FedHealth Conference Thought Leadership Compendium by Professional Services Council

Thought Leadership Compendium FEATURING ARTICLES BY:

Table of Contents

RAPIDE - A Professional Governance Framework for Data Science

Supporting Zero Trust Goals Without Redeveloping Your Cybersecurity Framework

Our Interconnected Health Infrastructure

Healthcare Evolution: Recent Trends Affirm the Ongoing Journey to Comprehensive Health

Executive Briefing Series: Health Care Innovation

Maximus Public Health Data Analytics

Spider Webs United Can Tie Up a Lion: A Syndemic Perspective on Advancing Mental Health Equity Amid the COVID-19 Pandemic

RAPIDE - A Professional Governance Framework For Data Science Why your data science projects aren’t working and what you can do about it

Why professional data science needs a dedicated framework Effective engineering frameworks were being built long before data science and software became formal disciplines. In common, they reflected experience and a deep understanding of the complex challenges they were designed to overcome and had the awareness to incorporate insight into human as well as technical factors.

The focus of data science is the controlled exploration and discovery of new information and relationships, meaningful insights and rigorous testing of hypotheses. All delivered with the speed, clarity and consistency needed for business to act decisively and with confidence within what may be a limited window of competitive advantage.

Data science is unique as a discipline but no exception to these principles. Building best practice for data science must reflect a mastery across a broad range of advanced mathematical, statistical and modelling techniques as well as a deep understanding of the nature of people and their relationship to data itself.

Agile software development methods suit high cadence and exploration, but lack any of the essential specifics that cover the design of training regimes, the identification and preparation of training data, bias identification and resolution and post deployment retraining using operational data.

Understandably, to date, most best practices applied to data science projects have been adapted from software engineering, including agile frameworks. A good foundation, but not enough. The discipline of software engineering is the controlled assembly of code into robust solutions; the conversion of clearlydefined requirements into software functionality.

How to build a professional data science framework Understanding that we need to do things differently, the next step is to understand the key principles and characteristics that a data science framework must possess. It makes sense to us to start from an understanding of which software engineering principles require extending, and then clarify those additional dimensions needed in a data science framework. Keep a clear sight on what you aim to achieve as there are several tensions that must be balanced. For example, data science calls for the controlled exploration of data within the context of its relation to a real-world problem. A framework can however quickly become overly prescriptive to the point of constraining the team, suppressing their natural talent, instinct, and sense of personal ownership of the solution. The result is a team working for the framework and not the framework working for the team. With the best will in the world, any attempt to narrowly encode good intentions into a fixed process immediately limits and reduces its effectiveness. We always prefer guidance to prescription, trusting in the intelligence and creativity of the individual to use the resources to direct them to the best solution and to seek further assistance when needed. Not least, the framework must be relevant and accessible to a range of abilities and experience, and have the flexibility to be future proofed, without which any best practice rapidly becomes obsolescent.

RAPIDE - Our professional data science framework RAPIDE is a data science governance framework RAPIDE is ... developed internally by Hybrid Intelligence. Distilled 1. Pragmatic guidance on how to make the right from decades spent designing and building data choices during the design, implementation and analytics, advanced statistical modelling, AI and industrialization of data science and datamachine learning solutions for a wide cross-section of driven solutions. high-tech industries. 2. Clear, transparent and accessible yet requiring RAPIDE has been crafted to enable a broad spectrum individual skill, judgement and experience to of data scientists to consistently identify and apply implement correctly. the best tools and approaches to meet each specific 3. Designed around the use of quality-checks at challenge. With only a single choice of data science each step to ensure: hammer to wield, no fancy technology makes you immune to the human tendency of wanting to turn a. Complex challenges are naturally broken what are in reality very different data challenges into down into manageable phases. the same type of nail. RAPIDE is the controlled way b. Poorly defined and underperforming to never get into that situation. workstreams are stopped. RAPIDE, though transparent, complete and c. The correct data science approaches are accessible, is fundamentally dependent upon taken at the right time and in the right individual practitioner skill, judgement and order. experience to implement correctly. As previously explained, it is explicitly not a predetermined, 4. Fully compatible and integrated with modern directed tool for planning and executing individual software development frameworks, including project tasks or a decision tree-based approach to be agile and traditional waterfall approaches. followed during development phases. Instead, RAPIDE directs the data scientist’s skill and understanding to inform the crucial choices that need to be made whilst negotiating all phases of data science solution engineering.

iv. Identify Candidate Algorithms

Hybrid Intelligence’s RAPIDE framework guides organisations through data science projects from data selection to model development to productionisation, with checks at key stages to ensure projects only progress when they are ready to do so. These steps are:

Based on outputs of the previous analysis, identify candidate modelling techniques (which could be empirical, physical, stochastic, hybrid). Shortlist most promising candidate algorithms and quickly assess feasibility of each.

v. Develop Powerful Models

i. Readiness Assessment

Decide on the most suitable model for the problem. Check implementation requirements such as user interface, required processing speed, architecture, etc. to ensure it will be a usable solution before you commit. Gather validation data. Build it.

Assess what data you need and what is available. Understand the type of analytics problem: Is it classification/regression, supervised/unsupervised, predictive, root-cause analysis, statistical, physicsbased? Understand how “dynamic” the problem is i.e. will the nature of the incoming data change over time, necessitating periodic retraining. A Proof of Value exercise will help guide this first stage and confirm the project is worth taking forward.

vi. Evolve and Embed Embed the solution into the relevant business unit and refine using data gained from in-service use.

ii-iii. Advanced Data Screening and Pinpointing Variables

If these steps are carried out correctly, no model should fail after deployment.

Explore the data using a range of simple techniques to spot meaningful correlations between events of interest. For example, do product characteristics such as tensile strength correlate with a change in the extrusion process. Identify constraints in the data that might limit model choice; such as overly broad data that might obscure variables that dictate behaviour. Early insights help direct your model to be most effective.

Supporting Zero Trust Goals Without redeveloping your cybersecurity framework By Daniel Carroll

A key element of Zero Trust principles is the verification of assets within the enterprise prior to providing access, and continued verification prior to execution of processes or lateral movement within the network.

Stephen Paul Marsh, Formalising Trust as a Computational Concept, University of Stirling, April 1994.

Scott Rose et al., Zero Trust Architecture, NIST, August 2020.

The White House, Executive Order on Improving the Nation’s Cybersecurity, May 2021.

An increase in ransomware, security vulnerability exploitations, and supply chain attacks has generated renewed interest in Zero Trust principles for cybersecurity. There have been a number of U.S. federal and DoD directives on the topic and a recent reference architecture by the National Institute of Standards and Technology (NIST). This has helped organizations reassess their current approach to and application of Zero Trust principles. These organizations face the challenge of how to understand where they are in their journey and whether their current cybersecurity framework will help them achieve the best outcomes.

Old is new again. The principles defined by Zero Trust are not new. Zero Trust is built on the definition of “never trust, always verify.” This is based on the idea that all identities within an architecture should be validated prior to allowing them to execute a function or access a resource (object). The concept dates back to 1994, when Stephen Paul Marsh introduced it in his doctoral thesis.1 Over the years these principles have been adopted into security control guidance and architectures defined by various cybersecurity industry leaders like NIST. What is Zero Trust? NIST defines Zero Trust in their Special Publication 800-207 (SP 800-207) as an approach primarily focused on data and service protection, but one that can and should be expanded to include all enterprise assets.2 It is not a single architecture but a set of 8

guiding principles for workflow, system design, and operations. A key element of Zero Trust principles is the verification of assets within the enterprise prior to providing access, and continued verification prior to execution of processes or lateral movement within the network. A variety of publications and media outlets have discussed Zero Trust, but how do you separate the noise from sound guidance? The truth is, if your organization already has strong cybersecurity practices and a defined roadmap, you don’t need to start over. New government guidance and directives can be used to assess the models already in place and the room for improvement. The Dell Technologies goal is to help U.S. federal customers meet their missions. Cybersecurity attacks have gotten bolder and more brash, and the President’s Executive Order on Improving the Nation’s Cybersecurity aims to tackle that challenge directly.3 How Dell Technologies looks at the Zero Trust model: • All data sources and computing services are considered resources. • All communication is secured regardless of network location. • Access to individual enterprise resource is granted on a per-session basis. • Access to resources is determined by dynamic policy. • The enterprise monitors and measures the integrity and security posture of all owned and associated assets.

• All resource authentication and authorization are dynamic and strictly enforced before access is permitted. • The enterprise collects as much information as possible related to the current state of assets and uses it to improve its security posture. Dell Technologies has developed a derivative model called the Seven Pillars of Cybersecurity. The goal of the Seven Pillars model is to make it easier for cybersecurity leaders to assess their current framework, and to explain how Zero Trust principles enhance the security model. The Seven Pillars are set up to allow for the visualization of distinct assets and communication flows:

Discover how Dell Technologies can secure your infrastructure and advance your federal initiatives. Contact us at DellFederalSales@ federal.dell.com or 855-860-9606.

1. Device Trust is defined as any physical device within the enterprise. Examples would include user devices (such as smartphones, tablets, and laptops), data center devices (such as servers, storage, and network switches), and IoT devices (such as sensors, cameras, and kiosks). 2. User Trust is defined as end user, administrator, and service level accounts. 3. Transport/Session Trust is defined as the communication path used to move into, across, and out of an enterprise network. 4. Application Trust is defined as local and cloud applications that enter, work within, or leave the network for data access. 5. Data Trust is defined by the organization as key assets used to execute the function and mission of the organization that can be held within the enterprise and extended into cloud services. 6. Visibility Analytics are defined by the resources from the previous five pillars that should be enabled, to the fullest extent, to allow for analysis of the secure state and function of the pillar definition. 7. Automation and Orchestration are defined through the use of the visibility and analytics output to perform policy enforcement, baseline configuration definitions, automated remediation, and conditional access models.

Why seven pillars? By organizing the NIST SP 800-207 model into a Seven Pillars model, Dell Technologies helps make the concept more accessible to organizations—from tech to legal. The Seven Pillars can be viewed as a communication flow from left to right: A device is accessed by a user to cross a communications path to access an application to obtain data. Logging and alerts should be configured to feed visibility analytics, to help improve automation and drive orchestration of policy enforcement.

Data governance The most critical aspect of a Zero Trust principle–driven cybersecurity architecture is data governance. Who owns the data, how sensitive and critical is the data, and who should have access? These are key questions not often well defined in many enterprises. This is due to the evolution of enterprise infrastructures over the decades and the massive amount of data being generated in modern infrastructures because of the advent of cloud and edge/IoT solutions that makes it hard to define an owner.

An effective path to success The key to effective improvement within a well-established cybersecurity framework and defined roadmaps is to ensure there are clear targets for improvement that assess the components and how they build out into the whole. As an example, there are usually departments, or split duties within an enterprise, focused on delivering IT services that support a particular outcome or mission. One team may be charged with managing the application infrastructure, separate from compute and storage management, separate from end-user management. These management teams need to work together to improve the total organizational cybersecurity framework adoption of Zero Trust principles.

About the author: Dan Carroll Dan Carroll leads the cybersecurity practice development for the Office of the CTO, Dell Technologies, Federal. He focuses on designing and implementing cybersecurity frameworks to help federal customers meet their diverse cybersecurity missions. Dan served in the U.S. Marine Corps Base Quantico. Copyright © 2022 Dell Inc. or its subsidiaries. All Rights Reserved. Dell, EMC, and other trademarks are trademarks of Dell, Inc. or its subsidiaries. Other trademarks may be the property of their respective owners. Published in the USA 02/22

Health

Our interconnected health infrastructure The fragility of our global public health infrastructure and healthcare delivery systems has been on full display over the course of the last two years as a result of the COVID-19 pandemic. Healthcare organizations at the international, federal, state, and local level must quickly identify emerging diseases, unlock insights and discoveries hidden in terabytes of health data to diagnose and treat illnesses, and reach vulnerable populations to share information and motivate healthy behaviors. Furthermore, improving health outcomes is highly dependent upon an interconnected array of social, economic, political, and community factors. Public health officials, health research scientists, and healthcare professionals need a comprehensive suite of solutions to address a wide variety of healthcare challenges now more than ever. Public sector health agencies can achieve better health outcomes by partnering with industry to address these complex and interconnected health issues and ensuring vulnerable audiences are at the forefront of solutions. With more than 1,500 healthcare, health science, bioinformatics, and technology professionals, ICF has invested significant time and resources over the last 40 years into the development of solutions that can advance better health outcomes: y y y y

Health IT & data management Health surveillance Bioinformatics Clearinghouses & resource centers

y Scientific & regulatory support y Health communications y Epidemiology & field health studies

y Social determinants of health y International health y Climate health

Healthcare solutions working together to advance better health outcomes

Our interconnected health infrastructure

Health IT and data management solutions Today, researchers can easily manage healthcare data with the advent of large data pipelines, data lakes, automation tools and technologies such as machine learning and artificial intelligence, predictive analytics, and cloud computing. With those tools, researchers can aggregate datasets and leverage graphics processing units (GPUs) to run models and experiments across studies, research disciplines, and datatypes. Also, data sharing is now possible through adherence to data science standards like Fast Healthcare Interoperability Resources (FHIR) and the National Institutes of Health (NIH)’s FAIR Principles. Health IT and Big Data solutions have led to the discovery of more effective diagnostic methods and treatment guidelines, personalized medicine, better clinical quality, and patient care. The evolution of data harmonization and data standards development also enables public health disease surveillance through the exchange of data from clinical records obtained from provider networks, hospital systems, and state and local health departments. Additionally, adoption of FHIR and electronic clinical quality measures (eCQMs) will facilitate improved quality of care and produce accurate and reliable measurement across provider/hospital organizations and EHR platforms.

Health surveillance Policymakers and researchers can make timely, datainformed decisions regarding disease outbreaks and patient care with the aid of real-time data ingestion, high quality standardized data, and data visualization. In an increasingly interconnected world, understanding how disease spreads, how addiction crises occur, and how hazardous conditions affect populations in real time is crucial for protecting public health. Cloud-based platforms such as AWS, Google, and Azure support the real-time ingestion of data from multiple concurrent data pipelines. Public health surveillance heavily relies on public health information systems to ensure standardization, integration, and timely detection of threats. Delays in data reporting could constitute a serious threat to global public health security. Modern surveillance systems like BioSense provide near real-time syndromic

data collection/exchange. This highly adaptable system continues to play a key role in the COVID-19 pandemic, from finding hotspots of infections based on chief complaints and discharge diagnostics to vaccine and treatment data—and even trends about the indirect effect of COVID-19 on mental health.

Bioinformatics Bioinformatics plays a significant part in leveraging technologies, tools, and processes to advance the health research agenda. At its core, the bioinformatics field brings the disciplines of science and IT together to make sense of biological data. With the advent of gene sequencing, and the sheer volume of genetic data, the importance of bioinformatics has elevated. The volume of genetic data collected, stored, and analyzed to extract meaningful findings presents an ongoing challenge. Researchers and scientists can devise new ways of personalizing treatment for patients using precision medicine through the application of large-scale proteogenomic analysis. Use of bioinformatics technologies has allowed National Cancer Institute’s Clinical Proteomic Tumor Analysis Consortium (CPTAC) to develop the largest proteomic data warehouse in the world comprised of 29 terabytes of data. Researchers around the world now have access to ovarian, breast, colon, lung, pediatric, and adult brain cancer data that advance our scientific understanding of the molecular basis of cancer. Personalized medicine can have a major impact on overall health outcomes, as patients won’t have to go through unnecessary treatments because treatments will be more targeted to their specific disease.

Clearinghouses and resource centers Through clearinghouses and resource centers, agencies can provide around-the-clock access to health information and health data to help build public awareness, influence behavior change, and improve program performance. A key component of effective clearinghouse and resource center operations is the use of sophisticated repositories and dissemination technologies that deliver information and resources in relevant formats on demand.

Our interconnected health infrastructure

Epidemiology and field health studies Improving health requires that we understand the internal and external causes of disease and the prevention and treatment measures that work. This understanding is informed through high quality epidemiology research conducted by multidisciplinary teams that implement study design, collect primary data, combine data from multiple sources, and manage massive amounts of disparate data in ways that facilitate analysis. Given the huge costs associated with primary data collection, it is critical to creatively use data previously collected, including in participants’ electronic health records. Combining primary data with EHR data is facilitated by a team that includes HL7/FHIR experts who can work alongside epidemiologists and cancer researchers.

Scientific and regulatory support Federal health organizations that have regulatory responsibilities must support the entire lifecycle of the process—from reviewing new legislation, evaluating regulatory issues and options, estimating economic and environmental impacts, analyzing public comments, and developing proposed and final rulemaking. The entire process relies upon a multitude of scientific data, analysis of quantitative and qualitative factors, expertise from multiple domains, and may take years before final rules or regulations are implemented. To protect public health, scientists and policymakers need specialized analysis to understand the effects of exposure to hazardous substances and pathogens or the risk profiles of drugs or therapeutics. Quality data and timely decisions are essential when human health and public health impacts are at stake. To aid in regulatory review and critical decisions regarding consumer, product, and drug safety, the use of “real-world evidence,” or RWE (including evidence

generated from observational studies) can serve to confirm effectiveness when confirmatory studies are not otherwise feasible.

Social determinants of health Public health professionals have long known that conditions associated with where individuals live, learn, work, and play contribute to both health inequities and overall health and well-being. The COVID-19 global pandemic shone a light on these inequities in a profound way. To develop effective public health interventions, tailored strategies addressing the social determinants of health must be developed by professionals with expertise in health equity and lived experience. Without these insights, communities with poor social determinants may not receive the engagement, support, and resources they need to improve health and reduce health disparities.

Health communications Misinformation. Disinformation. Ever-evolving social media. 24-hour news cycles. Mobile-first digital strategies. Digital divides. Equity gaps. The world of marketing and communications today presents some of the greatest challenges of our time—but also some of the most promising opportunities. When audiences are bombarded by a constant torrent of media and advertising, some intentionally misleading, it can be difficult for government agencies to find openings for their messages about information, services, and help, to break through. Effectively navigating the current media landscape requires a holistic approach to reach and move general and specific audiences through both national and micro-focused campaigns. Integrated capabilities and expertise are needed in marketing and communications; strategic planning and campaign implementation; creative development and social

Our interconnected health infrastructure

media deployment; audience engagement and behavioral change theory; citizen-facing digital and user experience; process analytics and outcome evaluation. A full-service communications agency with IT and research capabilities can help government partners break through the media clutter and deliver on their mission to improve the lives of all constituents.

Climate health While health risks are influenced by genetic factors, environmental exposure to toxins, and individual behavior, public health is also affected by climate change. In 2021, The World Health Organization stated that climate change is the single biggest threat facing humanity. Extreme weather events, heat stress, wildfires, poor air and water quality, food-borne diseases, and zoonotic and vector-borne diseases are all a result of the direct and indirect impact of the world’s built environment. It is estimated that climate change will cause approximately 250,000 additional deaths per year between 2030 and 2050 from malnutrition, malaria, diarrhea, and heat stress alone. The direct damage costs to health are estimated to be between US $2–4 billion per year by 2030.

International health Globally COVID-19 has highlighted significant gaps in countries’ abilities to accurately diagnose disease at the community and facility level; aggregate, analyze, and act on available data; and ensure the population can access prevention and treatment services, including vaccines and medicines. While the challenges are similar to those in the U.S., the burden of disease is different, and health systems may be more fragile and available resources more limited.

To reduce the risks of climate change, pollution, migration, and human behavior on public and environmental health, we must also recognize the multi-sector interconnection between people, animals, and our shared environment and adopt the principles of One Health. The One Health approach takes into account the potential spread of animal-borne diseases or possible spillover effects from wild animals, domestic animals, and livestock and their environments. One Health relies upon the collaboration of professionals across different sectors—including public health, agriculture, environment, and wildlife management—at the local, regional, national, and global levels to achieve optimal health outcomes.

To systematically address these challenges across countries, we can support and build the capacity of country governments and health systems to increase their compliance with WHO’s International Health Regulations and the Global Health Security Agenda. These global frameworks set standards for prevention, detection, and response to public health threats. Investing in countries’ institutions and health workforce will better enable them to identify future outbreaks with pandemic potential and contain them at the source. It can also improve the health of populations worldwide.

ICF experts—Dedicated to better health outcomes Social determinants of health

Health IT & data management

Bioinformatics

Colleen Murray – Director, Research Science

Karen Holloway – SVP, Chief Innovation & Strategy Officer

Anand Basu – SVP, Bioinformatics & High-Performance Computing

Vickie Gogo – Sr. Partner, Multicultural Communications

Michael Holck – VP, Health IT & Software Engineering

Karen Ketchum – VP, Bioinformatics & Data Analytics

Nicola Dawkins-Lyn – Sr. Partner, Health Communications

Bradley Epley – Sr. Managing Director, Public Health Informatics

Cecilia Kretz – Director, Bioinformatics & Surveillance

Our interconnected health infrastructure

Health surveillance

Scientific & regulatory support

Brooke Rivera – Director, Surveillance

Will Baird – VP, Regulatory Policy

Lisa Nichols – Project Director, Infectious Disease Detection & Surveillance Chuck Akin – VP, Health Technology

Clearinghouses & resource centers Kim McCarley – VP, Health & Human Services Tonja Kyle – VP, Survey Research & Data Coordinating Centers Maya Payne – Director, Training & Technical Assistance

Jordan Parsons – VP, Health Leader Jess Wignall – Director, Health Sciences

Health communications Mary Schwarz – Managing Partner, Digital Health & Communications Jennifer Folsom – Senior Partner, Digital Health & Communications Stephen Luce – Partner, Strategic Communications & Marketing

Epidemiology & field health studies Christie Barker-Cummings, Director, Epidemiology

Matt Curry – Director, Health Research

International health Susan Scribner – VP, USAID Account Leader Annah Ngaruro – Director, International Health Technology Solutions Rob Salerno – Director, Global Health Security

Climate health Jason Jones – Director, Economics Anna Belova – Director, Data Science Mike Greenwell – VP, Health Science & Policy

Kate Sauls – Lead Epidemiologist

For more information, contact:

Karen Holloway

Audrey DeLucia

Senior Vice President

Vice President

Karen.Holloway@icf.com

Audrey.Delucia@icf.com

ICF is a global consulting services company, but we are not your typical consultants. We help clients navigate change and better prepare for the future. We’ve played a central role in advancing public health around the world for nearly 50 years. As close collaborators and seasoned experts, we bring both leading-edge skills and a powerful drive to improve public health outcomes for all populations. We provide advisory services and project implementation to government agencies and top science organizations. From conducting surveys and managing sensitive data to motivating behavior change and assessing program performance, we combine our domain expertise with cutting edge technology solutions to maximize the impact of our clients’ programs.

Visit icf.com/work to learn more.

Healthcare evolution: Recent trends affirm the ongoing journey to comprehensive health

1 / jpmorgan.com

J.P. Morgan’s 2021 Twelfth Annual InstaMed Trends in Healthcare Payments Report outlines a tangible shift in how consumers, providers and payers view the healthcare ecosystem. It is evident in the findings of the report that the pandemic accelerated an already occurring move towards digital experiences and it continues to have a profound impact on the relationship among payers, providers and patients.

of consumers say the internet has been essential1

In this summary, we have highlighted a few important trends which reinforce the value of transparency to stakeholders, opportunities to use digitization and technological advances to create efficiencies and the continuing challenge of lack of financial inclusivity.

standard focus on acute and chronic medical care. University and state school systems, and other institutions that seek government-regulated healthcare, are contemplating methods for saving money, while delivering a high level of care. This is critical as many communities lack high-quality, comprehensive behavioral and mental health resources.

“Ongoing interactions between public and private enterprises will fundamentally reengineer and modernize the healthcare landscape to focus on value based positive outcomes and overall reduction in healthcare costs.” Mukundan Iyengar Global Sales Head – Healthcare J.P. Morgan Payments

Emergence of telehealth Telehealth quickly transitioned from an option for convenience to a necessity to accommodate for patient and provider safety. The use of telehealth has increased 38x from the pre-Covid baseline.1 As providers resume offering remote care, along with contactless

Digital adoption at the forefront Advances in digital adoption have initiated the movement towards greater payments efficiency, as most consumers want more digital options.1 Personalized payment experiences allow consumers to view and manage bills and make payments with just a few clicks with the option for contactless services.

“The use of telehealth has increased 38x from the pre-Covid baseline1.”

An additional trend is an increased openness about behavioral and mental health as an extension of the

jpmorgan.com

but instead, a more holistic view of what a consumer’s experience will cost in totality. This form of reimbursement seeks to supplement and eventually replace the fee-forservice model, and aims for better services for patients, reduction of healthcare costs, and improvement in health management strategies for the private sector to implement. Under this new model, providers are incentivized to efficiently and effectively use data to report trends and metrics for improvement to payers.

communication and payments with patients, they are signaling how digital acceleration is the driver towards an ecosystem of emerging capabilities. The primary incentive for providers to adopt new methods of digital connection is to remain a competitive force in the industry, especially for millennials who expect digital experiences in their daily lives.1

The value of transparency

Incentives for digital wellness adoption

Surprise medical bills remain a source of friction in healthcare payments experienced by consumers, providers and payers. Transparency in healthcare costs remains a focus area, as 90% of consumers want to know payment responsibility upfront and likely do not know the cost at the time of service.

An expanded transformation has been ushered in, which positions wellness as the objective and where the insured are rewarded for adopting healthier lifestyles. Overall, financial health of consumers has improved in 2021, offering a renewed focus on growth opportunities. The concerns of rising medical bills can influence whether a consumer seeks medical care at all, which can result in potentially higher healthcare costs.1

“87% of consumers were surprised by a medical bill in 20211.1”

73 of payers reimburse members for wellness programs1

Healthcare providers are facing new requirements, created by recent U.S. federal legislation, to increase price transparency for consumers. New care models, like value-based care, are emerging and will permeate through the healthcare system. In these cases, medical treatment is no longer a sum of various provider expenses,

The cost of inequality As healthcare costs continue to climb, inequity in healthcare payments continues to increase1. Minorities and low-income patients especially felt the brunt of economic anxiety, including higher hospital admission and death rates. Data shows that Black Americans are more likely to accrue medical debt, as more healthcare spending is used on White Americans.1 Greater levels of wealth have commonly been linked with better health, such as healthier living conditions and healthcare access. As a result, healthcare systems are focusing on addressing healthcare disparities and closing

90 of consumers want to know payment responsibility upfront1

jpmorgan.com

“As healthcare space witnesses transformational changes, the role of public sector in leading these changes only becomes more imperative. We are excited to be considered a trusted and capable partner for public enterprises as they continue the journey to enhanced citizen experience and improved economic inclusivity.”

the wealth gap through policies and across industries as an ongoing strategic priority.

Eva Robinson NA Industry Head, Public Sector J.P. Morgan Payments

The statements herein are confidential and proprietary and not intended to be legally binding. Not all products and services are available in all geographical areas. Visit jpmorgan.com/paymentsdisclosure for further disclosures and disclaimers related to this content.

Looking ahead The relationship between the public and private sectors extends across the entire ecosystem. This partnership is helping shift the current model from a transactional, individual basis, to a greater value base for consumers, providers and payers. To exist on the innovative edge, it’s vital to adapt to change and continue to invest in digitally enabled, holistic solutions. 1. InstaMed Trends in Healthcare Payments Annual Report

Transform your agency’s payments and financial strategy for the public sector LEARN MORE

4 / jpmorgan.com

EXECUTIVE BRIEFING SERIES:

Health Care Innovation

Sponsored by 19

Modern healthcare solutions for today and beyond DELIVERING INNOVATIVE SOLUTIONS THAT ENABLE BETTER HEALTH OUTCOMES FOR ALL Our team delivers secure, whole health solutions across ever-changing sites of care to improve patient outcomes and system efficiencies. We use our expertise in digital modernization, data analytics, life sciences, care enablement, and human performance to address our customers’ most important challenges and revolutionize the future of health.

PANEL OF EXPERTS

The age of wholeperson approach to health care delivery is dawning BY TOM TEMIN Health care organizations have long sought a whole-person approach to medical delivery. That is, care that takes into account the interconnectedness of peoples’ various mental and physical systems, using data and measurable outcomes to drive care delivery. And one that vastly improves the customer experience people have when encountering the health care delivery system. Efforts have fallen short. Now, the potential for whole-person – often called patient-centered – health care has advanced in recent years thanks to the maturing of several technologies that have enabled new thinking. In the federal health care domain, no less than in the private sector, the requirements of the pandemic coupled with updates to policy have accelerated that advance. The Veterans Health Administration, for example, even has a title: chief connected care officer. Neil Evans, who holds that job, described the work this way: “It’s caring for an individual in their entirety when it comes to thinking about health care. It goes beyond the more traditional medical aspects of health care of treating various diseases and moves into a paradigm where we’re thinking about how to help individuals live their lives to the fullest.” EXECUTIVE BRIEFING SERIES: HEALTH CARE INNOVATION

Neil C. Evans, M.D., Acting Assistant Secretary for Information and Technology and Chief Information Officer, Department of Veterans Affairs and Chief Officer, Connected Care, Veterans Health Administration Colleen Hole, BSN, MHA, FACHE, Vice President, Atrium Health Hospital at Home Administrator, Chief Nurse Executive, Atrium Health Medical Group Dr. Donald Kosiak, Senior Vice President and Chief Medical Officer, Leidos Jonathan Merrell, Deputy Director for Quality Health Care, Indian Health Service Chris Nichols, Program Manager/Chief, Enterprise Intelligence and Data Solutions, Defense Healthcare Management Systems (PEO DHMS), Defense Health Agency Elizabeth Porter, Health Group President, Leidos Dr. Eliot Siegel, Chief of Radiology, Veterans Affairs Maryland Healthcare System Lance Scott, Solution Integration Director, Federal Electronic Health Record Modernization

That means more emphasis on preventive care “and building a plan around what matters to patients,” Evans added. Evans spoke on a panel of federal health practitioners from both the civilian and military sides of the government. Convened by Federal News Network in conjunction with the Leidos Health Group, we discussed the state-of-the-art in health care delivery, including the thinking, workflows, and technologies required to bring it about.

Blocking and tackling

Genomics, artificial intelligence and machine learning, and a data-based approach to improving treatment are part of future whole-person approaches, panelists agreed. But what Dr. Donald Kosiak, senior vice president and chief medical officer at Leidos, called blocking and tackling can improve delivery immediately. Such strategies become apparent once the organization adopts a mindset toward whole-person health. For example, information exists to give a longitudinal, and therefore more complete, picture of a patient. But in a practical sense that data isn’t always available. Kosiak cited electrocardiograms taken over time. “Wouldn’t it be great,” Kosiak said, “if the system said, ‘Doctor, you ordered an EKG. I bet you might want to see an old one if it exists.’ And then be able to provide that for you without your having to go hunting for something. Simple from an AI perspective, but still not done today.” The challenge, then, is not just locating the relevant data at machine speed, but also integrating it into the clinical workflow, Kosiak said. The Indian Health Service, part of the Department of Health and Human Services, has adopted a wholeperson approach. According to the deputy director for quality health care, Jonathan Merrell, the challenge is ensuring the supporting systems are “integrated,

coordinated, responsive to needs, preferences, and values of individuals served by our health system.” Merrell said one success of the way health care is traditionally delivered is also an impediment to the whole-person approach. “Historically we’ve had good outcomes specifically treating an illness like diabetes, like heart disease, say, with anti-coagulation type therapy,” Merrell said. “But that tends to reduce that individual to an illness. Our mission is to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level.” Panelists also said that integrated systems and workflows, in the whole-person approach, must extend outside the walls of hospitals and clinics. The slow-rolling pandemic has greatly expanded options specifically in home-based telehealth.

Care where the patient is

Hospitals are great for many functions. But, said Colleen Hole, the chief nurse executive at Atrium Health Care Medical Group, “they’re inherently risky in terms of falls and healthcare-acquired conditions, and delirium, and insomnia, and immobility and all of those things that keep the patient unwell.” Hole said the pandemic prompted Atrium to innovate a program called hospital-at-home. The program was enabled thanks to a pandemic-induced rules waiver by the Centers for Medicare and Medicaid Services. “[Hospital-at-home] really, truly is whole-person care. We’re able to observe the patient in their own environment,” Hole said. She called hospital-at-home an “incredibly impactful, innovative model around truly delivering, and I mean, literally delivering, care to where patients are and prefer to be: in their home.” She added that the idea dates back decades, but is only now taking hold in a widespread way.

EXECUTIVE BRIEFING SERIES: HEALTH CARE INNOVATION

Data is another axis, in addition to geography, on which the whole-person approach to health care delivery turns. Chris Nichols, the chief of enterprise intelligence and data solutions at the Defense Health Agency, said data for about 80% of health determinants for a given individual lie outside the systems operated by health delivery organizations. Nichols cited behavioral, biological, physical, social and access to care among the factors for which data might exist. That presents the challenge of “how do we get to that information to drive better outcomes for our patients?” Integration and visibility of patient data is the whole point of development of the new electronic health record (EHR), now ongoing by the departments of Defense and Veterans Affairs. VA is working directly with technology vendor Cerner with Leidos as a team member, while the Defense Department is using Leidos as its prime system integrator for the Cerner base product. The goal is an interoperable EHR established for a service member upon induction, and lasting through his or her status as a veteran. The projects will result in a sort of data and records roundup, pursuant to the whole-person delivery approach. “DOD starts out basically scattering records everywhere in commercial facilities around the country, around the world, and within military facilities,” said Lance Scott, the solution integration director for the Federal Electronic Health Record Modernization office, a joint DOD-VA activity. “And then you add on the element of a deployment, you’ve got records out there, you’ve got records everywhere.” The initial task of the office was establishment of what Scott called the joint longitudinal viewer to gather the scattered data and bridge it to both VA and DOD. The result? “The most complete comprehensive picture

I can put in front of a clinician about that patient’s history. To me, that’s a better holistic-person view that I give to the clinician,” Scott said. He cautions, good outcomes won’t result from simply dumping terabytes of data on practitioners. If anything, practitioners across the board already struggle to spend sufficient time with patients, as opposed to peering into screens. As things stand now, Scott said, lots of data in an onscreen “outside records tab” makes all the information available in a sense. “But the clinician has to do another step, while they’re seeing the patient. They must go out and look at that data. They can manually reconcile some of that data into the record. But they have to think to do that, and they have to have time to do that,” he said. “It is my job, it is our jobs, to try to make sense of all this data and put the right data in front of the clinician at the right time,” Scott said. The program office is working on a couple of strategies to ease the data overload problem. One involves natural language processing, and one gives DOD and VA practitioners certain trusted data sources that automatically become reconciled in the EHR. Liz Porter, president of the Health Group at Leidos, said that in working with the Defense Department, she’s discovered a disconnect even between systems that store physical fitness records and those that store service members’ health care records. As an active duty military spouse, she said, “I know that my record is in 20,000 different places. If anybody wanted my medical history, it’d be really hard to find.” She added that the health record itself is only one element of person’s total health picture. Hence the need for both data integration and interoperability.

EXECUTIVE BRIEFING SERIES: HEALTH CARE INNOVATION

Prevention, not cure

Still another element in establishment of true patientcentered, whole-person health care is the set of policies concerning reimbursement. That is, the incentives driving health care organizations. And here, the Veterans Health Administration is a leader in how it emphasizes delivery of preventive services that can prevent physical or mental problems that will be more difficult and expensive to treat. Dr. Elliott Siegel, the chief of radiology at the VHA Maryland Healthcare System, underscored this point. The system, he said, “has a major emphasis on reimbursement just for diseases. If you’re outside of a system, such as the Department of Veterans Affairs, it’s really difficult to get reimbursement for things that, for example, are offered within the VA as part of the whole health system.” These include preventive and wellness measures such as stress reduction, yoga, tai chi, mindfulness, nutrition counseling and acupuncture. He and others noted that patients must be active participants in their own care. “The other thing that’s really important about wholeperson health,” Siegel said, “is empowering patients to be not just passive recipients of care – which I think to a large extent is the case within the U.S. – and make them essentially co-partners in their healthcare.” Merrell of IHS noted that one way to bring in patients as whole people, and not merely as cases with this or that disease, is by understanding and accounting for their varying background and cultural norms. “For IHS,” he said, “this also means integration of cultural practice, and traditional ways of knowing and healing into our healthcare delivery. Many of our facilities have developed both formal and informal ways of integrating traditional healing and culture into care.” He said IHS has, over the years, evolved to a team-

based approach to health care, with the patient as a key team member. The team approach to whole-person healthcare delivery means organizations have to pay attention to the vitality of the teams themselves. This is especially true when the health care profession as a whole is under stress thanks in part to the pandemic and thanks in part to a shortage of certain practitioners in certain areas. Faster and more intuitive access to relevant data will help. Hole of Atrium added that rethinking roles and responsibilities can also help. She described a multidisciplinary team approach in which the physician is not necessarily at the center of the care model. Of physicians, Hole said, “One, we can’t afford them. And two, we’re not gonna be able to find them. We’re not making enough of them.” She envisions registered nurses “as the non-provider care team lead, aggregating resources of social workers, care managers, health coaches, all of those who really touch a patient before the patient is in trouble.” She said such an approach would reduce physician burnout by taking them out of the model of constantly responding to acute situations in 15-minute intervals or fly-by morning rounds. Equally helpful to the health care profession itself would be greater portability of licenses from one geographical area to another. Payers have allowed portability at least temporarily in some instances because of the pandemic. Porter of Leidos said that’s exactly what has enabled specialists to do telehealth sessions with remote veterans, and enabled mobile clinics to deliver overdue examinations on Indian reservations. “License portability, certainly in the mental health space, it’s an area where there just aren’t enough providers,” Porter said.

EXECUTIVE BRIEFING SERIES: HEALTH CARE INNOVATION

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MIXED METHODS ANALYSIS We provide a range of analytic capabilities from predictive modeling using machine learning and artificial intelligence to qualitative analysis with industry experts to discern best practices from on-the-ground public health initiatives. Combining

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The African proverb that leads the title of this paper connotes the idea that collaboration, cooperation, and partnerships can be used to tackle arguably insurmountable problems such as risks to a population’s mental health. The “lion” in our story is the adverse impact (real and potential) of the intersection of the COVID-19 pandemic with racial inequities in communities of color. For this paper, this is the story of how institutions, agencies, and organizations might work collaboratively and in public-private-community partnerships to advance mental health equity for Blacks/Africanas 1 in the U.S.2 merely co-occur; the synergy among epidemics made each worse.”

A SYNDEMIC PERSPECTIVE: INTERSECTIONS OF COVID -19 PANDEMIC WITH RACE The impact of COVID-19 is affected by syndemic factors much like the intersection of HIV with other disease burdens as the concept of syndemics is described below: “Singer and colleagues (Singer, 1994, 1996; Singer & Snipes, 1992) developed the concept of syndemics in the early 1990s, in the context of research on the HIV epidemic, which was then ravaging poor, Black, and other communities of color in urban North America. Singer built on the long-standing observation that communities most impacted by new epidemics often are already facing other threats to their health. In the case of HIV among marginalized people in the U.S., those threats included “a set of closely interrelated endemic and epidemic conditions (e.g., HIV, TB, STDs, hepatitis, cirrhosis, infant mortality, drug abuse, suicide, homicide, etc.), all of which are strongly influenced and sustained by a broader set of politicaleconomic and social factors” (Singer, 1996). The crucial point, Singer argued, was that “these conditions did not

The disproportionate impact of COVID-19 on people of color has resulted in specific race-related COVID-19 worries (presented later). Moreover, in 2020, there was concurrently a racial injustice pandemic, fueled by the widely publicized murders of three unarmed Black people: Ahmaud Arberry, Breonna Taylor, and George Floyd. These murders are contemporary examples of racial injustice and state-sanctioned violence toward African Americans at the hands of police or former police. The simultaneous COVID-19 pandemic and racial injustice pandemic and their impact on minority health (specifically racial/ethnic inequities in mental health) have been referred to as a syndemic3,. The term syndemic has recently been redefined by CDC and Singer et al.4 to describe the aggregation of two or more concurrent or sequential epidemics in a population which exacerbate the prognosis and burden of disease.

We used the term "Black/Africana" to refer to people of Afrikan ancestry throughout our report. We used “Black/Africana” rather than "Black/African Americans" in our report, because our samples included not only African Americans but also persons of Afrikan ancestry from the Caribbean, Latin America, and continental Afrika who were living in the U.S. during the COVID-19 pandemic . The term "Africana" is a more inclusive term that represents people of Afrikan ancestry from different locations. Note: “Black” only is used in some places for simplicity in wording. 2

The views expressed in this paper are the opinions of the authors and not of The Association of Black Psychologists, Inc., The MayaTech Corporation, nor the research sponsors or institutions with which the authors are affiliated. 3

Gravlee C. C. (2020). Systemic racism, chronic health inequities, and COVID-19: A syndemic in the making? American Journal of Human Biology, 32:e23482.

Singer, M., Bulled, N., Ostrach, B, & Mendenhall, E. (2017). Syndemics and the biosocial conception of health. Lancet, 389 (10072), 941–50. 26

The COVID-19 and racial injustice syndemic has exacerbated the mental health toll on Black Americans. The synergistic effects include impacts on social determinants of health such as housing instability, job insecurity, and food insecurity. However, few studies provide evidence of the role of race-related COVID factors or racialized variables among these determinants. Applying a syndemic perspective in research on these intersecting issues can yield invaluable data to guide culturally responsive prevention strategies, clinical interventions, and policies to remove structural barriers to equitable health and mental health care. In this paper, we summarize key mental health findings emanating from a survey that was fielded as part of a national collaborative collecting needs and assets assessments in communities of color, one-year post-declaration of the COVID-19 pandemic.

Research for Indigenous Social Action and Equity Center, The National Latinx Psychological Association, and The American Psychological Association. Subjectmatter experts in public health, economics, education, health policy, epidemiology, social policy, and polling also conducted studies while the community-based participatory research was being implemented. This paper focuses on the Black/Africana findings. Study Objective. The objective of the ABPsi’s COVID-19 Needs Assessment Project was to assess the extent to which the COVID-19 pandemic has affected Black/Africana adults (ages 18 and older), who live in the United States of America (USA), especially as related to the impact on their mental health and the delivery of mental health services in Black communities. Design and sample. The design was a cross-sectional, mixed-methods, community systems analysis utilizing a multi-state online survey of Blacks in the U.S. age 18+, secondary analysis of existing data (e.g., census, community health plans), and key informant interviews. The Black sample included 2,480 respondents; and 31 key informants who were stakeholders in the communities that were the focus of the study. The sample was mostly women (69%) and less than 1% reported other gender identities. About 1 in 2 (48%) earned less than $35,000 in 2019; 46% had children under 18 years old; 56% were essential workers—exempt from stay-at-home orders and must report to work. The following are a few mental health highlights.

BACKGROUND As part of a research collaborative, The Alliance of National Minority Psychological Associations for Racial and Ethnic Equity, the authors were on a research team that was part of a multi-racial/ethnic collaborative effort that conducted a rapid online needs assessment of the impact of mental health in communities of color. The Black component of the research was sponsored by The Association of Black Psychologists, Inc. (ABPsi)5 Principal Investigator Theopia Jackson, Ph.D. In addition, other racial/ethnic affinity groups collected data for Latinx, Asian American, Native Hawaiian and Other Pacific Islanders, and Indigenous groups (American Indians and Alaska Natives). The larger needs assessment, conducted between December 2020 and April 2021, was commissioned by The Congressional Tri-Caucus, which included the Black Caucus, Latinx Caucus, Asian/Pacific Islander Caucus, and two Native American Congresspersons. In partnership with the National Urban League sponsorships were obtained from several funders, and no federal dollars were used. The funders included: the Ford Foundation, JPB Foundation, W.K. Kellogg Foundation, the National Urban League, The California Endowment, The Weingart Foundation, and The California Wellness Foundation. Congresswoman Karen Bass of California was Chair of the Congressional Black Caucus at the time and was influential in this effort; and the collaborative research effort was led by Principal Investigator, Cheryl Grills, Ph.D. The participating organizations included ABPsi, The Asian American Psychological Association, The Indigenous Wellness Research Institute, in partnership with the 5

The senior researcher for the ABPsi survey was Chief Science Officer at The MayaTech Corporation, which served as the Institutional Review Board for that project. Other co-authors are research team members.

Key variables. The graphic displays the domains of the variables included in the survey, interviews with community members, and reviews of secondary data sources on the needs and assets of the communities we studied.

Worries and Stressors during COVID-19 Among respondents’ worries over the course of the pandemic, their “Top 5 Worries” were about themselves getting COVID or family members with health conditions contracting COVID (38% and 40%, respectively); or Black friends, other people they know, or their family getting COVID; and 22% who were afraid of dying from COVID-19. Their “Top-5 Sources of Stress” were concerns about their finances (40%), mental health (37%), and physical health (29%). Impact on family (26%), and social distancing/quarantining and others not wearing masks (each at 22%) rounded out the top-5-ranked stressors.

Collaborative methods. Alliance members collaborated on common items for all surveys. Because this work was steeped in culturally-responsive, community-based participatory principles, the Alliance members established partnerships with community organizations to assist with wording for local instruments and recruitment of the nearly 25,000 survey respondents, interviewees, and focus group participants across the various racial/ethnic groups.

COVID-19 Coping Strategies Despite the worrisome news about (risks for) mental health, including negative coping strategies (e.g., eating more (27%), sleeping more (25%), and increased substance use (15%), there was hopeful news: Blacks/Africanas reported more frequently their use of Positive Coping strategies to deal with COVID-19. They reported most frequently talking with family and friends (67%), listening to music (46%), talking to healthcare providers more frequently (33%), spirituality/spiritual practices (33%), and exercising (29%). Several of these positive coping strategies are consistent with an Afrikan-centered worldview.

Analysis. Although the findings from this cross-racialethnic research collaboration revealed similarities in responses to the pandemic, differences that reflected the cultural uniqueness of each group also were evident. For example, although food insecurity was an issue for Blacks and Asian Americans, stigma was associated with food insecurity among Blacks whereas fear of going outside (due to anti-Asian racism) was associated with food insecurity among Asian Americans. Poor mental health outcomes for Latinx populations were associated with immigration status. Understanding the unique co-factors of mental health and social determinants was more important to addressing the impact of the pandemic on mental health outcomes than comparing Blacks, Asian Americans, Latinx, and Indigenous groups.

KEY MENTAL HEALTH FINDINGS Anxiety and Depressive Symptoms On a measure of mental health symptoms, the Patient Health Questionnaire-4 (PHQ-4), the percentages of Blacks who reported levels of anxiety or depressive symptoms that warrant further evaluation were 38% and 39%, respectively. These levels are similar to those for all Americans as reported by CDC. Approximately onefourth of the respondents described their mental health as fair or poor, and even more (37%) indicated that mental health was a source of stress. Moreover, based on two items based on the National Health Interview Survey (NHIS), almost one-fourth (24%) had taken prescription medications for their mental health in the past 12 months (during the pandemic ). However, only 17% received mental health counseling in the past four weeks. Although a small percentage, but notable because of the large sample size, four percent reported they needed more help with grief counseling.

Mental Health Needs and Assets First responders. Existing mental health staffing for first responder organizations did not always meet the needs of the larger organization. However, grants that provided funding for mental health training were reported by community voices as beneficial to their first responders’ organizations. Destigmatizing Mental Health. Mental health facilities are available; however, there is stigma in the Black community associated with receiving mental health services from formal mental health practitioners. For example, community members assigned negative connotations to the idea of seeking out assistance from traditional institutions. They instead discussed concerns or issues internally among family, friends, or religious leaders. Communities still need more support for individuals dealing with substance use issues and mental health issues in general. Findings in a forthcoming paper show the value of both informal and formal support in weakening the impact of some stressors on mental health. Grief and Loss. Some families experienced grief and the loss of close relatives during the COVID-19 pandemic due to exposure from essential workers in the family or family members initially exposed to COVID-19. First responders used grant funding to address grief and loss utilizing training for peer support specialists. However,

Recommendations to address family and child life changes include: 1. Support and provide technical assistance and training to community-based and faith-based organizations to establish culturally-centered parent training, marriage preparation, conflict resolution training and programs, and support groups for children, adolescents, and adults, and provide incentives for participation. 2. Establish safe/transitional housing for survivors of domestic violence and their children in rural, suburban, and urban areas and provide comprehensive, culturally-specific health, mental health, social and educational services in these facilities. 3. Support and provide technical assistance to HBCUs, community colleges, and other colleges and universities; professional associations; and related groups to provide culturally-grounded training to laypersons in areas of child development, parenting, healthy communication, trauma-informed care, and conflict resolution, and encourage agencies to hire persons with this training. 4. Encourage local governments to fund neighborhoods and rural community groups to create and disseminate information about Afrikancentered, family- and child-focused mental health services.

these assets were not available to the larger community given that faith-based institutions were closed due to pandemic restrictions and faith leaders themselves were adversely affected by the pandemic. RECOMMENDATIONS FOR COLLABORATIVE MENTAL HEALTH APPROACHES 1. Establish partnerships with Black professional organizations whose members are trained in culturallycompetent mental health approaches and other professional organizations to train these other professionals in providing culturally-accountable services to Black communities (e.g., in schools, health centers, mental health clinics, and workplaces). 2. Increase the numbers of culturally-accountable providers serving Black communities through grants for collaborations between private practitioners, public agencies, and nonprofits to offer culturallyaccountable mental and behavioral health services. 3. Support informal networks to provide communityinitiated, peer-led mental health education and support services (e.g., in faith-based institutions, youth-serving organizations, neighborhood associations, and community gathering places).

OTHER MENTAL HEALTH FINDINGS Family and Child Life Changes For family and child life changes, there was good news and worrisome news. Positive Changes in family and child life among adults included improved relationships with family and friends; increased quality time spent with spouse/partner; and increased quality time with children. Negative changes in family and child life included increased levels of verbal and physical conflict between spouses/partners in the home; parents reported use of harsher discipline with their children; increased parent-child conflicts; increased physical conflicts between their child and another child; increased child sleep difficulties; and increased child behavioral/emotional problems. Community voices shared that survivors of domestic violence have been trapped with their abusers during the stay-at-home and work-at-home orders. Also, organizations have limited access to help survivors remove themselves from the abusive environment. In addition, children are dealing with the loss of family members in ways that have impacted their way of life, including schooling. Thus, parents have had to deal with the toll that COVID-19 has had on their own as well as their children’s mental and emotional health.

SYNDEMIC FACTORS

SOCIAL DETERMINANTS OF HEALTH/MENTAL HEALTH As noted earlier, a syndemic perspective cannot ignore social determinants of health. COVID-19 has also adversely affected social determinants of health and mental health. For example, housing instability has resulted in increased homelessness or “doubling up” with family and friends, because people could not pay rent or mortgages and, thus, lost their homes or were evicted. This was due largely to another social determinant: economic instability. In this study, the percent of Blacks who reported receipt of unemployment assistance after the pandemic was double the percentage of those reporting they received unemployment assistance before the pandemic. Social determinants also served as barriers to seeking mental health services and coping effectively. Respondents reported concerns related to limited access to health care and COVID-19 services, stigma associated with getting services, and lack of

transportation to get to services. Under-investigated social determinants during the pandemic were structural racism and everyday discrimination, which affected Blacks as well as other racial/ethnic minority groups (as noted earlier with respect to anti-Asian racism and discrimination against undocumented Latinx immigrants). INTERSECTION OF COVID-19 AND RACIAL INJUSTICE Thus, this brings us back to the syndemic perspective in understanding mental health impacts of the pandemic— i.e., the intersection of the racial injustice pandemic with the COVID-19 pandemic. In addition to the COVID-related worries and COVID race-related worries described earlier, of specific mental health interest for Blacks were reports of police violence against Blacks and structural racism that were found to predispose racial/ethnic minorities to underlying health risks that exacerbated the effects of COVID-19. Two of the top three concerns for Blacks were race-based; in order, other than COVID-19, Blacks were concerned about: 1) racial injustices, 2) unemployment, and 3) police violence against Blacks. Both concern about COVID-19 as a threat to one’s health and perceptions of police violence as extremely/very serious were inversely related to one’s overall rating of their mental health (i.e., the more one perceived either the threat of COVID-19 or the seriousness of police violence, the worse they rated their overall mental health). On the other hand, only perception of the threat of COVID-19 to one’s health was related to higher anxiety and depressive symptoms. The longstanding issue of police violence may have provided time for Blacks to develop positive coping strategies to reduce anxiety and depressive symptoms (although they rate their overall mental health as poor/fair). Perhaps uncovering some of these strategies for positive coping might prove useful for assisting Blacks seeking mental health services for COVID-19-related worries. RECOMMENDATIONS TO ADDRESS INTERSECTIONAL MENTAL HEALTH ISSUES 1. Work with community partners to convene listening sessions with community members and mental health practitioners to uncover positive coping strategies that have proven effective for Blacks expressing mental health concerns related to race-related worries (everyday discrimination, exposure to structural racism),

COVID-19-related worries (grief and loss, fear of dying), and the intersection of these worries (perception of denial to COVID-19 treatment due to one’s race). Use the lessons learned from these sessions to culturally adapt mental health services so that these race-based sources of stress or worry are considered. 2. Additional community-engaged, communitybased participatory research, and/or communityacademic partnerships are needed to gather input from providers and community partners on the feasibility and utility of options for racebased/COVID-19 mental health interventions. CONCLUSIONS There are multiple ways in which the pandemic has adversely impacted the mental health of adults, couples, children, and families of Afrikan ancestry living in the United States. Most significant is the exposure of structural and systemic racism which is manifested in health, mental health, social, and economic disparities. It is not possible to separate the impact of these social determinants and racial injustices from the impact of the COVID-19 pandemic. Importantly, although Blacks live in communities that face a huge task in recovering from the pandemic and in circumstances that exacerbate these impacts, there are fortunately many assets that were also identified in this needs assessment that can be mobilized to confront these challenges. The recommendations made throughout this paper are aimed at addressing these issues and leveraging the nation’s assets in a culturallyappropriate and accountable manner. Interdisciplinary and inter-agency collaborations and partnership efforts are needed to leverage public and private resources that can address COVID-19’s impacts and advance equity factors related to: structural and individual racism, children’s mental health, family and couple relationships and adult well-being; inadequate resources for community-based organizations and informal networks to provide needed services; and inter-professional organizations’ engagement in culturally-responsive mental health training and service delivery. Importantly, these peeks into the windows of mental health impacts in Black communities as well as the insights from the other groups that were part of the larger needs assessment can provide insights for transforming our mental health practices to advance equity in mental health. Decision makers are encouraged to engage these stakeholders and their constituents in genuine partnerships that can accomplish this lofty aim. Together, spider webs united can tie up this lion!