Enhancing access to behavioral health services for groups that have been historically marginalized in California: executives’ views and recommendations

Introduction

Addressing barriers to accessing behavioral health services (BHS) has become a critical priority in California. The opioid epidemic and the coronavirus disease 2019 (COVID-19) pandemic have exposed significant gaps in health policies, infrastructure, and payment practices that hinder access to BHS, particularly for groups that have been historically underserved and marginalized (1,2). While California has made strides in addressing macro-level barriers—such as expanding public health insurance coverage and funding comprehensive services for individuals with mental health (MH) and substance use disorder (SUD)—further efforts are needed to align behavioral health policies, systems, and services to reach groups that have been historically marginalized effectively.

Despite having one of the largest behavioral health systems in the country, California’s unmet BHS needs exceed the national average (3). This gap is particularly acute among low-income and disenfranchised populations, who face systemic challenges such as limited insurance coverage, transportation barriers, poor care quality, and experiences of discrimination (4).

The Health Equity in Access to Behavioral Health Recovery Services (HEAR US) project addresses these disparities by collaborating with community-based providers, advocates, and other stakeholders to enhance the behavioral health recovery roadmap. By integrating community insights and evidence-based practices—such as culturally responsive care, whole-person care, low-threshold access, and harm reduction (5), the project aims to develop actionable strategies to improve access to care for underserved communities.

Because a BHS system that responds to the service needs of groups that have been historically marginalized in California requires special arrangements, the California Department of Health Care Services, in conjunction with The Sierra Health Foundation (6), funded various organizations across the state to implement the HEAR US (7) project. This project sought to build from the Substance Abuse and Mental Health Services Administration (SAMHSA) Recovery Roadmap Framework (8) to respond to the recovery needs of populations needing BHS in California. The SAMHSA Roadmap for Recovery relies on the following principles: person-driven, relational, and addresses trauma, holistic, hope, culture, peer support, many pathways, respect, and strength/responsibility (Figure 1). SAMHSA outlines recovery as a holistic, person-centered process of change in which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential. SAMHSA identifies four major dimensions of recovery: health, home, purpose, and community, emphasizing that recovery is supported by addressing trauma, fostering hope, and respecting cultural diversity (8).

Figure 1 SAMHSA recovery principles and approaches. The SAMHSA outlines recovery as a holistic, person-centered process of change in which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential. SAMHSA identifies four major dimensions of recovery: health, home, purpose, and community, emphasizing that recovery is supported by addressing trauma, fostering hope, and respecting cultural diversity. Key approaches include promoting peer support, ensuring individualized care, and integrating services that support mental health and substance use recovery within a framework of dignity and self-determination (8). SAMHSA, Substance Abuse and Mental Health Services Administration.

In this paper, we describe the organizing, facilitating, and documenting of constituency-focused generative listening sessions and focus groups with executive leaders of drug and alcohol programs in California. Through the robust community and conversations guided by the Sierra Health Foundation and managed by Health Management Associates (HMA), the research team of the California Association of Alcohol and Drug Program Executives (CAADPE) and the HMA coach gained valuable insights into the current landscape of SUD recovery services, including the definition of SUD recovery services and the needs of this system to effectively respond to the services of the most groups that have been historically marginalized in California.

Methods

This project relied on a descriptive qualitative approach (9), namely online focus groups conducted between March and June 2023. This study sought to inform the conceptual enhancement of A Roadmap to Improve Access and Equity for Communities in Recovery in California. The research team used a three-step process to gather feedback from participants to tailor the Roadmap to the recovery needs of minoritized and socially marginalized groups residing in California. Given the exploratory nature of the research questions, the research team gathered several sources of information to build a multi-dimensional understanding of the needs and concerns of providers on behalf of the clients they serve. The research team collected data to understand access to SUD care from multiple perspectives. Focus groups took place via synchronous online sessions and were divided between diverse and non-diverse groups (defined below). The study team implemented a two-phase participant enrollment process. In Phase One, through phone and email message invitations (see below under recruitment), providers were invited to provide informed consent and complete a screening questionnaire. In Phase Two, participants who met eligibility criteria (see below Sampling and inclusion criteria) were invited to participate in a focus group interview.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Research to End Healthcare Disparities Corp (No. IRB00011865). Interested persons were informed that they were providing consent to participate in the study by giving verbal consent and completing a screening questionnaire.

Participant recruitment

A research coordinator led the recruitment efforts, and participants were encouraged to refer other individuals eligible for study participation. The research staff completed informed consent, followed by initial screening information to assess eligibility to continue participating. Participants received a $30 gift card per focus group they attended for their participation.

Sampling and inclusion criteria

Purposive, convenience, and snowball sampling were used to recruit participants for the study using the inclusion and exclusion criteria. Participants completed a brief demographic survey at the beginning of the interview to determine study eligibility (Table 1). The inclusion criteria to continue participation was current role as director or upper manager of an SUD treatment program. Participants were selected based on their demographic characteristics. At times, participants served dual roles within their organization as clinical and administrative directors. To better capture the intersectionality of identities, the research team organized two different groups of participants to maximize homogeneity across specific dimensions, such as race and gender, in order to facilitate discussions among individuals with similar experiences. We also selected participants representing small and large programs serving urban and rural communities.

Informed consent and data collection

Interested persons were informed that by giving verbal consent and completing the questionnaire, they were giving consent to participate in the study. A total of 33 providers completed the screening questionnaire. Of those, 23 met the eligibility criteria and completed a focus group.

Focus groups design

Three sessions were completed, with two focus groups per session (6 total). These groups lasted 90 minutes each. Topics included equitable access to services and treatment, needed actions, barriers, ways to reduce obstacles, and feedback on the revised recovery Roadmap (Appendix 1). Additionally, all names and identifiers were removed from transcripts and other narratives to preserve confidentiality. Primary qualitative findings are presented below.

Qualitative data analysis

Interviews were transcribed by a professional service (REV.com), and the research team removed all identifying information before the analysis process. Data collection and analysis were completed using a generic qualitative approach (10), meaning that the analysis aimed to describe participants’ experiences and perspectives related to their needs and their clients’ needs.

Following the completion of the interviews, half of the transcripts were coded line by line by two researchers (L.M.H. and V.S.), then the researchers met several times to generate first-cycle code definitions, which were clustered by topic to develop the second cycle, thematic codes. Focus group data were coded first inductively using participants’ key phrases and then second using deductive strategies, using the constructs and principles of SAMHSA’s recovery roadmap framework. The most frequent and significant thematic codes were used to construct a codebook. Dedoose™ (Version 9.0.17, 2021) (11), a web-based qualitative data analysis platform, was used to facilitate data organization and coding (12). The codebook was uploaded onto Dedoose software, and Dedoose’s coding functions were used to code fifty percent of the interview transcripts. The finalized codebook was based on iterative discussions of interview transcripts (10,13).

Next, a thematic analysis (14) was conducted on the coded transcripts, iteratively refining themes until reaching a consensus. Authors maintained memos related to analytic decisions, consulted with other team members, and discussed the relationships among codes that emerged from the data (15,16).

Results

Participants who represented program leaders in the SUD treatment system in California highlighted three main areas to improve access to a comprehensive system of care: (I) culturally responsive policy, (II) adequate funding and sensible reporting, and (III) purposeful coordination across systems. Because research has shown that leaders’ ethnoracial background plays a role in their views and practices related to workforce diversity (1,17), data from two samples (diverse and non-diverse) were collected. The samples varied in terms of race, ethnicity, and gender identity. However, their views on culturally responsive policy, structure, and services did not significantly vary.

Findings showed no significant group differences in culturally responsive themes. Differences were primarily based on the scope of issues and solutions. The non-diverse group had longer tenures in the field and led larger organizations. They emphasized big-picture policy and structural approaches to improve the system. In contrast, the diverse group was heterogeneous in their practice experience and offered insights into specific barriers and innovative solutions. For instance, how the payment system in California and the coordination across systems can be improved to provide basic services (e.g., housing transition) to retain and stabilize clients. The non-diverse group offered more nuanced suggestions for measurement and implementation, possibly because of their significant experience responding to systemwide challenges in the provision of care.

Participants reported that for implementation, obtaining and testing the impact of comprehensive, long-lasting funding is critical to sustaining service delivery to groups that have been historically marginalized. Funding and supporting aftercare service delivery beyond three months of treatment is imperative to sustaining their recovery. Participants were warned about discrimination in funding, eligibility, and reimbursement, and baseline data on clients’ full-service experiences were collected based on quantitative and qualitative interviews.

Culturally responsive policy

The participants strongly emphasized broad policy and structural strategies to enhance the system. At the same time, the diverse group showed heterogeneity in their practical experience, providing valuable perspectives on specific obstacles and creative solutions. For example, they delved into issues such as the payment system in California and the need for better coordination among systems to ensure access to essential services like housing transition, ultimately aiming to support and stabilize clients. One participant illustrated how structural changes can lead to better client outcomes, “My two cents to add are that there should be enough lanes for access to recovery in the continuum of care to give the most people needing recovery access while not stigmatizing or limiting funding… and helping the whole person in their recovery journey.”

Adequate funding and sensible reporting

Program leaders appreciated the thoughtful questions and the opportunity to bring coherence to a “broken” care system. Participants highlighted that adequate funding meant financial/billing support for culturally responsive practices, including peer support, harm reduction, and a whole-person approach. They believed that by offering financial incentives and support to implement such strategies, the system could transform into a low-barrier system of care. Participants underscored the need for “payment reform”, focusing on mainstreaming and harmonizing Medicaid payment and reporting across counties in California to improve access to care for out-of-county clients. One participant outlined the need for payment reform, “I think it needs to come at the state level where counties aren’t so restricted by having to change the county where Medi-Cal is coming from. There are so many barriers there that it’s not only for the clients but for the providers.” Another participant shared limitations of the current system, “Payment reform is not addressing the Drug Medi-Cal carve out.” Another shared a possible solution, “In health centers, we call them P4P, pay for performance. We maybe eventually be able to address some of those issues.”

Focus group participants shared several key items that must be considered to measure the successful implementation of healthcare initiatives. Firstly, it is essential to focus on reducing payment differences and eliminating barriers that hinder individuals’ access to services. Additionally, despite the challenges of the current state, efforts should be made to establish treatment-on-demand programs to ensure timely and accessible care for all. Adhering to access to care standards can provide valuable insights into the effectiveness of the implementation.

Moreover, securing funding to provide comprehensive services that address the holistic needs of individuals is crucial. Testing various aspects of payment reform is essential to determine the most effective strategies. Aligning Medicaid policy with mainstream service delivery and payment methods can improve integration and accessibility. Regular assessments and surveys will enable providers and decision-makers to gather feedback from all involved parties, aiding in identifying successes and areas requiring improvement. They can make informed decisions and continuously enhance the healthcare system by tracking these measures.

Structure: workforce development and coordination across systems

During discussions on “workforce development”, it became evident that advocating for livable wages comparable to other healthcare positions is essential to attracting, retaining, and promoting talented individuals. Creating different pathways to access care across the continuum of care, with proper structuring and funding, emerged as a recurring theme.

The diverse group emphasized the importance of providing an adequate living wage and developing a comprehensive workforce development plan to retain skilled professionals. They stressed the need for higher parity between payments for medical offices and Department of Mental Health rates, recognizing the significance of treating SUD patients with the same respect as those seeking MH treatment. The concept of “payment on demand” was also discussed.

The groups agreed on the necessity for treatment on demand, walk-in clinics, mobile crisis, telehealth, and a “no wrong door” policy. Integrating licensing requirements was proposed to achieve low-barrier access, and multi-sectoral collaboration platforms were considered integral to integrated care. Additionally, mobile services and crisis services were suggested to be included in the list of offerings. Improving and implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) was identified as a crucial step in ensuring universal screening, smooth handoffs, and referrals to treatment. Transportation was also recognized as an essential factor to consider for improving access.

Addressing the challenges faced by the workforce offering peer support was highlighted, particularly the difficulty in retaining talented individuals with lived experience. The group acknowledged that higher wages in other fields posed a risk of losing skilled professionals to different industries. Specific requirements for peer support specialists were recommended to be removed to strengthen the peer support workforce.

The non-diverse group emphasized the value of incorporating the voices and perspectives of workers with lived experiences. They underscored the need for improved reimbursement to effectively integrate the workforce with lived experiences. Additionally, they acknowledged that the current state of treatment presented barriers to integrating peer support, and thus, creating better pathways was identified as a crucial area for improvement.

Focus group participants identified that measuring successful implementation requires careful consideration of key measures to assess the effectiveness and progress of the initiatives. They identified the following measures for evaluating the success of workforce development and peer support implementation.

Workforce development investment

One crucial measure is tracking the level of investment made in workforce development initiatives. This includes funds allocated for training, education, skill enhancement, and professional growth opportunities for peer support professionals. One participant highlighted the need for improved workforce development, “So, we do a lot in the field to develop projects, but I think basically we have to pay a livable salary, and somehow the SUD system needs to be infused with money to do that.”

Pipeline development from high school level

Evaluating the effectiveness of pipeline development programs that begin at the high school level is essential. Monitoring the number of students engaged in such programs and their transition into peer support roles can provide insights into the success of early interventions.

Community engagement in pipeline development

The community’s involvement in pipeline development, recruitment, retention, and promotion of peer support personnel is critical. Assessing the level of community support and collaboration can indicate the sustainability and acceptance of the peer support workforce.

Certification and training hours

Measures should include the number of peer support professionals who have obtained certification and the number of training hours they have completed. This information reflects individuals’ commitment to the field and the extent of their readiness to provide quality support.

Professionalization processes

Monitoring the implementation of professionalization processes, such as standardized competencies and ethical guidelines, can ensure the growth and credibility of the peer support workforce. The extent to which employers invest in these processes can demonstrate the seriousness of their commitment.

By utilizing these measures, providers and decision-makers can gain valuable insights into the successful implementation of workforce development and the overall progress of peer support initiatives. This data-driven approach can guide further improvements and ultimately lead to a more robust and effective peer support workforce.

Discussion

Organizational leaders’ involvement in the HEAR US project contributed to shaping a recovery roadmap for California. The organizing, facilitating, and documenting of constituency-focused generative focus groups was instrumental in identifying barriers and opportunities to enhance access to care for groups that have been historically marginalized in the state. Robust information provided a view of the current landscape of SUD recovery services. The information obtained from focus groups helped identify opportunities to expand the definition of behavioral health recovery services and address future needs at the system and service delivery levels statewide. Some of the key insights from this effort included (I) adequate funding, (II) sensible policy, and (III) coordination across system actors.

There is a need for adequate funding to support culturally responsive practices, including peer support, harm reduction, and a whole-person approach. Participants specified that offering financial incentives and support to implement such approaches is critical so the system could transform into a low-barrier system of care. Such a system would respond to the cultural service needs of populations who have been underserved (17). By aligning payment and service delivery policies, treatment providers could reduce SUD treatment service delays and/or interruption to out-of-county, uninsured or underinsured, and/or non-English-speaking clients.

Finally, participants emphasized the need to coordinate across multiple state actors (MediCal, insurance administrators, California Department of Health Care Services, criminal legal system; healthcare providers, social service providers) to strengthen the system (improve policy, funding, workforce, standards of care, low-barrier access to care). Such multisectoral partnership would reduce barriers to engaging hard-to-reach populations and improve treatment outcomes for all clients.

Recommended actions

Participants appreciated the thoughtful questions and the opportunity to enhance the roadmap to recovery for groups that have been historically marginalized. Although many participants have been asked these questions in previous engagements, they were excited about the HEAR US initiative’s intent to fund pilot projects that implement some of the areas presented. Most program leaders were interested in implementing organizational changes that promote diversity in leadership positions and shaping service delivery to enhance access, improve the standard of care, and improve community health in their communities. Program leaders generated various service and practice recommendations to enhance harm reduction and high-impact interventions. One key suggestion was the creation of drug and alcohol sobering centers, which would provide a safe environment for individuals to detox. Additionally, participants proposed the establishment of safe consumption sites to offer supervised spaces for drug use, reduce associated risks, and provide resources to users. Education and advocacy emerged as another critical focus, emphasizing the importance of continuous learning and efforts to engage with political entities, funders, and foundations to advance harm reduction strategies.

Participants also highlighted the value of integrating peers into the harm reduction process, recognizing their unique ability to build trust and offer support. Extending outreach and connection periods beyond the standard of 60 days was recommended to foster deeper and more lasting connections with individuals in need. Expanding Medication Assisted Treatment (MAT) options across diverse settings was another key priority, alongside broadening harm reduction strategies to include measures like syringe exchange programs, naloxone distribution, and fentanyl test strips.

The group also advocated incorporating recovery housing as part of the overall strategy to support individuals in their sobriety journey. While recognizing MAT as the preferred treatment standard, participants also called for the inclusion of abstinence-based programs to complement existing approaches. The need for linguistically responsive systems was underscored, notably to support communication in diverse languages, including American Sign Language. Participants further emphasized the importance of culturally based care, suggesting the involvement of “credible messengers” who can effectively engage with different communities. Finally, concerns were raised about the use of unclear terminology such as “community-based models” and “multi-sectoral collaboration platforms”, with calls for more accessible language to avoid jargon and ensure practical implementation.

To effectively implement these recommendations, program leaders identified several key measures. These include evaluating the impact of education and continuous learning initiatives on promoting harm reduction practices and assessing the integration and effectiveness of peers in supporting individuals. Trials were suggested to test the outcomes of extending outreach periods while implementing diverse MAT options in different settings that should be monitored to enhance treatment accessibility. Additionally, healthcare providers’ attitudes toward harm reduction strategies and various MAT types, including the potential stigma associated with treatments like methadone, should be investigated to address barriers and improve care delivery.

Limitations

Despite describing meaningful findings about enhancing access to BHS for California residents, this study has several noted limitations. Participants were selected using purposive, convenience, and snowball sampling methods, which may limit the generalizability of the findings with the state. The study focused on executive leaders, potentially omitting frontline staff or clients’ perspectives. Although efforts were made to create diverse and non-diverse focus groups, the relatively small sample size (23 participants) may not capture the full spectrum of experiences and perspectives across California’s BHS. The study used focus groups, which depended on participants’ self-reported insights. These data might be influenced by recall bias or the participants’ positions within their organizations, potentially leading to overemphasis on systemic or policy-level challenges (18). While participants were recruited from programs serving urban and rural areas, the study may not account for all regional or local nuances affecting California’s access to BHS. By concentrating on executives’ views, the study may have overlooked practical, on-the-ground challenges and innovative solutions identified by other stakeholders, such as counselors, peer support workers, or clients (8). These limitations suggest the need for further studies with broader and more diverse participation, quantitative measures, and longitudinal designs to build on these findings and ensure a more comprehensive understanding of the issues and solutions.

Conclusions

The findings from this study underscore the urgent need to address systemic barriers and inequities within California’s behavioral health system, particularly for marginalized populations. The HEAR US project provides actionable pathways to enhance access to care and support long-term recovery by emphasizing culturally responsive policies, adequate funding, and purposeful multi-sectoral coordination. Key insights from executive leaders reveal the importance of aligning payment systems, fostering integrated care models, and ensuring a diverse and well-supported workforce to bridge the gap in service delivery. These efforts, grounded in community-centered approaches and evidence-based strategies, have the potential to transform California’s behavioral health landscape, ensuring equitable and sustainable care for groups that have been historically marginalized.

Acknowledgments

The authors appreciate the support from funders, administrators, and coaches from Health Management Associates. The authors primarily thank agency leaders who provided critical information to advance their understanding of the recovery needs of groups that have been historically marginalized in California.

Footnote

Data Sharing Statement: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-101/dss

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-101/prf

Funding: This study received funding from the California Department of Healthcare Services, administered by the Sierra Health Foundation as part of the Health Equity in Access to Behavioral Health Recovery Services (HEAR US) project. The preparation, completion, and publishing of this paper were supported by a grant (No. REHD 003X23) from Research to End Healthcare Disparities Corp, a grant (No. R01MD014639-01A1) from the National Institute on Minority Health and Health Disparities, and funding from the HEAR US project.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-101/coif). E.G. serves as an unpaid editorial board member of Journal of Hospital Management and Health Policy from October 2023 to September 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Research to End Healthcare Disparities Corp (No. IRB00011865). Interested persons were informed that they were providing consent to participate in the study by giving verbal consent and completing the questionnaire.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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