The SAMHSA CCBHC Planning, Development, and Implementation (PDI) grants awarded in September of 2022 require grantees to develop a “Disparity Impact Statement” (DIS), to strategically define how they will address disparities in behavioral healthcare in their communities.
Each grantee defines the disparities they will address through the Community Assessment portion of the application package, following this definition:
“Behavioral health disparities refer to differences in outcomes and access to services related to mental health and substance misuse which are experienced by groups based on their social, ethnic, and economic status. Behavioral health disparities can be found in the U.S. based on age, sex, income, disability status, sexual orientation, language, geographic location, and other factors. Each year, behavioral health disparities lead to significant human and financial costs as racial and ethnic minorities experience worse health status and treatment outcomes, and more difficulty accessing services than their peers in other population groups.”
The Purpose of a Disparity Impact Statement for CCBHC Applications
Behavioral Healthcare disparity is such a critical issue, especially “post covid” when behavioral healthcare needs are at an all-time high. Providing access to all individuals who need services continues to be of the highest priority.
The Metropolitan Human Services District (MHSD) in New Orleans, Louisiana is a Qualifacts customer who received the SAMHSA CCBHC PDI grant in September of 2022. Engaging with the DIS process was eased by MHSD’s longstanding commitment to collecting and tracking client demographic data, which established a baseline of the population served over time.
To develop the DIS, MHSD brought together the Executive Director/Medical Director, the Legal team, Quality Assurance, and Data Management, and the Chief Financial Officer functioning as the Project Manager. “MHSD prioritizes addressing the needs of disparate populations in all areas of service. Developing a DIS was not a huge ask for MHSD, as prioritizing the needs of underserved communities is our mission and our standard operating procedure.” shared Dr. Rochelle Head-Dunham, Executive and Medical Director of MHSD.
While day-to-day adherence to the DIS is owned by the Project Manager and evaluation team, “data trends are shared with the leadership team of MHSD so that they can make data-informed decisions,” said Dr. Kashunda Williams, MHSD Director of Quality and Data Management.
MHSD used census data from city, state, and federal agencies as well as prevalence data from the Centers for Disease Control to establish the prevalence of specific characteristics or persons in our catchment areas including race, ethnicity, and diagnosis.
MHSD discovered that there were three specific populations for service expansion, inclusive of African Americans, Vietnamese, and individuals with substance use disorders. Individuals in these three populations were determined to be uninsured or underinsured. These gaps in service to these specific populations are invaluable information for MHSD. “The data for the DIS showed us we had work to do,” said Dr. Williams.
The results of the DIS indicated the development of an agency-wide goal for MHSD, to increase outreach and ultimately expand services to these three distinct populations. To accomplish this, MHSD’s strategy was multi-faceted.
- Form a partnership with established organizations currently serving these populations including churches and faith-based organizations
- Develop “cultural awareness training” for internal staff to ensure the people included in these populations felt comfortable with their treatment
- Redesign and develop policies and procedures specific to the service of these three populations
- Redesign forms to accommodate these varying cultures
Why is a Disparity Impact Statement important for a SAMHSA Grant Application
Dr. Rochelle Head-Dunham emphasized, “The relevance of culture and the impact of acknowledging diversity is a critical component of achieving desired outcomes for marginalized populations.”
MHSD is confident that through the work of the CCBHC grant, the agency will be incrementally successful in closing those identified gaps. The DIS is invaluable to MHSD and they have made it an integral part of their service delivery.
If you are in the process of applying for CCBHC funding and want to understand the DIS, or want to learn more about this approach to enhancing care and services, here are background references and resources:
According to SAMHSA, “the purpose of the Disparity Impact Statement (DIS) is to ensure that SAMHSA grantees are inclusive of underserved racial and ethnic minority populations in their services, infrastructure, prevention, and training grants. These populations have been underrepresented in SAMHSA grants.” The DIS is a condition of award for SAMHSA-funded grantees. It is an expectation in SAMHSA services, infrastructure, prevention, and training grants.
The DIS aligns with Presidential Executive Order 13985: Advancing Racial Equity and Support for Under-Served Communities Through the Federal Government as a data-driven, quality improvement effort with quantitative goals and objectives to ensure under-resourced populations are addressed through the grant.
How to develop a DIS
For guidance, you can find a SAMHSA grant application example along with additional resources for developing the DIS here. Understanding the DIS can help with writing a SAMHSA grant application. According to SAMHSA, the DIS consists of three components:
(1) Number of individuals to be served during the grant period and identify under-resourced population(s) (i.e., racial, ethnic, sexual, and gender minority groups) vulnerable to behavioral health disparities with a minority impact statement.
(2) A quality improvement plan to address under-resourced population differences based on the GPRA data on access, use, and outcomes of service activities.
(3) Methods for developing policies and procedures to ensure adherence to the Behavioral Health Implementation Guide for the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. Indicate what the disparity(ies) is and how your services and activities will be monitored and implemented to close the gap(s).
In addition to these requirements, the CCBHC will need to determine how it will evaluate and disseminate the findings to its stakeholders. Stakeholders include those impacted, those served, a Board of directors, the CCBHC advisory board, etc.
Healthy People 2030 defines a health disparity as a “particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; disability; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”
Writing a Strong and Strategic DIS
Any DIS must fully show an understanding of the impact of the social determinants of health on the availability and course of behavioral health treatment. The World Book sites 12 elements of social determinants of health:
- Income Level and Social Status
- Social Support Networks
- Education and Literacy
- Employment and Working Conditions
- Social Environments
- Physical Environments
- Personal Health Habits and Adaptability
- Early Childhood Development
- Biological and Genetic Heritage
- Health services
- Culture and Lifestyle
Understanding the SDOH community context can help CCBHC grantees identify the disparity itself, the population of focus which should result in the development of accurate measures to study and improve outcomes with the main purpose of the DIS strategy to be to identify and demonstrate the impact of SAMHSA’s investments to reduce and eliminate inequities among underserved populations. This makes the DIS critical.
By developing a strong and strategic DIS, grantee CCBHCs will be able to
- Identify the population experiencing the disparity
- Use data to more precisely direct resources and modify interventions to improve the SDOH situation and “Culturally and Linguistically Appropriate Services” (CLAS) while moving towards outcomes that will reduce disparities among the population(s) identified
- Share more specific population data that will assist in determining if SAMHSA’s grant investments are reducing disparities
Mental Health America shared statistics on the “Prevalence” of behavioral health disorders from the Center for Disease Control:
- Black and African American people living below poverty are twice as likely to report serious psychological distress than those living over 2x the poverty level.
- Adult Blacks and African Americans are more likely to have feelings of sadness, hopelessness, and worthlessness than adult whites.
- Blacks and African Americans are less likely than white people to die from suicide at all ages. However, Black and African American teenagers are more likely to attempt suicide than White teenagers (9.8 percent v. 6.1 percent).
Mental Health America also shared statistics on “Treatment Issues” for behavioral health disorders:
- Black and African American people are more often diagnosed with schizophrenia and less often diagnosed with mood disorders compared to white people with the same symptoms. Additionally, they are offered medication or therapy at the lower rates than the general population.
- Black and African American people are over-represented in our jails and prisons. Black and African American people make up 13 percent of the general U.S. population, but nearly 40 percent of the prison population. In 2016, the imprisonment rate for Black and African American men (2,417 per 100,000 Black male residents) was more than 6 times greater than that for white men (401 per 100,000 white male residents) and the imprisonment rate for Black and African American women (97 per 100,000 Black and African American female residents) was almost double that for white women (49 per 100,000 white female residents). Black and African American people with mental health conditions, specifically those involving psychosis, are more likely to be in jail or prison than people of other races.
- Because less than 2 percent of American Psychological Association members are Black or African American, some may worry that mental health care practitioners are not culturally competent enough to treat their specific issues.
- Stigma and judgment prevent Black and African American people from seeking treatment for their mental illnesses. Research indicates that Blacks and African Americans believe that mild depression or anxiety would be considered “crazy” in their social circles. Furthermore, many believe that discussions about mental illness would not be appropriate even among family.
With behavioral healthcare needs at an all-time high and outcomes and access to quality behavioral healthcare services being impacted by an individual’s social, ethnic, and economic status, the need for equality in healthcare for all has never been greater. CCBHCs are set up to address the disparities of care in their geographical regions and by integrating this priority throughout the organization, I anticipate the model will bring about great change.
For more information from SAMHSA on the DIS, including examples, see the resources below. For more information on my interview with Dr. Williams or to talk about anything CCBHC, don’t hesitate to get in touch with me at firstname.lastname@example.org.
1 “Disparities of Behavioral Health”, 12/20/2017, National Conference of State Legislatures, Behavioral Health Disparities (ncsl.org)
2 “Department of Health and Human Services Substance Abuse and Mental Health Services Administration FY 2022 Certified Community Behavioral Health Clinic Planning, Development, and Implementation Grant (Short Title: CCBHC–PDI) (Initial Announcement) Notice of Funding Opportunity (NOFO) No. SM-22-002 Assistance Listing Number: 93.696”, Appendix H – Addressing Behavioral Health Disparities, page 63, FY 2022 CCBHC–PDI (samhsa.gov)