also one of the co-creators of the SMART tool, which we'll be talking about today. So we are going to kick off with a case that's going to carry you through this presentation. Prior to my appointment at Morehouse School of Medicine, I was the director of an assertive community treatment team. If there's anyone here who doesn't know what ACT is, it's the most intense outpatient community treatment you can receive outside of an inpatient unit. It's 24-7 wraparound care with a 14-person interdisciplinary mobile unit that works with folks with serious mental illness. All of those patients have failed previous mental health interventions. They're usually flagged by a Department of Health and they're referred to an ACT program for services. So I was an ACT provider and an ACT director during COVID-19. So we're going to utilize a case. We will call him Patient S. I'm going to describe the case to help set a framework for our presentation today. So Patient S is a 28-year-old male of Puerto Rican descent diagnosed with schizoaffective disorder and polysubstance use. He has addiction-related dependence on opioids and heroin, multiple relapses with pharma-seeking behaviors for Klonopin and was receiving a biweekly injection of Zyprexa relprev mandated by Assisted Outpatient Treatment for services after multiple arrests related to psychiatric decompensation. AOT is a legal mandate that exists in almost every state, likely named after someone who was killed by someone who had serious mental illness that was decompensated. In New York it's called Kendra's Law. Kendra was someone who was pushed onto train tracks, unfortunately by someone who was having a psychotic episode. Due to childhood trauma associated with sexual abuse and the suicide death of his brother during onset of schizoaffective symptoms, Patient S carried a lot of rage towards his mother. When decompensated, he would become violent with her, which led to a precinct-enforced restraining order in her favor, rendering him homeless. When COVID hit, shelter placements and resources were strapped in New York City. As you all know, it was the epicenter. We were pretty decimated with our resources and our availability for services. It became increasingly hard for us to manage clients. He became a patient for us that was very, very hard to support in the community. Patient S had multiple near-death overdoses as the epidemic progressed. He became a client we started to say had nine lives. He started showing signs of severe weight loss. He was very difficult to engage. He was increasingly agitated. When experiencing withdrawal and unable to locate for medication adherence, his decompensation would lead him back to his mother's home, where he would become agitated, combative with his stepfather, often found sleeping in her hallway, likely because he was feeling sad that he wasn't able to be with his mom. Unfortunately, Patient S was arrested and sent to Rikers Prison for repeated violations of that precinct-enforced restraining order. We learned he tested positive for COVID-19 there and was placed in a converted psych ICU at Elmhurst Hospital in Queens, where he struggled to stabilize both physically and mentally and was hospitalized for a very long period. We're going to stop the case at that point. We'll revisit Patient S in a little bit, but I'm going to take it over to Dawn Tyus, who's going to bring us our next part of our presentation. Good morning once again. I'll be talking about and laying the foundation around the historical context of mental health disparities in the United States. You know, we can't talk about historical, talk about health disparities without really looking at the historical context of that. So I do apologize. When you think about history, you know, it's very wordy, so I'm just going to go through the slides. But as we're going through the slides, we want to make sure that you're paying attention that the incidents, the issues that Patient S incurred, they didn't just start today. There's been a long history of this in the United States, which has perpetuated a lot of these mental health disparities. This is the history of racial disparities in mental health. Our history has really laid the groundwork for some very stark and persistent racial disparities that still exist in the U.S. today. People with mental illnesses were discriminated against, they were denied full participation in society, and labeled as dangerous and criminal, as you heard Madhuri's story. Many were locked in institutions that acted more like prisons designed to punish them than hospitals that were designated and designed to treat them. The historical dehumanization, oppression, and violence against black and African-American people have evolved into present day what we call racism around structural, institutional, and individual racism. And it really cultivates a uniquely mistrustful and less affluent community experiences for individuals, experiences characterized by a myriad of disparities, including inadequate access to and delivery of care in the health system. Historical adversity, which includes slavery, sharecropping, and race-based inclusion from health, educational, social, and economic resources, translated into what we call now those socioeconomic disparities, which were experienced by black and African-Americans. Socioeconomic status, in turn, is really linked to the mental health, people who are impoverished, homeless, incarcerated, or have substance use problems, or at a higher risk for poor mental health services. Overall, the mental health conditions occur in black and African-American people in America at about the same or less frequency than in white Americans. However, the historical perspective that African-Americans have experienced in America has and continues to be characterized by the trauma and violence that's often been inflicted by the white counterparts, which truly impacts their emotional and mental health among youth and adults. There have been centuries which started with enslavement, freedom from the Civil War, a great promise made amend the political turn of reconstruction, and a great promise broken followed by disenfranchisement, segregation, and finally, the long struggle for equality. All of these created racial disparities that affected the mental health of black and African-Americans. I put together just this chart so that you can see that there has really truly been a long history, back all the way to slavery, the Jim Crow era, the Great Migration, civil rights, and then even the post-civil rights, all played a part in the mental health disparities that African-Americans are still incurring today. For centuries, racial disparities or unfair practices within the system of mental health have been documented. Black and indigenous people and people of color, they were less likely to have access to mental health services, less likely to seek out services, less likely to receive needed care, less frequently used in research, more likely to receive poor quality of care, and more likely to end their services prematurely. That is still incurring today. African-Americans were often unfairly misdiagnosed, underdiagnosed, and even in some cases, not diagnosed at all for mental health issues. Blacks suffer institutional, medical, scientific, and structural racism. The rates of mental illnesses in African-American are similar with those of general population. However, the disparities exist regarding mental health care. Black men were four times more likely than white men to be overdiagnosed with schizophrenia while underdiagnosed with post-traumatic stress or mood disorders. Blacks were overrepresented in the criminal justice system because the system overlaid race with criminality, and over 50% of those incarcerated had mental health concerns that were gone untreated. The standard of care in the criminal justice system was generally low, and the trauma inflicted by the prison practices were themselves traumatic, perpetuating continuous, increased, untreated mental illnesses. Most mental health providers in the United States, they were white, which created stereotyping, a factor of health disparities, which oftentimes lessens the quality of care for black and African-Americans. African-Americans often receive poor quality of care and lack access to culturally competent care. That's important. Only one in three African-Americans who need mental health care services receives it. Compared with nonwhite Hispanics and Hispanics, African-Americans with any mental illness have lower rates of mental health services, including prescriptions and medication and outpatient services, but they have higher use of inpatient services. The rates of opioid overdose among African-Americans is 6.6%. It's less than half of that for nonwhite Hispanics, which is 13.9%. Compared with whites, African-Americans are less likely to receive guideline consistent care, less frequently used in the research, more likely to use emergency rooms than have a primary care, and they also, rather than have a mental health specialist, they'll go to the emergency rooms. These historical facts, we know, they're just the tip of the iceberg. Mental health disparities, they're screaming loud today, they're still prevalent. Despite recent efforts to improve mental health services for African-Americans, there's still barriers that remain regarding the quality and the access of care for these individuals. Some of these barriers still today include stigma, which is associated with mental illnesses, the distrust of the healthcare system, there's still lack of providers who are racially and diversely culturally competent and that are of diverse backgrounds, the providers aren't seeking training of how to really actually work with this population, there's still a lack of insurance, and African-Americans and blacks are still underinsured, and there's still a lack of knowledge regarding the available treatment that's available to black and African-Americans. There's still concerns about medication and not receiving the appropriate information about how to even access the services. And dehumanizing services have also been reported to hinder African-Americans from accessing mental health services today. I'm going to turn it over to my colleague, Dr. Mary Rory, who will set the stage so you will understand more in depth some of the data points around this. Thank you. Okay. All right. So, thank you all for being here. It's great to wake you up. But before I wake you up, I want you all to pause with me for 30 seconds to honor the folks who we lost their lives to mental health disparities. And we're going to pledge today to actively do something about it and to never give up to do so. So, if you bear with me, let's do that for 30 seconds. Thank you. Okay. Now. But the most important thing I want you all to take away today from my wonderful colleagues is that we still have a problem and we have a lot of work to do, but we can't get that work done without what? Data. Data. I know. It's like, wow. Is she going to say data? Yes. Data. It's good that we care about each other. We love each other. All that fun, fuzzy stuff. But we're going to need data. And what I just did is mix up the room. Y'all notice who I called on, right? I called on a little bit of everybody. So, diversity, equity is like a hot thing right now. We don't want it to be a hot thing. We want it to be a lifestyle. This is what you do for the rest of your life. Treat each other like we just treated each other a moment ago with the utmost level of respect. That's simply what it is. When you get a moment, you'll go back. You'll read the slides. You'll take notes. You can take them, copy them. You can present it yourself. But it's just here for you to see where I'm going to be coming from. Thank you for indulging me. So we're going to jump right into it because I spent my time, I only give 15 minutes, with you all. But sharing is caring, right? And so, at SAMHSA, we have the National Survey on Drug Use and Health. It is our Maserati of credibility in terms of data collection tools. And what it does is really, you'll see on the slide, it's really a nice snapshot of what's going on across the United States as it relates to mental health and substance use disorders. Behavioral health, you'll hear me say that, is, to us, mental health and substance use disorders. It's not one without the other, it's the other or the one. That's what it means to us. It confuses a lot of people, so I want to make sure we leave here with that clarification. So, how bad is it? It's pretty bad. As you'll see in the light green circle, and don't take notes because you're getting a copy of this, there are about almost 40 million people age 18 or older in 2020 who had a substance use disorder. In the light blue circle that you can see, because you can't really see the dark blue circle, but neither can I, but I know the numbers, 53 million people age 18 or older had a mental illness. And what's working, when you look at both the circles, about 17 million people had both. Now, same circles, targeting population, African Americans, blacks, you have about 15.4 or almost 5 million people age 18 or older who had a substance use disorder, about 5 million age 18 or older who had a mental illness, and combined, about almost 2 million had both substance use disorder and a mental illness. What's the problem with this? Well, slide that you really can't see, but you're just going to have to trust me. You'll get a copy of them. Hopefully they'll be clear. African Americans, on a good day, make about 12 to 13 percent of the U.S. population. Here you say, we have 5 million that needed treatment for substance use disorder. And what breaks my heart the most, age 12 and older, almost 95 percent did not receive the treatment that they needed. Houston, we have a huge problem. Back in 2019, it wasn't better. We have African Americans, blacks, high prevalence, treatment gaps, substance use disorder, about 2.4 million, 90 percent, no treatment. Any mental illness, 67 percent, no treatment. 1.2 million, 42 percent, no treatment for serious mental illness, and I can go on and on and on. What's worse? Same pictures for my Hispanic counterparts, but here we'll switch gears to talk about lifetime crime because Dr. Tyus brought it up, so I had to weave it into my presentation because I had the data. And here you can see it doesn't get any better. So folks with a past year mental illness and substance use disorder among ages 18 and older with at least one lifetime crime, this is as of 2020, 12.2 million people age 18 and older, substance use disorder, 12.7 million people age 18 and older had a mental illness, and then combined, let's make sure I get this right, about 6 million 18 and older had both a substance use disorder and a mental illness. Same thing, but 2019, and what you'll notice is that it increased. So the numbers are not playing tricks with you. It increased. But here again, we have some more data among Hispanics with at least one lifetime crime, also high prevalence, huge treatment gaps. This is from 2019, and you can see this is overlaid with any substance use disorder ages 12 and older, 1 million folks, 82 percent, no treatment. Any mental illness, 18 and older, 67, let's call it 68 percent, no treatment, COVID-19. Well, it didn't get any better. but I'm just going to skip right to it. I actually have words for this, so I should probably read it so we can be accurate and I can wrap up for you. And as you know, by now, COVID-19 didn't help us. You can see 41% reported symptoms of at least one adverse behavioral health condition, 6,000 to 7,000 calls per day. You see all of these numbers, but I like to draw your attention to the last box, 24% from 5 to 11-year-olds and 12 to 17-year-olds, 31% increased visits for mental health to the emergency department. Got to pause there. I know. I think there are loads of things that we can all do to turn these numbers around. And remember, it starts with you. Continue to do more by learning about what you can do about your own implicit bias. We can keep blaming that, oh, the system is such this way and that way, but it really is us, right? And I know you're going to say, Marie, I don't have any biases, but I promise you that you do. I had to learn the hard way with my group. We took an implicit bias training, and I found out, ooh, and I'm ashamed to say it, but I have to say it, and I'm a woman. I work better with men than women. Uh-oh. Yeah, it hurt right in front of my staff. My staff is mostly what? Females. And the implicit bias trainer told me, Marie, this is how you can fix it. Twenty minutes a week, spend more time with women than you do with men. Start working on it. I implore you all to work on it. This makes the difference. This difference saves lives. We are part of the problem. Oh, the community is doing this, and the community, we're the problem. We got to fix it. It starts with us. So starts with you. Continue to do more by learning about your own implicit bias. Don't stop there. Learn how social determinants of health, social determinants of mental health, social determinants of political health. You'll learn more about that. And learn and adopt and disseminate the National Cultural and Linguistic Appropriate Services, also known as CLAS, which are a set of 15 action steps intended to advance equity, improve quality, and help eliminate care and behavioral health disparities, blah, blah, blah, blah, blah. You all get the picture. You could have gave this talk yourself. Let me wrap up. As we ride this equity wave, we also need to be reminded of the isms. I'm not going to let you all leave here without that. Sexism, colorism, racism, which any ism you can think of, which is advantage based on targeted identity. It's important that we apply, we are all guilty at some point, systems approach to our work and begin to analyze, uncover, and change the way the isms is operating at the personal, interpersonal, institutional, and cultural levels by being what? Patient. Taking assessments and tests, acknowledging, correcting, and regular maintenance, because you know we can slip up. I want you all to begin to get comfortable with the uncomfortable. It's a tough conversation to not only look at yourself and the world around you, but we can fix it. Together we can get there together. We greatly appreciate the APA and would like to thank them for being an exemplar of this work by preparing all APA members to be culturally competent psychiatrists and aid in eradicating mental health disparities by creating programs that align with the APA policy by increasing diversity and serving under-resourced populations. Thank you so much. Mahari, tell them about the rest of the case story. Thank you. Okay. So, one of the things that we thought would be helpful to do is kind of focus in on what equity means in clinical services delivery, to return back to our case and get a sense of what might have happened with this patient of ours. So at the Kennedy Satcher Center for Mental Health Equity, we're devoted to the study of exactly that, behavioral health equity and how it translates to our larger health care system. And we tackle it in a few ways, and one of the biggest things that we try and look at is the intersectional factors that come into someone's life, because what we often find is that in fields of psychiatry, psychology, and the allied mental health professions, it's siloed. We don't tend to see how much overall mental wellness interfaces with the rest of life. And this is specific to Dr. Rory's point in how things are collected. So I wanted to highlight some things here about communities that are characterized by both racial, ethnic diversity, and poverty, much like the community in Washington Heights that patient S is from. You will see lower rates of long-term retention and treatment. You will see stigma and cultural beliefs about psychiatric issues as barriers. There is a really difficult study that came out in 2016 that highlighted that medical residents at several universities in the United States had an implicit bias that they believed that patients that were black and brown had thicker skin, had a higher pain tolerance than their white counterparts as patients. When it comes to psychiatry and behavioral health, what does that mean? Allostatic load, stress tolerance, the type of pain that you can endure. And yet you're talking about BIPOC communities that have had generational trauma that has affected their livelihood. Historic misdiagnosis of brown and black children and adults, i.e. ADHD and schizophrenia. What a lot of folks don't know is that when community mental health reform happened in the 60s, it was amazing because we were moving towards deinstitutionalizing people in asylums, right? But what happened? You had a parallel movement just like you did in COVID-19 in the civil rights movement. And you saw an increase in institutionalization of brown and black civil rights activists, many of whom were given diagnoses of schizophrenia. We also know that brown and black patients in emergency rooms get schizoaffective disorder diagnoses at a much higher rate, which stays with them on their medical record for life. But we don't know if that's something that might actually be happening. I can say firsthand I've worked with so many children who came to me with an ADHD diagnosis and I don't think they had one. I think they were anxious. I think they were experiencing trauma at home. I think that they were lonely. We also know that individuals with limited English proficiency, what we call LEP, have greater difficulty accessing care and preventative services. We just don't have enough bilingual clinicians. There is so much evidence that shows that when a patient can come to a provider and speak the language that is native to them, it makes a huge difference. We have some things like medical interpretation lines, but think about what happens when someone is in crisis. Where do we go? We go back home, right? So even if they have proficient English speaking capacity when they're stable and they're doing well, if they're in crisis, they're going to need to talk to you in their language. It's a huge gap that we have. I will also add that we struggle to do this on texting lines and crisis lines. We all know 9-8-8 is coming out in July, right? And this is a big debate that we're a part of is how can we ensure that there is language access for folks that are in crisis? What does that mean? The closing of more than 120 hospitals in rural areas in the last decade, so 75% of United States counties are classified as mental health provider shortages. So there are no psychiatrists or prescribers. There are barely any counselors that can hold someone over. We have an extreme shortage of nurses in actually all health disciplines, 75% of those counties. So in rural areas, we've closed more than 120 hospitals simply because they cannot maintain the costs and the resources to keep those hospitals there. And so that comes to my last point is that we have a huge issue of a shortage in general. Following COVID-19, we have the biggest clinician shortage in the history of this country. We don't have psych professionals available. And we also know that medical schools don't do enough to really recruit psychiatrists into the field. We have folks that are going to maybe social work school, mental health counseling programs. We do know that the preference is to do this in urban areas where they feel that they may have more access to a clinical placement site. We don't have things that we do to incentivize a workforce to work in these rural areas, right? So we're going to talk through some of those solutions and how we can work through them. But it is important to also note what intersectionality means if we're talking about equity. The outcomes become more dire when they become intersectional. So the experience of a black man is different than the experience of a black woman, right? We do have a hierarchy in our culture. And this is something that we have to acknowledge. Your education status makes a difference. How you sexually identify makes a difference. Your gender identity makes a difference. Trans women of color are killed at higher rates than any other, murdered at higher rates than any other class in the United States. Also show the highest rates of substance use disorder, mental illness, and incarceration. So at the Satchel Health Leadership Institute, we actually reframed determinants of health to call them political. Daniel E. Dawes, who is our executive director, penned the political determinants of health and mental health. And they are that health involved the systematic process of structuring relationships, distributing resources, and administering power, operating simultaneously in ways that mutually reinforce or influence one another to shape opportunities that either advance health equity or exacerbate health inequities. What does that mean? These things have been written into law, right? We have things that have been written into law when it comes to housing segregation, for example, and where communities live. The fact that homelessness is still a crime in several states, right? So when we talk about patients that are incarcerated, I was talking to a police chief in rural Georgia and he said 30% of the folks that were incarcerated in his local jail didn't need to be there. They were people with serious mental illness who didn't have access to care. And this is disparate. There's so many folks who don't have a mental health diagnosis when they go into prison who come out with a mental health diagnosis. Sometimes the carceral facility is the first place someone actually gets access to care. What are we doing when they leave? If they don't have a place to live, there's no way they can actually access a medical appointment, right? So we look at these things in terms of the actual structural environment that people are in. And we tackle that from a political way. We say these are politically determined. These are parts of your policies. These are things that have been written into place. Mental health parity is a big part of that. Our insurance providers, in ensuring that access to mental health care is as accessible as primary care, right? And this is integral. It's amazing. In Georgia, actually, we just passed a parity law for the first time ever where it's a bipartisan consensus that there was a value in giving access to behavioral health at the same reimbursement rate as primary care services. That is a big deal in a state like Georgia, as you all can imagine. So we want to revisit patieness. And before I go through these questions, I just want to take a little poll. What do folks think happened with this patient that I presented at the beginning? Anybody want to take a stab at guessing what happened with him? Just based on your own understanding of these issues. Okay. Good. So you think he might have been reincarcerated back in the hospital. What else? What else do you think might have happened to his family? Anything? Didn't he say he had COVID? Yes. So we ended the story with patient S being hospitalized in a psych ICU with COVID-19 after he was rapid released from Rikers because he tested positive in Rikers. So just so folks know, the positivity rate in Rikers was 87% at the height of the epicenter. So you could not not get COVID in Rikers. Does anybody think patient S survived? Good. Right? Good. I'm glad you do. So the reason why we picked patient S for this presentation is that he made a miraculous recovery and he is a true example of resilience and having multiple lives. He made a miraculous recovery in the hospital after nearly dying. He had to be intubated and was actually given a defib a few times when he was there and was placed in a hotel shelter. So New York City actually, because they had such a homeless crisis at the time of COVID and COVID was basically ravaging through all the shelters, they partnered with hotels and gave hotel placements to a lot of folks, which was an amazing innovation to give people access to safety. For him, it was a game changer. He began taking steps to his recovery upon relief from homelessness. Because he wasn't homeless anymore and he had somewhere to stay, he was able to focus a bit more on his wellness. We started to see him gain weight. He started asking for snacks when he would start to see us. He started showing up to the clinic a lot more. He became diligent about his medications and counseling and he was able to abstain from drug use and complete a recovery program. The biggest thing is that he ultimately achieved his own housing placement and was able to reunify with his mom. The whole thing that he ever said was, all I ever wanted to do was show her I wasn't going to complete suicide like my brother. Who I personally provided family counseling to because she spoke Spanish and I was the only Spanish speaking provider on my entire team. She carried enormous guilt as well about her son's wellbeing and not being in a place where she could meet his needs because she was caring for another child who had mental illness. I want to talk about what we learned from a case like this. From an equity lens, our system has not always seen mental illness as a function of systemic suffering and oppression. We have a diagnostic ICD code that goes to the patient, the symptoms that we try and relieve, but the symptoms are systemic when we talk about things that patient S or other communities go through. We want to ask ourselves, are we setting up youth, specifically BIPOC youth, to thrive at a young age? When you think about this case, what might have he needed as a kiddo? Anybody? We know he had this miraculous recovery. We also know he's an exception. He's an exception. In COVID-19, loss became something very different for us who were running ACT teams. It wasn't just death. There was a lot of accidental overdose. There was a lot of unfortunate suicide. There was a lot of crime. There was a lot of reincarceration. We had a lot of patients go missing that we just couldn't account for and to this day still don't really know where they are. There's a lot of transients. That had to change the way that we think about what are our patients actually suffering from. For me, COVID-19 exposed that the system was cracked and then it became fractured and just kind of flooded. For folks like patient S, we weren't able to actually do what he needed to because he didn't have it in the first place. I want to ask you all, when you think about it, if you imagine having had him be a kiddo that came maybe for disruptive behavior in a classroom and he was referred to you, if you could redo his life, what would he get? Think about it. What would you offer him from an equity lens? Like a person that comes to my mind is like big brother, big sister, like a mentor. Mentor. Yeah. Yes. That's the first thing that comes to my mind. The other thing that comes to my mind is regular primary care visits. Yes. For someone who could identify... Street. Yeah. Sight. Hearing. All things would be like simple, all good things like that. I mean, then you think about neighborhoods. Do they have a place to play? Do they have age appropriate toys? Do they have all of those things that we think about? Not really so much thinking so much about psychiatry at that point. Exactly. Right? But that's what I wanted this to be about, right? Is that it has to move beyond just the medicalization of treatment. We have to treat the whole individual. And the onus is on us to ensure that as providers, we remain hopeful, we are patient, as Dr. Rory said. We are doing what we can to be culturally humble, right? If someone comes into your office and you see their needs and you say, I don't know anything about this person, what do we do? You've got to ask them about that, right? I can't tell you how many medical school trainings I've done where someone will say, I'm really uncomfortable asking about gender status. Why? Right? Make that part of your normal assessment. Can you please tell me how you identify? What pronouns do you prefer to use? How would that be helpful, right, for that perhaps woman who might be homeless and be facing a lot of adversity? We do a lot to re-traumatize our patients, unfortunately, by the medical system. But we have an opportunity here to also think about how we measure resilience, right? So the other part about data is that we have an enormous amount of information on the burden of mental illness in communities of color. We don't have enough information on how communities of color are resilient, how families have strong structures and cultures. The Spanish culture is one itself where eating together is a huge part of wellness, right? That is community. Music is community. It's the same in my culture. Why don't we measure that as a healing paradigm for folks who come from those? So I just want to leave you with that, that often humanity and resiliency prevails way more often than we think it does. We don't acknowledge how much our own clients survive and how much we endure with them vicariously in our role and the capacity that we have to empower them to do better. So hopefully patient S leaves you with some sort of feeling where what we might have assumed might have happened to him, and best believe I was there too. I was like, this is it. This is over. This is his final life. And he still proved us wrong, right, only at 28 years old. And it's remarkable that I just found out from my team he's enrolled in a GED program now, right? And so this is like two years later. And that gets me a little choked up too when I talk about it. So I'm going to carry it over to Dr. Soyinka, who's going to talk to you about the SMART tool, which is something hopefully you can utilize in your practice as well. Great job. Thank you, Monica. Thank you. Good morning, everybody. My name is Osamu Soyinka, Chief Medical Officer for Philadelphia's Public Mental Health System. Can you all hear me okay? All right. I want you to take a moment and think back to the beginning of COVID, those first couple of weeks in late March of 2020. Where were you? What were you doing? How did you feel? Just think about that for a moment. I'm sure you can identify with some combination of the following emotions. Confused or confusion, feeling overwhelmed, feeling uncertain, feeling frightened, feeling angry, perhaps. How could this have happened? Will I be safe, and so on. Now, I asked you to think about that point in time because my job in Philadelphia is to, essentially, my office is responsible for population health for all Philadelphians. Philadelphia is a city of 60% of the population are minorities, and it also has, unfortunately, the distinction of being one of the poorest large cities in the United States. So a lot of the things that we're talking about now, social determinants, access to health, Philadelphians experience that every day, and it's my team's responsibility to think about how we right some of those wrongs. We do that through a combination of policy on one hand, and what I think of as system engineering. We look at gaps in the system where it breaks down, and then you implement targeted fixes. Well, when you begin to do that kind of work, you very, very quickly run into disparity and inequity, especially in a context like Philadelphia. Now, one of the things that we learned at the very beginning of COVID, one of the things that happened, Dr. Jha mentioned her experience in the prison with people ending up at Rikers Island. Well, one of the things that happened very quickly was a decarceration of Philadelphia prisons emptied out their population for the same reasons that you talked about. There was high rates of transmission, guards as well as inmates were dying, and so a lot of the people that were incarcerated got released. That begs the question in the first place of why they needed to be there, right? It asks that, it begs that question, but we took a look at our data, and guess who didn't get released? Guess who didn't get released? Black and brown people. When you took a further look at that data, guess who didn't get released of that black and brown population? People with severe mental illnesses. And when we tracked back that data and looked back at the causes, it basically boiled down to accepted practice within the justice system, which could be justified in a number of ways, but when you took a closer lens, it started raising questions about why it resulted at every point in the intercept from the initial encounter with law enforcement to arrest to the decisions to charge to arraignment and all the way through, it really boiled down. There are disparities in every step of that system. Now, we also took a look at our crisis system. I'm getting at something with all of this, and I'll get there in just a moment, and how it relates to the SMART tool. We also took one of the big system fixes that we're working on right now. Who hasn't heard of 988? Thank you. Yeah. That's not the case in every setting. Well, one of the big efforts in Philadelphia to address access to mental health problems is what we're calling crisis 2.0, is a complete redesign of the crisis system from the point at which people call and ask for help until the point at which their crisis gets resolved. Well, we took a look at our data. One of the problems that we had in our system was it used to be very rigid, very coercive. The pathway to treatment for the majority of our population, again, majority minority population, was through coercion. People got, if a person was identified as being in a mental health crisis, they basically got what we call in our system 302. They basically got an order compelling them to be taken in by law enforcement to a crisis center where they would have to sit down and endure anything from four to 12 hours of an evaluation, and then subsequently be placed, typically, in an inpatient setting. So not a very user-friendly system from that perspective. Well, when we took a look at that system, guess what we found out? The rate of 302s, that is this coerced treatment, is sort of levering people into treatment using the legal system. Really, the burden was born primarily by minority population, so it was something like 60 to 80% of 302s were applied to minorities. Why is all of this important? Well, unfortunately, my colleague, Dr. Talley, had problems with travel arrangements, and her flights were canceled, and so I'll be speaking on behalf of both of us today. Why is this important? Because it gets at the idea, and I want you to keep this in mind. It's come up in everyone's presentations this morning, the idea of data and the importance of using data, and how without data, basically, what we have is an opinion, right? Anybody can have an opinion. We just lived through several years of all sorts of assertions and so on in the media, but without data, we really are flying blind, and we're just another person with an opinion, which could be right or wrong. Now, when we start this conversation about disparities, inequities, racial disparities and discrimination, racism, people get kind of uncomfortable, and by necessity, those conversations are uncomfortable because they speak to, they elevate something that none of us really wants to believe about ourselves or about the society that we're living in, which is injustice. Injustice is prevalent, and it is baked, essentially, into many of the aspects of society, and so what we're all psychiatrists or mental health clinicians here, and so we understand that the instinct, when you feel uncomfortable, is to do what? It's to flee, right? It's to bury that, to shy away from it, to avoid it, and so on. Well, the power of structural racism is that it largely operates in processes that are invisible, right? I just gave you two examples of how structural racism works in a large system. When you take data, when you look at data and you shine it on a process, now, not individuals, because I think, for the most part, people, for the most part, are well-intentioned, but operates in a system that is designed to lead to a certain end, right? I just gave you two examples. Well, data takes the spotlight of, am I a bad person? And it shines it on, what are the problems in the system that I work in, and how can I fix them? How can we work together to fix them? And that is the idea behind the SMART tool. It is that we can use data in each one of these areas that, where we know from the literature that disparity, inequity, structural racism is present, and we can use that data to begin to correct those wrongs in a sustained fashion. So let me talk very quickly about how the SMART tool was designed. So back, again, in May of 2020, when there was the national and global outcry around structural racism with the death of George Floyd, both Dr. Talley and myself are members of the board of the American Association for Community Psychiatry, and the same conversations that were happening everywhere else happened in that group as well, and we thought, what could we do? And how could we capture these conversations and the desire to do something? I'm assuming that everybody here came here with the desire to do something. So the SMART tool is just one way that you can actually do something in your own organizations. Now, SMART tool, we took a look at data from multiple areas where the literature, again, speaks very loud and clear about disparities, and it's summed up in these areas, hiring, recruitment, retention. We know, for example, in academia, that there is a significant and persisting disparity in hiring, in retention, in promotion of minority and women faculty as compared with Caucasian male faculty, Caucasian faculty generally, and Caucasian male faculty in general. This is not just in academia. This is in the business world. This is in, if you look at the data, the WMC data on recruiting of medical students, it's actually worse now than it was in the 1970s. So there's evidence for that. We know, we've talked about the disparities in clinical care. We know from diagnosis to the application of treatments, coercive, high use of more intensive treatment, very consistent disparities in what medications are selected, disparities in what, in the application of AOT. Those, the data is very consistent on all of that, very clear. Workplace culture is simply how we do business. This is, and I give you examples in our crisis system and the criminal justice system. This is just our sort of background operating system, the assumptions, the environment, what's permitted to be talked about, what's discouraged, what's this, we don't do that versus we do do that. These are very quiet, subtle, but very, very powerful forces that play in the workplace. And there's certain elements of it that can be teased out and elicited. Then community advocacy, because obviously in our field, as in mental health, our field abuts on so many other areas. We've talked about them, housing, schooling, education. We've talked about the criminal justice system and so on and so forth. So we, there is a role for the mental health industry, if you will, to speak to those issues. And then of course, this, as I said earlier, really comes back to population health. Now, what does SMART do? It provides, it takes, as I said, it takes, it moves the conversation away from opinion, from I'm good, you're bad, you're bad, I'm good, whatever, to, well, in our system, if we take a look at our data in any one of these five areas, then we can examine the outcomes that we see. We can examine our system for hiring. We can look at five, 10, 15, 20 years of data on, well, who gets brought in? Who gets invited to the interviews? Who gets promoted? How long do people stay? And why? And so on. And we can look at the same in any of those other areas. It also moves beyond, and I'm glad Dr. Rory mentioned the class standards. They're crucial. The SMART tool is yet another effort in that direction. And then I think the most powerful part of SMART is that it's, people often want these conversations to be a one and done because they're so intense and they're so uncomfortable. People want to train their way out of it, educate their way out of it. But the real fact is for something that is this ingrained, that operates in this sort of systemic unconscious format, it requires sustained effort. And so the SMART tool allows an organization to move in that direction, to look at its own data, make a commitment to fixing those problems and repeat that process over time in a sustained fashion, which is where you really have, that's how you have change happen. Now, what's the process? What's the recommended process of SMART? And I'll give you just one example as I sort of come to a close. Again, in many organizations, change happens in different ways. Many organizations try to implement change from the top down, and there's no question that leadership is crucial in any effort, any transformational effort, but it can't stop there because you need buy-in from all levels, right? You need the mid-levels, you need the frontline staff, you need everybody to basically be agreed on the outcomes you want. And so the recommended process is to bring together working groups from all levels of the organization, from senior management to middle management to frontline staff, with hopefully a diversity of backgrounds, education and training, and basically come together to decide what the group wants. Take the tool and then apply the tool. And we've done this in my organization, which is a county mental health office of 1,200 employees, and actually did experience some of this. And my organization, I would say, is ferociously committed to diversity and equity. But even in that context, even in that environment, still had opportunities, found opportunities to drive that conversation further. Now, the requirement to come to a consensus on a score is an interesting facet of applying SMART. Why is that so? Because people disagree, and oftentimes disagree rather strongly on how well we're doing. And so that process of trying to reach a consensus itself drives conversation. And the power of this process, again, continues with needing to generate an action plan and then reassessing in six to 12 months. Let me give you an example. Now, let's take a community mental health center, an academic department of psychiatry that runs a crisis service, you know, psyche or whatever. Now, in those settings, you typically will have to interface with law enforcement, either when people are getting civilly committed, or when people are being brought to the ED, right, for assessment. Ask yourself the question, the simple question, who gets brought into my ED in cuffs? Just ask yourself that simple question. Ask your organization that simple question. Then follow it to the subsequent question, who gets put in restraints in my inpatient unit? And why? Simple questions. In this example, to what extent, this is one of the questions in SMART, to what extent does your organization work in partnership with law enforcement and the local criminal justice system to eliminate potential disparities in arrest, incarceration, and diversion? Well, if we took a hypothetical situation of that inpatient unit, that academic department, that CMHC, who has sat down hypothetically and put that team together and begun to apply SMART to this question, a score of one would be, consensus score of one would be, we haven't even done this at all. We haven't even thought about this. A score of three would be, we have actually begun to develop relationships and conversations, and we're looking at the data. And a score of five is, we've eliminated this as an issue. It's not an issue for us. So that's an example of how SMART is applied. And I'll stop right there. Thank you. So welcome questions on any aspects of what's being talked about today. And if you have any questions, we just ask that you please use the mic because it's being recorded. Don't make me get up and get more steps in. Do I come and ask who has questions? Am I getting up? Or are you all going to the mic? Okay. How's the access to get to that tool? Or how does that work? It's freely available on the website of the American Association for Community Psychiatry. Actually, if you go in to Google and type AACP SMART, it comes right up. Yeah. How long does it take, and how often do you recommend repeating it? It varies. We actually have a presentation after this one on the SMART, and we'll walk through many of those details, including a case study of one organization in New York City that applied SMART. In our organization, it took a group of maybe 25 people about three to four months to finish applying SMART, to work through the entire thing. And as I said, one of the feedback items, pieces of feedback that we got was it actually drove conversation, some uncomfortable conversations, but needed conversations. Your session's at 10.30. We're at 2.95. That is correct. We're right next door. So you're welcome to come to that. Other questions? Can I pose a question to any of you? How do you all collect data? I'm curious to know some of the pieces we talked about in terms of the importance of disaggregating data, ensuring that it's inclusive of the actual patient population. Does anybody wanna share some things coming up for you on how you at your hospitals or agencies collect data? Sure. Yes, please. Thank you. Don't be shy. Hi, how's it going, everyone? Can you hear me okay? Yeah, it's perfect. So I'm actually a medical student. I'm a master's student right now, and we actually did a COVID-19 survey. And to understand how it impacted Latino health, one of the big things that came up consistently was just mental health, mental health, mental health, and social isolation. But we employed some really interesting strategies to get these respondents. And I'm talking no funding, like maybe a gift card raffle. We actually went around the city of Newark, which is where I'm based out of, and we did things like bus trips, meaning Latinos do bus trips around the state of New Jersey to get to other cities. And we literally went on these buses and were like, hey, anyone wanna fill out a survey during these next two hours? Because we were finding that just using community health festivals, using community nonprofits, that was introducing a bias within our data where you had health-seeking Latinos, and that population was already engaging with some of the mental health providers. It was engaging with physicians, if not psychiatrists, and at least community leaders and advocates that helped them get some semblance of mental health care. So we found that getting over this idea that we're making people uncomfortable, we might be intruding, wasn't the case. Latinos, even on a bus trip, were more than happy to engage with us. It just made it inconvenient for our team because it meant Saturday 8 a.m. going to this bus. So we definitely find that within the data, there's a big bias, and it may account for, we talk about Latinos and we talk about the Latino paradox, and we're wondering, is the Latino paradox born out of perhaps a sampling bias? So there's definitely a need for health systems to engage in more diverse ways. Fabulous. Yeah, and we're proud of you. Yes, ma'am. Yeah. Uh-huh. But you bring up a really good point, right, to speak to Dr. Soyinka's smart tool and how you can assess your organizations is accessibility. You had to go on your Saturday, right, to be able to actually reach the population. I remember working at a clinic. I saw folks till 10 o'clock at night on Friday. Was it really fun for me? No, but did I actually, I mean, my 9 p.m. patient was often my most loyal who would show up because it was really the only time that that mom could come in or that dad could actually come in and get help after working a whole day. So I think that even if we don't see that as innovation, sometimes it's on us to say, okay, I'm gonna push past my frustration with this being out of my nine to five. And organizationally, can we adjust? And what do we do to give incentives to our employees to do that? So that's an excellent, excellent example. Thank you for sharing. Any other questions? So I'm curious about who people are working with. Who are you all serving? And what are some of the, I wanna say problems you're having and making sure that everybody that you work with is on board with you. So I'm curious about how that is working for you. And this is y'all time. And so it's just like, I hate when people just go on and on and on and then you have this burning question and you leave the conference and you get back on the plane or you get back in your car. Like, I didn't get to ask my question. This is y'all time. So I want you all just get up and ask us anything that's on your mind. No question is a bad question. And if we don't have an answer, we can call in help. Yep, we sure can. Well, and I do have the same sort of primer question for the audience. We've had all this, what, two, three years of conversation around structural racism and so on. What's being done in your organizations? You took it out of my mouth, Dr. Bis. So please, go ahead. Yeah, go for it. Hi, I work at Kaiser Permanente Washington and we have very good resources data-wise and also commitment-wise. We collect and aggregate a lot of our health outcomes data in Tableau. And we have dashboards like ECHO, which I don't remember quite what the acronym stands for, but it's our equity and inclusion dashboard. And we can see a range of outcomes, mental health, physical health, and how we don't do the same job for our non-white patients as far as what we succeed in. We also have a lot of institutional commitment because we have anti-racism committees, we have equity and inclusion leadership. But I would say that the deficits we have are number one, a lot of our patients don't report how they identify, even when we ask. And the other thing is, I like the earlier quote about how a statement without numbers or without data is just an opinion. I think the other difficulty we have is that even though we can request consultation with our EID leadership, there is not a lot that we can find published on what effective interventions are quantitatively to move the needle, whether that's improving A1Cs or PHQ-9s for our populations. And so I think a lot of the time, even if we have good quantitative and institutional support, it's not always clear what we can actually do. I think that's a very important point. And I think Kaiser, as an institution, is actually uniquely positioned to address some of these things. I mean, Kaiser led the ACE study, for example. Now, some organizations, and this is a fairly new trend, but some, and I certainly welcome comments from my colleagues here, but some organizations are beginning to step beyond the traditional healthcare role. People are coming to me to get help and actually investing in those communities that they serve, specifically upstreaming, so making investments in things like education, making investments in things like food supply, making sure there's the right kind of food available. Many of these communities are food deserts, making sure, I mean, simple things, transportation, there are sidewalks, there's places for kids to play. I know three or four, I mean, just off the top of my head, Centene, I used to work for Centene, invested in something like this in St. Louis. I know Geisinger has done some of that. I know Children's Hospital in Dallas has done something like that. So the key here is, there's no one size fits all, but I think that the one step in that direction is for that organization to engage with the community. I remember reading a study about two years ago, outcomes for breast cancer, there's disparity, right, between black women and Caucasian women. Well, I don't remember the particular hospital, but they took a look at the neighborhood that they served and began to engage in a conversation, and some of it was a lack of trust, some of it was the community needed to be informed in a way that they could hear it in the language that they used, not sort of in the generic medical language that we often use when we talk to our patients, and those outcomes began to change. So I think that's where some of this work has to happen. I'd also add, we support a program in Maine through CDC where we're actually just employing, so Community Health Workers has been an evidence-based way that we can sort of bridge that gap in utilizing community peer liaisons to help collect some of that information. I agree the PHQ-9 is very rigid and likely I wouldn't always answer honestly, let's be honest, if your PCP is asking you a depression skill and you just don't feel comfortable. So the investment in community can also look like training programs for CHWs, which I know a lot of hospitals across the globe actually use them, and now in the U.S. we're really expanding our efforts to try and see how community health workers can be a help. I think that's also really helpful for those of you who may be in rural areas where access to a licensed professional who could do that assessment is probably not as accessible as you are in a big city like Los Angeles, New York. So in Maine, it's really helping that this team of 12 CHWs, they're getting trained on assessments, they're going out, they're building engagements, they're the reason why the person comes in then and actually sees the primary care provider to get access to care. And a lot of these resources that we're stating out of our center, the African American Behavioral Health Center of Excellence, we're funded to provide training and technical assistance for a lot of these issues. We don't do all the training or any of that ourselves, but we connect you with people like Madhuri and Dr. S. And you hear, I could call him Dr. S, I won't butcher his name. But please reach out to us as well because we do have a gamut of resources that you can utilize within your organization, but also individually. And one of the things that I really, really want you all to think about when you leave here is that all of us have a level of spirit of influence in some capacity. And just think about each day, what is it that I can do to make an impactful, an impact in the communities that I serve? So I think when Dr. Rory spoke of that, that truly resonated with myself and that's what I have my staff every day, is to say, what is it that we can do here at the Center of Excellence to make a major impact? Okay, so good. Y'all, I gotta read this that I didn't get a chance because I wanted to make sure my colleagues got to say what they wanted to say. But so our call to sustainable action is to leave here today, identifying, linking and becoming pockets of excellence. Thank you, Dr. Tines. In reducing health and behavioral health disparities and promoting resilience in behavioral health equity because there is no health without mental health. Also, I wanna encourage you all to take care of yourselves because the better you take care of yourself, the more that you can take care of the communities that you need to save. Remember, it's not about you, it's bigger than you. So I can't thank you all enough for being here today. We're still here if you wanna ask us any questions. Yeah, we got plenty of time. So it's all about y'all. Come on, let's get some questions. Let's talk about it. This is a great opportunity to have some bi-directional conversation. This never happens at conferences, right? The next thing you do is pick up your little satchel and go to the next room. Here, you get to hang out and ask some tough questions to my colleagues. I only answer easy questions. Go ahead. Hey, good morning. My name is William. I'm a psychiatry resident in Connecticut, but in less than a month, I'll be in New York City. So excited about that. This question's for all of the panelists, but about the SMART tool specifically. I like the point about buy-in from every level and curious what the SMART tool recommends in terms of meeting resistance at different levels and addressing that. Thank you, William, and congratulations on finishing your residency. Woo-hoo! That is exciting, exciting. So I think that's an incredibly important question, very practical question. The beauty of the SMART tool is you don't have to apply the entire thing. You can take sections, for example, the clinical section. That is one that resonates, I think, with most organizations that are involved in the direct provision of services. You can start that within your clinic. We've had colleagues, I have one colleague in particular, who was supervising nurse practitioners and noticed when these conversations began that every black patient that she came across, males in particular, were diagnosed with either schizophrenia or bipolar disorder and ended up on Seroquel, everyone. It just kind of jumped out at her after these conversations began. So what did she do? She started to apply the SMART tool to her own group, the patient population that she was responsible for, and just the clinical section of it. So I think being able to, particularly in the context that I think, if I'm hearing you right, you'll be stepping in as new faculty, new staff psychiatrist, wanting to make change. It might, a useful first step is oftentimes to just take what you can and apply it and then share the data. It's hard to argue with data. And it makes, if there's evidence of disparity, especially when you're assuming a caseload, right? You're assuming a caseload. So you're new to the organization and it allows you to ask questions and then offer, potentially offer the SMART tool as a, to the larger group as a tool. That's just one idea. Yeah. Oh, I definitely have something to say. You tell them that a change has gotta come. I heard you say the word resistance, right? So the whole idea is getting comfortable with the uncomfortable. I say it at every talk that I give. Nobody wanna talk about it. Racism, discrimination, sexism, ageism, any ism. We gotta get comfortable. We will never solve the problem unless some brave person such as yourself, like you got up to ask the question, that's the same attitude that you have to have at this new position. You can be the change agent. It's inside of you. It just has to come out. I used to always say that I was 289 pounds before the pandemic started, right? And I kept saying, it's a skinny girl inside of me. Well, she's coming out slowly, but surely. I've lost over a hundred pounds. And so it's just like, yay. So it's just, it's inside of us, but we just gotta, we gotta be bold with it. The other thing I'll say to you is don't wait till you turn to 50. I was 50 years old when the light bulb went off. I just turned 55 on May 19th. So happy birthday to me. But I was, the light bulb went off when I realized, I was like, oh my God, only got 50 years left. When do you get to be you? You get to be the best you right now. Don't wait. It's okay, we gotta talk about it. And if you wanna blame somebody or if you wanna just shift it, say, President Biden said in executive order 13985 that we will advance racial equity. It's present, it's at the highest level. So you have not only the data to support you, but it's law. We gotta make a change. We gotta make a difference. We cannot go on the way we have been. A change has gotta come. And if you need some help, email me. There you go. The only thing I'd add to is that some of the most effective spaces I've been are truly interdisciplinary, to Dr. S's point, is that the best clinic spaces are those that encourage interdisciplinary input. One of the things I love about ACT is that it's a true interdisciplinary treatment team. All 14 people are working with that, from the program assistant and the peer specialist all the way up to the MD or nurse practitioner prescriber are equally working with that patient. So think about what that does for the patient side too. So those kinds of discussions, I can't advocate for more. Rounds are amazing in a hospital, but they're a very, very small window where you get to see that interdisciplinary collaboration where people are coming together to talk about a case. I think the more you can do that in your space, the better. Right, and I think the more that you get to have conversations with your client and just getting to know your client, I think that adds to that as well. Adds value. More than seven minutes. More than, yep. Go for it. Hi, my name is Deepa, and I'm from London in the United Kingdom. My question is about joining the dots with data collected in different parts of the country. We have the advantage of having the National Health Service and various other national agencies in a very small country that does make it slightly simpler to connect the dots. But one of the things we have realized in COVID is actually how important it is to have microdata for little communities, which may be different from the surrounding communities. So that is one of the disparities we are looking at. I'm curious to understand how you'd address this in a country as large as the USA, and how you would then try a leveling up agenda. So we have something, we started with COVID-19 disparities at Central Health Leadership Institute. It's called the Health Equity Tracker. It's the first ever of its kind where we're actually pulling all public data sources at the zip code level to create a national visualization where you can actually layer multiple public health indicators on top of each other. It started with COVID-19. We have since expanded to chronic medical conditions, behavioral health indicators. We're now looking at political determinants of health, which include female representation in Congress, for example. Like if you can compare between the state of Texas with the state of Washington, what does that look like to see how it informs health outcomes? It's called, it's healthequitytracker.org. I encourage you to just check it out. It's been really useful in a lot of ways. I'll make a plug. We just won the HALO Award for it. But one of the things is that it's really important to answer that question and to think about why that visualization is important, because what it allows for us to do is academically comment on the gaps, right? So what you'll notice when you go to that is that there are some states during COVID that didn't report their numbers. They are great. Everyone else has a gradient of red at certain points in the epidemic. Why? Because they didn't report their data. There was a reason why they didn't want people to know what was happening there, right? That creates a sphere of influence then at the policy level where you can say, well, why is, we know that people are actually dying here because we're seeing it in the news, but there's no data being reported on this. And we always say, if there's no data, there's no problem. Right? So you cannot go to a congressional leader if you don't have that information. So that's one of the ways that we've tracked that. It's helped a lot of other places in the world as well tackle that same question. If you do it by zip code, can you visualize it? So I encourage you to check that out. I definitely want to add to that. So there's all some, and I'm going to get his name wrong, but Sidoche, who did a statistical tool called the Modified Kilman Filter. I got tired of people saying, no, we can't look at American Indians. We can't, if it's more than one person, we should be able to do some type of data analysis. It's like, are you kidding me? So there's all sorts of statistical tools. The other thing I would encourage you today to do is to work with the people you work with and pull the data. So you can begin to look at the gaps. The one thing that you just said that was really key is that once you get this data and you take it to Congress, and I'm a living example, they write you a check. It is so nice to say that, oh, we've collected data on such or that we've made a change in this community. But when you say you have data, it's a game changer. SAMHSA's budget went from 3 billion to 12 billion, over 12 billion. Data, data is really, really powerful. Again, remember that's one of y'all key lessons learned. I got up eight o'clock in the morning to come here. It's crazy lady talk. But she told me to make sure data is at the forefront of everything you do. It will make a major difference. And the money isn't so that we can feel good about ourselves, but it's to impact change. We've got to give it back to the communities so that they can fill those gaps. Go ahead, Dr. Tice, because you over there mumbling. Oh, no, I was agreeing with you. Okay, good. It's good to have agreeance up here. Anybody else want to add? We have probably time for one more question if anyone wants to pose one. Go forth and- Thank you. Go forth and conquer. Yeah, I mean, it's important to say, too, you all decided to show up here at eight o'clock in the morning. And I always say anyone who chooses to come to a talk like this, or this type of presentation, you are actually committed to equity, and you are a champion of equity yourself. Hold on to that feeling, right? So it's tough material at eight o'clock in the morning, but you decided to be here. So we thank you for that. Yeah, I'm excited. Woo-hoo!

health disparities

mental health care

racial determinants

social determinants

marginalized communities

access to care

racism

poverty

SMART tool

data analysis

interdisciplinary collaboration

equity