Greetings! Welcome to our telebehavioral health series. So thrilled you guys could join us today. I get to be your speaker today, and I get to talk about a topic that I'm quite passionate about. We're going to be talking about understanding the digital divide, and then practical tips to consider in your own clinic when if you're dealing with the digital divide and how you might be able to close that digital divide. 

So let's go ahead and get started. So here are our learning objectives today. We want you to be able to describe some of the factors that contribute to the digital divide. 

We want to be able to describe who are those most impacted by the digital divide, what is digital navigation. I want you be able to describe that and how digital navigation could potentially close the digital divide. So that's our goal today is for us to cover these learning objectives. So let's get started. 

The digital divide. So what is this thing called the digital divide? I don't know. Everyone's talking about it. So let's go ahead and try and define it. Basically, the digital divide is the growing disparity between those who have access to digital modalities to include digital health and those who do not have this ability. 

In the US, the Federal Trade Commission estimates that more than 21 million people lack the internet, more than 40% of schools lack broadband connection, and more than 60% of health facilities outside of Metropolitan area lack broadband connection. 

Now with my presentations, I always like to cite references. Some of these might be getting a little old, but trust me, the gist of them still holds. So don't hold me to these numbers exactly. But this is how you start to define the digital divide. 

Let's talk about some other ways to define the digital divide. Now, I've highlighted this group, the digitalinclusion.org. This is a fantastic group doing really important work in this area. If you want to learn more after this talk, I would highly recommend you go check them out. 

But typically, I don't like to read slides. But this stuff's important. So I think I'm going to go ahead and read it. This is how they define the digital divide. The digital divide is the gap between those who have affordable access, skills, and support to effectively engage online and those who do not. 

As technology constantly involves, the digital divide prevents equal participation and opportunity in all parts of life, disproportionately affecting people of color, indigenous people, households with low income, people with disabilities, people in rural areas, and older adults. 

I really like this definition because it beyond just health care. We're often so focused and have the blinders on and think only about health. But this group is getting you to stretch your mind and think about people who are excluded from their societies because of their inability to connect. 

They go on to define digital equity as a condition in which all individuals and communities have information technology capacity needed for full participation in society, democracy, and economy. Kind of what I was just saying. And this is necessary for civic and cultural participation, employment, lifelong learning, and access to these essential services. 

They go on then to describe five important elements related to the digital divide, the need for affordable, robust internet, internet devices that meet the needs of the user, access to literacy training, tech support, and then having applications that make sense to them, that will enable and encourage self-sufficiency, participation, and collaboration. 

So if you want to learn more about this topic, I really highly recommend you check out this group. They go on then and take it down to yet another level in terms of understanding the digital literacy and skills. How do they define it? Possessing a variety of skills, both technical and cognitive, required to find, understand, evaluate, and create digital and communicate digital information. 

Need to be able to use these appropriately and understand it. You need to understand the relationship between lifelong learning, privacy, and ownership. Take these skills and the appropriate technology to communicate with peers, family, and the public, and being part of a vibrant community. 

So this is how they define digital literacy and skills. All these things factor into what makes the digital divide. So let's dig down a little more and think about the causes of the digital divide. To me, this has been like peeling back the layers of an onion. 

Every time I think I understand what the digital divide is, I peel back another layer. First, I thought, oh, it's just old people. But then I thought, actually a lot of grandparents are communicating with their kids and grandkids via FaceTime these days. 

Then I thought, well, maybe it's just people living in rural areas. Well, yeah, but what about people in urban distressed areas? So this is, to me, just really fascinating. Every time I think I have my head wrapped around it, there's something else to think about. 

Well, maybe one of the most important predictors of the digital divide, and people who are at risk is related to educational level. As you can see, I'm quoting one of my favorite movies there, Casablanca, rounding up the usual suspects. A lot of these causes for health disparities will sound familiar to you, but education level is directly correlated with use of digital technologies. 

And if you think about it, it kind of makes sense. Because that's going to inform one's income, their occupation, their wealth, age and gender. And all those are considered secondary contributors to the digital divide. Interestingly, when you look at socioeconomic disparities, there's a big cutoff, around $30,000. 

And once again, these numbers are going to flex a little. I try and always root my material in literature. But I think that mainly, this holds-- those owners who make $30,000 a year. Quarter of them don't even own a smartphone. Almost half of them don't have broadband internet access. 

Almost half of them don't have a computer. However, if you look at people who are making over $100,000 a year, they have all of those things. So clearly, socioeconomic disparities are a major contributor to the digital divide. 

Rural versus urban. We touched on this earlier. Well, you have lack of internet infrastructure in both rural but also distressed urban areas. One study reported that urban residents were 51% more likely to have internet access. 

However, the rural areas really making huge gains of late to improve internet access in these areas. However, they still lag well beyond the suburban population, which seems to have the best access to the internet. Racial differences. These are very important to understand. 

African-American, Hispanic, and Native American ethnicities consistently come up as lacking access to the internet. Less likely to use technology for health-related purposes. Less likely to receive phone calls or look for health information. 

Further data has shown that much of the Black and Hispanic are much less likely than white and Asian households to have access to the internet, whereas Black Indigenous people of color also lack access to technology, have poor skills for effective use even after controlling for some of the factors we've already mentioned. 

Another interesting group to consider and this didn't and should have jumped out at me, but it didn't. Older immigrants. They really have some significant challenges in interacting with their community in particularly accessing the internet. And if you think about it, once again, think about that onion pulling back layers and some of the causes we've already talked about, a lot of these elderly immigrants really struggle with these factors. 

Speaking of the elderly, often identified as a high risk, that continues to be that, but it's not as bad as one would think. However, one group does jump out, and that's the elderly, widows, or widowers who are living alone. These people are really isolated in that risk for falling into the digital divide. 

And another interesting thing I found was you would think that, the older you get, the more challenges you would have, and that would be kind of linear. But it's not. It's almost more exponential. You can look at the numbers there before, but click down there in the last bullet point. But basically, the older you get, it's exponential increase in being at risk for falling into the digital divide. 

Disability status. This was another interesting one. That onion, you just keep peeling back the layers. It shows that those with low vision hearing, other disabilities are at greater risk of being victims of the digital divide. But the interesting thing, the thing that brings some optimism is it's been shown that if you can set these folks up with proper accommodations, they can access the internet and be just as productive as those without these disabilities. 

OK, we're going to shift gears now and talk about digital navigation and digital navigators. My hope is at this point, I've got you really thinking about the digital divide and thinking about that-- in thinking about all the contributors. My hope is you're starting to think some about your clinic, your practice, and who might be falling into that digital divide. 

But while you ponder, let's go ahead and talk about digital navigation, digital navigators. So what the heck is digital navigation and who are these people, who call themselves digital navigators? Well, the concept is really you bring in a new team member to your clinic. And their role is to really connect those who are at risk with your clinic to help them better access healthcare and connect with their providers. 

So I think of it as sort of a handshake, that the digital navigators in there connecting the client with the clinic. The digital navigation for health-- behavioral health providers has been shown to be acceptable and increase users confidence in the use of digital modalities and care for mental disorders. 

Now, the literature I'm sharing with you is really new. It's just emerging. There's just a very thin literature base for digital navigation and digital navigators. But I think this is going to be an important topic going forward. There's some further support for digital navigation. 

And digital navigation Training. Has been used in mental for mental health providers to do better care for psychiatric patients. And results have led to improved digital literacy, better outpatient care, and better use of smartphone-based care. 

So digital navigators, let's talk about them now, drill down a little more in details. You can see the way I like to give talks to start broad, and then really focus down into it. So these digital navigators are considered trusted guides to assist community members in internet adoption and use of computing devices. 

Digital navigation services include ongoing assistance with affordable internet, device acquisition, technical skills, and application support. So if you think back to some of the causes we talked about earlier, the digital divide, you can start to see how these individuals are tailor trained to address those factors and help close that digital divide. 

Here's that group again. I'm not going to read through this whole slide. Again, I would really encourage you to go check out the digitalinclusion.org. But this is how they break down-- again, they take it down another level. 

You're going to bring a digital navigator on board. What are their jobs? Well, I'll let you read through these. These slides will be available. Basically, they're there to really understand the client, really carefully work with them, assess where they're at, what level they are, what challenges they have, what challenges they have in the community, and see what they can do to problem solve so that these individuals can get better access to digital modalities and better connect with the clinic. 

They go on again and say, not just anybody can be a digital navigator. They're going to need some special skills. So these are people who think about your early adopters. As you start to look around your clinic and think, well, if we're going to do this, who might be a good digital navigator? 

Well, think about your early adopters. Think about the people who really embrace technology, but also they got to be really organized. They got to connect well with others. They got to be really sensitive to cultural competencies. 

They obviously have to have very good telephone communication skills. And also the interpersonal skills. They can't just be a techie, right. You got to be able to connect with other people and really understand where they're at, and be sensitive to those challenges and those insecurities. 

They got to be good problem solvers. Because these are really-- this is a whole new field. They're going to be seeing things. No one else has seen or thought about. They've got to be good with boundaries. They've got to be flexible. 

And ideally, they should probably speak several languages. I know here in Washington State, we're working with several communities with migrant farm workers. So it's nice when those digital navigators can speak other languages. 

So let's think about the digital divide a little bit more. So here's one of my frustrations with a lot of implementation work, is that if you notice all the references so far in the talk, it's all been talking about problems with the client, problems with their community, their challenges. 

We haven't heard anything about challenges with health providers or healthcare systems. If you're going to have a digital divide, right, it's both sides have to contribute. Otherwise, you just have a digital cliff. And years of implementation work has taught me that, as health providers and health systems, we're not so good at looking in the mirror and seeing how we might be contributing to certain healthcare challenges. 

And in this case, we're going to talk about the digital divide. So you're going to notice, all my previous slides were well referenced. Now, you're going to hear my reflections. And you're not going to see any other references for now except coming out of me. 

So you have, hopefully by now, a working understanding of the digital divide and how maybe digital navigators could help your clinic. And I asked you earlier to start pondering, how could the digital divide be active in your own clinic with your own panel? So let's think about that in a little more detail now. 

Look around your clinic. Think about the patients you take care of the clients you care for. Who might be at risk? So let's think about some practical tips that you can use to look at your practice, look at your clinic, and see if your clinic and practice is contributing to the digital divide. 

OK, let's look in the mirror for a moment. So here are some practical tips to think about, to look at. First, understand your clients, who you're taking care of. We've been over those who are at risk. The elderly, immigrants, elderly immigrants. 

We've identified educational level as probably the highest, best predictor of someone falling into the digital divide. What about those clients you who have disabilities? Could you get them accommodations that could better help them? 

We've talked about income, and we've talked about digital literacy. So my hope is that you're thinking about your patients right now. You're thinking about your clients. Oh, yeah. That person might be at risk. We might be able to do something to help them. 

What about your clinic? You may be ready to close the digital divide. You may be excited, but is your clinic there? Is your clinic ready to do this? So think about your clinic. Do you got access to broadband? 

A lot of clinics don't. Do you have access up to date equipment? Computers, smartphones, tablets. Are you using HIPAA software compliant, compliant software? During COVID, you got waivers. Those are long gone. 

You got to have HIPAA compliant software now if you're going to get into this space. What about your providers? Are they ready to do this? Do they want to do this? Are they ready to take on improved digital literacy or not? 

That's really important. Are they willing-- they have the right attitude? They're aware of the literature base to support this? They understand safety planning, that this is a recommended form of treatment, that sort of unique informed consent? 

Providers need to be on board with all of this too if this is going to happen. Years of implementation work has taught me that it just takes that one old crusty provider in the break room to sink an implementation project. So think about where your clinic is tech wise and where about your colleagues. 

What about admin support? Yeah, is it there? Do they want to do it? If they don't want to do it, it's not going to happen. You got good IT support for the tech challenges. 

Because if you've ever worked with me before, what do I always say about tech? Tech fails. So now that you've been warned, what's going to be your plan to address when tech fails? You had adequate space. 

Is this culturally appropriate for your clinic? And workflow. Workflow details are super important. You can't introduce a new program and have it just muck up the workflow. 

Otherwise, that project's going to be dead in the water. So think about how would digital navigation and the navigator seamlessly flow into the day to day operations. And what about outreach in the community? How are you going to better advertise these services, screen your patients, identify them, get them what they need? 

So these are just some things to think about as you look through your clinic and see, how could your clinic be contributing to the digital divide? And are you ready to take this on? Now, let's take it to another level. 

So let's say you've addressed all those things. You're ready to bring on the digital navigator. You got the admin support. Well, who would this person be? Think about it. I bet there's someone in your clinic who could do this. 

But what training would they need? What support, admin support? What space, what equipment? How do you set these individuals up to succeed? So there's a whole new field out there now called implementation science. 

And this is a body of literature that looks at actually implementing programs in the field. What has the field learned from taking something off the benchtop, and then actually getting it implemented in the field? 

As people know me, I'm always fond to say everything looks good on a whiteboard. Getting it implemented in the field is tough, tough work. So the good news is that there is a emerging body of literature out there that can help you think this through, and it's known as implementation science. 

Now, there's a lot out there on implementation science. So I'm just going to share with you two concepts that I find particularly useful that I think would be really helpful, that we've used actually to help implement digital navigation systems in the state of Washington. 

But I'm going to share this with you as well because I think this will be useful. If you want to think about other projects you might want to implement. So the first is known as promoting action on research implementation in health services. That's a big mouthful. 

Otherwise known as the Paris framework. And what I really like the Paris framework is it really helps to get your head wrapped around a project. Whatever the project is. Could be digital navigation, could be smoking cessation, could be diabetes control, whatever you want to be doing in your clinic. 

And you got this idea for a project. I like to start with Paris criteria because it asks you to think about the project in terms of three domains. The first is the context. What are you going to be? Where are you implementing this? 

What's the context? How is this-- how are you taking this out of a theoretical perspective, and in what context are you going to be implementing this program? If it is a digital navigator program, what is the context, and how you want to set this program up to succeed? 

The next thing that Paris criteria asks you to think about is what is the evidence, what's the background to support the program or the project that you want to do? And in this case, digital navigation. We've shared a lot of evidence with you already, but this asks you to-- you may have a great idea, but if there's no evidence out there to support it. 

Maybe you're breaking new ground, and that's great. But it's always good to see what the evidence base is. Because we're supposed to be practicing evidence-based medicine and mental health care out there. So after you've thought about the context, and you've looked at the literature, then you have to think about what are the actual steps? 

Well, how are you going to facilitate getting this implemented in the field? So I like Paris criteria because it helps me get my head wrapped around a project. But there's more. I mean, let's think about outcomes. The days of saying to your leadership, hey, I got a smoking hot project here, program. 

They're long gone. Long gone. You've got to have qualitative and quantitative data now to monitor the success of your program, whether it's achieving goals, how do you sustain it going forward, and all those things. So once again, getting your head wrapped around a project. 

I like to RE-AIM criteria. Because this asks you to think about a project in terms of what domains of outcomes that you'd actually want to use to measure the implementation and/or success or and/or sustainment of whatever project you're talking about. In this case, we're talking about digital navigation. 

So the RE-AIM criteria asks you to think about what is the reach? How well are you getting this out to everyone that you want to enroll? Effectiveness. How are you going to measure whether this is effective or not? 

Adoption. How are you going to measure whether people are picking up your project, in this case, digital navigation, and using it? How are you going to measure how this is being implemented? And then how are you going to measure over time whether it's continuing to work and maintain its goals? 

So these are two general ideas that I just wanted to share with you if you're really serious now about taking what we've talked about and actually starting to implement it in your clinic. We found that basing our projects on this criteria really helps to get it off the whiteboard and be successful on the field. 

So let's take another step and think now about the actual steps of the implementation process. We've talked about the practical tips of thinking about what you would need to do to do it. Now, let's talk about some practical steps of actually doing it now that you've got your head all wrapped around this project. 

So here, what we've found are really things to think about when you're actually now going to start-- where the rubber hits the road, essentially. So the first thing you want to do is take a look at where you stand. Where is the clinic at in terms of implementing a digital navigation program? 

How much digital inclusion is going on right now? Is there any going on? You need a baseline to start from. And the next thing you're going to want to think about OK, is we're going to be doing digital inclusion and digital navigation. What about devices? 

Where are you going to get the devices? What devices are you going to use? How are people going to get them? How are you going to implement them in the clinic? How are your clients going to get them? How are they going to get trained on those things? 

The next thing is think about all we've talked about in terms of the digital navigator role. We've talked about a very general. There may be more specific. And then some more specific. But now, you got to get really concrete. 

Now, you think about you've-- maybe you've identified someone who would be good in your clinic in this role. How can you really start thinking about what do they need to do on a daily basis to support closing the digital divide? And think about what are the responsibilities that are unique to your clinic, and how are they going to interact with other staff. 

And once you do that, you got to train them. You can't think that they're just going to know this off the top of the head. So you got to think about how are you going to train them, how are you going to get them trained up to be effective in your clinic. 

How are you going to increase their digital literacy skills. How are you going to help train them to interact with staff. How are you going to help them train them to interact with your clients and reach out. Like I said, how is this digital navigator going to make this handshake between your clinic and your clients, and what are the specific things they're going to need to do? 

What about other resources that are going to help support your program? You want to do some community outreach. You want to think about flyers, ways to advertise things, different handouts. I'm a big fan of the one page cheat sheet. 

In the Navy, we call them go bys. And so having these available are really helpful. You can ask clinics, and patients, and clients to look at this slide set. No one's going to do that. 

So having a go by or just flyers that are cheat sheets, that are available for your clients, for your providers to help increase their digital literacy, to understand this program that you're wanting to do it. We found little short how-to videos very effective. 

You can think about also just maybe having a kiosk in your waiting room, just with video testimonies, talking about the new program so people could see it and think about it and whether it would work. So we've talked a lot about how you do this in your clinic, but you got to think about reaching out to the community. 

Where are you? What local resources do you have? How can you connect out there? How you going to advertise this? How can you build successful partnerships and liaisons with the communities to help close this digital divide? 

I talked to you about the RE-AIM criteria, and here's where you put it into work. How are you going to specifically measure this program in your clinic? You got to have these metrics set up ahead of time. 

You don't have to have all the RE-AIM ones. Those RE-AIM were there just to help get your head around this huge topic of outcome metrics. So think about, what are you going to use to measure the success of this program, the success of the implementation, the success of the adoption, the effectiveness, the reach, and maintenance? 

How are you going to do that? How is that going to work in your clinic? Because like I said, the days of just saying, I got this great program. Everyone loves it. They're long gone. Long gone. 

You got to show data. Qualitative data works, but quantitative data works just as well. All right. So you've done all that. Now, think about the day to day activities of your digital navigator. How are they going to work into the patient flow of things? 

How are you going to incorporate them in your clinic? Because if they don't help with the efficiency, and next thing you're going to have are people complaining that the flow is being backlogged, wait times in the clinic are increasing. 

That's just going to be the death knell for this program. So think about how can this individual improve the efficiencies, and be ready to go, and help close that divide, and really provide a service to both the clients and your clinical admin staff? 

You got this set up. You've got your digital navigator trained up. You're working on training up the community. How are you going to train your staff? How are you going to introduce this new person and set them up to succeed? 

How are you going to train them so that they know how to efficiently reach out for help with this digital navigator. These are all really tips we've learned that you got to think through, and you got to do it. Otherwise, the programmers are grind grinds to a halt. 

Sustainability. There's a lot of information there to think about. I'm not going to read through all of that. But basically, think about the data you're going to be collecting. Think about who's getting included, who may not be getting included. 

We want to continue-- to promote that continuous dialogue with the community. So they're on board, and we're really looking to improve the digital literacy and ability of your clients to embrace these technologies, to improve their overall quality of life. Think back to those definitions from the digital inclusion organization. 

And so you think about the literacy. All these things can help sustain the program going forward. So we're about ready to close now. Hopefully, we've been able to cover a lot of material in this presentation. We've talked about what is the digital divide and all these things. 

But here are some resources that if you want to take it to the next step, particularly if you're in the state of Washington, that can really help promote the work you're doing. I'm sure if you're in another state, they have similar resources. 

So in conclusion, the digital divide is complicated. There's a lot to think about that layers of the onion, like I talked about earlier. Every time I think I understand it, peel something back, and there's something more to consider. It's complicated. There's many factors going on. 

And I would say it's probably still not totally understood. This is a whole new field, digital divide, digital navigation. But it's clear. The literature that's been out there already indicates this is a significant barrier to care, that now that we know about it, we got to address it. 

We just can't ignore it. One way to address it is through digital navigation and digital navigators. So the literature is early in its development and evolving. It does appear to be practical, and doable, and help to improve compliance with treatment. Help with efficiencies of care, help reduce no shows, reduce hospitalizations. 

There's an emerging literature base to support all this. If you want to do this, you just can't say, hey, you be the digital navigator. Good luck. Go get em. It's that it won't happen. 

So think about all the practical tips that we've learned the hard way that we've shared with you today. Anyway, and the good news is that it's being recognized. There's a lot of government support and federal support coming for this. 

So that's it. I hope you've enjoyed this. I hope I've given you some things to think about that are state of the art of the evidence base. Please know that the evidence base is moving quickly, but I doubt that the general information that I shared with you today is going to be changing anytime soon. 

I want to be very available to you. Shoot me guys if you need to get a hold of me. That's my email. So thank you so much today, and good luck out there in the field.