Policy Opportunities for States to Address Systemic Equities

Introduction

From hospitalizations to mortality rates, Black, Latine, and Indigenous populations were disproportionately affected by Covid-19.  These disparities reflect several other systemic inequities, such as the racial wealth gap, inadequate access to healthcare, and racial discrimination in the labor market. These inequities are rooted in historical practices and policies that excluded racially minoritized populations, especially Black people, from wealth attainment and political power. Furthermore, Covid-19 exacerbated already existing disparities among racially minoritized groups that occupy essential positions as workers at low-wage jobs,, which disproportionately exposed them to Covid-19 and in turn made them more susceptible to unemployment.

Historically, at times of economic crises, governmental leaders often cut funding for social programs and create tax cuts for the wealthy as a strategy to stimulate commercial activity. Yet, this also worsens social conditions for marginalized populations, in particular the racial wealth gap. Yet, at the peak of the pandemic in 2021, the federal government’s American Rescue Plan unprecedentedly offered state governments the opportunity to address systemically racist policies, the root cause of racial disparities caused by Covid-19.  In this paper, the authors provide an anti-racist framework for state officials to craft policies that promote equity and racial justice, in addition to insights to avoid the policy mistakes of the past.

This article was written by Cortney Sanders, Michael Leachman, and Erica Williams. Courtney Sanders is a State Policy Fellow with the Center on Budget and Policy Priorities. Michael Leachman is Senior Vice President for State Fiscal Policy and Co-Leader of the Center’s State Fiscal Policy division at the Center on Budget and Policy Priorities. Erica is currently the Executive Director of the DC Fiscal Policy Institute and during the time of publication was Vice President for State Fiscal Policy at CBPP.

Methods and Findings

The article’s framework centers on three principles which are outlined in detail below:

Principle #1: Target aid to those most in need due to COVID-19 and consequent economic crises.

This principle is rooted in the support of communities that have been historically marginalized and disproportionately affected by the pandemic,  which includes those who have been historically minoritized, the underinsured, the unhoused, immigrants, low-income individuals, and those currently or formerly incarcerated.  Without the appropriate communal and government support, these groups have a steeper path to recovery.   Thus,  the authors suggest the following policies to promote equitable policies to support these populations:

Build a robust outreach operation

o   Launch a public awareness campaign

o   Convene and train organizations that already help people access SNAP, Medicaid, or other supports

o   Fund organizations that are well-positioned to reach people with significant barriers to accessing support

o   Consider designing outreach efforts as part of a broader subsidized employment program

·  Use rental assistance to stop evictions

·  Serve people who otherwise would go hungry

·  Use federal funds to build a child care system that is more affordable and sustainable with a focus on equity and supporting essential workers

·  Avoid cuts in existing services for people in need and undo last year’s cuts

·  Provide premium pay (use of Fiscal Recovery Funds for up to $13 per hour in bonus pay) to essential workers (i.e. healthcare workers, sanitation workers, grocery store clerks, truck drivers) 

·  Create subsidized jobs

·  Provide unrestricted cash payments to individuals and families with limited incomes

·  Help children with  unfinished learning

·  Increase access to health coverage and services

Principle #2: Advance antiracist and equitable policies — both short and long-term — to dismantle persistent racial, ethnic, gender, and economic inequities and other barriers that non-dominant groups and identities experience. (Note: Per authors, “Non-dominant groups and identities can include Black and brown people, Indigenous people, immigrants, low-wage workers (who are often women and people of color), LGBTQ+ individuals, and families and individuals experiencing deep economic struggle, such as those who are homeless or face persistent barriers to work.”)

This principle highlights the many ways states can invest in programs and policies that support non-dominant groups that have traditionally been marginalized due to systemic racism and other structural barriers. Each of these policies emphasizes the urgency to support non-dominant groups both during and beyond the pandemic. These policy interventions include:

·  Investment in broadband, water, and sewer infrastructure projects

·  Adopt the Affordable Care Act’s Medicaid expansion

·  Make state unemployment insurance (UI) systems more inclusive

·  Adopt state-level emergency and permanent paid leave policies.

·  Boost incomes through state-earned income tax credits (EITCs) or state child tax credits.

·  Release youth from confinement and support re-entry into schools and communities while social distancing.

·  Eliminate criminal legal fees, and base fines on the ability to pay

·  Invest in high-poverty school districts.

·  Invest in higher education for those from non-dominant groups

·  Help tribal governments harmed by the pandemic.

·  Build a comprehensive support system for people with substance use disorders (SUDs).

Principle #3: Strengthen state revenue systems to sustain transformative, long-term investments in Black, Brown, Indigenous, Immigrant, and Low-Income communities.

This principle encourages states to use the temporary support of the American Rescue Plan to create new revenue funds that prioritize equity. Creating sustainable funding revenues can facilitate states embedding equity in their practices to reduce the effects of racism and other forms of inequality well beyond the pandemic. The suggested policy solutions include:

·  Raise revenue through taxation, especially from the wealthy and profitable corporations

·  Remove barriers to revenue raising, such as supermajority vote requirements

·  Roll back economic development incentives and other tax breaks for profitable corporations

·  Reform or repeal restrictions on local government revenue raising

Conclusions

Covid-19 has become known as the “great exacerbator” for the manner the pandemic amplified already existing inequities in our society. Governmental support through the American Rescue Plan created opportunities for states to respond to these inequities through antiracist policies that prioritize historically marginalized groups. Through the policies outlined above, states can galvanize this moment to create sustainable equity-oriented solutions that support these communities during the pandemic and beyond.

Moving from words to action in healthcare

Introduction

For Americans, the murder of George Floyd marked 2020 as the year of the “racial awakening” in the United States. Largely led by the Black Lives Matter (BLM) movement, protests and calls for racial justice spread across the country and inevitably reached medical institutions too. In collaboration with White Coats for Black Lives—a national medical student-run racial equity organization started in 2014—leaders at academic medical centers (AMCs) across the nation bent the knee in honor of George Floyd and made public denunciations against racism. The authors raised an important question—are these actions enough? 

They are not. The authors provide evidence to argue the imperative that AMCs move past empty platitudes and move toward specific and sustainable action that promotes racial equity. Mary T. Bassett reminds us of three avenues for action that must be considered, “critical research, internal reform, and public advocacy”. These pathways for action also include recognizing the painful past of medical institutions, such as the American Medical Association’s (AMA) sponsoring of the Flexner report that led to the closure of 5 of 7 historically Black medical schools. Even more, the call for action calls for interrogating the teaching of systemic racism in medical school curriculums while also uplifting the concerns and solutions of the marginalized communities surrounding AMCs. Only through intentional, action-oriented, and local community-led change by AMC leadership can medical centers truly improve the conditions of Black communities and Black, Indigenous, People of Color (BIPOC) healthcare workers. 

This piece was written by Bich-May Nguyen, Jessica Guh, and Brandi Freeman. Bich-May Nguyen is a clinical associate professor in the Department of Health Systems and Population Health Sciences for the Tilman J. Fertitta Family College of Medicine at the University of Houston. Jessica Guh is the site director and associate program director at Cherry Hill family medicine residency in Seattle, WA. Brandi Freeman is an associate professor of general pediatrics and Associate Vice Chair for Diversity, Equity, and Inclusion at the University of Colorado School of Medicine. 

Methods and Findings

Ultimately,  the authors highlight the following ways to promote equity in AMCs:  

Focus on Culture 

Create an inclusive culture in AMCs that treats antiracism training as a moral imperative at all levels of training– including medical students, residency trainees, fellows, attendings (senior physicians), and staff– to ensure that medical professionals are better equipped to respond to instances of racism. For example, if microaggressions are made, there should be training at all levels on how to respond and support the person on the receiving end of such aggression. Additionally, accountability standards that hold educators responsible for acts of racism within the classroom is essential to create systemic changes in academic medicine. Problematic teaching must have clear consequences regardless of academic stature. 

It is also important to examine the ways race and racism permeate clinical training and patient care. Race is still used in the clinical setting to justify clinical examination, like kidney function, despite growing common knowledge that race is a sociopolitical construct– not a biological one. Researchers, practitioners, and educators within AMCs must provide more clarity when using race (i.e., how much melanin one has, weathering impacts of racism, birth in a region with high disease prevalence). 

Focus on People 

It is essential for AMCs to increase the diversity of their physician workforce because it has several implications for care accessibility and care quality for racially minoritized patients. Studies have shown that ethnic/racial concordance (when physician and patient are the same race) leads to improved health outcomes (cardiovascular procedures, diagnostic colon procedures, lung cancer treatment, etc.).

To increase diversity within the AMC context, the authors make the following suggestions: 

At the medical student level—

• Increase recruitment and retention of BIPOC students 
• Develop curriculum that focuses on increasing the number of physicians in primary care and medically underserved areas
• Deprioritize standardized tests in medical school admissions 
• Use blind academic information (i.e. Medical College Admission Test (MCAT) scores and grades) prior to interviews for medical school so that personal characteristics and leadership skills have equal weight  
• Change admission rubrics so that life experiences and personal qualities have equal weight for medical school admission 
• Standardize the medical school interview scoring system so it is less biased 

At the medical faculty level—

• Treat research and efforts around diversity, equity, and inclusion (DEI) with the same institutional and financial support the biomedical sciences receive 
• Create academic pathways for promotion for DEI work, including training and support for methodology, teaching skills, and scientific writing 
• Create quality metrics to reach set goals around the aforementioned suggestions  

Focus on Environment 

It is imperative to consider the ways the environment of AMCs is harmful not only to BIPOC people that learn and work within them but also to the communities these institutions seek to serve. Therefore, the authors suggest the following solutions to address how the built environment contributes to medical racism:  

• Examine hallways of AMCs and academic buildings to search for photos, building names, and other symbolic representations of individuals who have caused harm to BIPOC communities.  These photos should be replaced with symbolism that reflects social justice and equity, such as imagery celebrating BIPOC and other minoritized communities.
• The history behind such symbols and the general history of medical racism should be elucidated to bring light to the ways the medical institution has contributed to the systemic harm of BIPOC communities. 
• There should be a clear understanding that the medical institution must earn the trust of communities and communities are not responsible for repairing the harms done by medical institutions.
• AMCs should invest in surrounding communities, like investing funds in initiatives like pipeline programs for students underrepresented in medicine, while also being mindful of the effects of hospital operations, like the potential displacement of local communities due to hospital expansions. 

Conclusions

The authors conclude that words must be followed with action; yet, they also highlight some of the pushback encountered engaging physicians with DEI work. Physicians have proclaimed that the role of the academic medical center is to improve health and not society. Others have argued that awareness of bias/racist actions will not change culture. Yet, the authors refute these arguments by re-emphasizing that conversations about equity are hard, but important. They additionally highlight the fact that medicine cannot and does not exist within silos and must address the social determinants of health to achieve optimal health outcomes for marginalized populations. 

A Systematic Review of Global Anti-Racism Interventions in Healthcare

Introduction

Racism in healthcare settings is a persistent and complex problem for both healthcare delivery and access to health services. Over the past decade, several publications demonstrate the experiences of racism faced by minoritized patients such as the enduring racist assumptions about pain tolerance of Black people, the low propensity for screening Black women for cervical cancer, and the chronic undertreatment of fractures for Black people in emergency rooms. These studies indicate a need for interventions to address racism in the healthcare setting because of its negative effects on patient care.

In the years following the murder of George Floyd, many health organizations declared anti-racism commitments and shifted their core values in an attempt to reform hospital-based interventions to implement antiracist change. To date, however, there remains a gap in providing a systematic review of these efforts to understand which interventions actually worked. In this paper, authors conducted an international systematic review for anti-racist interventions in healthcare to: (1) increase understanding of these efforts for the sector and (2) analyze the anti-racist interventions’ potential to influence policy and patient care.
Nadha Hassen is a Toronto-based doctoral candidate at York University that works on antiracism and community-centered interventions.  Aisha Lofters is a family physician and researcher at Women’s College Hospital and the University of Toronto. Sinit Michael is a policy analyst for Canada’s parliamentary relations office and at the time of publication was part of St. Michael’s Hospital’s Knowledge Translation Program. Aminta Mall is part of the Faculty of Medicine at the University of Toronto. Andrew Pinto is the founder and director of The Upstream Lab and is a public health, preventive medicine specialist, and family physician at St. Michael’s Hospital. Julia Rackal is a journalist and family physician at St. Michael’s Academic Family Health Team in Toronto.

Methods and Findings

The authors relied on several search engines to sample the literature landscape to include keywords such as “race”, “racism”, “drivers”, and “cultural competency”, which resulted in 3587 citations (excluding duplicates). Each paper was then screened by at least 2 team members. For inclusion into the systematic review, articles required focus on the development and implementation of antiracist interventions within the following care settings: (1)  outpatient care (out of the hospital, in the clinic setting, etc.) and (2)  public health practitioners providing individual patient care.

Analyzing AntiRacism Interventions 

The authors then examined the interventions three ways: (1) determining if the intervention was a true anti-racism intervention, (2) distinguishing the level of racism the intervention sought to address, and (3) classifying the focus of the intervention. 

First, the authors used Calliste and Dei’s definition of a true anti-racism intervention, which is interpreted as an “action oriented, educational and/or political strategy for systemic and political change that addresses issues of racism and interlocking systems of social oppression”. Secondly, the authors used Camara Jones’ framework for the levels of racism (institutionalized, personally mediated, and internalized) to delineate the levels of racism each intervention sought to address. Lastly, the Social Ecological Model (SEM), was used to analyze the focus of the intervention; SEM allowed the authors to determine if the intervention operated at the individual, interpersonal, community, organization, or policy levels.

Types of Anti-Racism Interventions 

The literature review provides readers with an understanding of the typical focus of an anti-racism intervention at each SEM level:   

·  Individual level: ex. cultural competency training (addressing concepts related to racism, implicit bias, stereotype, or prejudice)

·  Interpersonal level: ex. develop and implement guidelines on how to address racist or prejudicial comments in psychotherapy

·  Community level: ex. meaningfully engage Aboriginal/Indigenous and racialized communities at multiple levels and make these relationships sustainable

·  Organizational level: ex. “Develop a strategic leadership committee, consultation group, team charged with monitoring and addressing policies and practices, resource allocations, relational structures, organizational norms and values, and individual skills and attitudes and implementing action plans that work towards anti-racist strategic goals.”·  Policy level: “Recruit, retain, and promote Black, Indigenous and people of color at all levels of the academic ladder in mainstream admission and promotion policy and in the healthcare workforce.”

Overview of the Literature

The authors used 37 peer reviewed articles in their review:12 empirical studies and 25 theoretical or conceptual papers. The majority of the papers were written by authors in the United States (51%) followed by Canada, the United Kingdom, Australia, and New Zealand, respectively. Additionally, most of the data targeted Indigenous (Aboriginal and Torres Strait Islander people, Maori, First Nations, Inuit, and Metis/Native Americans) and Black patient populations.

Suggested strategies for creating anti-racist programs:

·  Define the problems and set clear goals and objectives

·  Incorporate explicit and shared anti-racism language

·  Establish leadership buy in and commitment

·  Invest dedicated funding and resources

·  Bring in the right support and expertise (i.e. community leaders and subject matter experts) 

·  Establish ongoing, meaningful community and patient partnerships

Suggested strategies for the implementation and evaluation of anti-racism programs: 

·  Use a multi-level, long-term approach (i.e. targeting two levels such as community and organizational intervention, then ensuring the effort is sustainable) 

·  Embed racial equity policies and procedures in hiring, retention, and promotion practices  Hiring, retention, and promotion)

·  Link mandatory anti-racism work (including staff education and training) to broader systems of power, hierarchy, and dominance·  Incorporate opportunities for pause and reflection within a cyclical, process improvement practice  reflect mechanisms in a cyclical process

Conclusions

The authors describe the paucity of research related to the implementation and evaluation of anti-racist efforts in the outpatient clinical setting while simultaneously recognizing the scarcity of these interventions. The authors also acknowledge the lack of institutional and societal level policies and practices focused on anti-racism in the healthcare setting. Overall, the authors’ work demonstrates the scientific imperative for anti-racist interventions in medical care and the need for more widespread reporting of these efforts to advance a more standard application of these practices from a global perspective.

How Historically White Institutions Have Excluded Historically Black Colleges Through Lack of Recognition As Peer Organizations

Introduction

In this study, the authors highlight the ways in which Historically Black Colleges (HBCUs) have been marginalized by Historically White Institutions (HWI) through social closure (systemic exclusion) and lack of reciprocity (lack of mutual recognition). The authors demonstrate how the academic legitimacy of HCBUs has been systematically withheld by HWIs through the lack of recognition as peer institutions.

While some may judge HCBUs as self-segregating and underperforming institutions, the authors reject this notion by demonstrating that HBCUs as equal, productive contributors to higher education. They highlight how, in 2015, the 100 federally designated HBCUs awarded 15% of all bachelor’s degrees granted to African Americans and 40% of STEM (Science, Technology, Engineering, and Mathematics) degrees granted in 2000. Similar trends can be observed in the number of Black physicians that have trained at HBCUs. HBCUs have been successful in serving Black communities despite experiencing federal and state-level systemic exclusion, which includes financial underfunding.

The authors highlight the aforementioned data within the historical context of HCBUs, specifically regarding how HCBUs were birthed. HBCUs were created out of the need to educate Black students due to the de jure and de facto segregation that denied them access to educational opportunities (elementary to post-secondary) reserved for white people. Today, HCBUs continue this mission, but their recognition as “true universities” will hinge on disrupting the power dynamics of HWI as the grantors of academic legitimacy. Graham Miller was a senior research analyst focusing on higher education policy at Brandeis university when this study was published. Freda B. Lynn is an Associate Professor of Sociology at the University of Iowa and conducts research on status and inequality using a variety of methodological approaches. Laila L. McCloud is an Assistant Professor of Educational Leadership at Grand Valley State University, and her research focuses on the use of critical theories and methods to broadly explore the professional and academic socialization of students within U.S. higher education.

Methods and Findings

Postsecondary institutions use comparison groups to declare their prestige, position, and place within the academic landscape. Comparison metrics include, but were not limited to, research funding, number of faculty, athletic leagues, and admission standards. These metrics are useful for assessing similarities and differences and enable institutions to communicate their status as an institution. This study seeks to understand how racialized identities and social closure marginalize HBCUs in this comparative system.

The authors sought to answer three primary questions:

1.)   Relative to other known institutional differences in the field of higher education (liberal arts vs. STEM, private vs. public, etc), how rigid is the boundary between HBCUs and HWIs?

2.)   Is the border between HBCUs and HWIs maintained by HWIs seeking distance from HBCUs or vice versa?

3.)   Why do HWIs fail to reciprocate HBCU efforts to be identified as peer institutions? 

The authors use an analytical framework to answer the questions noted above; the framework utilized both observations of dyad creations (reciprocal nomination between two institutions) and social exclusion (the lack of creation of dyad creations between HWIs and HBCU).

The data collection strategy consisted of observing reported comparison groups — groups of institutions one recognizes as peer institutions — in the 2015 Integrated Postsecondary Education Data System (IPEDS). IPEDS is a federal database of survey data administered with information from all universities that receive federal aid.  In this database, institutions can create custom “peer groups” that consist of institutions they nominate for comparison. Because there are no specific guidelines given for the nomination and subsequent creation of peer groups in the database, this can reveal patterns and biases in how institutions include and exclude certain institutions from their network of peers in reality. To demonstrate this, the researchers tracked the reciprocation of nominations for the creation of peer groups (a proxy for the recognition as a peer institution) of HWIs while controlling for the rank and prestige of nominations by HBCUs.

Researchers found that HBCUs have difficulty integrating into peer groups because of the lack of reciprocity of nominations, suggesting they would like to be compared to HWI but are forced to be viewed as separate entities. Notably, they found that HBCUs collectively nominate almost

50% non-HBCUs in their peer groups, but only 6% of those nominations are reciprocated. They also found that there was no evidence HBCUs make overly aspirational peer nominations generally, meaning HBCUs rarely nominated institutions that were above their rank in quality and prestige.

Conclusions

This study demonstrates the ongoing exclusion of HBCUs from the peer network of HWIs. It most importantly reveals that the observed self-segregation of HBCUs is not due to their own preferences, but occurs because of the lack of reciprocal peer nomination that indicates how HWIs undervalue HBCUs. Even after controlling for the status quality (looks at the admission rates, competitiveness, etc. to compare and status score between institutions) of the nominating HBCU, HWIs were still less likely to reciprocate a nomination by an HBCU. This highlights how the lack of recognition of HBCUs as peer institutions to HWIs is most likely related to their systemic exclusion rather than the quality of the institutions themselves. 

The authors encourage policymakers to consider the following: 

• Recognize the richness and academic rigor of HBCUs beyond their commitment to Black students, as this impacts how they are valued in the landscape of academia.
• HWIs and the academic landscape lose out when they fail to recognize the significant expertise of HBCUs. The institutional knowledge at HBCUs should be viewed as an asset.
•  Valuing HBCUs as peer institutions can lead to new, more equitable metrics by which all academic institutions can be assessed and valued. These new equitable metrics have the opportunity to improve education for all communities.

HWIs play a critical role in changing the narratives of academic legitimacy—it is up to them to take on this moral imperative.

A Tool for Assessing Anti-Racism Efforts in Community Behavioral Health

Introduction

Since the tragic murders of George Floyd and Breonna Taylor, many healthcare organizations have created initiatives to promote anti-racism; these initiatives have ranged from organizational anti-racism statements to Black Lives Matters lanyards to the development of numerous anti-racism taskforces. In this research article, the authors seek to move beyond these more symbolic forms of advocacy to more action-oriented commitments to equity. Specifically, the authors seek to develop a quality improvement tool that incorporates domains specific to anti-racism related to providing community behavioral healthcare services. The authors draw upon previous work on health equity frameworks, such as Metzl and Hansen’s approach to structural competency and the Robert Wood Johnson Foundation’s “Roadmap to Reduce Health Disparities”. While the authors point to these resources as helpful examples, their literature review showed a clear gap regarding how to integrate anti-racism into community behavioral health practice. 

Therefore, the researchers created the Self‑assessment for Modification of Anti‑Racism Tool (SMART) tool. Ultimately, this tool centers on a set of measurable domains promoted by the American Association for Community Psychiatry’s (AACP) anti-racist mission of: (1) creating safe spaces for patients who have experienced racial trauma, (2) challenging their own implicit biases, and combating discriminatory speech in the field (3) identifying structural inequity in hiring and promotion practices, (4) self-education on the racist practices and policies that impact patient care.  Rachel M. Talley, MD is an Assistant Professor of Clinical Psychiatry and the Director of the Fellowship in Community Psychiatry at the University of Pennsylvania. Sosunmolu Shoyinka, MD is an addiction medicine specialist with a passion for improving access to high-quality mental health treatment for underserved populations. Kenneth Minkoff, MD is a Clinical Assistant Professor of Psychiatry at Harvard Medical School and community psychiatrist with expertise in addiction psychiatry. All three authors are board-certified psychiatrists who bring considerable insight to the topic from their experiences in community practice.

Methods and Findings

The AACP board hosted a convening with over 250 community psychiatrists, and this meeting served as the inspiration for the development of the SMART tool focused on 5 central domains: (1) hiring, recruitment, and retention, (2) clinical care, (3) workplace culture, (4) community advocacy, and (5) population health outcomes. Each domain contains 2-9 self-reported items aimed to encourage community behavioral health service organizations to interrogate whether their organizational efforts, practices, and procedures have an actionable anti-racism focus. 

Domain 1: Hiring, Recruitment, and Retention 

This domain of the tool asks 6 questions that encourage reflection regarding workforce diversity and anti-racist hiring practices within the community behavioral health sector. The authors specifically highlight the fact that non-Hispanic Black and Hispanic make up less than 7% of the psychiatrist workforce, less than 4% of the psychologist workforce, and less than 12% of the social work workforce. An example of a question is the following: “To what extent does your organization track racial disparities in the backgrounds of those who apply for open positions, and make targeted efforts to recruit candidates of diverse racial/ethnic backgrounds to open positions?”.

Domain 2: Clinical Care 

This domain highlights the ongoing disparities in health outcomes and treatment of patients of minoritized backgrounds who seek out behavioral health. This domain asks 9 questions including: “To what extent does your organization track and address potential racial disparities in the imposition of involuntary commitment (either emergency commitments or assisted outpatient treatment, or both)?”.

Domain 3: Workplace Culture 

This domain highlights racism as a trauma that affects both staff and patients; hence, questions within this domain assess an organization’s ability to address this trauma through established structures of support. The domain includes 7 self-reported items including: “To what extent does your organization utilize formal training for staff and/or teams/programs to understand and identify structural, society-level factors (e.g. housing inequality, educational disparities, income inequality, etc.) that contribute to racial disparities in mental health?”.

Domain 4: Community Advocacy 

This domain asks organizations to consider how they promote advocacy and real-time solutions to documented forms of injustice and health disparities. It includes five self-reported items such as: “To what extent does your organization work in partnership with law enforcement and the local criminal justice system to eliminate potential racial disparities in arrest, incarceration, and diversion of people of color who have mental health and/or substance use conditions?”.

Domain 5: Population Health Outcomes 

This domain pushes organizations to understand how racism impacts community behavioral health outcomes on a population health level. It includes two self-reported items such as: “To what extent does your organization track disparities in health outcomes (death, medical comorbidity, avoidable readmissions, disease remission) outcomes and work to eliminate such disparities?”.

Conclusions

The authors encourage users of the tool to use it as a starting point for anti-racist efforts. They suggest choosing 3 areas to focus on with the creation of initiatives with measurable goals and outcomes. Through the use of the SMART tool, healthcare organizations, particularly ones with a community behavioral health focus,  can move from platitudes to action by using the domains above to guide next steps to develop anti-racist initiatives for the organization.