Natasha Arora, Maggie Jones, Erin Hertel, Center for Community Health & Evaluation
Diana Camacho & Catherine Teare, California Health Care Foundation
Disparities in access to health care persist for individuals with low incomes and Black, Hispanic/Latinx and Native American/Native Alaskan individuals (Agency for Health Care Research and Quality 2021) and are particularly acute in behavioral health. Behavioral health care utilization rates among Black, Hispanic, and Asian adults are less than half those of White adults (Cook et al. 2017). These disparities exist because of barriers in access such as limited provider networks, poor language access, a lack of culturally-aligned services, and technological barriers to telehealth. Working with health providers to create inclusive and accessible services is essential to building more equitable access to behavioral health care, and to healthier and happier families and communities.
The California Health Care Foundation (CHCF) has long supported safety net practice transformation efforts through multi-site learning collaboratives. From 2020 to 2023, CHCF funded three delivery system transformation initiatives in telehealth and behavioral health, both areas of strategic focus for the Foundation.
- Cultivating Outcomes through Equity in Behavioral Telehealth (COE-BT) convened specialty mental health and substance use providers with community-based organizations in 11 teams across California. This initiative, led by the California Institute for Behavioral Health Solutions, supported behavioral health organizations to make telehealth more accessible and equitable to underserved communities.
- Delta Center California (DCC) brought together behavioral health and primary care leaders and practitioners in California to accelerate care improvement, integration, and collaboration across silos, and to advocate for a strong, coordinated safety net. It was led by JSI Research & Training Institute, Inc. with additional funding from the Robert Wood Johnson Foundation.
- The Connected Care Accelerator – Equity Collaborative (CCA EC) convened 22 health centers to design, test, scale, and share new strategies to improve access to telehealth for people that experience barriers in primary care and behavioral health. It was facilitated by the Center for Care Innovations, with additional funding from Cedars-Sinai.
These initiatives all addressed health equity and racial equity in their goals, content, and designs:
- The desired outcome of all three initiatives was to address disparities in access to care.
- Content on racial equity and justice was a key part of the participating organizations’ learning activities.
- The initiatives used co-design by partnering with CBOs, incorporating community voices, people with lived experiences, and patient input.
Evaluations of these initiatives provided valuable lessons for integrating equitable processes in health system transformation initiatives.
What we learned
1. Initiatives focused on equity in health care need to define what equity means within the initiative.
Health equity and racial equity require multidimensional approaches—they can be addressed through the initiative goals, content, the voices included in the design, and the people and organizations involved in its implementation.
Addressing all equity dimensions at once may be unrealistic, so leaders need to clearly communicate goals. In the behavioral-health focused initiatives, DCC and COE-BT, the focus on racial equity involved developing partnerships with community-based organizations that were familiar with the needs of underserved communities, exploring sources of bias within organizational culture, and co-designing potential solutions to mitigate bias. In CCA EC, the focus was on reducing disparities in access to telehealth, with health centers concentrating on practical strategies to address known barriers to care. In all initiatives, tradeoffs were made: with the time and resources available, initiative leaders had to balance time spent on relationship-building, organizational culture, and implementing operational changes.
2. Co-design is a key component of a health equity agenda, often requiring initiatives to shift from their original focus.
Through co-design, two initiatives evolved to prioritize racial equity by addressing organizational dynamics, building cross-organizational relationships, and deepening understanding of underserved communities’ needs.
COE-BT required behavioral health organizations to partner with community-based organizations and conduct participatory research to identify the needs of underserved communities. The concerns raised in this process focused less on telehealth access—the original goal—and more on general access to care, cultural competence, and the impact of racism in behavioral health. In response, funders, the program office, and grantees all agreed to prioritize these broader equity issues over telehealth.
Similarly, DCC initially aimed to increase knowledge and skills in technical aspects of behavioral health/primary care integration, such as value-based purchasing policy. However, co-design process revealed the need to address organizations’ real-time concerns. Program office staff, the funder, and selected grantees shifted focus to advancing racial equity, such as by exploring how racism shows up in behavioral health services and increasing use of community health workers.
3. Engaging people with lived experience and community partners can help to advance racial equity goals but requires time and flexibility.
A key strategy for improving an initiative’s ability to address racial equity is to include perspectives from those directly impacted. The initiatives did this differently: DCC included people with lived experience in its policy roundtable, COE-BT engaged communities through a participatory research process, and CCA EC solicited patient input through a human-centered design process for clinical quality improvement.
These initiatives illustrate the importance of adequate time for authentic engagement, often taking longer than expected due to the need to build trust before the co-design process. Trust is essential, and failing to act on community input risks breaking trust and future engagement.
Furthermore, participants new to engaging people with lived experience often need targeted support. For example, DCC introduced a Lived Experience-Engaged Organization Ladder at its first convening, outlining engagement levels and helping participants plan meaningful strategies to advance inclusion in their projects; DCC later developed a practical workbook on this topic.
4. Prioritize peer sharing and learning across organizations to accelerate progress in equity-focused initiatives.
A key benefit of participating in multi-organization initiatives is the opportunity for peer learning. When organizations work toward similar goals and implement comparable strategies, they can share successes and challenges, accelerating collective progress. In innovation-focused initiatives, this exchange can spark new ideas and inspire organizations to explore new possibilities.
In equity-focused initiatives, organizations can learn and share with each other what strategies they are testing and how they are modifying their strategies to meet the needs of specific patient populations and organizational contexts. Leaders of these three initiatives emphasized the value of structured opportunities for challenging conversations about racial equity, such as in-person (rather than virtual-only) convenings, previewing content, building trust, and allowing time for discussion. COE-BT’s in-person meetings enabled deeper engagement and more open conversations. Leaders also noted that when all participants are new to equity work, outside expertise can be valuable to broaden perspectives and introduce new approaches.
5. Develop flexible measurement strategies that account for change in the initiative’s goals and approach to equity.
Work that is grounded in health equity may shift as input is received throughout the co-design process. Flexible, generative initiatives that involve multiple organizations may confront challenges with defining common measures. Measurement strategies should reflect individual organizational goals, track progress, and adapt to shifting goals or vision. Approaches should balance the feasibility of cross-cutting measures with leveraging data collected by participants.
In the telehealth initiatives (CCA EC and COE-BT), capacity assessments served as a common measure and facilitated discussions on equity in service delivery. COE-BT also introduced common tools to assess patient engagement and well-being, applicable across organizations. Qualitative data was vital for understanding successes, challenges, and perceptions of progress as well as how participants responded as the initiatives evolved. All three evaluations required a flexible measurement approach and close collaboration with initiative leaders to assess the impact of changes.
Conclusion
These lessons from three initiatives highlight both the opportunities and challenges of equity-focused initiatives. Such efforts can improve patient services, foster organizational culture change, and build cross-organization partnerships, and require thoughtful planning, co-design, partner engagement, and flexible approaches to implementation and evaluation as circumstances evolve. In a political environment that is hostile to health equity goals, philanthropies have both the opportunity and the obligation to continue to invest in health equity efforts. Approaching this work with humility and flexibility becomes even more important.
References
Agency for Healthcare Research and Quality. National Healthcare Quality and Disparities Report. Rockville, MD: 2021.
Cook BL, Trinh N-H, Li Z, Hou SS-Y, Progovac AM. Trends in racial-ethnic disparities in access to mental health care, 2004–2012. Psychiatric Services. 2017;68:9–16. doi: 10.1176/appi.ps.201500453