Getting to Know Each Other

Getting to Know Each Other
Interview each other in pairs (3 minutes each) Name, Institution/Organization, Position What part of your current job is your favorite? What's the craziest/most fun thing you've ever done in your life? Switch at the chime Introduce your partner to your table (1 minute each)

Welcome Ross McKinney, MD Chief Scientific Officer, Scientific Affairs

Building a Systems Approach to Community Health and Health Equity for Academic Medical Centers Year 2, In-Person Meeting: Implementation and Evaluation Planning Philip M. Alberti, PhD Senior Director, Health Equity Research and Policy March 8, 2018

Why are we here?

We are here to… “…integrate legal services into community pediatric settings to help address health harming legal needs of patients and their families living in poverty, and inform implementation of legal services as a way to reduce health disparities.” - MedStar Health

We are here to… “…establish a coordinated and sustainable institutional organization to advance community health and health equity for vulnerable populations across the research, educational, and clinical enterprise” -Vanderbilt University Medical Center

We are here to… “…implement a collective impact strategy to develop an equitable (by sex and region) statewide contact-sport concussion prevention system for adolescent athletes in Mississippi.” - University of Mississippi Medical Center

We are here to… “…to reduce the disparities in health outcomes contributed to by underlying food insecurity in older adults, families with children, those with less education, and the depressed and anxious.” -University of Florida College of Medicine

We are here to… “…build health equity and reduce ER admissions for preventable chronic disease by addressing the social determinants of health, providing access to primary care and controlling chronic disease in this low-income community at the doorstep of South Miami Hospital (SMH).” -Florida International University

We are here to… “…reduce the prevalence of elevated HbA1c (> 9) among the Hispanic population by 10% through increased identification and referrals for identified co-morbidities for adult patients…” -Baylor College of Medicine and Harris Health System

We are here to… “…reduce deaths from opiate overdoses by at least 10% per year without a disparity in benefit among race, gender, or socioeconomic status as measured by state-reported vital statistics.” -Virginia Commonwealth University

We are here to… “…develop comprehensive smoking cessation resources accessible to all Norfolk Redevelopment and Housing Authority residents.” - Eastern Virginia Medical School

We are here to… “…decrease the percent of births in Monroe County that are the result of an unplanned pregnancy from 32.4% of births to 30% or less, by decreasing unplanned pregnancy especially among Medicaid births and teens.” -University of Rochester Medical Center

We are here to… “…increase from 52% to 78% receipt of first trimester prenatal care among pregnant women of color and/or with low-socioeconomic status who will give birth in Kalamazoo County in 2020.” -Western Michigan University Homer Stryker MD School of Medicine

What have we done so far?

Processing… Intra-trans-cross-engaged systems scholarship?!
Internal and external infrastructure and support to get this done? How do we incorporate real-time feedback into our ‘best laid plans’? What if that changes our direction? Or the way we define success?

Where are we going?

Learning objectives Develop strategies to overcome implementation and evaluation barriers related to data, community engagement, governance, and sustainability Develop knowledge and deploy tools to account for non-linearity and the iterative nature of evaluating equity-focused community health improvement activities Develop knowledge and deploy tools to meaningfully engage communities when implementing and evaluating equity-focused community health improvement activities Develop strategies to recognize, discuss, and address power imbalances and dynamics when implementing and evaluating equity-focused community health improvement activities

CASE STUDY Middletown Addressing & Intervening on Depression and Anxiety Now: MAIDAN

Middletown Addressing & Intervening on Depression and Anxiety Now: MAIDAN
“To train the next generation of health professionals to provide the highest level of care to patients, families and communities” “To provide high value, high quality care to our patients” American Health Professional College (APHC) Universal Health Care (UHC)

Mental Healthcare Access, 2017
Self-reported ability to access behavioral health care, % responding “usually” or “always”: 75% of white residents 36% of racial/ethnic minority residents 39% difference 82% of high income residents 45% of low income residents 37% difference

Long term, equity-focused goal
In five years, MAIDAN will achieve at least 3 years of a downward trend in the racial and economic gaps in self-reported access to mental health care without decreasing self-reported access for white and upper income Middletowners.

3 Potential First Steps Ensure community-based clinical records communicate with UHC’s EHR to better coordinate mental health care. Align current nursing and medical student shelter-based efforts in terms of data collection tools and referrals in order to eventually expand program to other learners and sites. Train local police officers on appropriate ways to interact with citizens in mental health distress who are from different sociodemographic backgrounds.

Intermediate, Process Outcome
Within 1 year, and with input from a broad array of stakeholders including patients and their families, identify, test, and initiate ways to merge SON and SOM mental health screening and referral data in order to develop a patient-centered, unified data collection system that is better able to identify inequities and suggest action.

Morning Agenda How can MAIDAN ensure its evaluation strategy is culturally responsive to the context and needs of its community? Veronica Thomas, PhD How can MAIDAN effectively incorporate a systems perspective into its evaluation plan? Beverly Parsons, PhD How can issues of power and privilege be acknowledged and addressed in MAIDAN’s implementation and evaluation planning? David Chavis, PhD How can MAIDAN overcome implementation challenges unique to academic health centers? John Tomkowiak, MD, MOL

Afternoon Agenda How can we overcome barriers related to data availability, community engagement, governance, and sustainability? Subgroup lunch and walkabout What is an effective process to deploy – and the most productive conversations to have – as we develop our implementation and evaluation strategies? Can MAIDAN help us? PCI Framework exercise Beverly Parsons, PhD

Professor, Howard University President and Executive Director, InSites
Evaluation from a Culturally Responsive and Systems Oriented Perspective Veronica G. Thomas, Ph.D. Professor, Howard University and Beverly A. Parsons, Ph.D. President and Executive Director, InSites

Brainstorming Questions
When you hear “evaluation”, what words and concepts come to mind? Now, what feelings come to mind?

Evaluation is: a systematic applied inquiry process for collecting and synthesizing evidence (data) and drawing conclusions about the state of affairs, value, merit, worth, significance, or quality of an entity. The value feature distinguishes evaluation from other types of inquiry. (definition adapted from Encyclopedia of Evaluation)

Two Approaches to Evaluation
Culturally responsive evaluation (CRE) Systems-oriented evaluation (SOE)

Culturally Responsive Evaluation (CRE) is:
a holistic framework in which the evaluator understands the cultural context in which the project operates and incorporates those understandings in evaluation planning, implementation, and dissemination of results.

CRE Examples Share examples of work you’ve done through a CRE lens or framework What principles, values, and/or approaches come to mind when you think of culturally responsive evaluation?

CRE Targets the environment as well as individuals operating within that environment through principles of: ongoing stakeholder engagement, social justice and equity, strengths-based, and provision of data that stakeholders can use to better understand a project’s operations and outcomes within its cultural framework.

Benefits of CRE Builds trust Creates inclusive climate
Enhances cultural competence Includes multiple perspectives when determining what counts as “credible evidence” Promotes use of evaluation for community benefit

Systems-Oriented Evaluation
When you think of a system, what do you think of? What systems do you belong to?

Seeing in Systems; Thinking in Systems
What systems do you “see” in these pictures?

Systems and Systems Thinking
System: A system is a collection of entities that are “seen” by someone as interacting together to do something. (UK) Systems thinking: Thinking in terms of systems rather than the parts; thinking about structures, dynamics, and patterns across time and locations; thinking in systems.

Mechanical System Structures Hierarchical System Structures

Networked System Structures

Benefits of Systems-Oriented Evaluation
Draws attention to ripple effects Recognizes power of boundaries, relationships, perspectives More influential actions can be selected

Cultural and Systemic Complexity
Partnerships Communities

Summary Points About Both CRE and SOE
Recognize the importance of interconnections and exchanges View stakeholders as active participants in the evaluation process Value diversity, embrace multiple perspectives, and seek to ensure that the perspective of the less powerful or marginalized is represented

Summary Points About Both CRE and SOE
Examine factors outside boundaries of the intervention that can influence design, implementation, and outcomes of intervention Address link between interventions and outcomes by explicitly situating the intervention (and its stakeholders) within sociocultural, historical, political, and organizational context

MAIDAN Case Study: Major Areas of Attention
Racially and economically diverse groups Inequitable care Cultural clash/perspectives (e.g., b/researchers and church elders) Power dynamics (e.g., b/researchers and church representatives) Other relationship issues (e.g., b/police and homeless community) Structures of systems involved ,

MAIDAN Intermediate Outcome
Within one year, and with input from a broad array of stakeholders including patients and their families, develop a patient-centered, unified mental health screening and referral data collection system that is better able to identify inequities and suggest action.

MAIDAN Evaluative Action
Select manageable unit for action and evaluation Evaluative Action – hold a focus group Outcome: based on diverse stakeholder input, identify how a referral network (system) can surface inequities and suggest systemic action

General Question Addressed in MAIDAN Focus Group (Action)
How can referral processes identify inequities and suggest actions that are in keeping with cultural perspectives? What are the pros and cons of pursuing one or more of the suggestions? a

CRE & SOE Lens on MAIDAN Evaluative Action
What would you be thinking about regarding the focus group that brings together a: culturally responsive evaluation lens with a systems-oriented evaluation lens?

Focus Group: CRE and SOE Opportunities
Before formation of focus group Formation of focus group Implementation of focus group After focus group

Summary Points CRE and SOE
Interconnections and exchanges Stakeholders as active participants Value diversity, multiple perspectives, perspective of the less powerful or marginalized Factors outside boundaries of the intervention

Cultural and Systemic Complexity
Close with reminder of the need to be able to move back and forth among culturally responsive and systems oriented perspectives.

Break Program will resume at 10:35 a.m. EST

When the Rubber Hits the Road David Chavis, Ph. D. CEO Kien S. Lee, Ph
When the Rubber Hits the Road David Chavis, Ph.D. CEO Kien S. Lee, Ph.D. Principal Associate/Vice President Community Science

What is Community ? Community is a feeling, perception and a set of relationships among people. People form and maintain communities to meet their needs. Neighborhoods, schools, college campuses, or places of faith are context and environments for these communities but they are not communities themselves. Animations: Yes

Community Control Cash
What are the three most important contributors to physical, mental, and social health? Community Control Cash

Community, Culture, and Systems
System = an interconnected set of elements that is coherently organized in a way that achieves something Community functions like a system and is also part of a system Culture is a set of socially transmitted and learned behavior patterns, beliefs, institutions and all other products of human work and thought Community creates culture and culture forms community Animations: Yes System = that characterize the functioning of a particular population, profession, organization or community. Culture is continually evolving.

Arnstein’s Ladder of Community Engagement

Format of Presentation
Potential situations or challenges you might encounter in the MAIDAN situation To prevent the situations and overcome challenges: Questions Homework Potential strategies

Community and Community Representation
In a townhall meeting to solicit community member feedback, a South Asian participant asked you why nobody from the South Asian community was represented in the task force. Which community needs to be represented? Study demographic data Consider within group differences Who “represents” the community? Formal and informal leaders Identify and consult cultural broker or bridge builder How do you find that person? Neighborhood or ethnic media outlets Faith institutions/places of worship Ethnic restaurants and grocery stores Advocacy organizations for specific populations Animations: Yes

Different worldviews about mental health and other health outcomes
The information collected from a focus group in the Vietnamese community suggested that mental health was not a major concern, yet data trends indicate high levels of depression and anxiety for this particular population. What is the purpose of the focus group? Consider the ladder of community engagement History of “community engagement” Determine the mutual benefit Who organized and conducted the focus group? Beware of insider/outsider dynamics Certified interpreter Location of focus group Animations: Yes

Different worldviews about mental health and other health outcomes
The information collected from a focus group in the Vietnamese community suggested that mental health was not a major concern, yet data trends indicate high levels of depression and anxiety for this particular population. What do different racial, ethnic, cultural groups consider mentally healthy and unhealthy? Consult with cultural brokers or bridge builders (e.g., second generation Vietnamese youth, faculty members in the Asian studies department, Vietnamese leaders) What are their help seeking behaviors? Understand cultural taboos and related traditions, if any Ask directly who they go to for help and why Animations: Yes

How to bring it to scale and change systems
How will ownership of initiative by community be developed? Through building community? Through control? How can community and institutions change systems?

Perceptions of Researchers
During a focus group, APHC representatives had a difficult time getting participants to answer the questions; instead, several African American leaders criticized APHC for always collecting data from them but never sharing the results, and nothing ever changes. How is your institution perceived by community members, especially the communities experiencing health disparities? Convene a meeting of the schools Do a quick search of newspaper articles and other types of news for relevant information How do you ensure you don’t make the same mistakes and create further harm? Consider the ladder of community engagement Don’t make promises you can’t keep Be clear about how the data will be used and next steps Animations: Yes

Communities within Academic Institution
Representatives from SOM, SON, and other health profession schools recognize that they need to better align their programs, trainings, and data collection; however, they don’t believe they have leadership support or resources to do so. What is the connection between school’s mission, community inclusiveness, and health equity? Challenge how the mission is operationalized and plans for fulfilling the mission Who at the leadership level needs to engaged early on? Consider leveraging the influence of AAMC and peer leaders Identify how alignment can benefit each school and the whole institution (e.g., cost efficiencies, etc.) Animations: Yes

What You Can Do to Ensure a Respectful and Inclusive Community Engagement Process?
How will you address the inequities(or promote equity) in power and privilege community wide? What worked and didn’t work well in the past Data collection activities and broken promises Cultural brokers or bridge builders Physical space Experts in your academic institution Science and art of community engagement Recognition of institution vs. community’s priorities Animations: Yes

Implementation and Change ”Leadership” Strategy.
John Tomkowiak MD, MOL Founding Dean Elson S. Floyd College of Washington State University The ESFCOM team after 1 ½ years! Leadership word collage that most leaders could agree upon.

Barriers to Implementation Success
Governance and Sustainability Leadership and Centralized Governance Scope and Sustainability Community Engagement Imbalance of Power Outcomes that Align with Goals Data Management and Availability Coordination of Disparate Data This slide identifies issues that I compiled from the community engagement calls and barrier discussions that were disseminated to our group. These are some of the larger issues that seemed to come up over and over again, and as I read through each organizations projects, seem to be applicable to a great majority of teams. I will try to provide ideas or solutions by the end of the talk for strategies to begin to address some of these issues…

Leadership Behaviors in Cross Functional Teams
Envisioning Strategic objectives that inspire and are aligned Organizing Establish standards and methods for assessing progress and performance Social Integration Mediating conflicts External Spanning Monitoring the external environment of the team to identify constituent needs, emerging problems and political processes that affect the team Influencing people outside the team to provide resources, approvals and cooperation L This slide serves to set a very large box (framework) at maybe a 70,000 foot level of the kind of team they have formed. Important to differentiate from self managed teams which are the most likely teams that people have worked on previously. Understanding there are some difference in how problems arise and can be addressed in Cross Functional Teams vs self managed teams are an important jumping off point for all other points of discussion. The next two slides take us down to the 20,000 foot level, and are meant to be practical way team participants can frame and address problems in their teams. Cross Functional Teams are in contrast to Self Managed Teams : Self Managed Teams perform the same task repeatedly, usually are full time and membership is stable over time Cross functional teams have different specialists, are tasked with conducting a complex activity and require considerable coordination cooperation and joint problems solving. Membership is less stable and usually work in a part time capacity.

This slide is a commonly used model used by Organizational Development Consultants to analyze an organizations “problems” and discover solutions. It works hand in hand with the “Four Frames Model” and has additional concepts such as 1) what are the incentives for doing the work and 2) who keeps the boxes in balance? Speak about the importance of the respectful and inclusive nature of the project, and the paramount importance of the “outside environment”.

Bolman & Deal: 4 Frames Concepts: Needs Relationships Skills Image:
Empowerment Challenge: Align Organizational & Human Needs Concepts: Rules Roles Goals Policies Technology & Environment Image: Social Architecture Challenge: Align Structure to Task Technology Environment Structural Human Resources Political Symbolic Concepts: Culture Meaning Metaphor Ritual Ceremony Stories & Heroes Image: Inspiration Challenge: Create Meaning Concepts: Power Conflict Competition Organizational Politics Image: Advocacy Challenge: Develop Agenda and Power Base Bolman & Deals summary slide of the four frames. A lot of information here. Will spend a few minutes discussing the slide in generalities before diving into the case analysis. Symbolic: Use of Jargon: Is it a communication barrier? Political: Loyalty to functional unit vs. to the “team objective”

MAIDAN Initiative: Case Analysis
How Can MAIDAN overcome implementation challenges unique to academic health centers? Leadership and Centralized Governance Imbalance of Power Questions from the frames: Structural: What are the roles of each organization? Human Resource: Ability to contribute? Political: Who is in charge? Symbolic: Who are the Champions and Inspiration for MAIDAN? This slide takes the conversation through the first three paragraphs of the hypothetical case study. Even though teams have already initiated their teams, HOW they initially organized, HOW they are currently operating and governed will play a huge role in appreciating potential barriers, especially ones that may be laying below the surface. Is everyone getting their needs met? Is each contributing proportionally to the agreed upon arrangement? Are organizations within the team overtaxed, fatigued or underutilized?

MAIDAN Initiative: Case Analysis continued
Scope and Sustainability Outcomes that Align with Goals Coordination of Disparate Data Imbalance of Power Questions from the frames: Structural: How does MAIDAN align structure with task? Does MAIDAN have the right technology to coordinate data? Human Resource: Do you have the skills to coordinate data? Does MAIDAN have the resources to be sustainable? Political: Competition. Who are the winners and losers and how are they chosen? Symbolic: Whose culture is it? How is meaning created? This slide takes us through the next two paragraphs of the case study. Deciding to focus on existing programs potentially creates winners and losers. How are these decisions made. If you support everyone equally do you get to your goals? Knowing how to coordinate disparate data doesn’t mean it can happen! Do you truly have the expertise to do so? If so who bears the cost? Who “owns” the data? Existing organizations are often going to be misaligned with a new initiative. How do you align the Goals of the new entity with the Outcomes you expect, especially if there are exsisting goals of individual members that might be Not consistent with the new goals…

MAIDAN Initiative: Case Analysis continued
Governance and Sustainability Leadership and Centralized Governance Scope and Sustainability Community Engagement Imbalance of Power Outcomes that Align with Goals Data Management and Availability Coordination of Disparate Data Questions from the frames: Structural: What rules govern decisions? Self interest over best outcome? Convenience over Effectiveness? Human Resource: Does MAIDAN have the skills and resources to sustain initiatives? Political: Who advocates on behalf of MAIDAN? Symbolic: What will it mean if resources are shifted to this initiative? This slides takes us through the last paragraph of the case study. It also brings two concepts from the Six Box model to bear. What are the incentives for each organization and its individuals to engage in the initiative? Who are keeping all the boxes (purpose, structure, relationships, mechanisms and rewards in balance?

Potential Solutions Governance and Sustainability
Leadership and Centralized Governance Scope and Sustainability Community Engagement Imbalance of Power Outcomes that Align with Goals Data Management and Availability Coordination of Disparate Data This slide is meant to encourage participant discussion on solutions they may have employed to get at these issues.

Potential Solutions Leadership and Centralized Governance
Elect a Leader who is not a participant. Develop bylaws for the team as if you were going to incorporate Determine levels of commitment to the project Scope and Sustainability Realistic goals + Stretch goals Resources aligned before investment

Potential Solutions Imbalance of Power
How is conflict managed? Consider neutral party resolution. Encourage “skin in the game”. Outcomes that Align with Goals Identify mismatches and let data do the talking Coordination of Disparate Data Must have incentives. Expertise. Infrastructure.

Inspiration from other Leaders
- Future Leaders_RECUT.mp4?dl=0 This is a 3 minute video that I showed at the last AAMC meeting when talking about communicating to inspire change. However I think it absolutely fits here and reinforces many points that will be brought up during the discussion!

Bringing It All Together: The PCI Framework
Animations: No

Bringing Concepts Together
Results-based management Long-term goals (results for beneficiaries) Adaptive management Actions – Evaluation – Adaptation Cycles Intermediate outcomes (actions linked to results) Animations: Yes

Visual Display: 5 P’s and 3 C’s of PCI Framework
Content Context Connectivity Practices Programs Policies People Power Animations: No

Visual Display: 4 I’s of PCI Framework
Inform Improve Influence Impact Animations: No

Action–Evaluation–Adaptation Cycle Template
Animations: No

MAIDAN Impact = Long Term Goal: In five years, achieve at least three years of a downward trend in the racial and economic gaps in self-reported access to mental health care without decreasing self-reported access for white and upper income Middletowners. Intermediate Process Outcome (for an Action-Evaluation-Adaptation cycle): Within 1 year, and with input from a broad array of stakeholders including patients and their families develop a patient-centered, unified mental health screening and referral data collection system that is better able to identify inequities and suggest action. Animations: Yes Inform Improve Influence Impact

Already know: Need to learn: Content: People Power Already know:
Policies Content: People Power Already know: Need to learn: Practices Programs Animations: No Context: Connectivity:

Content: Within one year, and with input from a broad array of stakeholders including patients and their families, develop a patient-centered, unified mental health screening and referral data collection system that is better able to identify inequities and suggest action. Already know: Need to learn: Policies Content: People Power Already know: Need to learn: Practices Programs Animations: No Context: Connectivity:

Already know: Need to learn: Policies Content: People Power Already know: Need to learn: Practices Programs Context: Low income neighborhood within Middletown, shelter, SON, SOM, behavioral health providers, and local mental healthcare assets Animations: No Context: Connectivity:

Connections between AHPC and UHC
Already know: Need to learn: Policies Content: People Power Already know: Need to learn: Practices Programs Connectivity: Disconnects in (1) data; (2) AHPC and local groups; (3) SON and SOM (4) organizational missions Connections between AHPC and UHC Animations: No Context: Connectivity:

Already know: Need to learn:
Policies Content: Within one year, and with input from a broad array of stakeholders including patients and their families, develop a patient-centered, unified mental health screening and referral data collection system that is better able to identify inequities and suggest action. People Power Already know: Need to learn: Practices Programs Animations: No Context: Low income neighborhood within Middletown, shelter, SON, SOM, behavioral health providers, and local mental healthcare assets Connectivity: Disconnects: (1) data; (2) AHPC and local groups; (3) SON and SOM (4) organizational missions. Connections: AHPC and UHC

Initial Action Ideas: MAIDAN
3 P’s (Policies, Practices, Programs) 2 P’s (People, Power) Revised Actions Success Inform Influence Improve Conduct a focus group of patients Sub-Steps: • Develop protocol • Secure IRB approval • Identify patients • Determine incentives • Outline logistics (time, location, child care, etc.) Learn important views on practices and programs and fit with culture of patients. Explore institutional policies and practices (IRB, merit and promotion, etc.) around team community-partnered science and team science. Attend to patients’ power position relative to other groups. Attend to SON / SOM power dynamics. Attend to “competition” between community-based organizations. Rethink focus group facilitator; possibly multiple parties in focus groups; multiple focus groups. Bring in the experts and site leaders with attention to power dynamics. Treat all sub-steps as learning opportunities for partnership and stakeholders. Input from patient and community stakeholders results in: (1) A prototype patient-centered data collection system that better identifies inequities and suggest actions. (2) Ideas for how to test prototype system Focus group participants inform academic partners about important matters related to P’s and C’s relevant to mental health screening and referral. Academic and clinical partners inform patients and community members about mental health disparities and the initiative to collaboratively address them. Patients and community members are more willing to engage in development, testing, and evaluation of new mental health screening and referral practices. Academic and clinical partners are more willing to incorporate patient and community feedback into their mental health screening and referral practices. Patient, community, academic and clinical stakeholders collaborate to increase validity, alignment, and utility of learner-led mental health screening data collected in community settings. Cross walk screening data and processes to identify areas of misalignment. Map current mental health referral processes and outcomes. Animations: No

Intermediate Process Outcome (for an Action-Evaluation-Adaptation cycle): Within 1 year, and with input from a broad array of stakeholders including patients and their families develop a patient-centered, unified mental health screening and referral data collection system that is better able to identify inequities and suggest action. Initial Action Ideas Conduct a focus group of patients Cross walk screening data and processes to identify areas of misalignment Map current mental health referral processes and outcomes Sub-Steps: Develop protocol Secure IRB approval Identify patients Determine incentives Outline logistics (time, location, child care, etc.) Animations: Yes

SON and SOM data collection practices Organizational missions
Already know: Disconnects Among data systems Between AHPC and local groups’ screening practices and policies and their referrals SON and SOM data collection practices Organizational missions Need to learn: Policies Data systems Roles of community members in research Data sharing Programs SON and SOM community programs Practices Meetings among people working with data Use of data for decision making Already know: Disconnects Among data systems Between AHPC and local groups’ screening practices and policies and their referrals SON and SOM data collection practices Organizational missions Policies Programs Practices Already know: Need to learn: Policies Content: Within one year, and with input from a broad array of stakeholders including patients and their families, develop a patient-centered, unified mental health screening and referral data collection system that is better able to identify inequities and suggest action. People Power Already know: Need to learn: Practices Programs Animations: Yes Context: Low income neighborhood within Middletown, shelter, SON, SOM, behavioral health providers, local mental healthcare assets Connectivity: Disconnects in (1) data; (2) between AHPC and local groups; (3) organizational missions; (4) SON and SOM Connections between AHPC and UHC

Community has little power in AHPC, UHC decision-making
Already know: Need to learn: Policies People Power Already know: Community has little power in AHPC, UHC decision-making Police power over homeless Power dynamics between SON and SOM “Competition” between CBOs for resources People Power Already know: Community has little power in AHPC, UHC decision-making Police power over homeless Power dynamics between SON and SOM “Competition” between CBOs for resources Need to learn: Who are informal opinion leaders in all organizations Who controls data access, use Content: Within one year, and with input from a broad array of stakeholders including patients and their families, develop a patient-centered, unified mental health screening and referral data collection system that is better able to identify inequities and suggest action. People Power Already know: Need to learn: Practices Programs Animations: No Context: Low income neighborhood within Middletown, shelter, SON, SOM, behavioral health providers, local mental healthcare assets Connectivity: Disconnects in (1) data; (2) between AHPC and local groups; (3) organizational missions; (4) SON and SOM Connections between AHPC and UHC

Intermediate Process Outcome (for an Action-Evaluation-Adaptation cycle): Within 1 year, and with input from a broad array of stakeholders including patients and their families develop a patient-centered, unified mental health screening and referral data collection system that is better able to identify inequities and suggest action. Initial Action Ideas Conduct a focus group of patients Cross walk screening data and processes to identify areas of misalignment Map current mental health referral processes and outcomes Animations: Yes

Initial Action Ideas 3 P’s (Policies, Practices, Programs) 2 P’s (People, Power) Revised Actions Success Inform Influence Improve Conduct a focus group of patients Sub-Steps: • Develop protocol • Secure IRB approval • Identify patients • Determine incentives • Outline logistics (time, location, child care, etc.) Learn important views on practices and programs and fit with culture of patients. Explore institutional policies and practices (IRB, merit and promotion, etc.) around team community-partnered science and team science. Attend to patients’ power position relative to other groups. Attend to SON / SOM power dynamics. Attend to “competition” between community-based organizations. Rethink focus group facilitator; possibly multiple parties in focus groups; multiple focus groups. Bring in the experts and site leaders with attention to power dynamics. Treat all sub-steps as learning opportunities for partnership and stakeholders. Input from patient and community stakeholders results in: (1) A prototype patient-centered data collection system that better identifies inequities and suggest actions. (2) Ideas for how to test prototype system Focus group participants inform academic partners about important matters related to P’s and C’s relevant to mental health screening and referral. Academic and clinical partners inform patients and community members about mental health disparities and the initiative to collaboratively address them. Patients and community members are more willing to engage in development, testing, and evaluation of new mental health screening and referral practices. Academic and clinical partners are more willing to incorporate patient and community feedback into their mental health screening and referral practices. Patient, community, academic and clinical stakeholders collaborate to increase validity, alignment, and utility of learner-led mental health screening data collected in community settings. Cross walk screening data and processes to identify areas of misalignment. Map current mental health referral processes and outcomes. Animations: No

Initial Action Ideas 3 P’s (Policies, Practices, Programs) 2 P’s (People, Power) Focus group of patients Sub-Steps: Develop protocol Secure IRB approval Identify patients Determine incentives Outline logistics (time, location, child care, etc.) Will provide important views on practices and programs and fit with culture of patients. Will also need to explore institutional policies and practices (IRB, merit and promotion, etc.) around team community-partnered science and team science. Attend to patients’ power position relative to other groups Attend to SON / SOM power dynamics 3 P’s (Policies, Practices, Programs) Will provide important views on practices and programs and fit with culture of patients. Will also need to explore institutional policies and practices (IRB, merit and promotion, etc.) around team community-partnered science and team science. 2 P’s (People, Power) Attend to patients’ power position relative to other groups Attend to SON / SOM power dynamics. Attend to “competition” between community-based organizations. Animations: Yes

Initial Action Ideas 3 P’s (Policies, Practices, Programs) 2 P’s (People, Power) Revised Actions Success Inform Influence Improve Conduct a focus group of patients Sub-Steps: • Develop protocol • Secure IRB approval • Identify patients • Determine incentives • Outline logistics (time, location, child care, etc.) Learn important views on practices and programs and fit with culture of patients. Explore institutional policies and practices (IRB, merit and promotion, etc.) around team community-partnered science and team science. Attend to patients’ power position relative to other groups. Attend to SON / SOM power dynamics. Attend to “competition” between community-based organizations. Rethink focus group facilitator; possibly multiple parties in focus groups; multiple focus groups. Bring in the experts and site leaders with attention to power dynamics. Treat all sub-steps as learning opportunities for partnership and stakeholders. Input from patient and community stakeholders results in: (1) A prototype patient-centered data collection system that better identifies inequities and suggest actions. (2) Ideas for how to test prototype system Focus group participants inform academic partners about important matters related to P’s and C’s relevant to mental health screening and referral. Academic and clinical partners inform patients and community members about mental health disparities and the initiative to collaboratively address them. Patients and community members are more willing to engage in development, testing, and evaluation of new mental health screening and referral practices. Academic and clinical partners are more willing to incorporate patient and community feedback into their mental health screening and referral practices. Patient, community, academic and clinical stakeholders collaborate to increase validity, alignment, and utility of learner-led mental health screening data collected in community settings. Cross walk screening data and processes to identify areas of misalignment. Map current mental health referral processes and outcomes. Animations: No

Initial Action Ideas 3 P’s (Policies, Practices, Programs) 2 P’s (People, Power) Revised Actions Focus group of patients Sub-Steps: Develop protocol Secure IRB approval Identify patients Determine incentives Outline logistics (time, location, child care, etc.) Will provide important views on practices and programs and fit with culture of patients. Will also need to explore institutional policies and practices (IRB, merit and promotion, etc.) around team community-partnered science and team science. Attend to patients’ power position relative to other groups Attend to SON / SOM power dynamics Rethink focus group facilitator; possibly multiple parties in focus groups; multiple focus groups; Bring in the experts and site leaders with attention to power dynamics; treat all sub-steps as learning opportunities for partnership and stakeholders Revised Actions Rethink focus group facilitator; possibly multiple parties in focus groups; multiple focus groups. Bring in the experts and site leaders with attention to power dynamics. Treat all sub-steps as learning opportunities for partnership and stakeholders. Animations: No

Initial Action Ideas 3 P’s (Policies, Practices, Programs) 2 P’s (People, Power) Revised Actions Focus group of patients Sub-Steps: Develop protocol Secure IRB approval Identify patients Determine incentives Outline logistics (time, location, child care, etc.) Will provide important views on practices and programs and fit with culture of patients. Will also need to explore institutional policies and practices (IRB, merit and promotion, etc.) around team community-partnered science and team science. Attend to patients’ power position relative to other groups Attend to SON / SOM power dynamics Rethink focus group facilitator; possibly multiple parties in focus groups; multiple focus groups; Bring in the experts and site leaders with attention to power dynamics; treat all sub-steps as learning opportunities for partnership and stakeholders Success Input from patient and community stakeholders results in: A prototype patient-centered data collection system that better identifies inequities and suggest actions. Ideas for how to test the prototype system. Animations: No

Initial Action Ideas 3 P’s (Policies, Practices, Programs) 2 P’s (People, Power) Revised Actions Success Inform Influence Improve Conduct a focus group of patients Sub-Steps: • Develop protocol • Secure IRB approval • Identify patients • Determine incentives • Outline logistics (time, location, child care, etc.) Learn important views on practices and programs and fit with culture of patients. Explore institutional policies and practices (IRB, merit and promotion, etc.) around team community-partnered science and team science. Attend to patients’ power position relative to other groups. Attend to SON / SOM power dynamics. Attend to “competition” between community-based organizations. Rethink focus group facilitator; possibly multiple parties in focus groups; multiple focus groups. Bring in the experts and site leaders with attention to power dynamics. Treat all sub-steps as learning opportunities for partnership and stakeholders. Input from patient and community stakeholders results in: (1) A prototype patient-centered data collection system that better identifies inequities and suggest actions. (2) Ideas for how to test prototype system Focus group participants inform academic partners about important matters related to P’s and C’s relevant to mental health screening and referral. Academic and clinical partners inform patients and community members about mental health disparities and the initiative to collaboratively address them. Patients and community members are more willing to engage in development, testing, and evaluation of new mental health screening and referral practices. Academic and clinical partners are more willing to incorporate patient and community feedback into their mental health screening and referral practices. Patient, community, academic and clinical stakeholders collaborate to increase validity, alignment, and utility of learner-led mental health screening data collected in community settings. Animations: No

Action–Evaluation–Adaptation (3 I’s)  SUCCESS
INFLUENCE INFORM SUCCESS Animations: No IMPROVE

Success Inform Influence Improve Input from patient and community stakeholders results in (1) a prototype patient-centered data collection system that better identifies inequities and suggest actions; (2) ideas for how to test prototype system Focus group participants inform academic partners about important matters related to P’s and C’s relevant to mental health screening and referral. Academic and clinical partners inform patients and community members about mental health disparities and the initiative to collaboratively address them. Patients and community members are more willing to engage in developing, testing, and evaluating new mental health screening and referral practices. Academic and clinical partners are more willing to incorporate patient and community feedback into their mental health screening and referral practices. Patient, community, academic and clinical stakeholders collaborate to increase validity, alignment, and utility of learner-led mental health screening data collected in community settings Inform Focus group participants inform academic partners about important matters related to P’s and C’s relevant to mental health screening and referral. Academic and clinical partners inform patients and community members about mental health disparities and the initiative to collaboratively address them. Animations: No

Success Inform Influence Improve Input from patient and community stakeholders results in (1) a prototype patient-centered data collection system that better identifies inequities and suggest actions; (2) ideas for how to test prototype system Focus group participants inform academic partners about important matters related to P’s and C’s relevant to mental health screening and referral. Academic and clinical partners inform patients and community members about mental health disparities and the initiative to collaboratively address them. Patients and community members are more willing to engage in developing, testing, and evaluating new mental health screening and referral practices. Academic and clinical partners are more willing to incorporate patient and community feedback into their mental health screening and referral practices. Patient, community, academic and clinical stakeholders collaborate to increase validity, alignment, and utility of learner-led mental health screening data collected in community settings Influence Patients and community members are more willing to engage in developing, testing, and evaluating new mental health screening and referral practices. Academic and clinical partners are more willing to incorporate patient and community feedback into their mental health screening and referral practices. Animations: No

Success Inform Influence Improve Input from patient and community stakeholders results in (1) a prototype patient-centered data collection system that better identifies inequities and suggest actions; (2) ideas for how to test prototype system Focus group participants inform academic partners about important matters related to P’s and C’s relevant to mental health screening and referral. Academic and clinical partners inform patients and community members about mental health disparities and the initiative to collaboratively address them. Patients and community members are more willing to engage in developing, testing, and evaluating new mental health screening and referral practices. Academic and clinical partners are more willing to incorporate patient and community feedback into their mental health screening and referral practices. Patient, community, academic and clinical stakeholders collaborate to increase validity, alignment, and utility of learner-led mental health screening data collected in community settings Improve Patient, community, academic and clinical stakeholders collaborate to increase validity, alignment, and utility of learner-led mental health screening data collected in community settings. Animations: No

Action–Evaluation–Adaptation (3 I’s)
INFORM METRICS Focus Group Participants  Academic Partners: The P’s and C’s relevant to mental health screening and referral. Academic Partners  Participants: The existing mental health disparities and the initiative to collaboratively address them. Review of the focus group transcripts reveals: Participants made suggestions for potential new community partners and ways to make the screening questions and process more accessible and patient centered. Patient knowledge of mental health inequities has increased. Animations: Yes

INFLUENCE METRICS Patients and Community Members: More willing to engage in development, testing, and evaluation of new mental health practices. Academic Partners: More willing to incorporate patient and community feedback into mental health practices. Community groups have invited the MAIDAN team to local gatherings to further raise awareness and involvement. Other academic partners have inquired about MAIDAN’s process and its applicability to their own work. Animations: Yes

IMPROVE METRICS All Stakeholders: Collaborate to increase validity, alignment, and utility of screening data collected in by learners in community settings. New focus group identified partners are brought on board. Suggested changes to an aligned screening tool and process are implemented when feasible. It has become markedly easier to get additional patient and community feedback due to increased communication and trust. Animations: Yes

Action–Evaluation–Adaptation (3 I’s)  SUCCESS
INFLUENCE Patients and Community Members: More willing to engage in development, testing, and evaluation of new mental health practices. Academic Partners: More willing to incorporate patient and community feedback into mental health practices. Short-Term Evaluation Activities INFORM SUCCESS Focus Group Participants  Academic Partners: The P’s and C’s relevant to mental health screening and referral. Academic Partners  Participants: The existing mental health disparities and the initiative to collaboratively address them. Interim Success Input from patient and community stakeholders results in: A prototype patient-centered data collection system that better identifies inequities and suggest actions. Ideas for how to test the prototype system. Short-Term Evaluation Activities Animations: No IMPROVE All Stakeholders: Collaborate to increase validity, alignment, and utility of screening data collected in by learners in community settings. Short-Term Evaluation Activities

Action–Evaluation–Adaptation (3 I’s)  IMPACT
INFLUENCE Patients and Community Members: More willing to engage in development, testing, and evaluation of new mental health practices. Academic Partners: More willing to incorporate patient and community feedback into mental health practices. Long-Term Evaluation Activities Short-Term Evaluation Activities INFORM IMPACT Focus Group Participants  Academic Partners: The P’s and C’s relevant to mental health screening and referral. Academic Partners  Participants: The existing mental health disparities and initiative to collaboratively address them. Long-Term Evaluation Activities Long-Term SMART Goal: In five years, achieve at least three years of a downward trend in the racial and economic gaps in self-reported access to mental health care without decreasing self-reported access for white and upper income Middletowners. Animations: Yes IMPROVE Short-Term Evaluation Activities Long-Term Evaluation Activities All Stakeholders: Collaborate to increase validity, alignment, and utility of screening data collected in by learners in community settings.

Action–Evaluation–Adaptation (3 I’s)  IMPACT
Long-Term SMART Goal: In five years, achieve at least three years of a downward trend in the racial and economic gaps in self-reported access to mental health care without decreasing self-reported access for white and upper income Middletowners. Animations: No

Getting to Know Each Other

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