SAMHSA Disparity Impact Statement 

Services Example 

Purpose 

SAMHSA requires that its grant recipients prepare a Behavioral Health Disparity Impact 

Statement (DIS) as part of a data-driven, quality improvement approach to advance equity for 

all, and to identify racial, ethnic, sexual and gender minority populations at highest risk for 

experiencing behavioral health disparities as part of their grant projects. The purpose of the DIS 

is for recipients to identify, contextualize and address disparities1 and to develop and implement 

a disparity reduction action plan with a quality improvement process to address and close the 

identified gap(s). The aim is to achieve behavioral health equity2 for disparate populations and 

to improve systems addressing the needs of these populations. The DIS requirement aligns 

with expectations outlined in Presidential Executive Order 13985: Advancing Racial Equity and 

Support for Underserved Communities Through the Federal Government, which includes 

identifying the needs of underserved communities and developing policies to advance (health) 

equity within those communities. 

Background 

To address behavioral health disparities, it is important to understand the role that Social 

Determinants of Health (SDOH) 3 can have on the health of individuals and communities. SDOH 

are the conditions in the environment where people are born, live, work, play, worship, age and 

thrive that affect a wide range of health, functioning, and quality-of-life outcomes and risks. 

SDOH can be grouped into 5 domains: 1) Economic Stability; 2) Education Access and Quality; 

3) Healthcare Access and Quality; 4) Neighborhood and Built Environment; and 5) Social and 

Community Context. The SDOH framework recognizes that cross-sectoral systems contribute to 

advancing equity through a lifespan perspective. Understanding the SDOH community context 

can help recipients identify the disparity (or problem), population of focus and inform the 

development of accurate measures to study and improve outcomes. 

1 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.” 2 Behavioral health equity is the right to access high quality and affordable health care services and supports for all 

populations regardless of the individual’s race, age, ethnicity, gender (including gender identity), disability, 

socioeconomic status, sexual orientation, or geographical location. Advancing behavioral health equity involves 

ensuring that everyone has a fair and just opportunity to be as healthy as possible. In conjunction with quality 

services, this involves addressing social determinants of health, such as employment and housing stability, 

insurance status, proximity to services, and culturally responsive care – all of which have an impact on behavioral 

health outcomes. 

3 https://www.cdc.gov/socialdeterminants/index.htm 

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The purpose of this document is to support recipients in developing measures associated with 

DIS. All of SAMHSA’s discretionary grants are required to report Government Performance and 

Results Act (GPRA)4 data, which includes the National Outcome Measures (NOMS). Grant 

programs using the NOMS client-level outcomes tool uses data collected that includes 

demographics5

, ICD-10 diagnostic categories, substance use and abuse, mental health and 

physical health functioning and other variables. There are limitations to the categories 

regarding certain race, ethnicity, language, and disability. For some grant programs that are 

collecting Infrastructure, Prevention and Promotion (IPP) indicators, demographic data are 

collected, but are not housed within SAMHSA’s Performance Accountability and Reliability 

System (SPARS). 

Despite these limitations, the DIS can be used to identify and demonstrate the impact of 

SAMHSA’s investments to reduce and eliminate inequities among underserved populations. By 

developing the DIS, recipients will identify the population experiencing the disparity, share more 

specific population data that will assist in determining if SAMHSA’s grant investments are 

reducing disparities, use data to more precisely direct resources to improve the SDOH and 

CLAS while moving towards outcomes that will reduce disparities among the population(s) 

noted. 

For recipients serving distinct populations (i.e., tribes, etc.), disparities within these populations 

can be identified (e.g., age, gender identity, sexual orientation, disability). 

As recipients collaborate within their respective organizations to complete this DIS, we hope that 

it will inspire and guide an approach to reducing and eliminating behavioral health disparities for 

the populations being served. In the following pages the modernized SAMHSA Behavioral 

Health Disparity Impact Statement is included as a worksheet to support completion by the 

recipient. 

Resources, guidance, and training to support recipients in completing the DIS can be found 

here https://www.samhsa.gov/grants/grants-management/disparity-impact-statement; see also 

accompanying Appendices). 

4 https://www.samhsa.gov/grants/gpra-measurement-tools 5 https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=53 

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 3

St. Clair County

*In the yellow highlighted section above*

In the state of Illinois, the average prevalence of serious mental illness (SMI) among adults 18

and older is 4% (or 391,000). The average percentage of substance use among people aged 12

or older is 8% (or 851,000). The percentage of adults aged 18 or older receiving mental health 

services is 46.4% (or 827,000).

)

Disparity Impact Statement Worksheet 

Services Example 

Grantee Organization Name: ABC Community Behavioral Health Center 

Grant ID (SM/TI/SP/FG): SMXXXXXX 

Grant Program: Certified Community Behavioral Health Clinics-Expansion 

(CCBHC-Es) - *Note: this is an example and NOT a reflection of an actual 

CCBHC-E grantee or program. 

Project Director: Jane Doe 

Grant Project Officer: Tyler Brown 

SECTION I. Identifying Behavioral Health Disparities 

IDENTIFY and DESCRIBE THE SCOPE of the PROBLEM 

What is the disparity/problem/gap you are seeking to address as it relates to the grant program? 

What is the data to support this (e.g. SAMHSA National Survey on Drug Use and Health 

(NSDUH), CDC and OMH Minority Health Social Vulnerability Index (SVI), CDC/ATSDR Social 

Vulnerability Index (SVI), CDC Behavioral Risk Factor Surveillance System, CDC Youth Risk 

Behavioral Surveillance System, AHRQ National Healthcare Quality Disparities Report 

(NHQRDR), U.S. Census Bureau Data, U.S. Census Bureau American Community Survey 

(ACS), Federal Register Annual Update of the HHS Poverty Guidelines, CMS Informational 

Bulletin on 2022 Federal Poverty Level Standards, other federal, state, or county level data. 

Note: You may frame the disparity(ies) by looking at the individual/client level, organizational 

level, and/or systemic level. 

ABC Community Behavioral Health Center has multiple sites throughout the state of Maroon. We 

have 2 sites, one in Cerulean County (which includes the city of Sunshine) and one in Lavender 

County (predominantly rural). Sunshine is one of the largest cities in Maroon. 

In Maroon, the annual average prevalence with Serious Mental Illness (SMI) among adults 18 and 

older was 4% (or 391,000), which is lower than the national average (4.8%) from 2017-2019 

(NSDUH, 2020). For adults 18 and older with any mental illness (AMI) who received services in 

the past year increased between 2008-2010 and 2017-2019. During 2017-2019, the annual 

average prevalence of past-year mental health service use in Maroon among adults with AMI was 

46.4% (or 827,000), which is close to the national average of 43.6%. The rates of opioid use 

disorders among people aged 12 and older was 0.5% (57,000), lower than the national average 

(0.7%). However, in Cerulean County, the rate is 0.8%, which is higher than the national average. 

In Lavender County, the rate is the same at 0.7% (NSDUH, 2020). 

In Cerulean County (especially in the city of Sunshine), African American young adults, ages 18-

25, especially among women, have a higher rate of opioid overdose compared to all other groups 

in these areas, which has increased during COVID compared to pre-COVID years. In Lavender 

County, where it is primarily rural, among White, the rate of receiving services have also 

decreased and the suicide rate, especially gun deaths have increased. 

Other factors include the number of clients to the number of mental health providers at 

approximately 700:1 in Cerulean County and 500:1 in Lavender County, compared to 370:1 for the 

state of Maroon. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete a table that includes the disparity (the gap or difference) at the individual/client,

organizational, or systemic level as it relates to the grant data collection requirements: NOMs,

IPP (*specific to CMHS), or both related to access, use and outcomes. For examples, including 

the use of a table, please see Appendix A.

Per the requirements of the CCBHC NOFO, we completed a CCBHC Needs Assessment (as 

required in CCBHC Certification Criteria 1.A). Findings from the CCBHC Community Needs 

Assessment conducted last year per the CCBHC Certification Criteria Requirements showed that 

accessibility of services presented a significant impediment to services such as crisis and urgent 

care services. Factor impeding access included lack of transportation, lack of sufficient SUD 

Crisis Beds, and limited mobile crisis response services. In addition, the Needs Assessment for 

Cerulean County identified the barriers related to staffing and the lack of diversity representing 

the African American population being served. Feedback indicated that community outreach and 

engagement, as well as clinical and recovery support services were not always viewed as 

culturally responsive. 

DISPARATE POPULATION(S) OF FOCUS 

Identify the focus population(s) experiencing disparate access, use, and outcomes and that 

experience adverse SDOH with impact to behavioral health in your geographic/catchment area. 

Identify data source(s) that you are using to inform the DIS for the grant program. Grant 

recipients must select sound and reliable source(s) of programmatic, county, state, or national 

indicators the program deems best suited to the needs of this grant. Recipients may consider 

the same data sources listed above (e.g., ACS, NHQDR, SVI, NSDUH). The data referenced 

within the DIS should be in alignment with the data provided in your application. 

*Note: For client level data, SDOH Z-codes are available and can be used to collect data on 

disparities. It is recommended to use SDOH Z-codes more broadly and beyond the billing 

environment to support data collection on available determinants. For more information on 

SDOH Z-codes and how they are being used to narrow health disparities, please see 

https://www.cms.gov/files/document/zcodesinfographic.pdf; 

https://www.cms.gov/files/document/cms-omh-january2020-zcode-data-highlightpdf.pdf; 

and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207437/pdf/18-095.pdf. 

Demographic Table 

For the overall demographics for both counties are as follows: 

• White: 58% in Cerulean County; 75% in Lavender County 

• African American: 35% in Cerulean County; 15% in Lavender County 

• Hispanic/Latino: 5%, number XX in Cerulean County; 9% in Lavender County 

• Other (Asian American, Alaska Native/American Indian, Mixed race. Etc.): 2% Cerulean 

County; 1%, in Lavender County 

ABC CMHC, historically, serves on average 3000 people a year across both locations. For this 

new CCBHC-E grant program, we plan to serve 600 unduplicated individuals across both sites 

over the entire project period per our application. In Cerulean County, our goal is to serve 350 

unduplicated persons at this location. In Lavender County, our goal is to serve 250 unduplicated 

persons at this location. 

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We will increase the number of African Americans served from 27% to 35% (95 to 123) in 

Cerulean County and from 12% to 15% (30 to 38) in Lavender County across the entire grant 

period. 

Historically at these two sites, 27% of our clients are African Americans at the Cerulean 

County site and 12% are served at the Lavender County site, which are less than the county 

demographics. To increase access to mental health and substance use services, ABC CMHC 

will use the CCBHC-E grant to hire more providers to provide these services. 

Please see the following demographics (please refer to the table in Appendix for more details). 

Using grant activities, we will increase the number of screenings for mental health, substance 

use, and suicide risk for African American young women ages 18-25 by 5% [Note: please 

determine the numbers XX or X% for your grant, this is just an example] and the number of 

referrals to appropriate services by 5%. For Lavender, we will provide training to our staff on 

crisis services, suicide risk, and NARCAN. We will also increase depression and suicide risk 

screenings in Lavender by 5%. We will also be providing outpatient mental health and substance 

use services and targeted case management in Lavender among high-risk individuals. All of the 

required CCBHC-E required services will be provided at both locations but these specific ones 

will be implemented and monitored to focus on addressing the gaps. 

Total (2 Sites Together) 

Year 

1 

Year 

2 

Year 

3 

Year 

4 Totals 

Non-duplicated served 205 160 135 100 600 

Active # of Individuals to Be 

Served Per Year (can include 

duplicates) – if applicable 200 250 250 150 850 

By Race Year 

1 

Year 

2 

Year 

3 

Year 

4 Totals 

Breakdown by

Percentage 

White 147 114 97 68 426 71.0% 

Black or African American 49 43 37 32 161 26.83% 

Multiracial 3 2 1 0 6 1.00% 

American Indian/Alaska Native 2 0 0 0 2 0.33% 

Asian 2 1 0 0 3 0.50% 

Native Hawaiian or Other Pacific 

Islander 2 0 0 0 2 0.33% 

Total 205 160 135 100 600 100% 

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Ethnicity Year 

1 

Year 

2 

Year 

3 

Year 

4 Totals 

Breakdown by

Percentage 

Non-Hispanic 191 149 124 90 554 92.33% 

Hispanic 14 11 11 10 46 7.67% 

Total 205 160 135 100 600 100% 

Gender Year 

1 

Year 

2 

Year 

3 

Year 

4 Totals 

Breakdown by

Percentage 

Male 97 58 49 38 242 40.33% 

Female 106 98 83 61 348 58.00% 

Transgender 2 4 3 1 10 1.67% 

Total 205 160 135 100 600 100% 

Sexual Orientation Year 

1 

Year 

2 

Year 

3 

Year 

4 Totals 

Breakdown by

Percentage 

Heterosexual 196 153 129 94 572 95.33% 

Lesbian 3 1 2 2 8 1.33% 

Gay 1 3 1 2 7 1.17% 

Bisexual 5 3 3 2 13 2.17% 

Total 199 154 131 96 600 100% 

SECTION II. Addressing Disparities Using the Funding Opportunity 

SOCIAL DETERMINANTS OF HEALTH6 

Identify one or more SDOH domain(s) that your organization will work to address and improve 

for the identified population(s) of focus using the Notice of Award (NOA). Include a brief 

explanation about how your organization will address the specific domain(s) to support the 

reduction or elimination of disparities for the identified population. 

Social Determinant of Health Domains 

(Visit Healthy People 2030 for more information on the five (5) domains.) 

1. Education and Quality 

2. Economic Stability 

3. Health Care Access and Quality 

4. Neighborhood and Built Environment 

5. Social and Community Context 

6 https://www.ruralhealthinfo.org/toolkits/sdoh 

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Our grant activities will address the SDOH domains of Economic Stability, Health Care Access and 

Quality, Neighborhood and Built Environment, and Social and Community Context. 

The rates of violent crime and income inequality are all slightly higher than the state average. For 

social isolation and social trust, the rate is 9.9 in the state and Cerulean County is 15.7 and 10.9 in 

Lavender County for the social isolation and social trust, which is a predictor of health outcomes 

(Robert Wood Johnson, County Health Rankings Report, 2022). 

In Sunshine City in Cerulean County, we developed a community health improvement plan that is 

divided by urban, suburban, and rural regions. Per the required activities for the CCBHC-E grant 

program, we will increase the access to mental health and substance use services and improve 

outcomes within our catchment areas by hiring 5 integrated care staff, 2 of whom are substance 

use providers, 2 are mental health clinicians and 1 is a peer support specialist or recovery support 

specialist. We will recruit staff who are representative of the communities and people we serve. 

We will also partner with local community-based organizations, food banks, places of worship, 

schools, law enforcement agencies, hospitals, etc. to ensure appropriate referrals and resources 

can be made for our clients. 

We will develop a DEI Advisory Committee to develop recommendations that address the gaps in 

workforce diversity and cultural competence workforce training and other development activities. 

The program will also develop a strategic plan for adding a harm reduction site to mitigate Opioid 

deaths while working to further engage community members in services. 

For Lavender County, the program will dedicate grant resources to expanding capacity of our 

mobile crisis teams and to further developing partnerships with SUD crisis beds. The grant will also 

develop a plan for addressing transportation barriers, including enhanced use of telehealth ad 

provision of resources to clients that enable participation in telehealth, as well as the use of ride 

share services for medical appointments, and connection to peer support services, including 

warmlines. 

Behavioral Health Implementation Guide for the National Standards for Culturally and 

Linguistically Appropriate Services in Health and Health Care 7 

Using the Behavioral Health Implementation Guide, identify one or more of the CLAS standards 

(listed below) that your organization plans to meet, expand, or improve through this grant 

opportunity. Include an explanation on any activities, policies, and procedures that your 

organization will undertake to ensure adherence. 

(Review the Behavioral Health Implementation Guide for full explanations of the overarching 

themes and 15 CLAS Standards with behavioral health related samples, strategies, and 

examples.) 

Principal Standard 

1. Provide effective, equitable, understandable, and respectful quality care and services 

that are responsive to diverse cultural health beliefs and practices, preferred languages, 

health literacy, and other communication needs. 

Governance, Leadership and Workforce 

2. Advance and sustain organizational governance and leadership that promotes CLAS 

and health equity through policy, practices, and allocated resources. 

3. Recruit, promote, and support a culturally and linguistically diverse governance, 

leadership, and workforce that are responsive to the population in the service area. 

7 https://www.minorityhealth.hhs.gov/minority-mental-health/clas/?utm_medium=email&utm_source=govdelivery 

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SECTION III. Developing a Disparity Reduction Quality Improvement Plan

4. Educate and train governance, leadership, and workforce in culturally and linguistically 

appropriate policies and practices on an ongoing basis. 

Communication and Language Assistance 

5. Offer language assistance to individuals who have limited English proficiency (LEP) 

and/or other communication needs, at no cost to them, to facilitate timely access to all 

health care and services. 

6. Inform all individuals of the availability of language assistance services clearly and in 

their preferred language, verbally and in writing. 

7. Ensure the competence of individuals providing language assistance, recognizing that 

the use of untrained individuals and/or minors as interpreters should be avoided. 

8. Provide easy-to-understand print and multimedia materials and signage in the languages 

commonly used by the populations in the service area. 

Engagement, Continuous Improvement, and Accountability 

9. Establish culturally and linguistically appropriate goals, policies, and management 

accountability, and infuse them throughout the organization’s planning and operations. 

10. Conduct ongoing assessments of the organization’s CLAS-related activities and 

integrate CLAS-related measures into measurement and continuous quality 

improvement activities. 

11. Collect and maintain accurate and reliable demographic data to monitor and evaluate 

the impact of CLAS on health equity and outcomes and to inform service delivery. 

12. Conduct regular assessments of community health assets and needs and use the 

results to plan and implement services that respond to the cultural and linguistic diversity 

of populations in the service area. 

13. Partner with the community to design, implement, and evaluate policies, practices, and 

services to ensure cultural and linguistic appropriateness. 

14. Create conflict and grievance resolution processes that are culturally and linguistically 

appropriate to identify, prevent, and resolve conflicts or complaints. 

15. Communicate the organization’s progress in implementing and sustaining CLAS to all 

partners, constituents, and the general public. 

1) Hire clinical staff who are from the communities of the populations being served. 

2) Create treatment plans and medications for non-English proficient individuals in language 

(e.g. Spanish, Mandarin, American sign language, etc.) 

3) Create health information materials for individuals with low health literacy. 

4) Ensure that board members include representatives from the community, persons with 

lived experience, and family members who are active decision makers. 

5) Proactively engage the community via the community needs assessment process as 

required for CCBHC Certification. 

6) Expand peer support services that are reflective of and imbedded in the community. 

7) Expand community partnerships aligned with the CCBHC Certification Criteria 

requirements and that are responsive to the gaps identified in the Community Needs 

Assessment. 

8) Ensure that clinic hours and services are available at times and in locations that meet the 

community needs. 

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This final section of the DIS is to help you develop and implement a disparity reducing quality 

improvement plan as part of your DIS to address under-served population differences based on 

the (GPRA) data for access, use and outcomes of activities. 

For example: 

• Access: number of individuals served, number of outreach contacts, number of 

screenings, number of referrals. 

• Use: number of screenings, number of referrals, retention rate, number of trainings. 

• Outcomes: number of completed referrals, number of people trained, number and 

percentage of individuals who have demonstrated improvement in 

knowledge/attitudes/beliefs, number of programs/organizations/communities that 

implemented specific behavioral health practices or evidence-based activities. 

Include activities as they relate to both the grant requirements and your application. Also 

mention the identified gaps, disparate/population(s) of focus, and subpopulations listed above. 

Be prepared to provide at a minimum, an annual update on the disparity reducing quality 

improvement plan (what worked, what did not work, and what modifications were made) as part 

of the programmatic progress reports per the NOFO. The DIS should be viewed as a living 

document. 

IMPLEMENTATION OF ACTIVITY 

Based on the responses above, identify specifically how you will address these disparities and 

the populations’ needs with the required activities from the NOFO and within your application 

(using the SMART goals). Using the SMART goals, your application should be aligned with the 

DIS. Be sure to answer the following: What can your grant program activities do to address the 

disparity/ies? Address access, use, and outcomes (see Appendix C). How will you implement 

these activities? Who will be responsible to do so? How will you include 

client/peer/family/friends’ voices in your program activities? 

Please describe the activities that you will implement. 

In Cerulean County and Lavender County, we will: 

• Increase the number of screenings and referrals for trauma, mental health, substance use, 

and suicide risk for African American women by 5%. 

• Increase the number of screenings and referrals for trauma, mental health, substance use, 

and suicide risk for residents of Lavender County by 5%. We will also focus on identifying 

signs of depression and suicide risk and address access to lethal weapons for staff training. 

• Build and maintain least 3 partnerships in each county that will better support the needs of 

the populations to be served across the entire project period. We will offer peer and family 

support services. 

• Review policies, procedures, and workforce as they relate to providing crisis services to 

improve response time and provide culturally appropriate services and care on a quarterly 

basis. 

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INTENDED OUTCOMES AND IMPACT 

How will these activities improve the problem or close the disparity? How will you identify and 

outreach to the identified population(s) of focus in your catchment area? 

(Intended outcomes and impact should be directly related to your goals and objectives.) 

Through the implementation of the activities mentioned above, our intended goals and impact are to: 

• Increased access to and use of mental health and substance use services in both counties to 

improve the provider to persons served ratio and better overall behavioral health outcomes. 

• Increased number of suicide screenings and crisis interventions services with the goal of 

decreasing deaths by suicide. 

• Increased distribution of fentanyl test strips and Nalaxone kits with the goal of reducing opioid 

deaths. 

CLIENT/PEER/PARTNER INVOLVEMENT 

How will you include client/peer and family voices and other relevant partners in your program’s 

activities based on the identified population of focus? 

Per the CCBHC Community Needs Assessment, we will engage consumers/family members and also 

provide enhanced training on person-/family-centered planning (per the CCBHC Certification criteria 

requirements). We will be hiring at least one peer support and a recovery support specialist from the 

community to be part of the integrated care team for the CCBHC-E grant at ABC CMHC. Clinical 

supervision and training will be provided to the peer specialist and recovery support specialist. In 

addition, the rest of the clinical staff working with peer specialist and recovery support specialist will 

be educating about the roles of these peer job roles. We will also ensure that appropriate Board 

representation and decision-making will involve peers and family members. Peers and recovery 

support specialists will also be part of community engagement and outreach. 

TIMELINE 

When will you implement these activities? How often will they be reviewed and adjusted? 

(Recipient should follow NOFO specific NOMs data collection timelines with DIS reporting 

updates.) 

Per the NOFO, the implementation of activities will begin no later than 4 months of the grant award 

date. We will have hired our full clinical team and will begin providing trainings throughout the year, 

at least once a quarter. Enrolling clients and providing screenings and referrals will occur regularly 

in real time, throughout the project period. 

MEASUREMENT/ EVALUATION 

How will you measure your process, progress, and outcomes to show you were able to improve 

disparities (i.e., close the gap) within the identified population(s) of focus? How will you measure 

incremental progress achieved under this award? You should link measurement8 and evaluation 

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to goals and objectives submitted you’re your application and as noted earlier in the DIS. 

Please refer to Appendix D for additional resources. 

SUSTAINABILITY 

What changes will your organization make to enable sustainability and continue the process to 

improve disparities? (e.g., policies, financing, budget, training, systems, environmental 

changes) What external systems exist that can support sustainability efforts? (e.g., Local 

organizations adopting service priorities to support progress made under this award, 

partnerships with other community organizations, etc.) 

We use the CMHS National Outcome Measures – Client Level Tool in SPARS, which is 

administered at baseline, every 6 months, and discharge. This is conducted and collected in real 

time. In the NOMS questionnaire, demographic information and questions that focus on the SDOH 

domains are collected and updated every six months until discharge. 

We also collect and report on the Infrastructure, Prevention, and Promotion Indicators (IPP) every 

quarter in SPARS. For the IPPs specific to the DIS, we report on WD2 (workforce development – 

number of staff trained in mental health or substance use interventions); S1 (number of screenings); 

AC1 (percent based on the number of referrals made and number of referrals completed where the 

client is seen). 

Our evaluator will run monthly reports and present at bi-weekly staff meetings to the integrated care 

team to provide updates and progress on these activities. As part of the quality improvement 

process, we will present to agency leadership twice year on the progress for feedback. 

We will also provide an update in our required programmatic progress reports to the GPO per the 

NoA. 

ABC CMHC has strong relationships with our local hospital systems in both counties and they have 

supported our activities as they relate to outpatient service referrals post hospitalization for our 

clients. We also work with other community health providers and law enforcement agencies and 

created a pilot that will ensure better coordination of care across our partners for sustainability of 

services. 

We can start working with community colleges and local universities to begin recruitment of the 

workforce by offering field placements, internships, and rotations at the ABC CMHC. We will work 

with historically black colleges and universities for these opportunities. We will also explore the 

option of working with the National Health Service Corps to expand the number of providers in our 

areas. 

Our evaluator and project director will analyze our grant program outcomes to demonstrate cost 

effectiveness and cost savings for the CCBHC-E program. For example, if we can demonstrate 

increased enrollment of African Americans in both counties compared to the Emergency 

Department utilization rate over the course of the same time period and what those numbers looked 

like. We can do the same comparison as it relates to justice-involved individuals. We can highlight 

these successes and outcomes to various funding sources, including the state, county, and local 

government. 

11 

8 Measurement of Health Disparities, Health Inequities, and Social Determinants of Health to Support the 

Advancement of Health Equity. Journal of Public Health Management and Practice. 2016. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5845853/