Table 6.

Observations and Recommendations to Improve the Systems of Care for Substance Prevention and Treatment among SGM People in Hawai‘i

Service Delivery: Increase Prevention and Treatment Access and Integration • Require policy among state-funded agencies providing residential or inpatient treatment to allow self-attestation of gender identity • Create residential and inpatient treatment opportunities specific for SGM people (eg, housing staffed by and dedicated to serving transgender and/or gender non-conforming people) • Diversify outpatient support programs to include SGM-affirming and SGM-specific options • Diversify spousal/family support programs to include SGM-affirming and SGM-specific options (eg, Family Acceptance Project https://familyproject.sfsu.edu/) • Provide more programs to build resiliency and support for SGM people in Hawai‘i to prevent initiation of substance use • Create social hubs/areas that consolidate resources and also promote safety and support (eg, gay straight alliances in schools) • Establish mechanisms to coordinate service delivery between substance use disorder treatment and mental health services • Streamline intake processes to reduce redundancies and improve timely linkage to services.

Workforce Development: Recruit Community and Enhance Current Capacity • Promote hiring of people from SGM communities at all system of care levels (including ADAD and its contracted entities) • Provide professional development for new and existing substance use treatment providers, allied health professionals, social workers, case managers, administrative intake staff, and other relevant workers to provide competent care for SGM people in Hawai‘i • Mandate annual SGM cultural trainings for relevant workers (eg, Center of Excellence on LGBTQ+ Behavioral Health Equity https://lgbtqequity.org/) • Integrate workforce development activities for schools, Department of Education, and other youth-oriented programs • Communicate and enforce protections for SGM staff, clients, and others through clear and actionable policies at all levels

Nimble Financing: Allocate Funding and Resources Effectively and Appropriately • Develop incentive programs to recruit new and experienced providers for SGM-specific care and treatment • Fund workforce development through ongoing evidence-led trainings and mentorship opportunities • Fund SGM-specific treatment options in all island counties for both urban and rural settings • Establish and maintain an SGM Coordinator position within ADAD to solicit community feedback and coordinate systems-level services to improve care and treatment • Fund SGM-specific innovation grants to reflect cultural and community needs and particularities • Fund SGM-specific health promotion materials and stigma reduction campaigns to promote increased engagement with substance use prevention and treatment

Data to Action: Improve Data Collection, Evaluation, and Research • Conduct needs assessment through focus groups to determine specific needs of SGM communities, which will direct and inform proposed recommendations throughout this chapter • Integrate sexual orientation, gender identity, and sex assigned at birth as separate demographic fields in Web Infrastructure for Treatment Services (WITS), the shared treatment record portal for ADAD Recommended language can be found at https://www.cdc.gov/hiv/clinicians/transforming-health/health-care-providers/collecting- sexual-orientation.html • Improve data collection to align electronic health records and similar health-related systems with guidelines from the National Institutes of Health (https://dpcpsi.nih.gov/sgmro/measurement/questions) • Collect and report qualitative data (eg, photovoice project) on SGM communities to provide better contextual grounding of quantitative data • Mandate the collection and report of the three metrics above in WITS, or any other reporting system for all contracted ADAD services • Develop an annual special report on SGM data among ADAD contracted entities to highlight impact of programs, gaps in service, and recommendations for program improvement • Expand mandated integration, collection, and reporting of the three metrics above into all non-ADAD entities providing substance use treatment services (eg, hospitals, FQHCs, MedQuest providers/clinics, insurance payers) through ADAD technical assistance • Develop and implement mechanisms for staff and participant feedback (qualitative and quantitative) on ADAD contracted entities, with intentional inclusivity for SGM people and SGM-specific issues • Develop and implement an internal ADAD workgroup (in partnership with the DOH Sexual and Gender Minority Workgroup) that seeks SGM community input to identify and implement culturally-based evaluation approaches and practices (eg, the Aloha Framework from Culturally Relevant Evaluation and Assessment in Hawai‘i: https://www.creahawaii.com/resources).

Policy at All Levels: Transform Systems and Organizational Processes • Update workflow to include culturally appropriate assessment for SGM people, including preferred name, pronouns, and other identities (see recommendations on SGM metrics in Evaluation and Research section) • Update or implement a mechanism for actionable, safe, and accessible reporting of SGM discrimination in ADAD-contracted entities • Develop and implement ADAD protocol for quickly responding to SGM discrimination reports, including funding or program sanctions • Require inclusive language for SGM people in health practice settings • Require the collection and reporting of SGM data in health practice and substance use treatment settings • Support legislation or policy that promotes inclusiveness for SGM people in all settings, such as: Protection of transgender athletes in school teams and coverage of transgender healthcare services by insurance payers • Establish and fund a State Executive Office to address the needs of sexual and gender minorities (similar to the Hawai‘i State Commission on Status of Women) • Develop legislation or policy changes to ensure that the above recommendations are mandated and implemented in all substance use treatment settings, regardless of ADAD funding

Based on data findings, literature scan, and stakeholder feedback findings, the authors compiled this list of observations, recommendations, and opportunities for ADAD and its partners to improve the SUD system of care for SGM communities in Hawai‘i. These recommendations were shared with the DOH SGM Workgroup for feedback through an online presentation to self-selected workgroup members.