Sarafina Cooper: Hello, welcome to the American College of Preventive Medicine, Centering Equity and Crisis Preparedness and Response and Health Systems Evaluating Emerging Practices in the Care of Minoritized Populations is a pleasure to have you with us today. Before we begin, please review with me a few housekeeping notes. All attendees are in listen only mode. Please do not put us on hold. If you're calling in the CDC Accessibility Program is providing live transcription for this webinar. I will place the URL for the live transcription and pin it in the chat. Today's webinar is being recorded and to be made available on the ACPM Learning Management System at learn.Acpm.org. Please use a chat box, not the Q&A function to submit any questions for the presenter. Questions will be answered during the live Q&A session at the end. And lastly, an evaluation survey link will be sent out in a chat box. At the end. The evaluation survey will be emailed later today as well to all attendees completion and submission of the survey are necessary to receive CME credit I'm delighted to introduce the moderator for today's webinar. Dr. Wilnise Jasmin. Dr. Jasmin serves as the Medical Director of Behavioral Health at the Chicago Department of Public Health. She specializes in both family prevention and family medicine. Dr. Jasmin is an alumna of Johns Hopkins Bloomberg School of Public Health and the Cook County Loyola Family Medicine Residency program. She's a longtime American College of Preventive Medicine member and graciously serves as a subject matter expert on this project's advisory board. Dr. Wilnise Jasmin: Hello, good afternoon everyone. And welcome to today's session. before we get started, we thought it would be a great idea to start with, specific definition of "health equity" language. And so our use of health, our use of equity focused first person language throughout this webinar aligns with published guidance from the Centers for Disease Control Prevention, CDC, the guide called Health Equity Guiding Principles for Unbiased Inclusive Communications and the association of American medical colleges and American Medical Associations Advancing Health Equity Guide to Language, Narrative, and Concepts. You should see a link to these, guides for your future reference. Next slide. Today, I'll share the Disclosure, and Disclaimers. So, this session is supported by the American College of Preventive Medicine through a Cooperative Agreement with the Centers for Disease Control and Prevention Center for State Tribal and Local Territorial Support of the US Department of Health and Human services. The contents are solely the responsibility of the authors and do not necessarily represent the official views of nor an endorsement by the CDC or HHS or the US Government we do not have, and have not had in the last 12 months, any relevant financial or other relationship with any proprietary entity producing marketing, reselling, or distributing healthcare goods or services, including the manufacturer of any commercial products or device that we will discuss during our presentation. And now allow me to introduce our speaker today. You're in for a wonderful treat. So Ms., Crystal Sacaridiz joined AMA Center for Health Equity as Senior Program Manager of Strategic Operations after serving as founding member of the New York City Department of Health and Mental Hygiene's Center for Health Equity since 2015 She brings over 12 years of experience in healthcare and social service delivery, administration, strategy analysis, development, and advocacy with career commitment to social service and improving access for marginalized population. Crystal is trained in mixed methods, qualitative and quantitative research human-centered design, emergency management, change management and hospital and nonprofit administration with a focus on information technology prior to her work with the New York city health department, she was a foster care social worker with the Children's Aid Society and was Assistant Director for PCMH Primary Care Transformation across the New York City Health and Hospitals, Bronx Network at the New York City Health Department. She served as a social science researcher and an equity focused capacity building role, as well as a Strategic Advisor for multiple Community Health Worker programs, serving the neighborhoods facing historic injustices and disinvestment. And throughout the COVID-19 pandemic, Crystal multiple roles and, she developed information flow and data, collection mechanisms to support community based data capture, database, design, visualization, and reporting in addition to providing direct care services. And so now it's an honor for me to pass the baton to you Crystal. Crystal Sacaridiz: Thanks so much. and thank you all for being here. It's really a pleasure to meet with you all today. I'm gonna start by going through our agenda of what you can expect in today's presentation. And then, we will, into all of the different nuances. So for on today's agenda, we're gonna be talking about specifically inequities in the public health landscape. what it looks like to center equity in the space of emergency preparedness and response. We're gonna talk, take a look at equity in action practice, promising practices across the nation, and really those who are, putting this work in motion and what it looks like to get started and making changes. As with all presentations out of the American Medical Association Center for Health Equity, and AMA more broadly. Now we wanna start with a Land and Labor Acknowledgement specifically, making the point that we are living off stolen ancestral lands of Indigenous people, that this has come back for thousands of years. The images in this instance, and this slide in particular come from the Oregon Health and Science University's Native American Center of Excellence. And in this instance, and the Wyatt Post Baccalaureate pathway, In this instance, we wanna make sure that we're acknowledging this and that we both celebrate the resilience and strength of all Indigenous people and the descendants of Africa that have, shown the country been shown throughout the country and worldwide. We carry our ancestors with us and we are continually called to be reminded of this and called to do this work better specifically as we lead in equity work. So now for our presentation inequities in the public health landscape peace time, and at the point of crisis, I start this talk today by asking all of you a question. So feel free to respond in the polls, or in the chat, and really asking this question of what constitutes a crisis. so up on your screen, you should see what are often pulled up as being seemingly interchangeable terms, emergency public health, emergency catastrophe disaster. So feel free to respond. If you think, you know, the distinct distinctions here. the thing we'd like you to keep in mind is emergency is often defined as a natural or manmade catastrophe, warrants, life saving action. It's meant to protect property, public health and safety. But what often comes up is either nuclear incidents, natural disasters, such as a landslide, a mudslide, a volcano, an earthquake, or a hurricane catastrophe often means the same, but it's defined more by level of mass casualty, severity of disruption or damage, and destruction to infrastructure, a public health emergency. On the other hand, often comes, most recently to, you would think of monkeypox right now, you would think of COVID-19. these types of events are often called for action, but specifically for, medical departments and the inclusion of infectious disease, but also critical power outages. Disaster is another term often used similarly interchangeable to capacity, but is meant to describe a single incident and crisis is the term most often used to describe all of these things, but it's, used for when things are specifically time bound. so crisis is the term used for things that are ongoing, things that are happening currently. the situation you're all experiencing, at any particular moment when an emergency is happening. So here's the tricky part. If I were to ask you all, what do all crises have in common? How might you respond? So the biggest answer here, and the thing I'd like you most take away from this is that, historically minoritized and marginalized communities consistently carry the burden of excess suffering and loss and loss of life, anytime, any crisis occurs, no matter what kind. Dr. Wilnise Jasmin: I just wanna say that one of the responses is "overwhelming". Crystal Sacaridiz: It is. and so as we look at this next series of, I'm gonna show you a couple of different slides of, of different types of data, and I'll acknowledge the sources along the way. So this in particular came from a study with the Commonwealth Fund. But we're gonna look at several different examples, that show this. In the US racial and ethnic inequities are pervasive in all health systems. This is certainly worldwide, but in this particular instance, we wanted to point out examples of how this comes up in both the performance across states, by race, ethnicity, as well as different dimensions of performance across all health systems. So this was based on a Commonwealth Fund, studied in, done in New York State, where they looked at, levels of performance of both in health outcomes, care access, as well as quality and utility of services. So we see the pervasiveness of inequities across all systems in each of these categories. We also see very explicitly, and you know, too soon to say with monkeypox now, but, in looking at the COVID-19 pandemic, this is certainly true that health outcomes, including mortality. had demonstrated deeply embedded in equities in the us health systems, very much fueled by structural racism, other forms of oppression, and they were explicitly magnified during the pandemic. So in this instance, the top resource comes from, CDC data. The bottom comes from a study from the pew research center, making the point that, minoritized populations are consistently disproportionately impacted. In that instance, making them more likely to get sick, making them a more likely to experience severe symptoms, making them more prone to hospitalization, higher rates of mortality and the impact of non-medical other social factors that are certainly impacting their lived experience. So, job loss, different access to childcare, certainly grief, stress, mental health. and this is just some of the examples showing this, As we move further. again, these are rates that were, specifically based on CDC data. In this instance, we're looking at both social and structural drivers of health. but in this instance, we're looking at specifically case rates by race and ethnicity, as well as mortality rates. And in our next area, we saw this as well in both vaccine hesitancy, or what was often termed vaccine hesitancy was really more systemic of, really more systemic of mistrust in communities and distrust in government and institutions that were built over many, many years for, minoritized populations. so what often got expressed as, an unwillingness to, Take part in, new treatments or, you know, what definitely in the earlier days was due to supply chain was largely due to historical and contemporary harms, eroding trust the relationship between communities, health systems and providers. This also affected many different, populations. and so when we talk a lot about populations that have been minoritized, we wanna acknowledge, the oppression of many and, and the examples that I'm gonna show you here. What I really need to highlight is, the intersectionality across communities of who, whom this is affected. So in this instance, the example, that we were referring to speaks to, the Indian Health service, not just looking at, disproportionate, levels of mortality, as well as mental health, but also looking at the impact that even at the start of these incidents, The systems that were in place to take care of them were also disproportionately underfunded compared to need at the time of the start. So the example given in this instance is a tribal hospital system might only have six beds in their ICU and run out of space. And this was prior to when you were seeing lots of different aspects of hospital overflow, when you were seeing a great influx of, inpatient admissions, the system already in place to, take in this patient population and provide the highest quality care was predominantly underfunded and already overrun separate from the influx to happening. It needs to also be said that we saw an extreme rise in xenophobia with, south Asian communities who. Already, more vulnerable due to immigration status, domestic violence, unsafe working conditions, specifically experiencing a large rise in hate crimes during this period of time. So when we talk about all the different aspects of how crises can impact communities, this type of, pervasive hate and oppression shouldn't be ignored. even just because it's sometimes considered nonmedical another population, we also wanna specifically highlight, was the disproportionate impact of on people with disabilities. Now this goes across race, language, culture, age groups. so this really just impacts all, but, it was found that people with intellectual disabilities were found to contract the virus, where they. twice as like the die compared to those without there was higher rates of illness, there was also an inability for many systems to respond to the needs of those with, disabilities or neuro divergence. So the examples given throughout the pandemic that were probably most pervasive word, even just the loss of communication with mask wearing. it often got talked out as an unintended consequence, but, the social isolation, the economics instability, the inability, for people to move through the built environment in ways that they typically would've, you know, with isolation being, really eminent impacted communities all over the place and this was probably seen most pervasive in the school systems. And another thing that should not be ignored during this time, was we saw the public charge rule intentionally and strongly enforced at a time when these types of critical services were likely needed most by many populations. So this was resulting in increased fear, limited to access to critical services, such as SNAP, WIC, Medicaid, and this contributed to, higher rates of unemployment. people were experiencing increased rates of childcare expenses. People were experiencing, greater losses, on both an economic level of food insecurity level, as well as just critical access to many other services. the fear of deportation was eminently increased during this period of time. So there was both, this was, Again, another example of like oppression and hate as much as it was an access to care issue. We've touched on this a little bit so far. And, I'm using the examples that we've addressed thus far, really again as just examples of looking at crises from the lens of intersectionality, but I wanna remain mindful that I really could be picking any and all minoritized communities and we've seen many of these other impacts. So in this instance, a few other things to highlight, or specifically the, the job loss and the economic impacts specifically on, Latino communities and Black Americans, as well as the increase in discrimination. we saw this also with migrant workers. We've seen this in, again, the, the different, both in overlapping with neighborhood and quality conditions, as well as, The resurgence of the welfare narrative states that often come up during these times. So just making the point that, while this didn't impact all people across the country, these are just some of the basic examples of how, minoritized populations often vary the disproportionate burden of crises, no matter the impact, across multiple aspects of their communities and the factor that I'd like you all to drive home with as we look at the next series of timelines. and so this we're, I'm gonna leave some of these up as we go through. the point I'd like to make here is that whether again too soon to see it with monkeypox, but certainly throughout the pandemic, this particular emergency or disaster was just one other example of structural violence against prioritized communities. And the examples that we'll show here, we've seen this with, black and African American communities. We see this with Asian communities over time. We see this certainly amongst, indigenous and tribal communities. You've noticed most of these diagrams, some go back to, the early 18 hundreds or more, you see this with Hispanic and Latinx communities. We've seen this certainly, amongst populations that identify, as LGBT we see this amongst populations with disabilities and neurodivergence. I say all of this to say that the, the impacts that we saw throughout the pandemic, were not new, were not different and are exactly the impacts that we should expect to continue. Unless we make significant changes in the way that we address emergencies, prepare for emergencies, and acknowledge the unique needs of the populations we have, at the proportion and, and at the level of risk and level of resourcing that they really need. So that being said in moving on to the next section, we're gonna focus on what we can do about it. So in the section to, continue, we talk about, we want you to first go to a poll question. in this instance, when we talk about what it means to center equity and emergency preparedness. So please feel free to respond to the poll in the chat. The question is to what extent was your institution? Well prepared to center equity and the needs of diverse populations at the start of the pandemic. So we'll take a few minutes here to let you respond. Sarafina Cooper: I am now closing the poll. Majority of respondents were somewhat unprepared. Crystal Sacaridiz: Thank you. Those results are very honest. and you're not alone. whether this is more about, the extent to which institutions really had the, the staffing or the resources they needed to start this, or there was just a different shift in education. Many, many organizations have, shared anecdotes of feeling the same way, you know, whether they knew the right method or had the right resources needed to respond. and so the guide that we're gonna talk about now and the projects we're gonna talk about now share some examples of how to do that. so in one instance, we wanna share that there was a particular project that we've been working on. some of the participants are on this call. there was a collaborative, a cooperative agreement and titled Strengthening Public Health Systems and Services Through National Partnerships to Improve and Protect the Nation's Health. This was a project, that jointly, happened to partnership with the CDC, the American College of Preventive Medicine and the Center for Health Equity out of the American and Medical Association. The goals were specifically to identify and support and amplify the efforts of physicians working at the intersection of COVID-19 and, equity response. The populations that the project focused on, were distinct minoritized populations, specifically, black indigenous, Asian American, Pacific Islanders, American native, Alaska, native, Hispanic, or Latinx communities. The LGBT communi. populations, neuro divergence and disabilities. and also other groups explicitly minoritized due to, economic circumstances and other circumstances of social inclusion. In this instance, 13 organizations, were funded representing 15 care sites across, nine states. and we're gonna learn a little bit more about how they specifically, shifted their work and focused in on, how they centered these communities through their emergency response methods. it should be set up for all of these institutions. They did serve as social safety nets. many included were identified as Federally Qualified Health Centers or, or CHCs. There were also some independent practices, some universities as well as a, PharmD physician collaborative. and the population's also listed here crossed from states, such as, Hawaii and Texas, Florida, Chicago, Birmingham, Alabama, and Boston, but also specifically then focused on populations, with positive HIV status, communities, and so on these grant recipients, as well as for all of us going forward, one of the things we'd like you to take away and remember is the idea of, of what it means to root equity. So as we go forward in terms of how to do this and how to center preparedness, we think it's most critical for you understand the components of rooting and guiding principles and values in all of the operational work that we do. So the idea of where equity starts is it's both a process, and a method as well as, as well as a practice. And so in this instance, the guiding principles, we ask all of this work to continuously be rooted and, and to be revisited, include trust, transparency, accountability, collaboration, and mutuality, patient and family centered care, cultural attention to cultural, historical racial, and gender issues, explicit focus, and evaluation data driven care. Now it what's different is it's one thing for organizations to say that they do this often, but it's really in the practice. And in the methods that we see this come out, there's also some specific aims you should focus on in doing this type of work. One of which is to integrate equity into crisis and operations decision making. It's also critical to keep in mind those who are doing the work and are, both living the experience as well as being caretakers and providers right along with you. So really making a conscious effort to cultivate, protect, support, and engage your staff, during any crisis and response effort. And the reason for this is explicitly because, if you are already working as a safety net institution, or if you are already, working with minoritized populations, your staff, like we already mirror the population impacted most and are not only living with this, but are going home with it. So in this instance, you wanna be conscious not just to protect from burnout, but also looking at how. Your staff and those who are best caring for the community, maybe disproportionately impacted, themselves, both at home and through their line of work. You wanna specifically engage with partners to co-create a community wide response ensure based on the examples that we were looking at earlier in terms of how a crisis impacts, not just a community at a clinical or medical level, but impacts all other aspects of their socio and economic life that we're really looking at whole person and whole, whole community care and that we're working to build high equity capacity and fiscal and administrative readiness. So for those of you who answered the poll question before, I'm really curious to see how many. of you felt only somewhat prepared to address the pandemic because of either knowledge, gap or more resourcing. So, there's often a great intent to do this type of work, but your institution has to be prepared to be able to pivot quickly. it has to have a certain staffing model. There's definitely ways to shift the way in which your, your practice is set up, to be more nimble and to be more limber at a time when an emergency occurs. So moving on to our next poll question, this is one of the aspects that you'll see, all through the emergency response guide. We reference, the work of Kamara Jones and look at equity rooted through the framework of the Gardener's tale. So our question to you is how familiar are you with this framework and with this story of the Gardener's tale. Sarafina Cooper: Now closing the poll Most results were not at all familiar. Crystal Sacaridiz: No worries. We're gonna learn about it. That's great. Okay. So let's talk a little bit about the framework of the Gardener's Tale. I used the term earlier, and we'll use this all throughout the Centering Equity and Crisis Preparedness and Response Guide. We talk a lot about what it means to root equity. And so in terms of rooting equity, the Gardener's Tale and this, and in the framework borrow, very much from the work of Kamara Jones, talks about equity happens in a variety of ways. it has to happen through, it uses the framework of a tree to talk about soil roots, a trunk and branches and fruit. in this instance, the soil is social influences, society surrounding communities, roots, the pieces that instill an organization from inequities in the soil. The trunk, meaning the goals that provide the firm foundation for equity in your organization. sometimes thought from an operations perspective as infrastructure, branches are the strategies approaches the key actions that your organization would take, to specifically counteract, oppression, racism, and, and really strengthen equity and fruits in a, in a smarty goal, style fashion, being your measurable outcomes. This is the framework of the, the Gardener's tale. And as you go through, when you actually, get a chance to look through the centering equity emergency preparedness guide in the future, you will notice that the guide that we're introducing today, but that will be really shortly we'll use this analogy repeatedly throughout it. So this type of structure of what it means to, Structure the fruits, how the branches are laid out, how, how you can strengthen the trunk. This is all the framework that we introduce and use through the guide. So let's take a little bit of look at some examples of how this has been applied in real life by looking at equity and action. So we're gonna look at emerging practices from across the nation based on, the grantees that I was mentioning before are, are 15 practices. And here's some ways that they've been able to really live these values and apply this to their work. So Angel Kids, Pediatrics of Jacksonville, Florida, this is an organization, that specifically serves the Southwest of Jacksonville are greater Arlington and a primarily refugee population. The themes that they take most from, from the guide and. Put into lived experience where, building high equity capacity via fiscal and administrative readiness and ensuring equity via whole person in community care. They did this, by explicitly adopting the Phressia system to provide, social determinants of health or structural driver assessments to over, 409 families. this resulted in like, life saving care for over 1200 people and 227 referrals to care that would've otherwise gone, gone amiss. And this is explicitly during a time of crisis. they've also expanded their data collections. Sexual Orientation and Gender Identity, using over 21 categories of, of SOGI data. they implemented language services, for families to obtain psychotherapy services and mental health, including for children diagnosed with depression, anxiety explicitly throughout the pandemic. and the investment in Phressia during this time for many, and these other systems might for otherwise have seemed out of scope or out of the box. But in this instance, they felt that the strategic investment to close these gaps was going to be the best course of action for their population. And here's the look at the team further, including their mobile services, as well as an example of one of the culturally sensitive materials that they've developed. Boston Community Pediatrics. On the other hand, serves the population primarily of Black and Latinx children who are low income, single parent households. with over 60% identifying as food insecure, Boston Community Pediatrics is also unique in that they primarily opened during the time of the pandemic. So they, had a particular model that they were looking to serve and very quickly had to pivot in their practice and care, to almost exclusively respond to the pandemic. So, they completely shifted their model, to improve tracking and focus, heavily on social needs screening. with over 97% of their practice getting screened regularly at care. They also. integrated new, a new series of questions and shifted the way that they were going to adapt their EHR. If you go to the next slide, what we'll also see is their model explicitly integrated behavioral healthcare care navigation, right from the start. So the level of intense care management that they opened with in terms of their primary care model, including the story, I'll never forget of, making the point to even, vaccinate their, you know, their FedEx drivers and any of their other like delivery personnel that were coming to the clinic, as well as, parents at the time is a narrative. That's always stuck with me. The Los Angeles LGBT Center continued this theme, focusing again on whole person and whole community care, but also structuring again and prioritizing investment. So in the space of fiscal and administrative readiness, they serve over 16,000 patients annually. many of which are at diverse economic on MedCal or Medicare, many of which experiencing chronic disease, living with HIV. And in this instance, the Los Angeles, L G B T center continued their infrastructure project to really explicitly link to their electronic health record during this time. And really, pioneering and setting a trend for what proper data collection of L G B T data across, over 20 different, identities can look like, not just in terms of patient engagement and collection, but also what it looks like to agree that data and work, pulling it into the health information exchange. In the slide that follows, we have an example, two examples from them of the way in which they, engage their patients, both looking at the difference in terms of the data collection, leveraging their technology, to have distinct conversation about identity, attraction, expression, and sex assigned at birth are distinctly differently. And in the following slide, how they've explicitly, started pulling this into, the differential categories in their electronic health record. and again, this, this they've, they've presented this in another component and, this data has otherwise been shared. So it's the, the distinctness in the categories is really remarkable. It's certainly something that you would expect would not necessarily continue at a time of an emergency, but they, in terms of working with their population, they explicitly prioritize this AltaMed, of Los Angeles. On the other hand, focused on engaging partners to co-create a community wide response, cultivating and protecting and engaging their staff. AltaMed has one of the most diverse, and interdisciplinary outreach programs. I've ever had the pleasure of coming in contact with, and we'll talk about it a little bit here. Their method, for staff protection was explicitly to hire on, local community providers, to, to specifically connect with, cold strategy and related meetings for their staff, as well as look at the impact of how many of their staff were. local residents. And so their, their staffing model and attention to their staffing, is very much there. but they also, if you go to the next slide, had a multi-level outreach strategy that included, both street, vendor outreach, direct community outreach, social media, as well as partnering with diverse local businesses. And so they really, went above and beyond to engage all different levels of community, both through existing partnerships, as well as training, even local street vendors as ambassadors, East Hawaii IPA continued in this, the model of whole person in community care, serving, both on the Big Islands, maintaining screening for patients and the SDOH model. but really being one of the few providers in a extremely rural community, and maintaining their outreach, and their screening method across 20 languages is really, really the only provider, on the Big Island. The Grady Health System explicitly in this instance, identifies as, serving a over 74% Black/African American community, with a large population being food insecure, lacking access to transportation. In this instance, they also maintained SDOH screening, and referral processes across this time. And we're integral at creating, using their community navigator program to maintain community wide response. that didn't just address again, vaccination clinical care, but also explicitly food and security, transportation, and housing concerns, The Wellness and Equity Alliance of Texas. this organization explicitly focused in on crisis operations and decision making and whole person community care, their population, operated on the border, specifically with immigrant asylum and farming communities in South Laredo Texas. their population was over 30% lacking health insurance. again, this was a, new immigrant communities and asylum seekers. they explicitly focused on and worked in partnership with the, those in the ICE Detention Centers coming over. And engagement, contractual relationship with pieces connect, looking at not just ways that populations could, get vaccinated and connect to services, but what does it also look like for them to begin to integrate into the us health system? Southern Nevada Health District in Las Vegas, continued in, in the frame of crisis operations and decision making, engaging, partners in a co-create communitywide response. In this instance, implementing both a mobile health clinic, serving over two million patients again, providing not just vaccines and referrals and clinical care, but explicitly looking at social needs and risks of their patient population. they did partner with a preventive medicine residency program to support data analysis. And in this instance, the population, was with an extremely high percentage, rate of those undocumented. And so their staffing model, very much reflected the population they were trying to reach in terms of trust. And our final grantee will mention, in this instance, was Cook County Health of Chicago, primarily Mexican, certain, primarily at Mexican immigrants, populations, living with HIV, those, without a high school diploma being nearly 40%, and looking extensively, at a working class or poverty level population in this instance, they were one of the few organizations to look at crisis operations and decision making, but by implementing a long COVID, SAR-CoV, a long COVID acute, screening. the example here in, in terms of looking at long COVID is the example of the screener they've been using. they also strengthen their bilingual services for, for their staff, as well as for patients in care, but wanted to specifically share the example of the screening tool that they had used, because they're one of the few groups that had explicitly focused on, shifting to long COVID illness and making the point of integrating this into their electronic health record. And so for our last few minutes, we've given you a lot of different examples, of what it looks like in terms of the best practices emerging during this time period. For us, the ten most Emerging Practices of Advancing Crisis of Advancing Equity During a Crisis really come down to these ten factors. And these are the ones that we'd like you to keep in mind as you move forward and think about how to take some of what our practices have done, how your practice may already be doing some of this type of work, but where it could be strengthened and keep these lessons as mind as a leader, explicitly acknowledge equity barriers out loud, consider it first at every step in a crisis response. That's the intentionality component we were mentioning before, both in method in protocol and in practice. When making decisions always ask who benefits and who is burdened, the that, all decisions impact all the same, should never be used. Discuss and identify ways to prioritize equity over equality, compile a list of mutual aid resources and share with patients and staff reminding, those again that, you know, when your staffing model is closest to representing the community served, your patients and staff will sometimes be, homogenous groups develop and disseminate information and messaging with trusted community partners, really letting your partners lead and trusting your partners guidance and how to best engage elevate partner and community demands at the local state, tribal territorial federal levels and mobilize volunteers to safely weed the community's needs. The idea that it takes a village is explicit here, but not the idea that, we shouldn't also be listening to the expertise of the village. So, in your role and in your practice, even if you can't necessarily address everything yourselves, you can always have use your voice to bring things forward, prioritize personal equity, acknowledge and address the spike in discrimination that occurs every time a crisis arises, and use informed language and practices to acknowledge the, shift in discrimination, shift in racism, shift in, all forms of oppression of communities that inevitably occurs with every type of crisis. For our next poll question, we ask you to consider based on the last pandemic, which goals do you feel your organization should most prioritize to enhance current efforts around centering equity and emergency response, even if you're not in an emergency right now, as you prepare for future, which of these goals and lessons that we've talked about, might you be able to focus on more explicitly an improvement and largest impact.. Sarafina Cooper: Top responses, "integrate equity into crisis operations and decision making". Crystal Sacaridiz: Let's try another question. During the COVID-19 pandemic or other past emergencies, have you implemented any of the strategies recommended by our grant partners? And closing the poll. That's great to see that some of this is not new. Okay. For our last few minutes, I just wanna introduce a little preview of what you'll actually see as tools within the Centering Equity and Crisis Response Guide that, is being released. So here's a preview of a few of the tools you will see tools and examples, aim to challenge, assumptions, and bias. The guide itself will also include a series of organizational assessments. This leverages a Likert scale. but here talks about how you can, give practical strategies on how to integrate equity into emergency operations and decision making. So, building on social needs, but also looking at resources, looking at data disaggregation and looking at protocols and decision making. You'll also see examples, that focus explicitly on the health and safety of your staff. again, building on the, Gardner's Tale model, but looking at the importance of how to continue to build that rapport with your staff as they're, be going through a crisis along with you, and fighting against the examples of like when to share bad news and when not to, how to really build and maintain that transparency and maintaining a positive, and supportive communication hub with staff when you, when in your institution might feel most linked to, not focus on that at the time Clear examples of how to measure a whole person in community care, both in access, patient outcomes. And other, examples of, of impact. And finally, we leave you with this last aspect of, as you go through all of this work, you'll see this both in the guide, and it's really our ask to you if this is work that you're passionate about, continuing, we just ask that you, focus in on increasing advocacy and education in these areas. So, the way that this work all happens is again in terms from an advocacy lens, focusing on the needs of, safety net and minor institutions and minoritized ties communities, focusing on the expansion of telehealth and increased policies specifically, with attention to, multicultural able bodied accessibility, increasing support for community health worker models of care in all settings increasing and, advocacy and focus on SOGI data collection. As well as, collection of race and ethnicity data explicitly looking at review of regulatory restrictions for community based services and mobile based services, as well as the reimbursement rates that are appropriate for that type of care delivery. Formally looking for at Medicaid expansion across states, in areas where Medicaid in this instance is limited and increasing reimbursement rates, including, more systemization the coding system for screening and referral for social needs across all of these areas. So I thank you for your time today and being able to introduce this and hope that you all, do get a chance to pick up the guide and, learn more about these lessons in the future and how they might apply to your. Dr. Wilnise Jasmin: Hello, everyone just wanted to share, that diversity equity and inclusion are they're a core value embedded in ACPM's mission and strategic plan. It's grant funded initiatives has a deep commitment to and growing, footprint, of DEI and ensuring that the work that we do is centered in equity from a vaccination campaign aimed at activating preventive medicine physicians to addressing COVID-19 prevention to partnering, to prevent new infection among populations disproportionately affected by HIV the most, the most vulnerable to new infection. Here are some references in other project, examples of centering equity in crisis, preparedness and response in health systems. And as a reminder, please remember to complete and submit the post-evaluation form for continuing medical education credit. And you'll see the link in the chat in terms of the emergency, response guide, that is being released. we're we are anticipating it being released, next month. the, the guide itself will be circulated. both, through the, the American Medical Association website, we are also, engaging some of our partners and co-writers in the guide to help with dissemination, but first release of it, we're hoping, as early as next month to come out, which is, where this presentation will help to live. so this presentation itself will be also supplemental to introducing the guide. So the today's presentation will not just live, with ACPM, but this will be living on American medical associations, ed hub in that instance as well. So this presentation will also be used to promote release the guide through that method in that model, as well as, our co-writers in, in the guide. So institutions such as the birth equity coalition planned parenthood, as, as well as some other organizations, and the work of. Explicitly of like with the Pandemic Institute now, they will end up thus helping us in terms of support and dissemination as well as CDC. So more to come on the final release date, but, we will have everyone's information here and we'll be sure to, circulated as a follow up to this presentation. Sarafina Cooper: Thank you, Crystal, thank you for the Center for Equity at AMA, please remember the complete and submit the post evaluation that I'm dropping in the chat to receive CME credit you'll completion certificate as well. Dr. Wilnise Jasmin: Just wanted to say too, that, Crystal in your talk, you talked about, providing examples of cultural sensitive, materials, that the organizations that were funded through this cooperative agreement, they were able to develop some of these materials. So I think one of the key takeaways for, a project like this is, knowing, and amplifying the successes that occurred, and then allowing, a blueprint for other organizations to recreate that same success rather than having them create, recreate the wheel. Crystal Sacaridiz: Yeah, I think that's explicitly true. And I, I think one of the, one of the things to highlight for the, the grantees in this project, acknowledging that they've been doing this work for, for a long time. So this project is just one aspect of work that they've been doing for years and will continue to do with the niche populations that they work with is, The availability of culturally appropriate resources at the level needed often is incredibly insufficient, for, for diverse populations. whether that's just from a linguistic standpoint, whether that's from the imagery used the universal iconography and the language, a lot of materials that groups try to get access to even down to screening tools, availability, like the example that comes to mind most often is like the prepare tool now being probably the most widely translated tool, but translations often not enough, right? It's, you know, like there's literacy level, there's imagery, there's, the situational sensitivity to whether it's a more urban or more rural region of application of the examples. those things often get overlooked and they often, and are often get underfunded. And the tendency tends to be for institutions to just translate and think that that's enough. And I think that for the groups that we're working with and for others, in terms of anyone else on their own advocacy, explicitly making that, you know, continuing to make that point and making that point with communities, is the only way to change some of that in terms of infrastructure availability. And as you mentioned before, like I'm happy to stay on for questions. If, if there's others, you know. Dr. Wilnise Jasmin: Yeah, very early on in your presentation. there was someone who referenced, there was a, a graph you were showing that showed the different states. but Puerto Rico was not listed there. So, it was slide 12. so just in general, what are your thoughts about, more intention in including us territories when sharing data? Crystal Sacaridiz: Ah, so actually that, that slide is interesting so that's most a slide that we've created and I'll make a point of looking at that. that slide comes from a Commonwealth Fund study of the US States. and I'd have to look back at explicitly. Why, in terms of the inclusion of the territories, the Commonwealth Fund, may have not, performed that, or either grouped the data in that particular study that we were referencing. So, in that instance, on a personal level, I, you know, I would absolutely advocate for like the inclusion of that data. but in that particular slide, the profound, or we're talking about profound racial inequities, we're referencing specifically a Commonwealth, the study that the Commonwealth Fund had done in 20, in 2021 and a reference I'd have to reference exactly why their, in terms of the way their state health systems performance scorecard looked at data in, in terms of why that was either explicitly left out, or not grouped, but that's a great catch. Dr. Wilnise Jasmin: There's one person, raising their hand, Claudia. I don't think she can. Yeah. I don't think we can unmute you. Are you able to type in your, question in the chat? Oh, I think you can unmute yourself right now. If you give it a try and Crystal Sacaridiz: I'm just gonna drop in the chat. This is the link to the reference for the Commonwealth Fund study so that anyone can reference more about it. This is explicitly in response to the, the study that that particular slide pertain to, that may, may have chosen for certain reasons to admit Puerto Rico. Dr. Wilnise Jasmin: No worries, Claudia It's fine. We just wanted to make sure everyone's question addressed. So, is there any additional feedback you have from the participants, in the project in terms of, what are some of their next steps now that they have these, initiatives, further enhanced in terms of sharing with other organizations, their work or the impact, that it's making in the populations that they serve and where they're located? Crystal Sacaridiz: I think that our role in this is to continue to use, presentations, such as this use the emergency response guide itself. use the, you know, the report from the grant opportunity itself to continue to elevate and advocate for their work and their efforts. I don't think that this is. work that they will stop doing. I don't think that this is work that is just momentary or, or explicit to just this grant or just this project. You know, I think one of the things we've always found unique about this work is how much it is really about quality care for minoritized populations, you know, at the highest level that it should be. And how do we create more access to that? How do we create more demand for it? How do we validate, what they say all the time? And that was, you know, really just packaged and focused around the most recent health crisis. but knowing that it's. It's not specific to just a time of crisis and it's not specific to, you know, something that is just momentary. It is cyclical and it is what we would expect to see if we're not addressing the population needs or the infrastructure challenges or, elevating the disproportionate inequities that populations experience all the time. so I think for us, it's using those lanes to advocate for that as the point, as opposed to looking for short term supplemental funding on "Program X", which is often the approach. One question I see here, can you share some of the challenges that the sites experience and how they overcame or plan to overcome, their barriers? so in referencing one of the last slides of, from an advocacy perspective of why, where we're coming from in, in terms of that summary, I think those explicitly come from the challenges that partners experience from a regulatory perspective, from a funding perspective, and from a staffing capacity perspective. So as I mentioned earlier, most of these institutions operate as safety nets and new service, social safety nets. they also tend to work in, Some of the best form of quality community health worker models, out there, and really prioritize that in their care management strategy, hiring from the community, looking at stopping, regardless of maybe level, regardless of maybe full time capacity, but really being as representative of community, both culturally linguistically and otherwise all the ways you could identify, that we've seen within their, unique models. And they were also, many of them were operating. I used the term outside the clinic walls, you know, like in a, in a community based setting in a mobile based setting, both in rural and urban environments and environments, in some instances that were very isolated. so they really went above and beyond to, using the resources they could to meet people where they're at literally and figuratively. however, from an advocacy standpoint, from a funding standpoint, from a sustainability standpoint, healthcare's not caught up with that and, from an insurance reimbursement perspective and so from that perspective, the pervasive challenge of how to go about it is consistently hard and consistently seen impacts their staffing capacity, the sustainability of being able to provide those quality services, and the ability to make that consistently the standard of care they're able to offer all the time, because they're constantly in a place of having to supplement their staffing model or supplement their operations and infrastructure model. Not because of lack of need or because of lack of, ability to provide service, but more the, the, the consistent insurance reimbursed capacity to provide their service at an appropriate staffing level and reimbursement level. And many of them express this universally across the board, regardless of what state they were in. so it, you know, going above Medicare and Medicaid, being the only avenue, it's certainly a private insurance issue. It's certainly a, an ICD coding issue. but it really, in a lot of ways, it's fixable in a lot of ways. It hasn't, it's been framed more as a business case model in a lot of instances in healthcare, but really it's a, it's a quality care issue, for diverse populations. And it's not always framed that. Yeah. So there a lot of them, they recognized organizations that they had to meet, their clients and patients where there were, and that met, caring outside of the walls of the clinic. so I guess that could be while they're doing the work, by providing quality care, that also is why, organizations like ours exist too, to be that advocacy arm and to show that results a positive results can, can occur when care is, provided in a way that's not the norm or considered the norm right now. I think, I think that part's very true and, and I think correcting the narrative around level of need. I think that, I think this is something we've talked about and I know, is. I think is, is probably the most often like narrative I hear in healthcare when it comes down to like justifying the ROI or justifying the business case, there seems to still be this pervasive message that care at that level or care at that, at that either risk level stratification level, intensity level of, for minoritized populations, because of all of the other things that they're often, not being given from a systemic driver's perspective, is still seen as, is not seen as being at the proportional rate and demand as needed. So it's still seen as just high risk, high need, high utilizer, all terms. I , you know, that, that you'll hear used, but that are, not ones that I want in my vernacular. It's, it's a disproportionate narrative to just addressing. Systemic needs and structural drivers of populations that have been minoritized that have been oppressed. And that consistently, using the reference from the like can help service before the access isn't there, the infrastructure's not there, the funding hasn't been there before. So the idea that, that, that type of economic system and that type of structure like is just needed for fewer it's false, you know, and it's always been false and as it's good that you mentioned fewer, it's probably appears fewer because people who need help have don't have things like paid time off to come and receive the care they need. So, yeah, I like that you highlighted that the access to care issue, you know, is. I, I always like to say like any of the statistics around access to care only ever include the population that has ever been desperate enough to get care at the time when most needed. And it's most often seen in ER utilization, right? Like because of the economic barrier, that's, that's not, you know, an appropriate measure of need, you know, but it's often the only metric they have. And we have a comment in the chat. "I feel a real tension around increasing engagement of communities, most effective and pushes to move faster and faster and new CDC language". I've always understood that when we bring more people to make decisions, it takes longer, but we can go further. And another, comment is an issue I see is that often even if community marginalization is reflected in organization employees, it is very seldom reflected in leadership. This causes and contributes to inequalities, marginalized people already face. So how do people in these positions, the leaderships and or, or employees best champion equity in these So I'll take, the, the statement first and then we'll come back to the second one. So I think that, and, so I, I identify very much as an infrastructure and operations walk, you know, like I'm very much a method person. And, and I spend a lot of my time in this and at AMA center for health equity now looking at methods and how in practice and infrastructure, So the, the comment on the tension of like, how do you increase engagement without slowing down process? Or how do, how do you, you know, act, work in a participatory way without, adding to the administrative burden of time when there is urgency is one, I understand a lot. And I will say that, in initial change management, there is always, while you're figuring out the better process or the newer process, there is always a bit of a shift because something's new, but I find along the way, you also end up the more participatory you are in terms of, and from a community engagement perspective, in terms of really understanding the aspects and the nuances you would otherwise miss, just because you know, like who can know. Who could ever know a community better than the community themselves. Right. You know, it's like, and so, like, let's say if you're an institutions, such as CDC, where you are responding to the diverse needs of the whole country and the diversity of, you know, that many different communities, I'm a New York City resident. And so like as an example, the hospital standard for New York City used to be, to work in state required mandate was 13 languages but really there was over 400 spoken on a daily basis in the city. and that's not even getting to religion culture or all of the other aspects of a ways like someone identifies. So the, the challenge of how to do that for populations in the most participatory way is certainly vast and broad, but in accounting for that in process, and in building that into process, you end up having to correct less later if it's part of your process to start. And it's part of your. Focus and design to know that, you know, maybe here's the key message, but there's no way like any one person could get that delivery. Right. For everyone who needs to hear it or receive it. and I mean that in a, you know, like, not just hear and see like in a non-abled body way, like as well, you would realize that the most effective method is through that participatory framing, in terms of urgency, because the you'd spend less time having to guess who else to engage, to translate, to visualize, to figure out the right channels. It's, it only seems longer when you don't have the infrastructure in place to start. And the after effect of building the right infrastructure to do it in a more consistent way results in, more efficiency and a better method of doing so after. So it does, once you get there, it ends up not just more efficient, but more culturally appropriate and faster. Dr. Wilnise Jasmin: Yeah. All that makes sense. and when you brought up, the idea of not having to guess at the beginning, it also avoids having to implement something based off of stereotypes, what you think, the person or group of people, how they best interpret it. So, yeah. So thank you so much for joining us today. And, let me just check to see if there's any other questions., I think there was one other question from Tamara. Oh, yes. So the leadership and employees may not have, marginalized communities reflected in leadership. And if there is a disparity between, or difference between employees and leadership, how do, what impacts can, those in leadership and employees best champion equity when situations like that exist? Crystal Sacaridiz: So certainly globally and certainly across the country, the, I think this, this most oftern comes up in statistics as, representation in like c-suite or senior leadership positions, but it's in a lot of different areas, right. You know, for, across diverse population. So. That. And it happens for a lot of reasons, you know, it it's happened because of, opportunity, racism, discrimination, all of the different forms of oppression that maybe made somebody's pathway to getting into that leadership role in the first place, much more challenging than someone else. Right. and that is certainly the case in the us that is certainly the case. you know, a lot of that is changing, but, is it really changing at a, you know, at a mass rate that we would maybe all like to see? No. You know, like at least not proportionally. I think that, that doesn't mean that, I, I think that while that gap certainly exists, I think that there's a lot of work leaders can do in terms of the way that they set up their institutions, the way that they look at their own bias. The way that they, consciously resist the urge to resort, to hierarchy and structure being like a default for decisions, as opposed to looking at their staff and structuring the way that they make decisions. similar to like the community engagement model that we were talking about in the last question, there's a lot as a leader that you can do in an institution where you are restructuring, how you are influenced, who is acting as a subject matter expert on particular subjects, and how you are making decisions. You know, so there's a, there's a big difference between being like the executive sponsor on a project or initiative and, being someone who is a advisor, but is really taking in the collective wisdom of. Multiple levels of staff and making sure that that transparency is part of your decision making process. So it's certainly not impossible. I think the other factor that shouldn't be ignored in there is when you are a leader at that level, you have a lot of influence over staff training and promotional opportunities and making sure people have career pathways, such that this is getting addressed. you have the opportunity to, engage employee resource groups explicitly in, different areas of influence. So it just because it's, built into traditional structures doesn't mean it's impossible. And I would like to see like more leadership in that method. I think that's where a lot of, equity reform and like, organizational change methods really do lead to that. Dr. Wilnise Jasmin: Thank you. I feel like we got our two for one deal today during our talk. so I'd like to hand it back over, to ACPM. Are there any additional announcements you wanna make before we officially wrap up? No, there's a reminder to, complete the survey and, this will be, made available, on ACPM's website and also a AMA's website as well. And with that, I'd like to thank those who are able to stay with us, for those who weren't, you could watch their replay when they're available. And I see there's a reminder to complete the survey and submit the post evaluation for CME credit.

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