The Self‑assessment for Modification of Anti‑Racism Tool (SMART): Addressing Structural Racism 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.