All right. Well, good afternoon, and thank you to everybody who has joined us today for this presentation on the Self-Assessment for Modification of Anti-Racism Tool, or SMART, Addressing Structural Racism in Community Mental Health. My name is Dr. Rachel Talley, and I am an Assistant Professor of Clinical Psychiatry at the University of Pennsylvania, as well as an early career board member of the American Association for Community Psychiatry. I'm going to allow my colleagues to introduce themselves, and then we will get started. I am Susumu Ushinka. I'm Chief Medical Officer for the Philadelphia Department of Behavioral Health and Intellectual Disability Services, and I'm also on the board of the American Association for Community Psychiatry. And hi, my name is Ken Minkoff. I'm a board member emeritus for the American Association for Community Psychiatry, and in charge of the product development plank on the board, which got me involved in this. I'm also a Senior System Consultant, Chief Operating Officer for Zia Partners in Tucson, Arizona, which is a consulting company, and a part-time Assistant Professor of Psychiatry at Harvard Medical School. All right. So, to get us started, I'm first going to start with some information about funding, as well as disclosures. So, a funding disclaimer is that funding for the Striving for Excellence series was made possible by a grant from SAMHSA of the U.S. Department of Health and Human Services, and the contents this presentation are those of myself, Dr. Shrank, and Dr. Minkoff, the authors, and do not necessarily represent the official views of, nor an endorsement by, SAMHSA, HHS, or the U.S. government. I also want to share that this is an Americanist Psychiatric Association. The American Psychiatric Association is accredited by the Accreditation Council for Continuing Medical Education, the ACJME, to provide continuing medical education for physicians. The APA mandates this live event for a maximum of one AMA PRA Category 1 credit, and physicians should claim only the credit commensurate with the extent of their participation in this activity. I next want to share some information about how to download handouts for this presentation. You are able to download the slides that we are sharing here on the screen, and the instructions are here on this slide. Additionally, in terms of participation during the talk, we certainly encourage questions as we're giving the presentation. Our goal is going to be to answer your questions in the Q&A section of the web application as we go along, so please consider typing in your questions as we proceed with the presentation, and here are some instructions on where you can go within your application, either on the desktop or the Instant Join webinar, to post questions as we present. And we, as authors, have no financial relationships or conflicts of interest to report. So the learning objectives of this presentation. At the end of this presentation, we hope that you will be able to describe three ways in which structural racism manifests, describe the five domains of the SMART tool, and then our third objective, that you will list three ways in which the SMART tool can be used in your organization. So to begin in terms of background, and so my portion of the presentation, I'm going to provide a little bit of background on the development process for the SMART tool, which is a new quality improvement tool designed to address structural racism, specifically in the community mental health setting. So of course, over the past about year and a half, there has been a reinvigorated dialogue nationally around issues of structural and systemic racism. And the American Association for Community Psychiatry, of which Dr. Sriyanka, Dr. Minkoff, and I are all board members, was among many organizations that considered sort of what this new reinvigorated focus on these issues meant for our organization and our members, and how to think about addressing some of these issues in the ways in which they uniquely impact the community mental health space. So posted here on the slide, I have four commitments that our board made on behalf of our organization in response to the killing of George Floyd, as well as other events over a year ago, in terms of committing to be very thoughtful and proactive about how to address the issue of structural racism as it is relevant to community mental health. But I think beyond, you know, creating the statement, creating these four commitments, something that was very much on the minds of our board, as well as our author group here, was how can we take a step beyond statements and move towards action? How can we, as a member organization that supports the work of community mental health practitioners nationwide, encourage those practitioners to be proactive and take concrete steps to address structural inequity in the community mental health setting? So with that in mind, basically our goal following the issuing of the statement and thinking about the development of the SMART tool was that ideally we wanted to create a tool that would meet three goals, that would provide metrics specific to disparity and inequity issues in the community mental health space, so something that would really be unique to the settings and the populations that we as community mental health providers are serving, to provide a tool that would extend beyond cultural competency and linguistic appropriateness, to incorporate structural factors relevant to inequity and disparity in these populations. And I think most importantly, promote a stepwise concrete QI process that could be adapted for self-directed use in the community mental health setting. And so our hope was to draw on the extensive evidence base relevant to inequity in community mental health, draw on our boards, our membership's expertise on these issues, and boil all that down into some form of simple, easy-to-use tool that could be applied in the community mental health setting that community mental health practitioners ideally could use for a self-directed process towards quality improvement in this arena. So next, I'll tell you a little bit about our process in developing the tool. So this was not a formal research process per se, but what we did was we aimed to really draw on both the range of expertise of our board, which consists of community mental health practitioners and leaders from across the country, as well as our larger membership. Similarly, the wide swath of community mental health minds that make up the American Association for Community Psychiatry, to start to boil down on what the key issues might be, the key areas in which inequity and disparity might come up in the community mental health setting. And so sources that we drew on in terms of thinking through how to put together this tool included a membership town hall in which members of the American Association for Community Psychiatry were invited to provide their reactions and their feedback and their ideas as far as where inequity is most relevant to the community mental health provider and what areas felt most ripe for change and quality improvement in the minds of our membership. Discussions among two of our board subcommittees. So Dr. Minkoff already mentioned the product subcommittee of the American Association for Community Psychiatry's board. We also have an advocacy subcommittee as well, in which we started to boil down an idea of key topic areas that might be most relevant to issues of disparity in community mental health. And we then searched the primary literature to identify disparity issues for which there was evidence to indicate a likelihood of disparity, as well as a review of the literature to identify prior inequity frameworks. In pulling together this tool, we were of course aware that we were not the first to come to this topic, that inequity in health care is certainly an age old issue, an issue that has been studied prior. And knowing that there had been prior work specifically around organizational change to address inequity in health care, we reviewed prior frameworks, both to make sure that we weren't reinventing the wheel as far as creating something that already existed, but also ideally to draw on some of those prior resources in order to make the most effective tool for the community mental health setting. And so that was our process as far as developing this tool. Now we do have a publication out that describes that process in more detail, but I'm going to say a little bit about some of the prior inequity frameworks that we looked at in creating this tool. This is by no means an exhaustive list, either of all of the inequity frameworks relevant to the health care setting that are out there or all of the frameworks that we considered in developing this tool, but just to give an idea of some of the major prior frameworks or organized sets of principles that we thought about in putting this tool together. So first there is the framework of structural competency developed by Drs. Jonathan Metzl and Helena Hansen, which gives us five organizing principles to think about structural inequity in health care and really encourages us to think about patient care through a structural lens as far as how we conceptualize patient problems. And so we certainly found the mindset and the ideas of this set of four organizing pillars very helpful in terms of informing our thinking to create the smart tool. We did find that for the most part that the resources that have been created under the umbrella of structural competency consists of a variety of curriculum materials as well as training materials for health care professionals. At least to our knowledge, we weren't able to identify an organizational QI tool that had previously been created from these framing principles, but certainly found them extremely relevant and useful as far as developing our own inequity tool. Next, the National Standards for Culturally and Linguistic Appropriate Services in Health and Health Care, or the CLAS Standards. These are developed by the Office of Minority Health, DHHS, and provide 15 standards as well as a blueprint to assist organizations in meeting certain standards in order to provide culturally and linguistically appropriate services. So again, we found that process of creating a blueprint to assist an organization in moving towards those goals to be incredibly important, incorporated elements of cultural competency and linguistic appropriateness into our thinking for creating this tool, but wanted to be sure we created something that extended beyond those categories to include more structural factors as well, but certainly found this to be an incredibly useful set of principles to consider in creating our framework. The Roadmap to Reduce Disparities is a six-step framework from the Robert Wood Johnson Advancing Health Equity Initiative. This certainly, I think, was one that very much informed the thinking of how to put our tool together in that it really breaks down the process of addressing inequity into concrete steps, provides structured exercises to guide staff and health care organizations in a quality improvement process to reduce disparities. And so this certainly inspired exactly what we tried to do with the SMART tool as far as giving concrete stepwise guidance to assist the standard frontline on the ground provider or organization in drawing on inequity issues from the research literature and finding ways to identify those issues within one's own community practice and address them. While this was, I think, an incredibly useful framework to consider, we did find that the available resources to the Roadmap didn't seem to fully address the population that we had in mind with our framework, specifically community or public mental health. As an example, the Roadmap to Reduce Disparities includes a searchable literature database to allow organizations to identify disparity issues to target, but that database doesn't necessarily cover all the range of clinical issues most relevant to the population we often deal with in community mental health, those with serious mental illness. And lastly, the EQUIP framework. This is a primary care QI tool that engages organizations in identifying priority areas for change and encourages organizations to come up with an action plan to address those issues. And so certainly exactly what we hope to do for community mental health. This is a tool that's been piloted in the primary care setting in Canada with positive self-report results in terms of confidence among staff in addressing inequity, but was created, of course, particularly for the primary care setting. And so our goal was to really create something of a similar vein, but target specifically to community mental health. Another key difference with the EQUIP framework is that it involves bringing in a trained consultant to assist with the process. And our hope in creating SMART was to create a tool that ideally a community mental health organization could self-apply, drawing on the expertise and understanding and wisdom of an organization's own staff as far as the ins and outs of the organization, what is and is not working in regards to inequity to create a self-directed quality improvement process. So I'm going to turn it over to Dr. Minkoff to pick it up from here. Thanks, Rachel. And you're going to continue to change my slides, I trust. Thank you. Of course. So I just want to say how honored I am to be working in partnership with Dr. Talley and Dr. Schoenka on this amazing project. And one of the things that I brought to this discussion is my experience over decades as a system change consultant, helping to work with large systems of all kinds, states and counties and all that kind of thing, helping systems to figure out how to make progress in improving service delivery and outcomes for people with complex needs. And so a lot of that work has involved developing a broad system framework for change around how to deliver integrated services for people with co-occurring mental health and substance use conditions or behavioral health and cognitive intellectual developmental disabilities or brain injuries or health and behavioral health or criminal justice and behavioral health and so forth. So that background and experience in developing tools and helping systems to use them to make change on a large scale is something that I brought into this discussion to say, what can we do as the American Association for Community Psychiatry to change, to transform our own energy and purpose that Dr. Talley listed in the first four commitments of the organization into something that could potentially be available to organizations in the space of delivering community or public mental health and or substance use and or intellectual disability services the opportunity to quote unquote do something to make progress in being anti-racist organizations. And within that frame, there are two intersections, if you will, of understanding that are important. So one of them is implementation science. One of the things that we wanted to emphasize in this work was action. One of the things that we know is that a lot of people think that the antidote to racism, if you will, is somehow training. But training all by itself is not the best way to create change in behavior and practice in a sustainable way. It's important for organizations at all levels to be able to utilize the tools of implementation science, which incorporates a variety of strategies within a broad application of continuous quality improvement or practice improvement or all of these terms that connect a whole variety of interventions within which training staff is only a small subset. It involves looking at organizational processes and workflows, both clinical and non-clinical, and it looks at using data to evaluate what is being produced by those workflows in the spirit of the quality improvement mantra that every organization is perfectly designed to achieve the results that it gets. And if you want different results, you have to look at the organizational design, because most organizations have wonderful people producing the inappropriate results because they're in an inappropriate design that's determined by policies, procedure, practice, structure, and so forth. So we wanted to apply the quality improvement framework to being the translation between something needs to be done, something must be done about anti-racism in the world of behavioral health specifically, which is our purview, and how to provide tools, essentially a tool, to help organizations go about doing it. The second component of this is what it means really to think about anti-racism as a shorthand for anti-structural racism, because I want to emphasize the structuralness of this. Racism, you know, is often thought about as just like bad people having bad attitudes, but the power and the perniciousness of structural racism is that it's often embedded into organizational structures at many different levels, so that good people who are not consciously racist are part of organizational activities that have racist results as measured by real data. So the idea of applying quality improvement technology to this is literally directed at the structural embedding of racism into behavioral health organizations by perfectly lovely people who do not wanna have this result at all. And it's not gonna be changed just by training everybody to have better attitudes unless the structures and processes themselves are identified, looked at, and addressed. So those two key themes came together in designing this tool. The third component of this is we wanted to create a tool that would lead people to take action. And being in the system change business for many years, I know, as you guys out there probably know, that it's very easy for people to say things like, something should be done and somebody should do it. And people are great at that. I can think of all kinds of things somebody else should do to make the world a better place. But we wanted to own this in our universe of behavioral health and specifically community or public behavioral health to say, well, as an individual practitioner or leader or an individual program or agency, I mean, I can write letters to whomever's telling them all the things I wish they could do, but that's not gonna, that's just a drop in the bucket. What do we do in our organization? How is our organization affected by structural racism? Structural racism, and what can we do in our organization? Because no matter what anybody else does, nobody's gonna wave a magic wand and fix us. We've gotta do that. So the operating framework is what I call the serenity prayer of system change. And in this webinar, we are purposely welcoming all of you into a change process, as if we were welcoming you to a 12-step recovery meeting for anti-racism change, but we wanna welcome you in the spirit of the serenity prayer, the serenity to accept the things you cannot change, which is everyone else, the courage to change the things you can, which is your own practice, your own program, your own agency, your own span of control wherever you happen to be, and the wisdom to know the difference. This tool is an opportunity. Well, you're saying, well, what do I do then? I would say, well, pick up the tool and use it in your world. It's not hard. It may feel challenging, but it's not hard. It's not terribly time-consuming. It's not a lot of hard work. It does require that you bring people together, as we'll talk about, to engage in the steps of a quality improvement process, out of which, if you find even one thing that you can then change as a result that produces a measurable result, you've made a difference that is more than if you had just waited for somebody else to fix you. So there are many models of quality improvement, if you will. The one that is probably the most common, simple, across-the-board approach, and many of you have probably heard about it, is called FOCUS PDCA, and the PDCA or PDSA, the Rapid Change Cycle Plan-Do-Check Act, Plan-Do-Study Act, is part of the activity of change. The FOCUS part is a simple acronym that guides the basic process of how you get to deciding what you're gonna be working on, if you will. And so this process informed our thinking about how to design the tool and how to provide instructions for its use. So in this slide, you'll see, if you're not familiar with it, F stands for find a process to change. Well, structural racism, okay? The next step, which is where you begin, organize a team, ideally to use the tool, but you may wanna start by organizing a team to talk about using the tool. But bring some people together. Don't start with the people that are the most resistant. Start with whoever you can bring to the table, because there are probably already people in your organization who are thinking this is an issue and wondering what kind of action could be taken. Clarify the baseline, C. Clarify the baseline reminds us that structural racism is, again, not just about whether we think good thoughts. It's about data-driven processes within our own organization. So if you're saying, does our organization have structural racism? The answer is yes, because all organizations do. The question, of course, is to what extent does it manifest in our organization and in what areas? Well, the way to do that is to use the tool to measure your baseline. And measurement involves, the tool provides you some structured data just by using it, but it also points you in the direction of places where you may or may not even be gathering data to know the extent to which your processes reflect structural racism or they don't. So it's helpful for you to use the tool to get an understanding of where you currently are. So the other thing we would say is wherever you are, that's great. Just by recognizing the baseline, you're already making progress compared to ignoring the baseline. Once you recognize the baseline, you don't immediately go to randomly fixing things. You go to you, understand why your baseline is the way it is. And if you're sitting there, and some of you have done this before in quality improvement, others may not have, but there's this whole technology about fishbone diagrams and Ishikawa diagrams and all of this. But the main idea is whatever you're seeing is multiply determined. There are multiple contributors built into your organizational processes that lead you to having the structurally racism affected outcomes in the different processes that you have. So take some time, try to understand what's happening that contributes to the processes that you're seeing in each of the domain, or even in one of the five domains of the tool. I mean, you can do it in all of them, but again, whatever is doable is great. And out of those S means select some of those processes that contribute to the variance in your baseline, select some of them to address. And as a rule, you don't pick the hardest ones. You pick ones that you feel like you can do something about in the short run to get yourself started. Okay, and then once you select some things, you come up with some ideas of stuff to try, because you don't have to have the perfect solution before you start. You try them, plan, you come up with a plan, you do try it, check, see what it did. And then based on that, either keep it going, make it bigger, revise it or whatever. And out of the tool, you may have three or four different cycles that you're working on at once as an organization, but you can point to yourself with pride and say we're engaged in helpful practice. Okay, can I get to the next slide? No, I'll go through this more quickly. So the idea for using the tool is move from subjective impression to actionable information. Look at organizational processes rather than whether you have good or bad people. Generate data to use for quality improvement. Identify where you have to put more energy into identifying data, because you may not even be tracking it. Create a structured framework for diverse staff, not only racially diverse, but also hierarchically diverse and job diverse. People that come together and talk about organizational processes. By engaging people, they are learning what structural racism really means, and they are empowered to participate in change. And the scoring process kind of creates an organizing way for the group to come to closure or consensus on these items that promotes a better discussion. Next. Now there are five domains or organizational domains that we derived from the review that Rachel went over. Like where are the areas in any organization? And then where specifically in behavioral health organizations? Are there measurable things that are connected to structural racism? So there's hiring, recruitment, retention, and promotion, all the employment related specific things. There are domains of clinical care that so similar will go over that affect the way people are diagnosed, whether they have access to the best possible treatments and a variety of other things. The culture of the workplace itself, terms of organizational safety and communication and trauma that may be connected to racial inequity and disparity. And then there are things that are out in the community that the organization may be participating in, not fully in control of, that have to do with say differential response in terms of involuntary treatment or criminal justice involvement or child welfare involvement. And then finally, there's how does the organization position itself in terms of its data collection and evaluation? What is it measuring in general? How does it organize itself within the data that it collects to be looking specifically and continuously addressing issues of racism? Next. Next. So the process is very important because the most important aspect of the tool is to produce a quality improvement conversation as a group or a team. And this can be done throughout the organization. It can be done in different components or programs because different parts of the organization may have different structural issues that can be addressed. The instructions are in the tool, but this is a summary. Bring together a diverse group of staff that's horizontally and vertically mixed. So because that's quality improvement best practice. Use this as a catalyst to open the conversation because it's easier to talk about the organization in some ways than it is to talk about, you know, everybody's personal anxieties, but it opens the door for further discussion. You use consensus scoring on the items. Don't have people score separately and have an administrative person average it. And then out of that, identify priorities for improvement, create an action plan, and then use the tool again in six to 12 months. I'm gonna hand it over to Sosin Mollem. Thank you, Ken. And thank you, Rachel, for that excellent lead-in to this aspect. So I'll be talking about, I'll be walking the audience through the application of the tool in the way that Ken has laid out. As he described, these various different domains are carefully selected as being areas that are particularly relevant to community psychiatry. And the first of those is hiring and employment. And why is this important? So we know from the literature, for example, that there is increasingly recognition that there's concordance between the matching of the patient and provider's ethnicity as with outcomes. And so, we also know that the representation of, for example, minority physicians is not consistent with what you see in the general population. And so, in using this tool, a group that's been constituted in the way that Ken mentioned could select any one of these areas, promotion, recruitment, hiring, retention, or disciplinary action. These are all areas in which the literature is pretty clear that disparities exist. So if the HR department, for example, decided to take a look back over a 10-year period, over a five-year period, at who responded to job posting or, say, medical director or staff psychiatrist or charge nurse, or any one of these positions, if the HR department decided to take a look back and looked at the data, who applied, who was selected, and who stayed in the organization over that period of time, that would be an example of one area to focus on. Next slide. Next slide. And so, the scoring, and again, I want to emphasize that the scoring is done on the basis of a consensus, arrived at through means of discussion, weighing and considering various views from a broad cross-section of participants drawn from various ethnicities, other identities, and levels of the organization, as well as task assignments. Reaching, the task would be to reach a consensus on, for example, to what extent is there a disparity in hiring within our organization? To what extent does our organization track racial disparities in promotion, times promotion, percentage of employees receiving promotion, and so on? A score of one would be, we haven't even started working on this. We haven't done anything. This is not even recognized as an issue. A score of two would be, we do track this or have begun to look at this, but we really haven't started to see much progress based on objective data. A score of four would be, yes, we have begun to track this consistently, have identified disparities, and have made significant progress, again, based on actual data collection and analysis. And I think in just the process of just thinking about this, I think it's evident that just arriving at consensus certainly would require discussion and possibly generate additional conversation, which is essential to real anti-racism work. Next slide, please. Okay. Clinical care is, if you will, the meat and potatoes of community mental health. It's kind of our business, if you will. That's what we do. And so, again, in this area, the literature is pretty consistent about, and pretty clear about the disparities that exist. So we know, for example, that if you look at point number four there, the use of any kind of restrictive treatment, any kind of coercive treatment, is there's a market disparity in the application of those treatments to minority populations as compared with non-minority populations. We know the same about access to care. For various contextual, structural reasons, we know that there's disparities. We know that there are disparities in who receives what kind of care, clozapine being one example of a potentially lifesaving treatment for treatment-resistant psychosis, for example, or impulsivity, suicidality. And yet the rates of application or use of these treatments in ethnic minorities is consistently lower than in other areas, than for non-minority populations. And so this is an area that's really rich, both in terms of the literature around it, but also in terms of opportunity. And so then, next slide, please. If you say, for example, just, for example, a clinical team on an inpatient unit decided to focus on clinical care as the aspect of the SMART tool that they wanted to apply, the process would be we gather everybody from the doctors, the physicians, the nurses, to the techs on the unit, and all created a work group or committee and sat down and decided to look at, the group would decide to look at the data and whether prospectively or retrospectively look at the application, say, for example, of restraints to patients on the unit. And the team could decide to look at how that breaks down by ethnicity, by racial categories. Now, depending on what the team, the consensus of the team, that the team arrives at, it could be, again, a score of one, which would be, we don't track the use of clauzapine, we don't track the use of restraints, we don't track the use of involuntary commitment, whatever, choose one of those, we don't track it, have not addressed it, to a score of three on the LIPAS scale, which would be, yes, we do. We have begun to look at this, we have identified disparities, we've made some progress, you know, as evidenced by data, and a score of five in this regard would be we have, we really have got this locked down, we've, you know, tracked this over quite a significant period of time, and according to our data, we have eliminated disparities. I mean, I think just thinking about that, that would be quite a remarkable achievement. So that would be an example of how to use, how to work through domain number two, which is the clinical domain. Next slide, please. And the third domain is workplace culture, and in some ways, this is the, could be the hardest domain to work on. Part of that is simply because, how do you measure something as intangible as culture? The manifestations are fairly robust, but in many places, it's just, we just, it's just something we get socialized into, this is just the way we do business. This is how we operate, this is how we do things, without really the sort of critical analysis that the smart tool advocates, and so, again, I would say this is probably one of those areas where the smart tool is maybe the most useful, because this is one of those areas that's the hardest to really wrap one's mind around or hands around. So you know, look, again, the same basic process, the group, a group would be convened to look at various aspects of workplace culture, individual, comprising individuals drawn from all, you know, all levels of the organization, and preferably multiple ethnic racial backgrounds, other identities, as well as specialties. And then, you know, walking through the two, through each of these questions would be, to what extent, you know, does the organization, has the organization implemented implicit bias training? To what extent is the organization trauma-informed, you know, and specifically here, we're talking about racial trauma. To what extent is there a formal reporting process that actually leads to outcomes, you know, that actually takes concerns or complaints about inequitable treatment seriously, and actually acts on those things? To what extent are difficult conversations facilitated or allowed or supported in those environments? Next slide. And so again, you know, the same basic framework, if we selected, if the team selected item number one, an intentional anti-racism workplace culture, to what extent has the organization explicitly identified creating a safe space for staff and clients to discuss racism and its effects, and ensuring that formal processes exist, which include accountability, and so on, to achieve a goal? Item number one, the score of one would be, we really have barely begun to think about this, but haven't really taken any steps, really going all the way up to a possible score of five, which is formal goals have been established, there's a well-established structure and processes, and there's data to back improvements in these areas. Next slide, please. And so, as Ken mentioned earlier, and Rachel mentioned earlier, community psychiatry by its very nature is positioned in such a way that it necessarily interfaces with multiple systems that are themselves impacted fairly significantly by structural racism. Again, this is not a commentary on individuals that work in the systems, but I think there is abundant evidence of disparity, for example, in the involvement of incarcerated persons, specifically those with severe mental illness, or other forms of behavioral conditions, addictions, and so on. And even within that category, there's evidence of disparities based on ethnicity and race. It's a well-known fact that the school-to-prison pipeline disproportionately impacts black youth and Hispanic youth, particularly the males. To also note, the same is evidence for child protective services and who becomes involved in those services, and the same is true for elder care and housing insecurity. So these are known facts supported by literature. The way that this impacts community mental health is we get to deal with people that are enmeshed in all of those systems. And so the basic idea is that where, for example, the criminal justice system interacts or interfaces with our system, the community mental health system, there are opportunities to identify disparities and speak to them. And that really follows the same process. So next slide, please. So an example would be taking a look at involvement in law enforcement and the criminal justice system. A very simple, one very specific area would be who comes to the ED in cuffs, who comes to the psychiatric response center, the crisis response center in cuffs, who ends up leaving and going back to jail as opposed to leaving and going back to the community, for example. And so, again, the way this would be processed within the group would be a specific question to be considered, investigated, discussed would be to what extent does our organization work in partnership with law enforcement to eliminate disparities in arrest, incarceration, and diversion of people of color who have mental health and substance abuse conditions. It might not even have shown up on the radar of the organization as even a target or something of interest. I'm ranging all the way up to a score of three, which would be there are existing collaborations, there are discussions, there is data showing some improvement, and all the way up to score five, which would be that the work done in this area has been so substantial as to eliminate all disparities in this area. Next slide, please. And as Ken said, the ultimate goal of all this work is population health. And I think COVID has been the ultimate reminder that these disparities exist in a pretty stark and striking fashion. So when we look at that level of outcome, or we look at a less, shall we say, life and death outcomes, such as who gets employed and who spread the differential graduation rates and so on, this is also an area in which it would be useful to collect data, certainly at a macro system level. So this could be another area of focus for a group that's interested in anti-racism work. Next slide. And so again, sample item, to what extent does your organization track disparities in homelessness, employment, graduation, recidivism, and work to eliminate all such disparities and the same basic framework for scoring? And I will turn it back over to Rachel. Thank you. All right. Thank you. So to bring us to the end here, and then perhaps we'll be able to address a few questions in the chat, as well as talk about some of the common questions that we've gotten about this tool. First, in terms of future directions for this tool. So as we've laid out here, and hopefully given the attendees a better understanding of, we developed this tool with the process informed by the existing evidence, as far as areas where the literature supports the existence of disparities in the community mental health space, as well as drawing on the content of existing inequity frameworks. If you'd like more information on the details of how we've developed that process, we've described it in an article that we recently published in the Community Mental Health Journal. And so we've aimed to give you a broad overview here of that process, but we'd encourage those on the call who are interested in some more details of the evidence that we drew on, as well as existing frameworks that we considered. We certainly encourage you to take a look at that publication. I think in what will, I believe, address one of our questions here in the chat, in terms of future directions. So this tool is available in a PDF form on the website of the American Association for Community Psychiatry. We have the link here in our slides and posted with the PDF of the tool. We also have a structured feedback survey, because the stage that we are at now in terms of this tool is that we have drawn on the evidence to create this tool, but we're very much at the stage of proof of concept and looking for early adopters to assist us with informal piloting, to advise us on the process of using this tool, how it works when it's actually applied as directed, any challenges that early adopters encounter in attempting to apply the tool, so that we can ideally revise it in order to move towards more formal piloting. So those on the call, I think if there's one, I'm sure Ken Sosumolo would agree with this, that if there's one takeaway message beyond our learning objectives that we'd love for you to take from this talk, please consider downloading the tool, particularly those of you working in the community and public mental health space, and attempt to use it in your organizations and give us feedback on how it works and what sort of experiences you have using it, so that we can think towards refining this tool and ideally continue to build an even improved version to assist in this process of addressing racism in the community mental health space. And so with that, these are some of our references. And so at this point, of course, we've seen that questions have been submitted all along here, but we encourage you to continue to submit questions as to your thoughts on our presentation here. As I mentioned, I did see that one of our questions was about accessing the tool. So it is available on the site for the American Association for Community Psychiatry. I guess if I could speak to another comment that I saw as far as how to measure progress as you're moving along with the tool. And I guess taking off from that question, I'll make a comment that in creating this tool, we're sort of intentionally tried to toe a line in not being overly prescriptive about what progress looks like, that we've created this Likert scale for each item to give some guidance for an organization to have a structured, measurable way of moving forward. But we also built this tool with the recognition that community mental health is a very diverse space. A range of different types of organizations that have different structural needs that have served different populations are in this space. And so in our tool, we're not overly prescriptive as to what progress looks like on each of these domains. The goal is for an organization to consider what consistent tracking and disparity looks like on each of these domains for their organization, depending on who you are serving and who the population is, and think towards making progress with the metrics that make most sense to you, depending on the type of services that you are providing. So hopefully that at least in part answers that question. I'll invite, of course, Sosamol and Ken to weigh in as well, as far as common questions that we've received about this tool. Yeah, well, I just think that, did you guys hear me? Yes. Yeah. So I just, I, you know, I think one of the things we found is that the hardest thing that people have to do in using the tool is getting started and actually using it. So there's a lot of, we found it easy for folks and organizations to move from being pre-contemplative about the tools to being contemplative. And then people, you know, seem to get stuck in like, well, I actually am going to use it and then use it and tell us about it. And we've tried to make that barrier as easy as possible. So we, you know, what we're hoping is that, you know, if you get to the point of thinking something like this might be useful, that you pull together a group of people that even if they're your friends and just sit and try to do some of the questions and then think together about, you know, is this turning into a useful conversation and who else might we involve? It's not intended to be so, you know, this is not a research project. This is a tool to help your, you and your organization to make progress. And however you can figure out how to get that conversation going and pay attention to what the tool is guiding you to think about, you're going to get some value out of it. And we're very interested in learning from folks who do whatever about what works and even what doesn't so that we can, you know, eventually improve the tool and make it even more available. But don't stand on ceremony. And one of the commonest questions that we've received to piggyback on to both those comments is how long does this take? And you know, I think that we, first of all, we'd be really interested in hearing back from the audience on, you know, if there's an average length of time that it takes. But to Ken's point, I think the more important thing is to get started. And it might be that an organization, maybe your organization, those listening will choose one of these five domains to focus on to start with, something that's maybe more, I think Ken said this earlier, lower hanging fruit and start with that. There is really no prescribed format in that regard. In terms of time consuming this, two helpful tips. One is once you're sitting with the tool, have somebody in the group, not necessarily the person with the most formal authority, but someone should be a timekeeper. Because once the conversation gets started, people can go all over the map. And it helps somebody to say, hi, guys, you know, we said we would talk about this to make sure everybody got their contribution and come to consensus. But now we're starting to talk about all the problems of the universe, and we're losing our focus. So can we just get back and answer the question, please, and move on to the next one. And that's very helpful. The second thing is, remember that the tool is a baseline assessment, and the goal is to have enough discussion to come to consensus and to identify potential areas that you want to follow up. It is not for you to talk through each question until you solve the problem. Because if you try to do that, that will take forever. So you're using the tool as part of a quality improvement process to give you a baseline understanding of your organization and to give you ideas and energy from the group to make change. And if you stay focused on that, you know, it has maybe 25 questions or so. So you know, you get to the point where you get in the flow, and the whole thing may take a couple of hours to get through, and you can do it in a couple of sessions. And that's if you do all of it, you know. So don't make it too hard. Absolutely. An additional comment I'll share as we get to our last minute or so is, as far as I think a very common question we've gotten are, who are the right people? How big should this group be? The main thing that we emphasize in our tool is, ideally, the people who implement this tool, who take a look at the organization, should represent a diverse array, both in terms of identity, but as well as role in the organization. We really think of it as, you know, potentially a lost opportunity if, say, you know, someone in leadership, just the CEO, sits in his office by himself and goes through this tool on his own and comes up with a score, that this is really about drawing on the wisdom and the perspective of people across an organization to think through together areas where there, you know, there may be a little bit of disagreement, depending on your role, depending on your perspective as to an organization's progress and where it stands. So certainly we encourage a diverse group, both, again, in terms of background, but particularly in terms of role in the organization. So I think in this final minute, we'll, you know, we'll thank you for your attention to this webinar. Again, encourage you to consider using the tool and give us feedback to continue to push towards action in this realm of anti-racism and really, you know, tackle these concrete disparity issues. Our hope is that the SMART tool offers a concrete sort of anchoring point to begin that process of moving ideally from talk into action to find ways to support our most vulnerable populations and ensure that we're doing the best work by all of our patients. So thank you for attending.

SMART

structural racism

community mental health

scoring system

disparities

quality improvement

download

feedback

diverse representation

collaboration