Healing Our Nation: State-Based Solutions For Connecting People to Mental Health Care and Addiction Recovery Services
People across the country are emotionally exhausted. The coronavirus pandemic and resulting economic downturn have precipitated fears of illness, job loss, and health insurance loss–all while keeping people apart. The latest national reckoning on racism, which came as no surprise to those who have always borne the weight of discriminatory policies and practices, only underscored the pressure of stress and oppression. In the face of these compounding forces, most kids, young adults, and adults are experiencing worsening mental health. Reported symptoms include anxiety, depressive episodes, and elevated stress, with some Americans reaching “chronic states of anxiety and stress.” Untreated substance use disorders are also on the rise, and localities are reporting concurrent increases in opioid-related mortality. Without intervention or support, rising mental health burdens will be the next epidemic to sweep the nation.
Though demand for mental health care continues to grow, the American mental health care delivery system is underprepared for response. Moreover, non-white communities weren’t equitably receiving needed care before the pandemic, and the current crisis continues to disproportionately impact the same populations; they include Black, Latinx, several Asian American and Pacific Islander communities, and Native American people, as well as those of us that have disabilities or experience homelessness. As investments, partnerships, and reform efforts build, it will be essential to focus on traditionally underserved populations. Successful, equitable efforts at the state and local levels must center their needs.
Even with serious budgetary concerns and no end to the pandemic in sight, states and localities are acting to address the impending national mental health crisis. Expanding virtual care, encouraging safety protocols to reduce the stress of working in high-risk locations during the pandemic, and addressing barriers to useful health coverage are just a few of the essential efforts that states, localities, and private organizations are implementing to improve access and save lives.
Building off of a framework from Well Being Trust, a partner of United States of Care dedicated to the mental health and well-being of the nation, USofCare is offering immediate and long-term strategies to address and alleviate mental health concerns in every community. It won’t be enough to address problems within the health care system alone; workplaces, early learning centers, schools and academic institutions, the justice system, and our communities all play an important role in delivering mental health and addiction recovery support services. Each of these pathways is facing pandemic-related capacity issues and, without swift action, this fragmented system will fail to meet people’s needs.
In the absence of comprehensive action at the federal level, states, localities, and private entities are seeking and implementing both well-established and innovative approaches to addressing people’s mental health care needs. Due to a fragmented system, lack of access to treatment, and discrimination, people are seeking treatment for mental health needs beyond traditional health care settings alone. States should develop policies that improve all five major entry points through which people access mental health and addiction recovery care, including:
- The Health Care System: States should require insurers to cover mental health and substance use disorder care before deductibles and without referrals, and radically expand access to medication, emergency overdose products, and other evidence-based treatment and recovery support services. Further, states can temporarily suspend some licensure requirements for telehealth care provision during emergencies (such as accepting licenses from other states), and continue to broaden scope of practice regulations beyond the pandemic. They should also enforce parity and consider payment innovation to expand access to psychological services through virtual and telephonic care.
- The Education System: States should target barriers to care by ensuring students can access resources when and how they are needed, especially as students’ routines–and their access to mental health services within schools–are disrupted. In the short term, crisis text and call hotlines are invaluable, as are stress-reduction efforts that account for the significant disruptions in care and routines. Looking beyond the pandemic, states and localities should make every effort to expand access to mental health care by offering virtual and co-located services, as well as outreach and engagement activities that shift the culture around seeking care.
- The Justice System: States should craft policies that prioritize the safety and support of justice-involved populations by suspending, rather than terminating, Medicaid for those who are incarcerated; expanding free mental health care resources, including telemental health, for those in incarceration; requiring correctional facilities to offer resources that support and improve mental health, including opportunities to connect with their families; and implementing reentry protocols that connect people leaving incarceration with resources, including medical coverage, social programs, and addiction recovery support.
- Our Workplaces: States should encourage and incentivize workplace programs that maintain worker mental health and physical safety, including accommodation of caregiving responsibilities and no-cost access to licensed therapists. Moving forward, states should offer state health coverage options (such as public options) that include mental health coverage, which could insulate workers from some of the turmoil and stress of job loss.
- Our Communities: States should weave mental health and substance use disorder screening into contact tracing solutions, and broaden public service announcements to explain available resources. Harm reduction must be emphasized in every approach; to that end, leaders should reconsider the role of policing in managing community mental health and substance use concerns. In particular, it may be useful to expand distanced or mobile services staffed by mental health professionals or peer recovery support specialists. And in the face of the crisis, every community must rapidly roll out crisis counselor training.
The pandemic is an unprecedented and collective event, exacerbating mental health needs and challenges to our wellbeing. We will need to work together to address the most pressing concerns, while laying the groundwork for long-term, systemic policy improvements.
The Health Care System
Nationwide, people seek out and receive mental health care from a wide range of settings, including primary care offices, hospitals, outpatient facilities, and community centers. Of them, most patients receive mental health care through their primary care provider. It makes sense that the health system is on the front lines of mental health care delivery; mental and substance use disorders are illnesses like any other, and people value integrated and accessible care.
Unfortunately, the health care system is under significant strain. Many states have limited ICU capacity for non-COVID-19-related illness, and health care organizations ranging from hospitals to community behavioral health organizations (CBHOs) have faced budget cuts, layoffs, and reductions in programs. Some hospitals have even resorted to using psychiatric beds for COVID-19 patients, reducing available beds for those with serious mental illness.
People want to know that the health care system will be there for them when they need it, including for mental health concerns and disordered substance use. All needs deserve to be met and addressed equitably–but mental health and substance use disorders demand particular attention because of their negative impact on adherence to therapeutic care plans, likelihood of employment, and quality of life. As the health care system bears significant cuts and reduced capacity, investment and innovation will be necessary to continue connecting people with needed services and treatment.
Numbers to Know
The National Burden:
- Half of American adults claim the pandemic has taken a negative toll on their mental health and Americans are reporting depression symptoms three times more than prior to the pandemic.
- There has been a 30% increase in U.S. suicide rates since 2005, including a 200% increase among girls 10-14. Death by suicide is the second leading cause of death for all youth ages 10-24.
Barriers & Failures:
- A third of adults with serious mental illness did not receive mental health treatment from 2017-2018.
- On average, one in four people in the U.S. must choose between getting treatment for mental health or paying for daily necessities.
- 42 percent of the US population note cost and poor insurance coverage as their top barriers to accessing mental health and addiction recovery services.
- Fewer than one in ten Community Behavioral Health Organizations believe they can continue to operate for more than a year under current conditions.
- Eliminate cost and time barriers to care by requiring insurers to cover mental health and addiction recovery services without cost-sharing or referrals. In an attempt to alleviate some of the serious cost burden of care during the economic and health crises, some insurers are temporarily extending all-member cost-sharing waivers; these include expanded in-network telephonic and virtual care for mental health and addiction recovery services; broadened networks to include new mental health clinicians through emergency credentialing processes; and donations to causes that provide and support mental health care. At a minimum, extending these efforts for the duration of the pandemic will be lifesaving.
- Address geographic and pandemic-related barriers to care by permanently expanding and requiring payment for telehealth services for treatment of mental health and substance use disorders. Due to the pandemic, many states took quick action to expand access to telehealth, including through Medicaid and other insurers. Many of these changes are explicitly tied to the national emergency declaration and are set to expire once the declarations are lifted. To keep these policies in place beyond the pandemic, states should codify these efforts and specifically refer to telehealth services for mental and substance use disorder treatment; Louisiana and Colorado have enacted legislation to this effect.
- Eliminate state and local regulatory barriers to medication, emergency overdose products, and other evidence-based treatment and recovery support services. Substance use disorders are worsening and killing more people as a direct result of the same crisis reducing access to direct care and supportive services–a perfect storm, and it’s only getting worse. To directly address the rising mortality rates, more states should consider issuing statewide standing orders to allow for the provision of naloxone and medication-assisted treatment without barriers like cost-sharing or prior authorization. And though there is risk involved in interacting with people so closely, first responders should be encouraged to continue to administer opioid overdose antidotes.
- Enforce and expand mental and physical health care parity laws. The impact of the pandemic on mental health, including disordered substance use, will far outlast the coronavirus. Unfortunately, despite efforts at the federal level, mental health care is often still not accessible or reimbursed at parity with physical health care. States are taking action–including Arizona’s reforms in partnership with the JEM Foundation and California’s recent successful legislative effort–but they could be doing much more.
- Incentivise and facilitate integrated care through new payment models that reward team-based care. Too often, mental health and addiction recovery care are not coordinated with the rest of a person’s health care, resulting in fragmented, expensive care experiences and measurably worse outcomes for patients. Expanding access to integrated care, including care provided virtually or telephonically, will improve outcomes.
- Broaden scope of practice regulations beyond crises. As the nation began to respond to the pandemic, many states suspended some licensure requirements for clinicians to aid in emergent COVID-19 care provision. Some, like Maine, also expanded telehealth options (and reimbursement requirements) for psychologists and social workers. As mental health care needs rise, an ‘all hands on deck’ approach will be essential; clinicians must be allowed to practice to the full extent of their abilities.
The Education System
Across the nation, students rely on schools to identify, address, and treat mental health concerns, as well as provide the social and community support to mitigate mental health problems. Most mental health issues begin in childhood, and youth are up to 21 times more likely to visit a school clinic for mental health services than a community-based one, underscoring the need to minimize disruptions and ensure access to school-based mental health services during the pandemic.
The need is significant and has been exacerbated during the COVID pandemic: as many as one in five primary and secondary students show signs of mental health disorders, rising to one in three in postsecondary programs, and the vast majority of those struggling have unmet mental health care needs. Students are even less likely to receive needed care if they are lower income or non-white. Students at every age are experiencing deteriorating mental health due to the disruptions caused by COVID, loneliness and social isolation, economic uncertainty, and more. In the starkest example, death by suicide has risen for years among children and young adults.
Because of the COVID pandemic, the American education system has been engaged in crisis response, as school and university closures impacted millions of students nationwide and schools are grappling with decisions about whether and how to re-open. As school closures/alterations and physical distancing measures continue on, state leaders must ensure there are adequate programs and services available for students who are experiencing elevated mental health needs and/or increased needs related to substance use disorders.
Numbers to Know
- 57 percent of the primary and secondary school students receiving mental health care receive it in a school-based setting.
- Over 6 million 12-25 year olds in the U.S. exhibited substance use disorders in 2018.
- About one in three university students reported that their academic work has been negatively affected by their poor or deteriorating mental health.
- Youth are three times more likely to develop depression in the future after experiencing isolation resulting from extended physical distancing measures.
- Create pathways for students and families, including those without internet access, to access care. Especially during the pandemic, online resources and remote services are essential to safely expanding access to mental health care for students who have been receiving mental health care services as well as those that will for the first time. As students enter altered or remote school schedules this year, it is important that those without access to reliable internet connections are still able to receive mental health and substance use disorder services. Schools can consider providing phone-based services in relevant languages and/or wifi hotspots and other necessary technology to students and families in need. This can help mitigate disruptions to routine for young children by continuing to provide care, albeit remotely.
- Create or connect students with crisis and care hotlines and youth-led places for support. Text and call hotlines centralize and streamline care across communities, and can provide a wide range of services ranging from resource triage to direct mental health aid. From Los Angeles, CA to Philadelphia, PA, school districts around the country are connecting hundreds of students and their affiliated adults with counselors and resources in locally-relevant languages. Schools can also provide students with opportunities to support one another in youth-led initiatives.
- Fund remote supportive programming, including online platforms that promote mental health. School support personnel (including counselors, nurses, and social workers) can be involved in providing remote lessons to kids that center on improving social and emotional skills in addition to the regular coursework they’re receiving. Well-constructed tools, such as Blue Shield & DoSomething.org’s New State of Mind and Johns Hopkins’ SilverCloud product, too, can be used to help students learn and practice coping strategies, as well as build community peer support.
- Address root causes of stress and anxiety by adapting education grading systems. Over 150 Universities and several school districts nationwide altered their grading systems early on to give students flexibility and reduce stress during the pandemic; continuing to adapt grading to accommodate students’ high-stress environments offers one small step toward alleviating pressure on youth mental health.
- Create and offer tele-mental health services for students and their families. In the long term, virtual care will continue to improve access across the U.S. From BlueSky in California to Universities in Michigan and North Carolina, students and their families are benefitting from remote counseling services.
- Offer services in locally relevant languages and through a culturally sensitive lens. Our schools are serving ever-more ethnically and linguistically diverse populations. It is critical to offer cultural and linguistic adaptations for care services to best meet the needs of students.
- Co-locate and integrate mental health care and social services with education system services wherever possible, and seek to meet youth where they are. In efforts to improve care delivery while lowering costs, school districts and universities will need to consider innovative approaches and prioritized investments to continue delivering social services and addressing care needs. Some community health centers are finding that the pivot to remote services is improving care delivery and access, as it allows them to more easily (digitally) meet with families and accompany children to meetings with educators: an approach worth replicating, where possible.
The Justice System
People living with mental health concerns and substance use disorders are increasingly sent to jail rather than sent to appropriate places they can receive care. As a result, the judicial system is one of the five major pathways through which people receive mental health care; nearly half of municipal, state, and federal inmates have mental health issues, and an overwhelming majority of those people also have a comorbid substance use disorder.
Despite the significant need, many do not receive essential care and jails and prisons are generally disconnected from the broader health care system. The pandemic is shining a harsh light on the many cracks that exist within the judicial system’s mental health care infrastructure–all while adding additional strain on resources and justice-involved populations. These compounding issues require immediate action from states and localities.
At the same time, states, counties, and local governments have a pressing duty to address the long-standing issues in the judicial system’s mental health care delivery. Too many Black and other people of color continue to be targeted by the American policing and justice system. Intentional reform will be essential to change. And as prison and jail populations fall in response to COVID-19 precautionary court closures and early releases rise, states and localities must improve the reentry process for those leaving incarceration. After serving time, people often experience a lack of linkages to health care coverage, mental health care services, and other critical safety net programs they rely on to stay safe and connected to their community.
Number to Know
- About a quarter of men and a third of women booked into jails have serious mental illness–about three to six times the prevalence in the general population.
- Due to living in such close quarters and having a high prevalence of underlying conditions, people who are incarcerated are more likely to become infected with the coronavirus, and are more likely to experience complications if infected, driving the need for states to develop immediate solutions.
While longer-term structural changes also need to be made, states can take action now to improve the mental health care people receive through the justice system, including in the following ways:
- Suspend, rather than terminate, Medicaid for those entering incarceration so coverage can easily be activated upon an individual’s release. Reconnecting individuals to coverage more easily allows them to access the mental health care services they need. While many states have enacted policies to do this, many have yet to do so–and states that have implemented these policies must still address the technological and other barriers to making this policy work as intended. States can make these changes legislatively or administratively.
- Improve reentry programs. Establish programs that enable corrections staff and probation/parole officers to better assist with successful reentry, including for the many people reentering who have mental health and substance use disorder issues. This includes connecting those leaving incarceration to health coverage and care, mental health and substance use disorder treatment, and the other social and supportive services needed to thrive. States can seek funding from the federal government for many of these initiatives.
- Emphasize and prioritize mental health interventions. For correctional facilities the state oversees, offer supportive mental health practices to help with heighted mental health issues arising due to the pandemic, such as increased out-of-cell time, free phone calls, and virtual visits with family members (especially as some systems increase solitary confinement in an attempt to slow infection rates), similar to efforts being taken by The Pennsylvania Department of Corrections.
States can build on the progress they make through immediate action by taking action that is aimed more broadly at improving the structural inefficiencies that many people within the judicial system experience. These changes will take time, but are essential, and include:
- Expand access to care for justice-involved populations. Prioritizing the safety and support of the justice-involved population by expanding access to mental health care resources and programs, including virtual mental health services. New York City’s Rikers Island Jail, for example, has demonstrated promising results from working closely with a large local safety net health system (NYC Health & Hospitals) to stand up a telemedicine pilot program. Structural changes, additional resources, and technology are needed in order for these services to be appropriately paid for and services provided on a larger scale, and this needs to paired with policies aimed at expanding access to in-person mental health care more broadly as well.
- Improve access to quality care for justice-involved populations. The mental health care provided to inmates is in need of significant improvement. While individuals in prisons receive hospital care outside of the prison setting, the care (including mental health care) provided to people through the corrections system is inadequate; many go without needed mental health care altogether.
Our Workplaces & Unemployment
The economic impact wrought by the COVID-19 pandemic has been devastating. Private and public organizations are straining to keep their doors open under the weight of the losses, and employees are facing increased risk of depression and burnout–the majority of whom will go without diagnosis, treatment, or support. When polled, most employees do not feel their employer offers adequate resources to address mental well-being, even though half of employers report offering additional emotional health support during the pandemic. And while job-connected insurance is the most common form of health coverage in the U.S., states are powerless to legislate on the coverage requirements of self-insured plans (which are federally regulated). Absent federal action, employers must recognize their role in and impact on the mental health of their employees, and do everything in their power to mitigate both the short- and long-term mental health burdens of the pandemic.
Unemployment rates are hitting historic highs and, with these job losses, millions of people have lost their job-connected insurance. Those who experience job loss are at elevated risk of mental health concerns, including substance use disorder (SUD) and suicide. In our current system, employers play essential roles in care, and must prepare now for the coming wave of serious mental health concerns.
Number to Know
- One in three workers report experiencing symptoms of depression during the COVID-19 pandemic.
- Only 7 percent of employed people have reached out to a mental health professional during the pandemic.
- Some positions–especially unpaid labor–have much higher mental health burdens than others. Thirty percent of unpaid caregivers for adults reported seriously considering suicide in June, and most reported at least one mental health concern.
- Mental health conditions cost an estimated $400 billion dollars in lost productivity annually (through reduced performance and absenteeism, among other pathways).
- Ensure and promote workplace safety. Working during the pandemic is challenging for everyone, but especially low-wage essential workers–the vast majority of whom cannot work from home. High-risk workplaces that cannot operate remotely can alleviate some of the stress of potential exposure to the coronavirus by promoting safe workplaces, which may include: providing additional protective equipment resources; implementing extensive infection prevention measures, including staggered, smaller work shifts and new ventilation installation; and communicating clear procedures for identifying and isolating potentially ill coworkers, including flexible leave policies that do not require positive diagnoses or doctors’ notes, which may be difficult to obtain on short notice.
- Encourage employers–especially those employing front-line workers–to provide access to licensed therapists, mental health care, and addiction recovery resources without cost sharing. Clinicians, grocery clerks, transit workers, and other ‘essential’ workers are all at a higher risk of contracting COVID-19 due to their high-exposure roles. As the pandemic stretches on and continues to take a toll on people’s mental health, expanding access to confidential, no-cost mental health care, support systems, and resources–and normalizing their use–will be evermore valuable for the wellbeing of the U.S. workforce.
- Support health coverage enrollment assistance. Given the current upheaval in employment and the complications of selecting and enrolling in health insurance programs in normal times, state-funded impartial navigators that connect people to coverage are essential. Navigators are proven to be particularly effective connecting low-income, Black, and Latinx people with coverage: essential during a crisis that is disproportionately impacting these communities. As the federal government has dramatically reduced funding for navigation programs, state and local investments are ever more important.
- Require paid family leave and other accommodations for caregiving duties. Paid family leave and other family care plan benefits are essential for wellness, especially during the pandemic. Some corporations, like Target, have waived eligibility requirements and copays to allow employees access to a backup family care benefit plan. Many states have mandated employer provision of paid family leave to employees unable to work due to COVID-19, and some even offer Paid Family Leave to those receiving less than 14 days of paid leave for quarantines.
- Consider rolling out a state coverage option, such as a public option or a Medicaid buy-in program. If a worker receives employer-sponsored insurance, job loss is accompanied by the increased stress of the loss of health care coverage. This is often an untenable burden, particularly during the pandemic. Offering options that separate employment from coverage will only improve stability and continuity for peoples’ health care. So far, only Washington has passed a state coverage option, though Colorado and Connecticut have seriously considered one.
People across the U.S. need more than just access to care–we deserve communities that build collaborative, cross-sector efforts to improve our health outcomes. Community-wide issues include stigma and discrimination; integrated, accessible provision of social services; and training and standards for rapid responders. In particular, many localities are reconsidering the role of policing in their communities–and some are investing in other urgent and emergent response teams that are specifically trained to support those with serious mental illness.
As care providers consider and develop solutions within their areas of expertise, the pandemic continues to exacerbate disparities across the fragmented mental health care delivery system. It will be ever more important to integrate mental health care and addiction recovery services. We all have a role to play.
Numbers to Know
- Mental health conditions are the leading cause of disability in the U.S., and half of adults will meet the criteria for a mental health condition in their lifetime.
- The average delay between onset and treatment of the symptoms of anxiety, mood, and substance use disorder symptoms health symptoms is 8 to 11 years, underscoring the value of early outreach and intervention.
- At least one in four of all fatal police encounters in the U.S. (and 10 percent of all law enforcement encounters) involves a person experiencing serious mental illness. Adults with SMI are 16 times more likely than other civilians to be killed in an encounter with the police, though they’re no more likely to be violent than anyone else.
- Weave mental health, substance use disorder, and other social need screening into contact tracing efforts. Implementing an integrated care response at this level will be complex and require significant coordination–and will save lives. Large municipalities across the U.S. are using contact tracing and supported isolation efforts to deliver social services; Massachusetts’ collaborative contact tracing effort has served hundreds of people so far. It’s possible and effective to reach out to community members to simultaneously address medical and social care needs.
- Support crisis counselor training and staffing efforts, and continue to integrate mental health and addiction recovery services into broader health care efforts, including the pandemic public health response. Benefitting from FEMA major disaster declaration funding and other federal grant support, most states rolled out crisis counselor support during the beginning of the pandemic. Many localities, like King County, Washington, also wove emergent mental health interventions and substance use disorder care into their supported isolation efforts.
- Double down on public service announcements and awareness campaigns to ensure people have access to available resources. In the face of the crisis, states across the U.S. are continuing to promote awareness of mental health and addiction recovery resources; two are New York and Indiana.
- Integrate social services, and build platforms that coordinate social and medical care solutions. Some communities benefit from a rich thicket of resources, but become complex to navigate for those who require their services. New York City has several organizations, including Public Health Solutions and AIRnyc, that seek to coordinate and improve mental health care, addiction recovery services and social services delivery. Efforts like these enable people to safely physically distance while still receiving necessary care–essential when trying to protect people during a pandemic while continuing to provide supportive services.
- Invest in explicitly-designated mental health urgent responders. Police forces are tasked with–but not equipped for–responding to people experiencing mental health crises. As mental health and substance use disorder crises rise with the continued economic and broader health crises roiling the nation, our communities must seriously reconsider the role policing has in responding to non-criminal situations. Communities in Massachusetts, Georgia, and Washington are rolling out and expanding crisis mobile services staffed by mental health professionals; it’s past time for these teams to be centered, empowered, and offered independent of policing efforts.
Caring For All of Us
The coronavirus pandemic has taken its toll on us all–but those bearing the brunt of the crisis have long been failed by our health care, justice, education, and vocational systems. The pandemic, paired with a steep economic downturn and a national reemphasis on combating racism, has exposed discriminatory systems and practices, inequitable legacies and policies, and countless other barriers that limit people from accessing the mental health services necessary for their best possible quality of life.
This moment of crisis and its cascading effects have brought the failures of our systems to the center of the national conversation. To move forward, we must target and prioritize efforts that improve care and services for the people who have historically been failed by–and continue to face discrimination in–our systems and safety nets. Though each system will require different targeted actions and implementation efforts, there are best practices that apply across delivery systems.
Grappling with the pandemic and its impact is going to take some time; as our communities respond and rebuild, it is important to use this opportunity to center peoples’ needs, rethink our investments, and build more equitable systems.
Key Actions for Equitable Solutions:
- Define and understand the impact of discriminatory systems and policy choices:
- Collect data and stories on experiences to identify disparities, analyze trends, and pinpoint effective interventions. Make de-identified data and research publicly available whenever possible so outside experts can also identify patterns and offer insights.
- Center people that the reforms intend to serve in the decision-making processes in order to best understand their real challenges and needs; success can only be realized if those facing the problems are invited to the table.
- Directly meet immediate needs of those affected with integrated mental health and addiction recovery solutions:
- Integrate screening and connections to health resources into the provision of housing, food support, educational spaces, and emergent care responses.
- Emphasize harm reduction in every effort; personal and community health are the ultimate goal.
- Continue to target root causes and systemic issues wherever possible:
- Treat mental health issues and substance use disorders as medical concerns influenced by social factors, rather than criminal actions. Deprioritize policing and criminalization as response methods, which often disproportionately target people of color, and reduce reliance on the justice system for managing serious mental illness. Create and invest in other pathways for crisis de-escalation and community safety.
- Ensure the provision of culturally and linguistically-appropriate services by encouraging care providers to collaborate with community organizations and Native American tribes that have the expertise, staffing, and programs needed to effectively engage their respective populations. Resources should be allocated to develop these relationships.