Equity, Sustainability, and Reflections in Austin

Introduction

In April 2023, the Delta Center for a Thriving Safety Net convened primary care association (PCA) and behavioral health state association (BHSA) grantees and Delta Center partners (JSI, The ACT Center, NACHC, National Council for Mental Wellbeing, and RWJF) in Austin, Texas for opportunities to learn from each other, celebrate the successes, and plan for ways to sustain Delta Center activities. 

PCA and BHSA leaders from Alaska, Kansas, Louisiana, Mississippi, Oklahoma, New Hampshire, and Pennsylvania focused the first day on sustainability and relationship building and the second day on equity. Over the course of two days, grantees participated in a panel discussion on the layers of equity, learned about national policy updates and priorities, and began planning discussions for the next phase of the Delta Center.

Below are some key takeaways from the convening.

Grantee Sharing

Grantees shared updates on their projects and current priorities. Telehealth remains a priority for several states. In the Gulf Region and Pennsylvania, a disproportionate amount of people do not have access to high-quality broadband compared to the general US population. In Mississippi, there is only reimbursement parity for audio-visual visits, so they continue to advocate for audio-only reimbursement. In Pennsylvania, the governor recently signed a bill to oversee and support broadband development. Alaska also continues to work on expanding access to telehealth and crisis services. Both the Mississippi and Kansas teams are advocating for Medicaid expansion in their respective states. In Oklahoma, OKPCA, OBHA, and Patient Care Network of Oklahoma have encouraged the state Medicaid agency to require reporting on health disparities and have spoken with plans about ways to address equity. Oklahoma is also co-hosting a health equity and social determinants of health collaborative. 

Another priority for teams is leveraging community-level relationships. Kansas is focusing on community health workers (CHW’s) and expanding peer support networks, as well as creating career ladders in behavioral health beginning at the high school level. Similarly, Alaska Primary Care Association will be convening a meeting between CHW’s and peer support specialists with lived experience to promote peer learning and identify opportunities to strengthen integrated care at the community-worker level. Oklahoma similarly advised others to build relationships at the community level to leverage statewide impact.

If there’s something we’re competing over, let’s talk about that. — Kansas

States also reflected on advice they would give teams that are beginning their Delta Center journey. One major theme mentioned was wishing that they had created more opportunities for intentional collaboration with their Delta Center counterpart earlier. The Kansas team noted that meeting in New Mexico in September and developing a 90-day work plan made them realize the importance of bringing intentionality when developing shared interests. New Hampshire reflected on the steps taken to establish a strong foundation of trust between the two partner associations by prioritizing frequent and transparent communication. Pennsylvania added that having regularly scheduled meetings between the two groups has assisted in the success of their project, leading to a better working relationship that benefitted both their members and communities. Grantee teams also appreciated seeing how other teams have dealt with difficult situations, such as states with similar political landscapes sharing best practices.

Sustainability Gallery Walk 

After grantees shared their updates, there was a “gallery walk" activity where grantees spent 15 minutes at 4 different stations to brainstorm ideas and strategies for sustainability. Grantees shared their ideas for sustainability around 4 different aspects of the work: 1) maintaining the PCA-BHSA relationship, 2) funding and resources, 3) external coalition building, and 4) engaging membership, encouraging collaboration. 

1. Grantees brainstormed strategies to help maintain their PCA-BHSA relationship. Strategies included: 

• Setting up a standing meeting (biweekly or monthly)
• Presenting at each other's meetings
• Amending bylaws to allow membership to both associations
• Co-locating physical office spaces
• Attending national conferences together
• Offering free membership to each others’ conferences
• Sharing policy priorities before the state’s legislative session
• Embedding services in each other’s agencies (e.g. trainings hosted by one association available to membership from both associations) 
• Collaborating on patient cases 
• Participating in a coalition of state organizations
• Leveraging PC cooperative payments for BH staff to support the partnership
• Hosting events together (e.g. joint trainings)

2. Additionally, grantees came up with wonderful ideas on how to sustain funding and resources after the Delta Center funding comes to an end. Ideas included:

• Approaching health-specific foundations (e.g. health plan foundations)
• Investment from member organizations
• Association fees for services (E.g. credentialing and marketing)
• Submitting co-applications for state/federal grant opportunities
• Pursuing federal funding akin to HRSA grants 
• Building in-staff time, in particular with government association roles, to foster collaboration
• Advocating for a line item in the state budget
• Influencing existing grants in the state (DoH) to support BHSA + PCA priorities
• Leveraging human resources to access data and other existing entity resources 
• Seed funding for demonstration projects from MCOs
• Using Medicaid Reinvestment Requirements

3. Several themes emerged when discussing how to sustain external coalition building efforts. Grantees identified two types of coalition building efforts: 

1. Well-established groups — These groups already exist, and what needs to be done is identifying a common agenda and strengthening existing relationships. 
2. New groups — There is always an opportunity to collaborate with external groups. To do so, associations need to seek out and listen to unheard voices in new spaces. While doing so, it is important to acknowledge and address interrelated needs to build that connection and create that relationship.

Grantees emphasized the importance of honoring where other partners are on their journey in coalition building, especially as partners may be new to the world of partnerships. Grantees named many ways to build trust which would allow them to engage in these partnerships authentically and openly. Some trust building techniques discussed were:

• Supporting and empowering partners
• Acknowledging their past harms and owning up to the harms their organization may have perpetuated
• Engaging in advocacy trainings for associations
• Uplifting and arming people with lived experience with tools to succeed
• Sharing one’s own stories
• Being flexible with logistics 

Coalition building continues to be the most powerful advocacy tool we can utilize. — Alaska 

Additionally, when working with external partners, setting an agenda for partner meetings and designing solutions should be done together. Codesigning the agenda allows all partners to have an equal voice at the table. When designing solutions, compromise without condescension, and be transparent about limitations. There is much power to make change in coalitions. To quote an African proverb: “If you want to go fast, go alone. If you want to go far, go together.”  

4. The last focus of the gallery walk was around sustaining membership engagement and encouraging collaboration. The main takeaway around this topic was that associations must work together to successfully sustain their membership engagement and to truly encourage collaboration among their PC-BH membership. 

It’s important to understand a state’s vision and the people in charge of creating the vision. — New Hampshire

To create a space for more collaboration and membership engagement, individual associations must first understand the needs and goals of their respective memberships. Associations can begin by defining their individual organization needs and noting where common needs are cross-cutting between PCAs and BHSAs. These shared needs can be opportunity to collaborate on tackling the need for both memberships. 

We all do better when we all do better

External facilitation support was a popular strategy to go about tackling how to engage members and collaboratively work towards addressing their needs. Bringing together BH and PC providers with the help of an objective party is a useful strategy to engage in difficult conversations and to ensure both parties are heard. In partnership with one another, PCA & BHSA’s can then begin to tackle these joint needs together. When doing so, grantees shared the necessity of establishing joint values upfront, maybe through a shared value proposition, and ensuring authority is not consolidated on one side of the partnership.

Layers of Equity Panel

Day 2 included a panel on the layers of equity. Deborah Riddick (Alternate Frame) moderated a panel between Andrea Ducas (Robert Wood Johnson Foundation), Angel Bourgoin (Health Equity Compact, JSI), Scott Cook (University of Chicago), and Shelina Davis (Louisiana Public Health Institute).

We often think of health equity as being “out there,” when in reality, it is all around us, and our current circumstances are a reflection of past harms. — Scott Cook, University of Chicago

The biggest takeaway is that equity is a process rather than a destination. When asked to define equity, panelists emphasized that equity is not one thing, it is embedded in all the work they do. At Robert Wood Johnson Foundation, it is a set of principles. Scott remarked that we often think of health equity as being “out there,” when in reality, it is all around us, and our current circumstances are a reflection of past harms. 

All of the panelists discussed how their organizations have operationalized equity. Shelina discussed the importance of uplifting voices who do not traditionally hold power in the community, because it proves futile to do equity work in a silo. Louisiana Public Health Institute has also established race-based affinity groups, and Shelina advised working on internal and external equity in parallel. Angel built on that, noting the power that is felt in a collective of BIPOC executive leaders, where policy work is rooted in both an equity task force and community engagement across the state. The group has chosen six policy priority areas to focus on and recently filed health equity legislation. Andrea discussed where Robert Wood Johnson has made mistakes in the past and what they are doing differently now. She mentioned that people do not like equity when it feels like things are getting taken away from them. The organization has had to grapple with that, realizing that there is no such thing as neutrality when it comes to equity. Now, there is an executive responsible for considering how to infuse equity into every aspect of RWJF’s work by employing nuanced approaches to increase accountability. Scott discussed funding healthcare entities to tackle health disparities, but not including racism as an explicit focus. He encourages organizations to do root cause analyses, to think about issues from a system level instead of putting the burden of health on individuals. 

There is no such thing as neutrality when it comes to equity. — Andrea Ducas, Robert Wood Johnson Foundation

When asked by the audience how they deal with individuals who are focused on money, Shelina remarked that Louisiana Public Health Institute works with funders who will support them and understand both what they are willing to compromise on and what are non-negotiables. Deborah added that sometimes it’s necessary to change who’s in the room— “if all they care about is money, you need more diverse perspectives.” When asked how to deal with negativity, Scott suggested asking the person who is being disrespectful what is causing them pain and not working for them. Overall, the panelists emphasized that equity is not a destination that one arrives at, but rather a continuous process and lens to evaluate with.

National Council for Mental Wellbeing and National Association of Community Health Centers Landscape Updates

Day 2 ended with a presentation from the National Council for Mental Wellbeing (NCMW) and National Association of Community Health Centers (NACHC). The presentation went through NCMW and NACHC’s policy priorities, and their joint areas of priorities.

NCMW’s policy priorities included: 1) strengthening the mental health (MH) and substance use (SU) workforce, 2) bolstering SU prevention, care and recovery, 3) protecting and growing funding for MH and SU programs, 4) increasing equitable access to high quality services by expanding CCBHCs, 5) promoting comprehensive 988 implementation, 6) elevating initiatives impacting justice involved populations, 7) supporting MH and SUD parity, 8) expanding access to MH and SUD services via provided via telehealth, 9) supporting youth and maternal MH and SU prevention and treatment, and 10) addressing social determinants of health. 

NACHC’s shared 3 main policy priorities which aim to preserve, strengthen, and expand the community health center system of care. The policy priorities are: 1) reauthorizing health center base funding, 2) protecting the 340B program, and 3) addressing workforce challenges. 

Joint Priorities

Together, NCMW and NACHC shared joint priorities their associations had alignment on. 

The end of the public health emergency (PHE). The PHE has medicaid coverage and telehealth implications. Both national associations urged states to review their state 1115 & 1135 waivers and flexibilities to be aware of the changes that will happen as the PHE comes to an end. 

We are all used to operating in a scarcity mindset and if we don’t operate in it well, we end up pitting ourselves against one another and it’s special that Delta helps us bring one another together in order to achieve systems change. — Samantha Holcombe, National Council for Mental Wellbeing 

Addressing the workforce crisis. NCMW and NACHC shared 3 main focus areas with the greatest alignment among their associations to address the workforce crisis. First, the associations agreed upon clinical model innovation using team-based and integrated care models. The clinical model innovation will focus on community-based models or systems, and elevation of prevention, early intervention, and community needs. Second, there was joint agreement on workforce expansion. Workforce expansion would focus on leadership and development programs (e.g. pathways to entering the field, paraprofessional). Third, NCMW and NACHC agreed upon certain policies and regulations, including: expanding eligible provider types, addressing reimbursement rates, and enhancements and changes to loan payment and other training programs. NCMW and NACHC will be developing shared action around these initiatives and policies to drive these 3 elements.

PC/BH integration. The national associations uplifted the information around CCBHC expansion and its importance in advancing PC/BH integration efforts. 

Ending on a High Note

To close out our time together in Austin, grantees, national partners, and program staff reflected on the wonderful insights gained from two days of education, discussion, and collaboration by writing down 3-5 personal takeaways/highlights on notecards. Remaining true to the spirit of collaborative learning, attendees then exchanged cards with one another in order to create the following list of fan-favorite nuggets of wisdom:

On Collaboration

• “If you want to go fast, go alone. If you want to go far, go together.” – An African Proverb
• FQHC(s) and CMHC(s) need a clear understanding of each other’s business and payment models to truly engage in meaningful collaboration, advocacy and potentially CBHC implementation.
• We have an opportunity to shift from competition to collaboration to dismantle the system that has kept us operating in scarcity.
• The value of transparency with other stakeholders that midnight initially be viewed as competitors
• The power of relationships and importance of breaking down myths to build trust
• We have to be willing to be uncomfortable and lean into generative conflict in order to change systems
• People are remarkable and can do remarkable things when they work together.

On Equity

• The importance of DEI self-evaluation must be deeper than the surface, no matter how difficult the conversation
• Operationalizing equity to grow our staff, better support our membership, and become a stronger org.
• Reframing the conversation out of traditional power dynamics can be the catalyst to get movement in stuck conversations
• Need to have the difficult conversations about DEIB with the powers that be.

On Workforce

• Workforce crisis is severe enough that government should use “PHE level” actions to rapidly fund + change reduce regulations