Proceedings of a Workshop—in Brief

Convened July 1–2, 2025

Enhancing Care and Services for Mental Health and Substance Use Disorders

WELCOME AND OPENING REMARKS

The Forum on Mental Health and Substance Use Disorders¹ convened a virtual workshop, Enhancing Care and Services for Mental Health and Substance Use Disorders, on July 1–2, 2025. The workshop examined how health and human services structures influence mental health and substance use disorder outcomes, particularly in communities with limited access to care. Over two days, it featured six sessions with subject-matter experts addressing definitions of structural determinants of health (SDOH), approaches to operationalize them, the role of community voices, strategies for education and workforce development, financing and accountability policy, and considerations for building a future-ready framework.²

Forum member Benjamin Miller (Stanford University, School of Medicine) opened the workshop by calling for a deeper, more accountable approach to address SDOH. He introduced the concept of “SDOH 2.0,” framing it as a shift from passive acknowledgment to active transformation. Miller described SDOH as the broad range of non-medical factors that influence health outcomes, including housing stability, food access, transportation, and other conditions shaped by policy, infrastructure, and social systems. He referenced George Engel’s biopsychosocial model³ and noted that while “we’ve done a phenomenal job of articulating the problem, we’re still very much in a space where we’ve not figured out how to fix the systems that keep people from accessing what they need.” Miller acknowledged the value of SDOH 1.0 when identifying factors like housing, food insecurity, and transportation, especially as they shape people’s ability to access and benefit from care and services for mental health and substance use disorders. However, he emphasized that “recognition doesn’t equal reform,” and most systems are still stalled at the stage of screening and referrals.

Miller referenced the 2019 National Academies of Sciences, Engineering, and Medicine consensus study report Integrating Social Care into the Delivery of Health Care, which offered recommendations as a framework for progress and described this workshop as an opportunity to explore “the hard truths about why we haven’t seen progress.” He encouraged speakers to consider potential paths forward as recommended in the report and emphasized community partnership, greater accountability, and more coordinated structural investment (NASEM, 2019).

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He noted that workshop discussions would tackle both barriers and opportunities in improving the behavioral health care continuum—with the goal of highlighting infrastructure gaps, economic pressures, intersectoral fragmentation, and the need for long-term policy change to sustain prevention, treatment, and recovery at scale.

ADVANCING STRUCTURAL DETERMINANTS OF HEALTH

Danielle Hessler Jones (SIREN Network, University of California, San Francisco)⁴ opened the first session by introducing its objectives, which would focus on setting the context for understanding the landscape of SDOH. She framed the discussion as an opportunity to unpack how these determinants are defined, measured, and prioritized across research, health systems, and communities. Hessler Jones emphasized that while the concept of structural determinants has gained traction, there is still some ambiguity in the field around the terms used, particularly regarding operationalization and accountability. She added, “We use terms like ‘upstream’ and ‘structural,’ but we don’t always take the time to define what we mean or acknowledge the diversity of perspectives and lived experience that shape these definitions.” Hessler Jones encouraged speakers and attendees to explore how decisions about evidence gathering and priorities are shaped by policies, funding, and perspective.

Rishi Manchanda (HealthBegins) outlined a multilevel approach to addressing structural determinants, encouraging the field to move upstream from individual-level interventions to systemic transformation. He emphasized the importance of structural competency—not only cultural awareness or social needs screening but the ability of health care systems and care providers to recognize and respond to the broader structural forces that create barriers to care, such as fragmented service systems, lack of structural alignment, and limited power-sharing between institutions and communities.

Manchanda shared a case study from HealthBegins illustrating how integrated clinical–community partnerships and multi-level strategies to advance health equity can shift institutional practices (Manchanda, 2023). He challenged conventional thinking around return-on-investment frameworks and advocated for a “blended values” approach—expanding traditional financial or economic measures to integrate social returns, offering a more holistic understanding of system impact (Bugg-Levine, 2011). He also discussed the limitations of pilot projects or one-off interventions, arguing that portfolio-based strategies and cross-sector partnerships offer more sustainable pathways to structural transformation. “We don’t have a shortage of innovation—we have a shortage of structural alignment and power-sharing,” he said. Manchanda encouraged attendees to see communities not just as sites of need but as co-designers and co-investors in the transformation of the health care system.

Donna Washington (University of California, Los Angeles) shared insights from the Veterans Health Administration (VHA), one of the largest integrated systems in the United States, where systematic social needs screening and tailored care models have been implemented at scale. She emphasized the importance of conceptual frameworks that address both proximal and upstream determinants of health and described how such frameworks are used to inform VHA policy, quality improvement efforts, and equity-focused interventions. Washington called attention to disparities in patient experience, particularly among those with substance use disorders, and noted that more rigorous data are needed to develop and refine assessment tools that can better identify and address such inequities. Washington also highlighted the VHA’s efforts to embed social services, such as housing supports, directly into care delivery models to better serve veterans experiencing homelessness.

Len Nichols (Urban Institute) traced the historical arc of U.S. social policy, noting a departure from early integrated approaches like those of Jane Addams⁵ that addressed health and social conditions simultaneously. He argued that health care and social services have become siloed, particularly for mental health and substance use care, leading to fragmented services that often fail to meet people’s full needs. Nichols emphasized the need to “reconnect the dots” through more deliberate integration. He proposed treating interventions to address social determinants as public goods and advocated for collaborative financing strategies that recognize shared value across sectors.

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Following the panelists’ presentations, Hessler Jones opened the discussion by asking panelists to imagine a future where “SDOH 2.0” is a reality and to reflect on the key actions that would lead to that future. Washington emphasized the importance of long-term, trust-based partnerships between health care systems and communities, particularly those addressing national populations like Veterans. She called for sustained cross-sector collaboration, not short-term or fragmented efforts.

Nichols underscored the role of personal relevance in policy change, suggesting that meaningful structural reform often follows when decision makers have a personal concern, such as a family member in need. He cited the shift in opioid use policy as an example, noting that amid the crisis’s growing impact on white, suburban, and politically influential communities, the national response moved away from punitive measures toward greater emphasis on treatment and prevention, illustrating how public empathy and action can change when problems affect more influential populations. Nichols proposed creating a “council of social work advisors” to elevate the voices and stories of social workers and bring public attention to social needs. Manchanda argued for a fundamental shift in the narratives that guide social policy (Manchanda, 2022). He critiqued conventional, individual-focused approaches, such as the “teach a man to fish” metaphor, that place responsibility on individuals without addressing systemic barriers that shape opportunity. In contrast, he advocated for moving from a charity-based model toward a justice-based framework that views access to resources and opportunities as individual rights and a systemic responsibility.⁶ Referencing Seth Berkowitz’s book (2024), Manchanda called for reimagining the welfare state as essential for creating equitable health outcomes, emphasizing that viewing social supports as entitlements—not charity—could shift political and institutional priorities.

In response to an audience question about aligning efforts to address social and structural determinants of health with community health needs assessments (CHNA)⁷ by nonprofit hospitals, Washington referred to publicly available data sources like the County Health Rankings. She also noted newer frameworks, such as the VHA’s ACORN⁸ and the Health Equity Implementation Framework (Woodward et al, 2019), which highlight structural factors such as housing, economic stability, and transportation access. Nichols argued that CHNA requirements are insufficiently action-oriented and should extend beyond hospitals to broader community collaboration. Manchanda added that the fragmentation of assessments across hospitals, health plans, and jurisdictions burdens communities. He suggested aligning these processes and elevating them from compliance tasks to strategic tools, referencing California’s efforts to harmonize Medicaid assessments as a model.⁹

Nichols stressed the need to remove policy constraints—such as restrictions on using health care funds for non-medical services, limitations in reimbursement, and siloed funding streams—that limit health care organizations from investing in social needs. Washington advocated for richer, multilevel data collection to better reflect community realities, including variations in social needs, disparities in patient experience, and structural factors like housing, economic stability, and transportation access. Manchanda introduced a framework of “resources, rights, and relationships,” emphasizing the need to shift from screening-first approaches to resource-first care, adopt a rights-based service delivery model, and strengthen both interpersonal and institutional relationships to support health equity.

Moving Forward

The first session closed with Terri Tanielian (Bluebird Road Advisors), who began by sharing her professional trajectory, from school-based counseling to policy development in the White House, highlighting a consistent theme: the need to address environmental and structural factors influencing behavioral health outcomes. She helped craft and implement the first-ever

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White House strategy on mental health and substance use, which aimed to transform care delivery through a comprehensive, whole-of-government approach.¹⁰ Its three pillars included: (1) building system capacity, (2) connecting individuals to care through integrated settings and improved coverage, and (3) fostering supportive environments with prevention and recovery supports. She emphasized the need for a “North Star” vision that centers on enabling all communities to thrive, which includes not just access to services but also safety, economic opportunity, housing, and social connection.

Drawing from her federal experience, she reiterated that mental health cannot be addressed in isolation because it intersects with immigration, education, justice reform, and economic policy. Tanielian noted that while meaningful progress has been made, the political and fiscal climate, marked by shifting policy priorities, budget constraints, and competing demands on federal and state resources, poses risks to discretionary programs and could exacerbate workforce challenges. However, she also framed this as a “blank slate” moment, suggesting that leaders across sectors have a rare opportunity to rethink policy and funding structures. She emphasized the need for pragmatic tools, such as implementation checklists, sample policy language, and data dashboards, to support implementation at state and local levels, noting that policy blueprints can complement academic frameworks in advancing the work. Tanielian also pointed to advocacy, interagency accountability, and cross-sector collaboration as key levers for sustaining momentum.

She expressed particular concern for the future behavioral health workforce, citing challenges in sustaining recruitment and retention, as well as the stability for funding for opioid-related prevention, treatment, and recovery services. Tanielian concluded by highlighting the importance of viewing behavioral health as interconnected with broader social systems and urged participants to “seize the moment” to align strategies, investments, and values across sectors.

OPERATIONALIZING STRUCTURAL DETERMINANTS OF HEALTH

Miller opened the second session by highlighting developing legislation that would cut Medicaid, the Supplemental Nutrition Assistance Program (SNAP), and Affordable Care Act (ACA) subsidies, framing these developments as a vivid example of how upstream policy decisions can influence health equity. He emphasized that structural determinants are not abstract concepts but are embedded in funding choices, eligibility rules, and benefit designs. Miller encouraged participants to move beyond improving individual programs and examine the root causes that contribute to health inequities. He described the session’s focus on operationalizing structural determinants as an opportunity to move from identifying problems to considering how they might be addressed in practice, reminding participants that “naming the problem is not the same as disrupting it.”

Donna Lynne of Denver Health described the organization’s extensive social services infrastructure, underscoring its role as a large, urban safety net system that integrates housing, transportation, and addiction services into health care delivery. She noted the growing homeless population in Denver and explained how the local health care system has responded by investing its own resources into transitional and recuperative care housing (programs that provide shelter and support for medically stable patients experiencing homelessness). Lynne also described Denver Health’s Center for Addiction Medicine as well as its efforts to leverage electronic health record data to identify housing instability. Lynne acknowledged concerns about future funding constraints and noted the importance of maintaining investments in social supports.

Bianca Faccio (Sasha Bruce Youthwork, Inc.) spoke about her organization’s work with youth experiencing homelessness and behavioral health challenges. She detailed their multipronged service model, which includes drop-in centers, transitional housing, and trauma-informed supports designed to meet the complex needs of young people. In Table 1, Faccio shared internal data showing high exit rates, referring to successful transitions out of their residential program, to positive destinations (e.g., permanent housing, securing employment, reunification with family) but pointed to a shortage of behavioral health care providers in Washington, DC, particularly those trained to work with youth. She advocated for a greater role for Medicaid with funding in-house cli-

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TABLE 1
Exit Destinations from Sasha Bruce Youthwork Residential Program (FY24)

NOTE: *Other includes self-discharge where the Sasha Bruce Youthwork staff does not know where the client went or terminations.

SOURCE: Bianca Faccio workshop presentation, July 1, 2025. Percentages updated September 3, 2025.

nicians and outlined administrative and financial barriers that small nonprofits face in becoming Medicaid providers, such as lengthy enrollment and credentialing processes, upfront costs for billing and compliance systems, and delays in reimbursement.

Adrianna Nava (National Committee for Quality Assurance [NCQA]) discussed ongoing efforts to embed structural and social determinants of health into national quality measurement. She explained that NCQA is the country’s largest health plan accreditor and is leveraging its Health Equity Science Center to realign metrics and incentives to promote health equity. Nava described NCQA-led initiatives to develop tools that support sustainable partnerships between health systems and community-based organizations, noting that quality measurement should reflect real-world conditions and relationships. These efforts, connected to NCQA’s Health Equity Accreditation programs, address structural factors such as housing instability, food insecurity, and transportation access, and are paired with measures for social needs screening and intervention. She emphasized that disaggregated data and structural accountability are necessary for meaningful progress.

During the panel discussion, Lynne expanded on Denver Health’s use of mobile health units and school-based clinics to reach communities directly, particularly in under-resourced neighborhoods. She noted that telehealth has also expanded Denver Health’s ability to connect patients to behavioral health and primary care services without the need for travel, offering a vital link for those in geographically isolated areas or facing transportation barriers. She emphasized the importance of sustained, flexible funding to support these efforts and acknowledged the difficulty of making the financial case for social interventions in the absence of clear reimbursement pathways. Faccio spoke about limitations that small community-based organizations face when trying to bill Medicaid, citing administrative burdens and restrictive funding criteria. She also emphasized the importance of incorporating youth voices into program design and evaluation to ensure services reflect real needs.

Nava stressed that quality measurement should go beyond patient-level indicators to assess structural conditions and noted ongoing efforts to bring community priorities into the quality measurement process. She emphasized that metrics should reflect what matters to communities, not only what is convenient to measure, and that advancing health equity requires investment in structural accountability as well as individual outcomes. Faccio reinforced the importance of trust and collaboration between health systems and community-based organizations, particularly in efforts to engage marginalized youth. Lynne echoed this sentiment, underscoring that partnerships with schools, housing providers, and other sectors are critical for addressing the full scope of health needs.

COMMUNITY VOICES AND IMPLEMENTATION REALITIES

Ruth Shim (University of California, Davis) opened the third session with reflections on the limits of expert-driven models, citing Donovan X. Ramsey’s When Crack Was King (2023) to illustrate how systemic change has often emerged from within communities rather than institutions. She emphasized that improving mental health outcomes requires empowering and resourcing communities to address unmet needs, while acknowledging that professionals and policymakers still have important roles to play. Shim introduced the session’s objectives, which

focused on how communities can meaningfully engage in shaping behavioral health systems.

Keris Myrick (Inseparable) encouraged a shift in behavioral health systems to better align with what communities value rather than what payers prioritize. Drawing on her own lived experience and long-standing advocacy, she highlighted ongoing challenges related to autonomy, respect, and culturally responsive care for individuals diagnosed with serious mental illnesses. Myrick expressed concern that Housing First, despite being an evidenced-based approach, has seen limited adoption and questioned why structural barriers, like food swamps¹¹ and targeted alcohol marketing persist in marginalized communities. She stressed the importance of a whole-person public health approach, which she described as addressing structural barriers alongside the full range of social, economic, and health needs of individuals and communities. She advocated for more upstream investments that consider the “long-term impacts of systemic issues such as racism and ableism.” Myrick emphasized that metrics, funding, decisions, and system design should reflect community input and priorities, not institutional convenience or historical present.

Alex Briscoe (Public Health Alliance) discussed how reimbursement structures influence system behavior and underscored the importance of recognizing how community-based organizations (CBO) can be used to expand participants in the health care ecosystem. He described how Medicaid State Plan Amendments can be used to expand the care provider pool to include nontraditional health workers, such as peers, doulas, wellness coaches, and community health workers. Briscoe noted that while expanding eligibility is an important step, many CBOs face practical barriers to participation, including limited access to electronic health records, billing infrastructure, and other administrative tools required for reimbursement. He highlighted emerging intermediary models in California and other states, like the Justice Serving Network, designed to support CBOs by centralizing administrative functions and facilitating direct engagement with payers.

Seth Berkowitz (University of North Carolina, School of Medicine) described the Healthy Opportunities Pilot (HOP) in North Carolina, launched under a Medicaid 1115 waiver.¹² HOP created a network of CBOs delivering health-related social services through a hub model. Berkowitz explained that centralized entities provided technical assistance, a shared IT platform, and invoicing infrastructure. He cited participation by more than 150 organizations across three regions, along with integrated system design, sustained capacity building, and consistent regional coordination as indicators of the program’s early success.

Shim opened the discussion by noting how stigma toward peer specialists is reinforced by paternalistic attitudes within the clinical care provider community, such as undervaluing contributions or limiting autonomy within care teams—a dynamic she has encountered in practice. She pointed to power imbalances between peer specialists and clinicians as a contributing factor in these dynamics. Myrick expanded on the challenges that peer-led organizations face in achieving parity, noting that some are perceived as “anti-treatment,” particularly regarding the use of medication in recovery. She explained that attitudes toward medication treatment vary across peer-led organizations as well as among individuals and are not always aligned with national guidelines or best evidence. Many peer-led organizations take a treatment-agnostic approach that supports a range of recovery pathways rather than adhering to a single model. She called for greater investment in education and technical assistance to help individuals with lived experiences to navigate complex systems, such as Medicaid and the U.S. Department of Housing and Urban Development.

Shim asked Myrick what it would take to shift perceptions of peer specialists and support their involvement in leadership. Myrick responded that intentional investment is needed along with accessible training to ensure peers are equipped to engage in systems-level decision making. Briscoe followed by sharing an example from California’s effort to create four new nontraditional provider types, with an initial goal of hiring 25,000 individuals. He noted

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that, in practice, only about 1,000 people were employed, pointing to challenges in integrating new workforce models into existing health care structures, particularly when resources are limited. Briscoe suggested that more attention could be placed on investing in nontraditional health care settings, which may offer more flexibility and openness to innovative, community-based approaches.

Shim then asked Myrick how historical community practices could inform future models of care. Myrick reflected on a Black Panther Party Museum exhibit in Oakland, California, and described how the group’s mutual aid and survival programs from the 1960s and 1970s offered valuable templates for current efforts like free breakfast programs for children and community health clinics. “Systemic racism and neglect are not new,” Myrick stated, emphasizing that historically marginalized communities have long developed creative solutions (e.g., Black Panther Party’s survival programs) in response to unmet needs. She called for reimagining care models that are currently constrained by traditional systems, drawing on examples of mutual aid, education, food security, and trauma-informed supports.

Shim asked panelists to share their thoughts on how to move beyond discussion into meaningful action. Berkowitz emphasized the role of power and political organization in holding decision makers accountable for systemic underinvestment. He argued that issues such as mental health, substance use, food insecurity, and housing instability are often mischaracterized as individual failings rather than structural problems. Reframing these as systemic challenges, he said, creates space for institutional reform. Briscoe outlined five specific actions: (1) pursue institutional reform, (2) eliminate diagnosis as a prerequisite for care, (3) designate schools as essential community providers, (4) allow caregivers to access mental health services through their children’s coverage, and (5) match all non-federal spending. Myrick discussed current reforms like 988 Lifeline and crisis response redesigns, which aim to reduce law enforcement involvement in mental health crises. While acknowledging their potential to improve crisis intervention and reduce reliance on law enforcement, she cautioned that these are reactive measures or tertiary prevention efforts that respond after a crisis has occurred rather than primary prevention. She called for upstream interventions to prevent crises, quoting Desmond Tutu, “There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in.” She also stated concerns about coercive approaches, such as involuntary treatment, especially in states where basic needs like housing remain unmet.

During the audience Q&A, a workshop participant, David Hamilton, asked about the impact of Medicaid cuts on CBOs. Briscoe noted that CBOs are low-cost and still well-positioned to play a critical role. Berkowitz added that the scale of federal funding is difficult to replace and cautioned against assuming that non-federal sources could fill the gap. Shim cited Black maternal health as an example where traditional systems have fallen short, while community-based approaches—such as midwifery and birthing centers—have demonstrated better outcomes. She suggested similar potential exists in mental health care.

Another workshop participant, Eric Gibson, asked about the role of faith-based groups. Myrick shared two examples: a past example in which Black patients received medical care at a church during segregation which functioned as an integrated care model that bridged mental health care services, community assistance, and social welfare while demonstrating the power of community-rooted health solutions (Doyle, 2009). A more recent example involved a Catholic diocese repurposing a facility into a multipurpose community center and gym, offering spiritual connection, cultural activities, recreation, and support for mental health and substance use. Briscoe cited National Institutes of Health research showing that over 70 percent of drug and alcohol treatment programs include spirituality (Grim and Grim, 2019). Shim referenced the work of Dr. Sidney H. Hankerson, who has researched the role of churches as mental health hubs, particularly in Black communities (Hankerson et al., 2013). Myrick added that trusted community spaces—like churches, barbershops, and salons—can be leveraged for support, suggesting a shift toward meeting people where they already are.

Stephen Fry, a workshop participant, asked about expanding peer support services. Myrick stressed the importance of valuing and fairly compensating peer sup-

port specialists. She also highlighted the need for trained and credentialed supervisors who understand peer support. Myrick encouraged states to enable certified peer specialists to supervise others and to support peer-run organizations in becoming Medicaid site certified. She concluded that Certified Community Behavioral Health Clinics (CCBHC)¹³ can incorporate peer leadership within their organizational structure while meeting Substance Abuse and Mental Health Services Administration’s federal standards, as well as any applicable Medicaid certification requirements, which include delivering the full range of CCBHC services. While peer services are required but other services, including primary care screening and outpatient mental health care, are generally peer-supported rather than entirely peer-run.

REFLECTIONS

Octavio N. Martinez (Hogg Foundation for Mental Health) and Halaevalu Vakalahi (Council on Social Work Education) summarized discussions from first 3 sessions, which emphasized the following key takeaways:

• Shift from describing to addressing structural determinants of health through upstream policy reform (e.g., Integrating Social Care into the Delivery of Health Care report, Housing First)
• Build data infrastructure, ensure interoperability, and coordinate across sectors to address fragmentation and strengthen accountability (e.g., County Health Rankings, NCQA Social Need Screening and Intervention Measure, Health Equity Accreditation Plus)
• Strengthen community partnerships, leverage trust in CBOs, and incorporate people with lived experience (e.g., community-health partnerships, Black Panther Party survival programs, Catholic diocese multipurpose center)
• Provide culturally responsive care that reflects the needs of various populations
• Recognize health and mental health as human rights and move from awareness to advocacy to inform policy and practice
• Offer opportunities for healing in nontraditional spaces such as community centers, faith-based institutions, and libraries
• Reimagine care to support the wholeness of people, families, and communities, using a “blank piece of paper” approach to design a more equitable system

EDUCATION, TRAINING, AND THE WORKFORCE PIPELINE

Vakalahi began the fourth session by affirming the field’s shared commitment to lifelong learning and the need to build a strong, future-ready behavioral health care workforce. She emphasized the session’s focus on education, training, and the behavioral health workforce pipeline, highlighting the need for integrated approaches that reflect the diversity of professions and communities involved in this work.

Keawe Kaholokula (University of Hawai’i—Mānoa) began by focusing on strengthening the behavioral health pipeline for Native Hawaiian and Pacific Islander (NHPI) communities. He described how cultural values, historical trauma, and colonization can shape mental health outcomes and access to care. Workforce challenges include underrepresentation, lack of culturally relevant training and mentorship, geographic isolation, and professional barriers to include burnout and retention issues. Kaholokula advocated for place-based, community-rooted training. He introduced Mōhala Liko Lehua, an initiative designed to prepare psychologists and social workers to address social determinants and systemic barriers, and to teach trauma-informed and resilience building approaches through culturally grounded, community-partnered education models that reflect NHPI values and sustain local behavioral health care providers. He emphasized the program’s role in building a culturally competent workforce to improve access and continuity of care in NHPI communities. Kaholokula noted that the program incorporates strategies such as recruiting local NHPI students, integrating traditional healing practices and language, partnering with NHPI-serving health centers, schools, churches, and cultural organizations, and providing place-based training in rural and neighboring island communities.

Patricia Saleeby (Bradley University) outlined the central role of social work in addressing behavioral health across clinical and community settings. She emphasized that a

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large share of Master of Social Work graduates provide services to individuals with mental health and substance use disorders, often in high-need, under-resourced contexts. Saleeby emphasized that social work education is grounded in the social determinants of health, guided by national accreditation standards, and built on competency-based and field-based learning. Saleeby also highlighted the profession’s longstanding commitment to social justice and the need for advocacy, citing frameworks like the 5As (awareness, adjustment, assistance, alignment, and advocacy) to integrate social care into health care. She discussed the use of tools like the International Classification of Functioning¹⁴ to improve continuity between health and social services, especially in post-acute care. Throughout her remarks, she elevated the importance of listening to lived experiences and tailoring care to the individual’s context.

Kathleen Delaney (Rush University, College of Nursing) provided an overview of the psychiatric nursing workforce and its evolving contributions to behavioral health care, particularly in community settings. She outlined distinctions between psychiatric mental health registered nurses (PMHRN) working in psychiatric settings and psychiatric mental health advanced practice nurses (PMH-APRN), highlighting that the majority of PMHAPRNs now practice in outpatient environments. Delaney emphasized that both roles are essential to improved access, noting that PMHRNs are often responsible for care coordination, symptom monitoring, and patient engagement. She cited studies showing that when registered nurses (RN) work at the top of their training and licensure, patient outcomes improve across multiple domains, including increase service access, better care coordination, improved patient engagement, and more effective symptom monitoring (af Winklerfelt Hammarberg et al., 2022; Nembhard et al., 2020). For example, in a nurse-led integrated care clinic in Colorado, registered nurses helped manage care for patients with moderate complexity by conducting follow-up, coordinating services, and tracking treatment plans, which was associated with improved care coordination and patient engagement (Weber et al., 2021). Another study in a primary care setting expanded the RN role to include medication management and behavioral health education, contributing to greater continuity of care and increased adherence to treatment plans (Lukewich et al., 2022).

Delaney also discussed the current structure of nursing education, including standardized psychiatric practicums and a national competency framework designed to prepare nurses for patient-centered and system-based care. She noted that several structural barriers continue to affect the visibility and deployment of the nursing workforce, particularly in behavioral health settings. These include limited role clarity within the team for care coordination, gaps in billing infrastructure and training, and insufficient workforce tracking of RNs in federal data systems, such as the Uniform Data System.¹⁵ To support broader integration of psychiatric nurses, she encouraged updates to workforce categorization in state and federal databases, increasing the number of community-based training placements in nursing education, and aligning payment models that better reflect population needs and nursing licensure.

Laura Bond (Harvard Medical School, Mental Health for All Lab) presented on the EMPOWER initiative,¹⁶ a model designed to expand the behavioral health care workforce by training nonspecialist providers to deliver mental health interventions. Adapted from global task-sharing strategies originally developed by Vikram Patel in India, EMPOWER seeks to address care gaps in under-resourced U.S. communities where there are not enough clinically trained care providers to meet demand. Bond explained that many communities lack enough clinical care providers, but nonspecialist workers—those without formal mental health training—can deliver evidence-based interventions such as behavioral activation.

The EMPOWER model uses digital platforms to train and support these community-based behavioral health care providers, she said, followed by a practice-based internship phase and ongoing oversight by licensed supervisors. Bond noted that in some settings, these digital training tools are paired with telehealth delivery of interventions, enabling nonspecialist providers to serve clients who may not have access to in-person care, thereby extending the reach of behavioral health supports into

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underserved communities. She emphasized the importance of tailoring implementation to each setting, drawing on formative research to adapt content and delivery. “Our goal is to make learning fun,” she noted, describing the interactive, video-based training tools developed in both English and Spanish. She added that supervision, mentorship, and a structured referral system remain critical to ensuring quality and safety.

In the United States, EMPOWER has partnered with community colleges, churches, veteran-serving organizations, and federally qualified health centers to integrate mental health supports into local systems. Bond shared that initial results from India showed more than a 50 percent reduction in depression symptoms among participants receiving care from trained community health workers (Vikram et al., 2016). While optimistic about the model’s potential, she also acknowledged its financial and operational limitations, stressing that sustainability will likely depend on policy changes, including reimbursement structures and broader recognition of community-based care providers. She noted that nonspecialist-delivered interventions are often most effective when paired with timely access to appropriate medications, highlighting the importance of integrated care pathways that include pharmacological treatment when indicated. “None of this is sustainable until we have billing codes that can work for nonspecialist providers,” Bond said.

Vakalahi summarized the practical and philosophical shifts needed to strengthen and sustain the behavioral health care workforce, while panelists shared ideas and aspirations. Kaholokula emphasized the importance of upstream investment in the pipeline, especially through community colleges and high schools. He noted that Indigenous and minoritized students often come to education through nontraditional routes and need mentors who share cultural values and lived experiences. He shared that his own path into psychology began with encouragement from a community college instructor. Kaholokula also stressed the importance of visibility and representation, emphasizing that behavioral health should be better promoted in early education and supported by role models from within communities. Delaney called for expanding community-based training practicums for nurses and for formalizing the role of RN preceptors in these settings. “Hospital nurses are used to being preceptors, but community-based nurses are not,” she said, noting the need for clearer structures to support student learning in nonhospital settings. Delaney advocated for retooling education systems to prioritize community placements and for teaching nursing students the economic realities of health care financing, highlighting the importance of this as financial structures shift.

Vakalahi asked speakers how global wisdom (drawing on knowledge, practices, and perspectives from cultural, international, and community experiences) could inform workforce education. In response, Saleeby emphasized the importance of listening to lived experiences. She shared a story about a patient with a spinal cord injury who, when given a new assistive device, expressed that his primary goal was to stand and kiss his wife. The example underscores how personal goals can shape the way success is defined in care delivery. Saleeby also highlighted new tools that enable the capture of functional status and social determinants of health within electronic health records. She noted that these tools open the door to expanded billing codes, making it more feasible to finance care aligned with what communities actually need. Bond added that effective models often lack long-term funding. She explained that EMPOWER’s model, though successful, relies on external grant funding and cannot be sustained without more durable reimbursement strategies. Bond emphasized the need to build a payment infrastructure that compensates nonclinical community care providers for their time, training, and supervision.

In closing, Vakalahi invited each panelist to complete the sentence, “This moment is an opportunity to . . .” Their responses reflected the themes of structural change, workforce development, collaboration, and community-centered care:

• “. . . drastically shift the paradigm.” (Kaholokula)
• “. . . bring nurses out of the hospital and into the community.” (Delaney)
• “. . . work together and make a difference, to bring change in the world.” (Saleeby)
• “. . . bring expertise down into the communities themselves.” (Bond)

FINANCING AND ACCOUNTABILITY POLICY

Howard Goldman (University of Maryland, School of Medicine) said the fifth session of this workshop aimed to explore the relationship between financing models, policy design, and accountability systems in improving behavioral health care and integrating attention to social and structural determinants of health.

Heather Saunders (KFF) provided an overview of Medicaid’s role in financing behavioral health services and addressing social determinants of health, drawing on recent KFF analysis of federal and state trends.¹⁷ She emphasized Medicaid’s broad coverage and flexibility, while noting the coverage of specific behavioral health services differs by state. Saunders reviewed the evolution of federal policy supporting Medicaid-financed social services through Section 1115 waivers and highlighted recent uncertainty about the rollback of Centers for Medicare & Medicaid Services (CMS) coverage for Health-Related Social Needs. She also discussed Medicaid’s growing role in supporting individuals leaving incarceration and noted that pending federal work requirements could reduce coverage for adults with behavioral health conditions.

Richard Frank (Brookings Institution) highlighted how the structure of the federal budget may limit opportunities to expand investment in behavioral health and social services. He noted that such services (e.g., housing assistance, food support programs, and community-based mental health care) represent a small portion of overall federal spending, particularly within the discretionary budget, and that most new program funding is constrained by the broader emphasis on budget neutrality. Drawing comparisons to other high-income countries, Frank observed that the United States allocates a greater share of spending to health care services than to social supports, despite research that suggests a more balanced approach may be associated with improved mental health outcomes (Bradley et al., 2011). He described options for shifting this balance, including hybrid funding models that combine mandatory and discretionary sources and pointed to examples such as federally qualified health centers and childcare development funds. He also spoke about Medicaid waivers, which are state-specific agreements that allow flexibility in how Medicaid funds are used, as vehicles for innovation. He noted that states may use waivers for a variety of purposes, which include piloting new care delivery models, expanding eligibility, or integrating services such as behavioral health and social supports. Frank said in some states, these waivers have also been used to expand access to medications for opioid use disorder, particularly in areas where provider availability or regulatory barriers have limited treatment options. He emphasized that the effectiveness of these innovations often hinges on state-level decision making, the vision and priorities of leadership, and administrative capacity to implement and manage complex programs.

Ellen Meara (Harvard University) discussed how value-based payment models, including accountable care organizations (ACOs), have the potential to improve care delivery for individuals with behavioral health needs but may fall short if accountability mechanisms do not reflect the complexity of those populations. She emphasized that outcome measures tied to these models often prioritize cost containment or efficiency, which may not fully capture patient-centered goals or the needs of individuals with serious mental illness or substance use disorders. Drawing on a body of research from Medicare and Medicaid ACOs, multi-institutional surveys, and qualitative interviews with health system leaders, Meara described how organizational context and contract design shape the extent to which behavioral health is addressed. For example, when behavioral health is excluded from the financial risk borne by medical care providers—commonly referred to as being “carved out”—it can reduce incentives for integration. As she explained, “In behavioral health, this issue of whether services are carved in or carved out of spending could potentially matter,” because it affects whether organizations are financially accountable for outcomes. Meara also noted that community-based organizations and safety net providers frequently lead in innovation, often adapting out of necessity rather than formal incentives. These efforts, she suggested, may offer insights to the broader field, particularly in identifying care models that respond to both clinical and social needs with limited resources.

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Alexandra Quinn (Health Leads) presented a vision for reimagining care systems by centering community leadership in both design and governance. She described how Health Leads has worked at the intersection of health care, public health, and community organizations to elevate the voices of those most affected by systemic barriers. Quinn explained that policies and reimbursement models that appear neutral on the surface may unintentionally exclude critical contributors to care, such as community health workers and doulas. She described a Health Leads–supported initiative in New York in which doulas and people giving birth were directly involved in shaping policy and infrastructure.¹⁸ While these efforts represent meaningful progress, Quinn noted that questions remain around how enrollment processes are structured and whether reimbursement rates fully acknowledge the time and effort required for this type of care. “You can take out ‘doula’ and put in ‘community health worker,’ and the barriers are nearly identical,” she said. Quinn encouraged consideration of accountability not only in terms of outcomes but also in terms of “who holds power in shaping systems.” She described meaningful accountability as a process that includes shared governance, transparency, and long-term investment in local capacity, saying, “If we’re not designing with the people most impacted, we’re not designing for health—we’re designing for compliance.”

Brendan Saloner (Brown University) asked whether efforts to strengthen social supports effectively entail shifting resources away from health care, framing it as a potential zero-sum game. Frank noted that spending on human services constitutes a small fraction of total federal expenditures and described it as a “rounding error” within the broader budget. He suggested that even a meaningful increase in investment in social services would have only a modest impact on overall federal spending, given their relatively small share of the budget. Rather than focusing primarily on cost savings or redistributing existing resources, Frank encouraged policymakers to consider how financing structures could better sustain social supports and human services. “The focus should not be on saving money,” he said, “It should be on improving how we use the money we already spend.”

Frank noted that while cost savings are often discussed in the context of reform, expectations should be tempered, as relatively few interventions consistently deliver substantial reductions in spending. He asserted that the case for investing in behavioral health and social services is strong from a cost-effective perspective.

Saleeby raised a related issue by asking who determines which services are considered appropriate or necessary for coverage and reimbursement. Goldman reflected on how services such as transportation, once considered peripheral in health care planning, are now recognized as “essential,” particularly in efforts to support employment and independence for individuals with disabilities.

In her concluding remarks, Meara noted that even in settings with limited resources, community-based and health care organizations often adapt in creative ways to meet unmet needs. Meara referenced findings from her research on health care organizations, which indicate that under significant resource constraints, staff may devise creative solutions when performance goals are clearly defined and prioritized (Lewis et al., 2014). She noted that this pattern of innovation in response to unmet needs echoes a point raised by Nichols, “You have to make it salient for people, and they will do it.” She emphasized the importance of recognizing the efforts of those working in constrained environments and suggested that these local adaptations may inform future policy design. “In these low-resource, big-change times, people do really creative things,” she said. Goldman closed noting that while incrementalism was once seen as a limitation, it may provide a path for steady progress when combined with strategic flexibility.

BUILDING A FUTURE READY FRAMEWORK

Martinez moderated the final session and invited participants to think expansively about the future of behavioral health care systems. He framed the discussion around the challenge of moving from pilot projects to sustained policy, focusing on the support structures, cross-sector collaborations, and strategic levers needed to align systems and create meaningful change. He emphasized the importance of shaping a behavioral health continuum that is future-ready and has the capability to respond to social and structural determinants of health.

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Laura Nissen (Portland State University) opened her remarks by encouraging the use of “futures thinking” to help behavioral health systems navigate compounding disruptions (e.g., social fragmentation, technological disruptions, lack of public trust). Nissen discussed foresight as a discipline that emphasizes strategic imagination, scenario planning, and early signal detection—not prediction—to enable readiness for various possible futures. She called attention to the need for institutional humility, civic imagination, and investment in mechanisms that support collective resilience. Foresight, she suggested, promotes a moral commitment to “embolden our collective best chance at a set of healthy and inclusive futures.” Nissen also emphasized that foresight “always acknowledges the power dynamics present in terms of who asserts dominion over the future and who is not actively involved.” Nissen encouraged the development of a more future-facing capacity within behavioral health systems—one that draws from community knowledge, embraces uncertainty, and supports the exploration of shared and equitable futures.

Brendan Saloner discussed the policy landscape shaping behavioral health, highlighting the intersection of innovation and stagnation. He acknowledged the emergence of promising models—such as integrated care approaches, expanded roles for nontraditional health care providers, and Medicaid reforms like Section 1115 waivers—but noted that these advances have yet to produce broad improvements in population-level outcomes. Saloner characterized this gap as a “scaling crisis,” where effective models remain under-implemented due to regulatory, workforce, and funding barriers.

He traced structural constraints back to the legacy of the Affordable Care Act, which expanded insurance coverage but left social safety net systems underdeveloped. Saloner observed that Medicaid has become the de facto vehicle for addressing social risk instead of broader policy solutions, a dynamic he described as “both necessary and insufficient.” He noted that policy proposals, such as work requirements, and administrative changes could place pressure on Medicaid and potentially limit recent progress. Looking ahead, Saloner called for a more focused project, describing it as one dedicated to “rebuilding public systems through investment, engagement, and civic legitimacy.” He stressed the importance of durable infrastructure, cross-sector coordination, and community-rooted policymaking to advance health equity and respond to emerging threats. Framing his remarks in the context of strengthening behavioral health systems broadly, he emphasized that without greater alignment across programs and sectors, efforts may remain short-term and difficult to sustain.

Keith Humphreys (Stanford University) reflected on two recurring themes throughout the workshop discussions: first, that structural factors like housing, education, and policy, shape health outcomes; and second, that health experts are positioned to reform those systems. While he acknowledged the influence of structural factors on health, he questioned the assumption that health professionals are equipped to lead reforms in those domains, pointing to limitations in authority, public trust, and cross-sector expertise. Humphreys added that trust in health care professionals vary—and is often limited, particularly outside clinical settings or among populations who have experienced harm within medical systems. Rebuilding public trust, he said, should be a critical area for attention. Humphreys encouraged the exploration of ways to bring behavioral health care financing and quality standards into closer alignment with broader health care systems, noting the limitations of fragmented or discretionary funding approaches. He reflected on earlier periods when services for mental health and substance use disorders were treated as peripheral, relying on what he described as “bake sale” funding. He suggested integrating these services into standard reimbursement systems to help position behavioral health as a consistent part of health care and to support more stable and equitable access to care.

Martinez continued the discussion by reiterating the importance of rebuilding trust and asked speakers how health institutions might begin to address the longstanding distrust held by minoritized communities. In response, Humphreys acknowledged the depth of the challenge and said that outreach efforts often neglect large populations, such as rural and religious communities. He emphasized that restoring trust will likely depend on expanded outreach efforts to reach a broader range of communities. Building trust, he said, depends

on “honesty, listening, shared activities, shared goals, inclusiveness.” Saloner noted that, at present, efforts to engage communities take place within online environments shaped by large technology platforms, which can affect communication and trust-building. He suggested that a coordinated national approach could serve as an aspirational pathway to restoring confidence in public health.

Martinez shifted the focus to implementation by revisiting Saloner’s earlier mention of a “scaling crisis.” He asked how the successful models mentioned throughout the workshop could be more broadly disseminated and implemented and why community-level innovations remain isolated despite available evidence and publication. Saloner replied that scaling is complicated by local context, uneven capacity, and structural barriers. Saloner and Humphreys noted that telehealth has eased some of these challenges by allowing evidence-based behavioral health interventions to be delivered across broader geographic areas, though disparities in broadband access and digital literacy remain barriers to equitable adoption. Saloner noted that lower-complexity interventions, such as naloxone distribution, have scaled more easily, but emphasized that scalability should be treated as a primary design consideration, not an afterthought. Humphreys added that most academic networks are self-contained and translating ideas into policy requires cross-sector efforts. He described the Stanford Network on Addiction Policy,¹⁹ which brings together scientists and policymakers, and shared examples in which the network’s collaborative work informed state-level legislative changes related to addiction prevention and treatment. Humphreys added that the Network includes people who are simultaneously scientists and community members, parents, pharmacists, and others with a broad range of personal and professional identities. He noted that political diversity is also intentionally represented.

Martinez asked how to make equitable, high-quality behavioral health care a reality, especially given the historic marginalization of substance use treatment. Saloner described parity as a financing issue and suggested aligning care for mental health and substance use disorders with other areas of health care, rather than treating them as separate domains. He underscored that achieving true parity also depends on ensuring equitable access to medications for mental health and substance use disorders, noting that coverage gaps and prior authorization requirements can delay or deter treatment. He also suggested redirecting investment toward meeting social needs that impact outcomes. Humphreys added that integrating addiction services into mainstream funding systems could elevate standards by aligning behavioral health with established quality metrics and accountability mechanisms. Nissen described foresight work as an opportunity to meet amid uncertainty and to reestablish a shared social contract between professionals and communities.

Martinez concluded by asking each panelist what voices were missing from the conversation. Nissen pointed to the limited presence of family and consumer voices (individuals with lived experience of mental health and substance use conditions). Humphreys proposed including voices that question whether health systems should engage in areas such as income, policing, or housing, suggesting that disagreement could help clarify the scope of reform. Saloner agreed, emphasizing the value of discomfort and disruption in testing the durability of ideas.

CLOSING REMARKS

Miller concluded the workshop by reflecting on the breadth of the discussions and the persistent challenges facing efforts to improve care services for people with mental health and substance use disorders. While no single solution emerged, he observed that new possibilities surfaced—particularly the need to engage communities more meaningfully, confront entrenched power dynamics, and build systems that reflect widely held values. He noted that these conversations were not simply conceptual but grounded in the lived experiences of those navigating fragmented care systems and structural inequities.

Miller returned to a question that had surfaced throughout the discussions: Why revisit structural determinants now? He pointed to what he described as a persistent “mismatch between the causes of distress and the structures tasked with addressing them,” and noted that improving behavioral health outcomes will likely take more than innovation or scale—it calls for “greater

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accountability to the principles of prevention, justice, and dignity.” Miller called this an inflection point, noting that system failures are not theoretical but “affecting health, hope, and lives.” He urged those in positions of influence to move beyond “admiring the problem” and instead focus on realigning structures, policies, and investments with what matters most. “The work ahead,” he said, “is not only to act, but to act in alignment with evidence, equity, and purpose.”

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DISCLAIMER This Proceedings of a Workshop—in Brief was prepared by Alexandra Andrada Silver as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

Zoom Transcript was used in the initial drafting of this Proceedings of a Workshop—in Brief. All material generated by an AI platform used in this document was fact-checked to ensure accuracy of the presented information.

PLANNING COMMITTEE Benjamin F. Miller (Co-Chair), Stanford School of Medicine; Rosalie L. Pacula (Co-Chair), University of Southern California; Danielle Hessler Jones, SIREN Network, University of California, San Francisco; Octavio N. Martinez, Hogg Foundation for Mental Health; Jeanne Miranda, University of California, Los Angeles; Halaevalu Vakalahi, Council on Social Work Education. The National Academies’ planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. Responsibility for the final content rests entirely with the rapporteur and the National Academies.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Danielle Hessler Jones, University of California, San Franciscso, and Social Intervention Research and Evaluation Network (SIREN), and Zach Sartor, Waco Family Medicine. We also thank staff member Lida Beninson for reading and providing helpful comments on this manuscript. Leslie Sim, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSORS This workshop was supported by contracts between the National Academy of Sciences and American College of Clinical Pharmacy, American Psychiatric Association, American Psychological Association, American Psychiatric Nurses Association, Centers for Medicare & Medicaid Services, Council on Social Work Education, Hogg Foundation for Mental Health, The Jed Foundation, National Association of Addiction Treatment Providers, and Substance Abuse and Mental Health Services Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

STAFF Alexandra Andrada Silver, Forum Director and Program Officer; Chidinma J. Chukwurah, Senior Program Assistant; Eliana Pierotti, Senior Program Assistant; and Sharyl J. Nass, Senior Board Director, Board on Health Care Services.

SUGGESTED CITATION National Academies of Sciences, Engineering, and Medicine. 2025. Enhancing Care and Services for Mental Health and Substance Use Disorders: Proceedings of a Workshop—in Brief. Washington, DC: National Academies Press. https://doi.org/10.17226/29242.

For additional information regarding the workshop, visit https://www.nationalacademies.org/enhancing-MHSUD-care.

Health and Medicine Division Copyright 2025 by the National Academy of Sciences. All rights reserved.