Equity in behavioral health is now a foundational requirement. For all settings, the most critical compliance actions you can take are:

• Assign accountability to a senior leader with authority and budget.Stratify your access and engagement data to uncover disparities.
• Assess and mitigate digital barriers to telehealth for specific populations.
• Screen for and respond to social needs that undermine treatment success.
• Develop a written Equity Action Plan that identifies a disparity and outlines measurable goals, action steps, and progress.

If you’re unsure where your organization stands, or you want help building a practical, survey-ready Equity Action Plan, our team can walk you through precisely what surveyors expect and how to put those expectations into daily practice.

Equity in Behavioral Health

In this article, I walk through three practical “how-tos” to support your team’s disparity and equity work.  If you prefer a brief overview—or want a version to share with staff, this 4-minute briefing video summarizes the essentials: 4-Minute Briefing Video: Share This with Your Team.

For behavioral health, implementation of the standards looks very different from what most published guidance describes. Much of the available material was written for hospitals, not for organizations navigating waitlists, staffing constraints, telehealth workflows, and community-level barriers that shape access long before a patient ever reaches the door.

You likely already understand what the standards require. The real challenge, and the space where Barrins focuses its work, is helping teams figure out how to implement those expectations in the realities of outpatient behavioral health.

For outpatient, community-based, and telehealth Behavioral Health Center leaders, health care equity is no longer an aspiration; it is a measurable compliance expectation. Regulators now expect organizations to identify at least one meaningful disparity, develop an action plan to address it, and demonstrate measurable improvement over time.

This shift became explicit in early 2023, when reducing health care disparities was elevated to a formal quality-and-safety priority across accrediting bodies.

Ensure Equity in Behavioral Health – 3 How-tos

1) Use Stratified Data to Reveal Access Barriers

One of the clearest expectations across accrediting bodies is the requirement to stratify your data. This is not optional. Surveyors will expect you to show how your organization examines key metrics through the lens of race, ethnicity, preferred language, and other demographic factors.

Why this matters: In outpatient and community settings, inequities show up in patterns such as:

• How long someone waits for their first appointment.
• Who disappears into the waitlist and never returns.
• Who struggles to stay engaged in treatment.

What to stratify: Many suggest that you focus on two core access metrics, such as:

• Time from referral to first appointment.
• Treatment engagement rates.
  

These metrics are the most sensitive to hidden disparities and the ones surveyors are most interested in. You must also apply what you learn to drive continuous improvement across all populations.

Leadership action: Ensure your EHR is configured to collect and report standardized demographic data. If you can’t retrieve a clean REL (race, ethnicity, language) report tomorrow, you are not ready for an equity survey.

Request a 30-minute Review of Best Practices in Equity Data Stratification.

2) Close the Telehealth Divide

Telehealth has expanded access in essential ways, but it has also created new inequities, particularly for people navigating limited bandwidth, older devices, unstable housing, or unfamiliarity with technology. Accrediting bodies now view this through the lens of equitable access, requiring organizations to actively assess and address the digital divide.

How to: Embed a short digital access assessment into your intake workflow:

• Do clients have a reliable device?
• Do they have stable internet access?
• Are they comfortable using video platforms?

Then, monitor whether specific demographic groups have higher no-show rates for telehealth appointments. Significant gaps here are a reliable indicator of digital inequity and may be questioned during the survey.

3) Address Social Determinants of Health (SDOH) in a Meaningful Way

For outpatient and community behavioral health providers, social needs are often the strongest predictors of dropping out of care or missing appointments.  Accrediting bodies expect that you assess for key social needs and then take action based on what you learn.

How to: Screen for 2–3 high-impact social needs such as:

• Housing instability
• Food insecurity
• Transportation barriers

And here’s the part many miss: Assessment without follow-up is non-compliance. Staff must be trained and prepared to connect clients to resources. Document the training and those interventions.

The Mandatory Written Action Plan

Accrediting bodies expect a written action plan that addresses at least one identified disparity. Surveyors will ask to see it and look for:

• Clearly defined disparity
• Measurable goal to address it.
• The action steps you’ve taken.
• Evidence that leadership is reviewing progress and adjusting as needed.

This plan must live within your existing PI/QAPI structure. A well-built Equity Action Plan demonstrates that you’re not only compliant, but proactive and intentional about the populations you serve.

Where These Equity In Behavioral Health Expectations Come From

Here are publicly available summaries of their priorities:

• CMS Framework for Health Equity (2022–2032) emphasizes stratified data, equitable access, and disparity reduction.
• CARF – Mission and Values includes commitments to culturally responsive, person-centered care and reducing barriers to access.

Frequently Asked Questions

1. What minimum access and engagement metrics should Behavioral Health Centers stratify to meet expectations?

The two highest-value metrics are the time from referral to first appointment and the treatment engagement/no-show rate. Stratifying these by race, ethnicity, language, age, insurance type, and other locally relevant demographics helps reveal where certain groups experience longer waits or lower retention.  Surveyors will expect you to be able to show both: 1) the stratified data itself, and 2) what actions you’ve taken based on what you learned.

Start small: pick 1–2 core metrics, stratify consistently, and build improvement efforts over time.

2. How should we structure a digital access assessment to demonstrate telehealth equity?

Keep it short and practical. Integrate 3–4 simple questions into your intake workflow, such as:

• Do you have a reliable device for telehealth (phone, tablet, computer)?
• Do you have stable internet access?
• Are you comfortable using video platforms?
• Do you need help with setup or test calls?
  

Then monitor telehealth no-show rates by demographic groups. If specific populations consistently struggle to connect, surveyors will expect to see what supports you put in place, such as device loan partnerships, technology coaching, or scheduling flexibility.

3. What counts as “meaningful” SDOH follow-up, and how should we document it for compliance?

“Meaningful follow-up” means you did more than screen for housing, transportation, food insecurity, or financial/linguistic barriers. It means staff:

• Identified a need
• Connected the client to resources or supports
• Documented the intervention and the outcome
  

Examples include arranging transportation assistance, connecting someone to a food pantry, supporting a Medicaid re-enrollment, or facilitating interpreter access. Surveyors consider “assessment without action” a form of non-compliance, so documentation must clearly show what your team did next.

4. What elements must a written Equity Action Plan include to satisfy accrediting body expectations?

A compliant plan is simple, focused, and measurable. Surveyors will look for:

• A clearly defined disparity (e.g., longer wait times for Spanish-speaking clients).
• A specific population affected (e.g., adults preferring Spanish).
• One achievable, measurable goal.Action steps, assigned owners, and timelines.
• Regular progress review within your PI/QAPI structure.
• Documentation of adjustments when something isn’t working.

5. How will surveyors evaluate whether our staff understand and can articulate our health equity work?

Surveyors will test alignment between what’s on paper and what staff actually describe. They may ask intake staff, care coordinators, clinicians, and supervisors questions like:

• “How do you identify digital access barriers?”
• “What do you do if a client screens positive for a social need?”
• “What disparity is your organization working on right now?”

Staff don’t need memorized talking points; they need to describe their part of the workflow confidently. The best preparation is clear workflows, brief periodic training refreshers, and real examples of improvements your team has made.