Linking Primary Care to Community-Based Mental Health Resources via Family Navigation and Phone-Based Care Coordination.

Family navigation (FN) and phone-based care coordination may improve linkages from primary care to community-based mental health referrals, but research on their differential impact is limited. This mixed-methods study compared FN and phone-based care coordination in connecting families to mental health services from primary care. Families of children (56.3% male, mean age = 10.4 years, 85.4% Black) were sequentially assigned to either receive FN through a family-run organization or phone-based coordination via the child psychiatry access program (CPAP). Caregiver-reported children's mental health improved in both groups and both groups were satisfied with services. More families in the CPAP group had appointments made or completed (87%) than families in the FN group (71%) though the difference was not statistically significant. Future research with a larger sample that matches family needs and preferences (e.g., level and type of support) with navigation services would be beneficial.

Assessing a pilot scheme of intensive support and assertive linkage in levels of engagement, retention, and recovery capital for people in recovery housing using quasi-experimental methods.

INTRODUCTION: Strong and ever-growing evidence highlights the effectiveness of recovery housing in supporting and sustaining substance use disorder (SUD) recovery, especially when augmented by intensive support that includes assertive linkages to community services. This study aims to evaluate a pilot intensive recovery support (IRS) intervention for individuals (n = 175) entering certified Level II and III recovery residences. These individuals met at least three out of five conditions (no health insurance; no driving license; substance use in the last 14 days; current unemployment; possession of less than $75 capital). The study assesses the impact of the IRS on engagement, retention, and changes in recovery capital, compared to the business-as-usual Standard Recovery Support (SRS) approach (n = 1758). METHODS: The study employed quasi-experimental techniques to create weighted and balanced counterfactual groups. These groups, derived from the Recovery Capital assessment tool (REC-CAP), enabled comparison of outcomes between people receiving IRS and those undergoing SRS. RESULTS: After reweighting for resident demographics, service needs, and barriers to recovery, those receiving IRS exhibited improved retention rates, reduced likelihood of disengagement, and growth in recovery capital after living in the residence for 6-9 months. CONCLUSION: The results from this pilot intervention indicate that intensive recovery support, which integrates assertive community linkages and enhanced recovery coaching, outperforms a balanced counterfactual group in engagement, length of stay, and recovery capital growth. We suggest that this model may be particularly beneficial to those entering Level II and Level III recovery housing with lower levels of recovery capital at admission.

(Cost)-effectiveness and implementation of integrated community-based care for patients with severe mental illness: a study protocol.

BACKGROUND: As severe mental illness (SMI) is associated with a high disease burden and persistent nature, patients with SMI are often subjected to long-term mental healthcare and are in need of additional social support services. Community-based care and support services are organized via different providers and institutions, which are often lacking structural communication, resulting in a fragmented approach. To improve the efficiency of care provision and optimize patient wellbeing, an integrated multi-agency approach to community-based mental health and social services has been developed and implemented. AIM: To present a research protocol describing the evaluation of flexible assertive community teams integrated with social services in terms of effectiveness, cost-effectiveness, and implementation. METHODS/DESIGN: A quasi-experimental study will be conducted using prospective and retrospective observational data in patients with severe mental illness. Patients receiving care from three teams, consisting of flexible assertive community treatment and separately provided social support services (care as usual), will be compared to patients receiving care from two teams integrating these mental and social services into a single team. The study will consist of three parts: 1) an effectiveness evaluation, 2) a health-economic evaluation, and 3) a process implementation evaluation. To assess (cost-)effectiveness, both real-world aggregated and individual patient data will be collected using informed consent, and analysed using a longitudinal mixed model. The economic evaluation will consist of a cost-utility analysis and a cost-effectiveness analysis. For the process and implementation evaluation a mixed method design will be used to describe if the integrated teams have been implemented as planned, if its predefined goals are achieved, and what the experiences are of its team members. DISCUSSION: The integration of health and social services is expected to allow for a more holistic and recovery oriented treatment approach, whilst improving the allocation of scarce resources. This study aims to identify and describe these effects using a mixed-method approach, and support decision-making in the structural implementation of integrating mental and social services.

Lockdown logistics in consultation-liaison psychiatry.

We describe the adaptation of services to allow flexible and practical responses to the coronavirus-19 (COVID-19) public health crisis by four Consultation-Liaison Psychiatry (CLP) services; Galway University Hospital (GUH), Beaumont Hospital, University Hospital Waterford and St Vincent's University Hospital (SVUH) CLP services. This article also illustrates close collaboration with community adult mental health services and Emergency Department (ED) colleagues to implement effective community diversion pathways and develop safe, effective patient assessment pathways within the EDs. It highlights the high levels of activity within each of the CLP services, while also signposting that many of the rapidly implemented changes to our practice may herald improvements to mental health patient care delivery in the post-COVID-19 world, if our psychiatry services receive appropriate resources.

Children and Adolescent Mental Health in a Time of COVID-19: A Forgotten Priority.

Globally, 10-20% of children and adolescents experience mental health conditions, but most of them do not receive the appropriate care when it is needed. The COVID-19 deaths and prevention measures, such as the lockdowns, economic downturns, and school closures, have affected many communities physically, mentally, and economically and significantly impacted the already-neglected children and adolescents' mental health. As a result, evidence has shown that many children and adolescents are experiencing psychological effects such as depression and anxiety without adequate support. The consequences of not addressing the mental health conditions in children and adolescents extend through adulthood and restrict them from reaching their full potential. The effects of COVID-19 on children and adolescents' mental health highlight the urgent need for multisectoral home-grown solutions to provide early diagnosis and treatment and educate caregivers on home-based interventions and community outreach initiatives to address children and adolescents' mental health challenges during this pandemic and beyond.

Effectiveness of a housing support team intervention with a recovery-oriented approach on hospital and emergency department use by homeless people with severe mental illness: a randomised controlled trial.

AIMS: Many people who are homeless with severe mental illnesses are high users of healthcare services and social services, without reducing widen health inequalities in this vulnerable population. This study aimed to determine whether independent housing with mental health support teams with a recovery-oriented approach (Housing First (HF) program) for people who are homeless with severe mental disorders improves hospital and emergency department use. METHODS: We did a randomised controlled trial in four French cities: Lille, Marseille, Paris and Toulouse. Participants were eligible if they were 18 years or older, being absolutely homeless or precariously housed, with a diagnosis of schizophrenia (SCZ) or bipolar disorder (BD) and were required to have a high level of needs (moderate-to-severe disability and past hospitalisations over the last 5 years or comorbid alcohol or substance use disorder). Participants were randomly assigned (1:1) to immediate access to independent housing and support from the Assertive Community Treatment team (social worker, nurse, doctor, psychiatrist and peer worker) (HF group) or treatment as usual (TAU group) namely pre-existing dedicated homeless-targeted programs and services. Participants and interviewers were unmasked to assignment. The primary outcomes were the number of emergency department (ED) visits, hospitalisation admissions and inpatient days at 24 months. Secondary outcomes were recovery (Recovery Assessment Scale), quality of life (SQOL and SF36), mental health symptoms, addiction issues, stably housed days and cost savings from a societal perspective. Intention-to-treat analysis was performed. RESULTS: Eligible patients were randomly assigned to the HF group (n = 353) or TAU group (n = 350). No differences were found in the number of hospital admissions (relative risk (95% CI), 0.96 (0.76-1.21)) or ED visits (0.89 (0.66-1.21)). Significantly less inpatient days were found for HF v. TAU (0.62 (0.48-0.80)). The HF group exhibited higher housing stability (difference in slope, 116 (103-128)) and higher scores for sub-dimensions of S-QOL scale (psychological well-being and autonomy). No differences were found for physical composite score SF36, mental health symptoms and rates of alcohol or substance dependence. Mean difference in costs was €-217 per patient over 24 months in favour of the HF group. HF was associated with cost savings in healthcare costs (RR 0.62(0.48-0.78)) and residential costs (0.07 (0.05-0.11)). CONCLUSION: An immediate access to independent housing and support from a mental health team resulted in decreased inpatient days, higher housing stability and cost savings in homeless persons with SCZ or BP disorders.

Expanding Possibilities: Flexibility and Solidarity with Under-resourced Immigrant Families During the COVID-19 Pandemic.

The novel coronavirus has added new anxieties and forms of grieving to the myriad practical and emotional burdens already present in the lives of underserved and uninsured immigrant families and communities. In this article, we relate our experiences since the COVID-19 crisis to the lessons we have learned over time as mental health professionals working with families in no-cost, student-managed community comprehensive health clinics in academic-community partnerships. We compare and contrast the learnings of flexibility of time, space, procedures, or attendance we acquired in this clinical community setting during regular times, with the new challenges families and therapists face, and the adaptations needed to continue to work with our clients in culturally responsive and empowering ways during the COVID-19 pandemic. We describe families, students, professionals, promotoras (community links), and IT support staff joining together in solidarity as the creative problem solvers of new possibilities when families do not have access to Wi-Fi, smartphones, or computers, or suffer overcrowding and lack of privacy. We describe many anxieties related to economic insecurity or fear of facing death alone, but also how to visualize expanding possibilities in styles of parenting or types of emotional support among family members as elements of hope that may endure beyond these unprecedented tragic times of loss and uncertainty.

El novedoso coronavirus ha agregado nuevas ansiedades y formas de duelo a la infinidad de cargas emocionales y prácticas ya presentes en las vidas de las familias y las comunidades de inmigrantes marginados que no tienen seguro. En este artículo, relacionamos nuestras experiencias desde la crisis de la COVID-19 con las lecciones que hemos aprendido en el transcurso del tiempo como profesionales de salud mental que trabajamos con familias en clínicas comunitarias de atención integral de la salud gratuitas y administradas por estudiantes en asociaciones académico-comunitarias. Comparamos y contrastamos los conocimientos de flexibilidad del tiempo, del espacio, de los procedimientos o de la asistencia que adquirimos en este entorno clínico comunitario durante momentos habituales con los nuevos desafíos que enfrentan las familias y los terapeutas, y las adaptaciones necesarias para continuar trabajando con nuestros pacientes de maneras que respondan a sus necesidades culturales y los empoderen durante la pandemia de la COVID-19. Describimos a las familias, a los alumnos, a los profesionales, a las promotoras (vínculos comunitarios) y al personal de asistencia en tecnologías informáticas que se han unido en solidaridad como solucionadores creativos de problemas ofreciendo nuevas posibilidades cuando las familias no tienen acceso a wifi, a teléfonos inteligentes o a computadoras, o sufren el hacinamiento y la falta de privacidad. Describimos muchas ansiedades relacionadas con la inseguridad económica o con el miedo de enfrentar la muerte solos, y también cómo visualizar la ampliación de posibilidades en los estilos de crianza o los tipos de apoyo emocional entre familiares como elementos de esperanza que pueden perdurar luego de estos tiempos trágicos de pérdida e incertidumbre sin precedentes.

Making sense of it together: Youth & families co-create sensory modulation assessment and intervention in community mental health settings to optimise daily life.

INTRODUCTION: Occupational therapists work collaboratively with young people experiencing mental ill-health to enable meaningful occupational participation in daily life. Sensory modulation is used as a means of developing self-regulation and enabling occupational participation. Published literature on sensory modulation in mental health settings is primarily located within acute inpatient settings and focuses on self-regulation. Little is known about the use of sensory modulation within community settings to enhance occupational participation in daily lives of people with mental-ill health. This study investigated the experiences of young people and their families who engaged in sensory modulation assessment (Adolescent/Adult Sensory Profile) and intervention (between one and twelve sessions) as part of community mental health care at a large area mental health service in Melbourne, Australia. METHODS: The qualitative study used naturalistic inquiry methodology involving semi-structured interviews with six young people and three families. Nine interview transcripts were thematically analysed to elicit the experiences of sensory modulation assessment and intervention, and how this may influence daily life. RESULTS: Thematic analysis revealed that young people and their families' positive experiences of sensory modulation were underpinned by processes of co-creation: (a) knowing yourself; (b) understanding 'the why': developing shared reasons for engaging in sensory modulation; (c) creating comfort; (d) creating connection; and (e) constantly learning. Sensory modulation supported occupational participation in young peoples' daily lives in the areas of sleep, study, relationships, self-care, independent living, being in the world, and doing new things. CONCLUSION: Young people and their families valued the process of co-creating sensory modulation assessment and intervention to enhance occupational participation. Results revealed that sensory modulation assessment and intervention was optimised when it was a process of co-creation. Future research should investigate the effectiveness of sensory modulation in enhancing occupational participation in these domains that influence daily life.

Changes in community mental health services availability and suicide mortality in the US: a retrospective study.

BACKGROUND: Despite the fact that the overwhelming majority of mental health services are delivered in outpatient settings, the effect of changes in non-hospital-based mental health care on increased suicide rates is largely unknown. This study examines the association between changes in community mental health center (CMHC) supply and suicide mortality in the United States. METHODS: Retrospective analysis was performed using data from National Mental Health Services Survey (N-MHSS) and the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) (2014-2017). Population-weighted multiple linear regressions were used to examine within-state associations between CMHCs per capita and suicide mortality. Models controlled for state-level characteristics (i.e., number of hospital psychiatric units per capita, number of mental health professionals per capita, age, race, and percent low-income), year and state. RESULTS: From 2014 to 2017, the number of CMHCs decreased by 14% nationally (from 3406 to 2920). Suicide increased by 9.7% (from 15.4 to 16.9 per 100,000) in the same time period. We find a small but negative association between the number of CMHCs and suicide deaths (- 0.52, 95% CI - 1.08 to 0.03; p = 0.066). Declines in the number of CMHCs from 2014 to 2017 may be associated with approximately 6% of the national increase in suicide, representing 263 additional suicide deaths. CONCLUSIONS: State governments should avoid the declining number of CMHCs and the services these facilities provide, which may be an important component of suicide prevention efforts.

The Vital Role of a Full Continuum of Psychiatric Care Beyond Beds.

The authors make the case for expanding the national discussion of inpatient psychiatric beds to recognize and incorporate other vital components of the continuum of care in order to improve outcomes for individuals with serious mental illness. They review the varied terminology applied to psychiatric beds and describe how the location of these beds has changed from primarily state hospitals to the criminal justice system, emergency departments, inpatient units, and the community. The authors propose 10 recommendations related to beds or to contextual issues regarding them. The recommendations address issues of mental illness terminology, criminal and juvenile justice diversion, the Emergency Medical Treatment and Labor Act, mental health technology, and the mental health workforce, among others. Each recommendation is based on findings from publicly available data and clinical observation and is intended to reduce the human and economic costs associated with severe mental illness by promoting a robust, interconnected, and evidence-based system of care that goes beyond beds.

The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review.

BACKGROUND: Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations. METHODS AND FINDINGS: We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management. CONCLUSIONS: Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.

Atmiyata, a community-led intervention to address common mental disorders: Study protocol for a stepped wedge cluster randomized controlled trial in rural Gujarat, India.

BACKGROUND: While lay-health worker models for mental health care have proven to be effective in controlled trials, there is limited evidence on the effectiveness and scalability of these models in rural communities in low- and middle-income countries (LMICs). Atmiyata is a rural community-led intervention using local community volunteers, called Champions, to identify and provide a package of community-based interventions for mental health, including evidence-based counseling for persons with common mental disorders (CMD). METHODS: The impact of the Atmiyata intervention is evaluated through a stepped wedge cluster randomized controlled trial (SW-CRCT) with a nested economic evaluation. The trial is implemented across 10 sub-blocks (645 villages) in Mehsana district in the state of Gujarat, with a catchment area of 1.52 million rural adults. There are 56 primary health centers (PHCs) in Mehsana district and villages covered under these PHCs are equally divided into four groups of clusters of 14 PHCs each. The intervention is rolled out in a staggered manner in these groups of villages at an interval of 5 months. The primary outcome is symptomatic improvement measured through the GHQ-12 at a 3-month follow-up. Secondary outcomes include: quality of life using the EURO-QoL (EQ- 5D), symptom improvement measured by the Self-Reporting Questionnaire-20 (SRQ-20), functioning using the World Health Organization's Disability Assessment Scale (WHO-DAS-12), depression symptoms using the Patient Health Questionnaire (PHQ-9), anxiety symptoms using Generalized Anxiety Disorder Questionnaire (GAD-7), and social participation using the Social Participation Scale (SPS). Generalized linear mixed effects model is employed for binary outcomes and linear mixed effects model for continuous outcomes. A Return on Investment (ROI) analysis of the intervention will be conducted to understand whether the intervention generates any return on financial investments made into the project. DISCUSSION: Stepped wedge designs are increasingly used a design to evaluate the real-life effectiveness of interventions. To the best of our knowledge, this is the first SW-CRCT in a low- and middle-income country evaluating the impact of the implementation of a community mental health intervention. The results of this study will contribute to the evidence on scaling-up lay health worker models for mental health interventions and contribute to the SW-CRCT literature in low- and middle-income countries. TRIAL REGISTRATION: The trial is registered prospectively with the Clinical Trial Registry in India and the Clinical Trial Registry number- CTRI/2017/03/008139. URL http://ctri.nic.in/Clinicaltrials/regtrial.php?modid=1&compid=19&EncHid=70845.17209. Date of registration- 20/03/2017.

Feasibility and acceptability of a novel community-based mental health intervention delivered by community volunteers in Maharashtra, India: the Atmiyata programme.

BACKGROUND: Many community-based intervention models for mental health and wellbeing have undergone robust experimental evaluation; however, there are limited accounts of the implementation of these evidence-based interventions in practice. Atmiyata piloted the implementation of a community-led intervention to identify and understand the challenges of delivering such an intervention. The goal of the pilot evaluation is to identify factors important for larger-scale implementation across an entire district in India. This paper presents the results of a feasibility and acceptability study of the Atmiyata intervention piloted in Nashik district, Maharashtra, India between 2013 and 2015. METHODS: A mixed methods approach was used to evaluate the Atmiyata intervention. First, a pre-post survey conducted with 215 cases identified with a GHQ cut-off 6 using a 3-month interval. Cases enrolled into the study in one randomly selected month (May-June 2015). Secondly, a quasi-experimental, pre-post design was used to conduct a population-based survey in the intervention and control areas. A randomly selected sample (panel) of 827 women and 843 men age between 18 to 65 years were interviewed to assess the impact of the Atmiyata intervention on common mental disorders. Finally, using qualitative methods, 16 Champions interviewed to understand an implementation processes, barriers and facilitators. RESULTS: Of the 215 participants identified by the Champions as being distressed or having a common mental disorder (CMD), n = 202 (94.4%) had a GHQ score at either sub-threshold level for CMD or above at baseline. Champions accurately identified people with emotional distress and in need of psychological support. After a 6-session counselling provided by the Champions, the percentage of participants with a case-level GHQ score dropped from 63.8 to 36.8%. The second sub-intervention consisted of showing films on Champions' mobile phones to raise community awareness regarding mental health. Films consisted of short scenario-based depictions of problems commonly experienced in villages (alcohol use and domestic violence). Champions facilitated access to social benefits for people with disability. Retention of Atmiyata Champions was high; 90.7% of the initial selected champions continued to work till the end of the project. Champions stated that they enjoyed their work and found it fulfilling to help others. This made them willing to work voluntarily, without pay. The semi-structured interviews with champions indicated that persons in the community experienced reduced symptoms and improved social, occupational and family functioning for problems such as depression, domestic violence, alcohol use, and severe mental illness. CONCLUSIONS: This study shows that community-led interventions using volunteers from rural neighbourhoods can serve as a locally feasible and acceptable approach to facilitating access social welfare benefits, as well as reducing distress and symptoms of depression and anxiety in a low and middle-income country context. The intervention draws upon social capital in a community to engage and empower community members to address mental health problems. A robust evaluation methodology is needed to test the efficacy of such a model when it is implemented at scale.

Applying the triple bottom line of sustainability to healthcare research-a feasibility study.

OBJECTIVE: The triple bottom line (TBL) of sustainability is an important emerging conceptual framework which considers the combined economic, environmental and social impacts of an activity. Despite its clear relevance to the healthcare context, it has not yet been applied to the evaluation of a healthcare intervention. The aim of this study was to demonstrate whether doing so is feasible and useful. DESIGN: Secondary data analysis of a 12-month randomized controlled trial. SETTING: Community based mental health care. PARTICIPANTS: Patients with chronic psychotic illnesses (n = 333). INTERVENTION(S): Community treatment orders. MAIN OUTCOME MEASURE(S): Financial and environmental (CO2 equivalent) costs of care, obtained from healthcare service use data, were calculated using publicly available standard costs; social sustainability was assessed using standardized social outcome measures included in the trial data. RESULTS: Standardized costing and CO2e emissions figures were successfully obtained from publicly available data, and social outcomes were available directly from the trial data. CONCLUSIONS: This study demonstrates that TBL assessment can be retrospectively calculated for a healthcare intervention to provide a more complete assessment of the true costs of an intervention. A basic methodology was advanced to demonstrate the feasibility of the approach, although considerable further conceptual and methodological work is needed to develop a generalizable methodology that enables prospective inclusion of a TBL assessment in healthcare evaluations. If achieved, this would represent a significant milestone in the development of more sustainable healthcare services. If increasing the sustainability of healthcare is a priority, then the TBL approach may be a promising way forward.

A Systematic Review of Trauma Interventions in Native Communities.

American Indian/Alaska Native and First Nations communities suffer from health disparities associated with multiple forms of trauma exposure. Culturally appropriate interventions are needed to heal current and historical trauma wounds. Although there are evidence-based trauma interventions for other populations, few have been implemented or evaluated with Native communities. Understanding the extant research on trauma interventions in Native communities is crucial for advancing science and filling gaps in the evidence base, and for meeting the needs of underserved people. In this systematic review of the literature on trauma interventions in Native communities in the United States, Canada, Australia, and New Zealand, we identified 15 studies representing 10 interventions for historical and/or current trauma. These studies involved the community to some extent in developing or culturally adapting the interventions and suggested positive outcomes with regard to historical and interpersonal trauma symptoms. However, notable limitations in study design and research methods limit both internal validity and external validity of these conclusions. Only one study attempted (but did not achieve) a quasi-experimental design, and small sample sizes were persistent limitations across studies. Recommendations for researchers include working in partnership with Native communities to overcome barriers to trauma intervention research and to increase the rigor of the studies so that ongoing efforts to treat trauma can yield publishable data and communities can secure funding for intervention research.

Gathering Diverse Perspectives to Tackle "Wicked Problems": Racial/Ethnic Disproportionality in Educational Placement.

Among students receiving behavioral health and special education services, racial/ethnic minority students are consistently overrepresented in settings separate from general classrooms. Once separated, many young people struggle to improve academically and face significant difficulty upon trying to return to a general education setting. Given the complex, ongoing, and multifaceted nature of this challenge, racial/ethnic disproportionality can be identified as a "wicked problem," for which solutions are not easily identified. Here, we describe our community-engaged research efforts, eliciting perspectives from relevant partners in an ongoing dialogue, to better integrate diverse stakeholders' perspectives when attempting to address such disparities. We conducted focus groups and qualitative interviews with members of three stakeholder groups: community-serving organizations, individuals with lived experience of behavioral health conditions, and state-level policymakers, with a shared interest in addressing racial and ethnic disparities. Participant responses illustrated the "wickedness" of this problem and highlighted the need for additional supports for students, families, and school personnel, increased collaboration across relevant systems and agencies, and reduced barriers related to funding. Overall, this methodology bridged differing perspectives to develop, in concert with our partners, a shared language of the problem and a core set of issues to consider when seeking to effect change.