Implementation of a LGBTQIA+ Evidence Based Toolkit in an Outpatient General Psychiatry Clinic: Quality Improvement Project

LGBTQ+ youth are at high risk for significant mental health disorders, including mood, anxiety, and substance use disorders. Initiating mental health care is arguably intimidating for most; LGBTQ+ youth report they fear being judged and feeling invalidated by MHPs who are supposed to help them. LGBTQ+ youth are less likely to seek mental health care, and timely assessment, diagnostic, and psychotherapeutic intervention opportunities are lost. Utah mental health providers (MHPs) report a lack of knowledge, clinical training, experience, and confidence in understanding and working with LGBTQ+ youth presenting with behavioral health disorders. Most mental health providers have not received training in school or at their job sites to provide culturally sensitive care to LGBTQ+ youth. Therefore, it could cause situations where LGBTQ+ youth are unintentionally invalidated. A toolkit was developed by researching existing toolkits and tailoring said toolkits into one specific and appropriate for the mental health providers employed at Lone Peak Psychiatry. Pre- and post-intervention surveys and bi-weekly surveys were created through REDcap (Research Electronic Data Capture) and distributed to providers to gauge the results of the intervention. An evidence-based toolkit was administered to mental health providers at Lone Peak Psychiatry. Pre- and post-intervention surveys and bi-weekly surveys administered during the intervention assessed MHPs' knowledge and confidence in providing culturally sensitive care, toolkit feasibility, useability, and user satisfaction. In the pre-intervention survey, three providers reported they were somewhat comfortable, five providers reported feeling neutral, and three providers reported they were comfortable. In the post-intervention survey, four providers reported comfort working with LGBTQ+ youth, one reported feeling neutral about working with this population, and three reported feeling somewhat comfortable working with this population. In the post-intervention survey, most providers reported they felt the toolkit was feasible to implement into their practice-two providers reported feeling toolkit use was very feasible, three reported feeling it was feasible, one provider reported feeling neutral, and one provider reported somewhat feasible. Additionally, most reported they were satisfied with it-three providers reported they were very satisfied, two reported satisfied, two reported feeling neutral, and one reported feeling somewhat satisfied. A comparison of the pre-and post-intervention surveys did not demonstrate notable changes in MHPs' knowledge or confidence levels concerning LGBTQ+ youth. Toolkit feasibility and user satisfaction scores were favorable. Despite the bi-weekly distribution of toolkit evaluation surveys during the intervention period, the lack of completed surveys precluded conclusions.

1 Implementation of an LGBTQ+ Evidenced Based Toolkit in an Outpatient Psychiatry Clinic: A Quality Improvement Project Dallin Bawden, Deven Jennings, Sara Webb College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 25, 2024 2 Abstract Background: LGBTQ+ youth are at high risk for significant mental health disorders, including mood, anxiety, and substance use disorders. Initiating mental health care is arguably intimidating for most; LGBTQ+ youth report they fear being judged and feeling invalidated by MHPs who are supposed to help them. LGBTQ+ youth are less likely to seek mental health care, and timely assessment, diagnostic, and psychotherapeutic intervention opportunities are lost. Local Problem: Utah mental health providers (MHPs) report a lack of knowledge, clinical training, experience, and confidence in understanding and working with LGBTQ+ youth presenting with behavioral health disorders. Most mental health providers have not received training in school or at their job sites to provide culturally sensitive care to LGBTQ+ youth. Therefore, it could cause situations where LGBTQ+ youth are unintentionally invalidated. Methods: A toolkit was developed by researching existing toolkits and tailoring said toolkits into one specific and appropriate for the mental health providers employed at Lone Peak Psychiatry. Pre- and post-intervention surveys and bi-weekly surveys were created through REDcap (Research Electronic Data Capture) and distributed to providers to gauge the results of the intervention. Interventions: An evidence-based toolkit was administered to mental health providers at Lone Peak Psychiatry. Pre- and post-intervention surveys and bi-weekly surveys administered during the intervention assessed MHPs’ knowledge and confidence in providing culturally sensitive care, toolkit feasibility, useability, and user satisfaction. Results: In the pre-intervention survey, three providers reported they were somewhat comfortable, five providers reported feeling neutral, and three providers reported they were comfortable. In the post-intervention survey, four providers reported comfort working with 3 LGBTQ+ youth, one reported feeling neutral about working with this population, and three reported feeling somewhat comfortable working with this population. In the post-intervention survey, most providers reported they felt the toolkit was feasible to implement into their practice—two providers reported feeling toolkit use was very feasible, three reported feeling it was feasible, one provider reported feeling neutral, and one provider reported somewhat feasible. Additionally, most reported they were satisfied with it—three providers reported they were very satisfied, two reported satisfied, two reported feeling neutral, and one reported feeling somewhat satisfied. Conclusion: A comparison of the pre-and post-intervention surveys did not demonstrate notable changes in MHPs’ knowledge or confidence levels concerning LGBTQ+ youth. Toolkit feasibility and user satisfaction scores were favorable. Despite the bi-weekly distribution of toolkit evaluation surveys during the intervention period, the lack of completed surveys precluded conclusions. 4 Implementation of an LGBTQ+ Evidenced Based Toolkit in an Outpatient General Psychiatry Clinic: A Quality Improvement Project Problem Description Lesbian, Gay, Bisexual, Transgender Queer+ (LGBTQ+) youth are at a higher risk of developing mental health disorders compared to non-LGBTQ+ youth. 41% of LGBTQ+ youth considered attempting suicide in the U.S. (The Trevor Project, 2023). One significant contributing factor to the elevated risk of developing mental health disorders is facing invalidation and unacceptance in their environment (Arijs et al., 2023; Kiekens et al., 2022). In 2022, nearly one in three LGBTQ+ youth reported having poor mental health most or all the time due to anti-LGBTQ+ policies and legislation (The Trevor Project, 2023). LGBTQ+ youth also reported frequently experiencing invalidation of their identity while seeking mental health treatment, which often led them to avoid getting mental health treatment (The Trevor Project, 2023). Healthcare providers report a desire to provide culturally sensitive care to LGBTQ+ youth, but many report having a lack of training to work with this population (Roth et al., 2021). Available Knowledge To improve care provided to LGBTQ+ youth, many mental health organizations now offer training in culturally appropriate and specific care to LGBTQ+ populations (MedinaMartinez et al., 2021). The training helps providers feel more comfortable, knowledgeable, and confident about working with this population. The training can also help address the gap in receiving culturally sensitive mental health treatment LGBTQ+ youth face. Course formats that are easy to use and can be worked into differing employee schedules are the most sustainable (Fish et al., 2023). 5 The training often includes elements addressing specific health concerns (including mental health concerns, cultural education, and how to provide affirming care). Additionally, these trainings include information about how LGBTQ+ youth are at an elevated risk of developing mental health disorders and what factors lead to it. Cultural education includes information about terminology and values common to many LGBTQ+ youth. Training also emphasizes how mental health providers can provide affirming care by asking sensitive questions and avoiding potential microaggressions. Rationale The John Hopkins Evidence-Based Practice model is a three-step model that includes practice questions, evidence, and translation. It aims to appraise and synthesize evidence and translate it for practical use. In this project, the practice question addresses the gap in mental health providers giving culturally sensitive care to LGBTQ+ youth. In the appraisal and synthesis of evidence step of this project, research showed that education for providers about how to deliver culturally sensitive mental health treatment can improve mental health care for LGBTQ+ youth. To implement this training, an evidence-based toolkit was tailored for use in clinical practice. Specific Aims This Doctor of Nursing Practice (DNP) quality improvement (QI) project aimed to develop and implement a toolkit for clinicians to use to enhance the provision of culturally sensitive care for LGBTQ+ youth in a mental health private practice setting. 6 Methods Context An evidence-based toolkit was delivered at Lone Peak Psychiatric Clinic, an outpatient psychiatric clinic in a suburban setting in Murray, Utah. The primary patient population is white, middle-aged, cisgender individuals, with approximately 10% LGBTQ+ youth treated. This clinic has nine psychiatric mental health nurse practitioners (PMHNPs), three physician assistants (PAs), one psychiatrist, and two PMHNP students. Intervention(s) Phase one of this project involved creating an evidence-based toolkit for providing culturally sensitive care to LGBTQ+ youth. This phase also involved surveying (Appendix A) the team of providers about their comfort and confidence levels in working with LGBTQ+ youth. In phase two, the evidence-based toolkit was presented via a PowerPoint presentation (Appendix B). The toolkit was then distributed electronically to the team of providers. In phase three, the toolkit was implemented into practice for about three months. The PDSA cycle was employed as regular online discussions about the toolkit with providers, and their questions were answered. Bi-weekly surveys (Appendix C) were distributed to determine how frequently providers used the toolkit. In phase four, a post-intervention survey (Appendix D) was distributed to determine whether the comfort and knowledge levels of the providers changed after they used the toolkit, along with assessed usability, feasibility, and satisfaction with using the toolkit. Study of the Interventions(s) After implementing the toolkit, the frequency of its use was assessed through bi-weekly surveys with Likert scale questions. Additionally, weekly discussion hours were offered during the implementation phase of this project. During these discussions, reminders were sent over 7 Microsoft Teams that providers could ask questions about providing culturally sensitive care to LGBTQ+ youth patients in their practice. Measures This project measured outcomes through a pre-intervention survey (Appendix A), biweekly progress surveys (Appendix C), and a post-intervention survey (Appendix D) developed through Research Electronic Data Capture (RedCap). The pre-intervention survey included eight questions. Seven of the questions used a Likert scale format, and the last question was openended for any feedback providers wished to provide about the toolkit. The bi-weekly surveys included two questions: one Likert scale question assessing the frequency of use of the toolkit, and the other question was open-ended for providers to provide anonymous feedback about the toolkit. The post-intervention survey included ten Likert scale questions and one open-ended question for MHP feedback. Additionally, feasibility, useability, and provider satisfaction were assessed. Analysis Quantitative information was collected in pre-intervention and bi-weekly surveys during the intervention phase and via a post-intervention survey. The pre-intervention and postintervention surveys contained Likert-scale questions determining comfortability, knowledge, and confidence in working with LGBTQ+ youth. The bi-weekly surveys contained Likert-scale questions to determine the frequency of use of the toolkit. They also contained one open-ended question for general feedback about using the toolkit. Content analysis was conducted on these responses, and they were organized and summarized into common themes. Mental health providers completed a pre-intervention survey, bi-weekly surveys during the intervention, and a 8 post-intervention survey. The results were gathered between November 6, 2023, and February 2, 2024. Ethical Considerations This project was determined by the University of Utah’s Institutional Review Board (IRB) to be a QI, thus exempt from the review process. Surveys were anonymous and voluntary. The discussion sessions were held over Microsoft Teams, allowing privacy and conversations to remain discreet. There were no conflicts of interest with this project. Results Ten providers completed the pre-intervention survey (Table 1). Seven providers attended the toolkit dissemination presentation. Four bi-weekly surveys (Table 3) were conducted, and one to three of the initial providers completed the bi-weekly surveys. Eight providers completed the post-intervention survey (Table 1). The pre-intervention survey asked providers about their comfort and knowledge levels working with LGBTQ+ youth. Three providers reported they were somewhat comfortable; five said they felt neutral, and three responded that they were comfortable. On the knowledge question, one provider responded not feeling knowledgeable, six reported being somewhat knowledgeable, and three reported feeling neutral. One provider responded to the open-ended question, suggesting combining all the resources into the PowerPoint (Table 2). In the bi-weekly surveys, providers were asked how frequently they used the toolkit with patients. Four bi-weekly surveys were sent out, and in them was a Likert-scale question assessing the frequency of use of the toolkit and an open-ended question for feedback on the toolkit. In the first bi-weekly survey, one provider reported that they had not referenced the toolkit; in the second bi-weekly survey, one provider reported using the toolkit some of the time. In the third 9 bi-weekly survey, one provider reported using the toolkit sometimes, and two reported using the toolkit most of the time. In the final bi-weekly survey, one provider reported using the toolkit sometimes, and one reported using the toolkit most of the time. No feedback was reported in the bi-weekly surveys. In the post-intervention survey, providers were asked about their comfort and knowledge levels regarding working with LGBTQ+ youth to assess for changes. Toolkit feasibility, usability, and satisfaction were also assessed, with four providers indicating comfort with LGBTQ+ youth; one reported feeling neutral about working with this population, and three reported feeling somewhat comfortable working with this population. Two providers reported feeling knowledgeable about working with LGBTQ+ youth, two reported feeling neutral, and four reported feeling somewhat knowledgeable. For feasibility, two providers reported feeling toolkit use was feasible, three reported feeling feasible, one reported feeling neutral, and one reported feeling somewhat feasible. For the usability of this toolkit, two providers reported it was very usable, one provider reported it was usable, one provider reported it was neutral, and two providers reported it was somewhat usable. For satisfaction with the toolkit, three providers reported they were very satisfied, two reported being satisfied, two reported feeling neutral, and one reported feeling somewhat satisfied. The open-ended feedback about the toolkit included a comment that s/he would have preferred a physical copy of the toolkit. Another provider commented that s/he forgot how to access the toolkit (Table 2). Discussion Summary The key findings of this project are related to implementing a toolkit in an outpatient setting to assist in providing culturally sensitive treatment to LGBTQ+ youth. The comfort level 10 and knowledge level of clinicians in providing culturally sensitive care to LGBTQ+ youth were surveyed, as well as the feasibility, usability, frequency of use, and satisfaction when using the toolkit. Results from the pre-intervention and post-intervention surveys did not indicate that providers felt more comfortable or gained more knowledge about delivering culturally sensitive care when working with LGBTQ+ youth from the toolkit. Providers reported that using the toolkit was feasible and usable. Providers also reported overall satisfaction with the toolkit. Interpretation For the QI project, providers at Lone Peak Psychiatric Clinic were provided with an evidence-based toolkit to help provide culturally sensitive care to LGBTQ+ youth. Results from the pre-intervention survey showed that some of the providers were aware of gaps in their knowledge regarding providing care for LGBTQ+ youth and reported not feeling entirely comfortable being able to do so. After the implementation of the project, there was no clear indication that providers grew in knowledge and comfort levels in providing culturally sensitive care to LGBTQ+ youth. However, providers did report that overall, they felt like the toolkit was feasible to implement and usable and were satisfied with the provided toolkit. This suggests that implementing an evidenced-based toolkit to promote culturally sensitive care is possible. However, there was no apparent direct impact on providers’ comfort and knowledge levels. Limitations Overall, this project collected fewer survey responses than was hoped for. Because the project required ongoing completion of surveys, many of the providers did not complete all of them. Additionally, there were some changes in staffing at Lone Peak, which may have affected who completed both pre- and post-surveys and how many providers were involved during the intervention. 11 There were some limitations regarding the accessibility of the toolkit. In the post-implementation survey, one provider reported that s/he struggled to reference the toolkit because hard copies were unavailable. Another provider reported that s/he forgot how to access it electronically. Lastly, because the surveys were anonymous, it was hard to know if the providers who completed the pre-survey also completed the post-survey. Conclusions This project did not demonstrate provider growth in comfort and knowledge by mental health providers working with LGBTQ+ youth. This could be due to the limitations of this project. However, usability, feasibility, and satisfaction with the toolkit were highly rated. This suggests that toolkits are valuable and sustainable for mental health providers to use in practice. In terms of generalizability to other types of practices, more research should be done in other types of clinics and practices. 12 Acknowledgments A special thanks to Dr. Sara Webb for assisting in developing this project in all its stages. Thanks to Dr. Deven Jennings and Drs. Julie Gee for assistance in content development and editing for this project. Thank you to Dr. Landon Moyers and Lone Peak Psychiatry for allowing this project to be completed and participating. For the final stages of my project, thank you to Dr. Sheila Deyette and Dr. Gillian Tufts for edits and support. 13 References Arijs, Q., Burgwal, A., Van Wiele, J., & Motmans, J. (2023). The Price to Pay for Being Yourself: Experiences of Microaggressions among Non-Binary and Genderqueer (NBGQ) Youth. Healthcare (Basel, Switzerland), 11(5), 742. https://doi.org/10.3390/healthcare11050742 Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidencebased practice for nurses and healthcare professionals: Model and guidelines. 4th ed. Sigma Theta Tau International Fish, J. N., King-Marshall, E. C., Turpin, R. E., Aparicio, E. M., & Boekeloo, B. O. (2023). Assessing the Implementation of an LGBTQ+ Mental Health Services Training Program to Determine Feasibility and Acceptability During the COVID-19 Pandemic. Prevention Science, 1–15. https://doi.org/10.1007/s11121-023-01505-5 Kiekens, W. J., Kaufman, T. M. L., & Baams, L. (2022). Sexual and Gender Identity-Based Microaggressions: Differences by Sexual and Gender Identity, and Sex Assigned at Birth Among Dutch Youth. Journal of interpersonal violence, 37(21-22), NP21293–NP21319. https://doi.org/10.1177/08862605211056729 Medina-Martínez, J., Saus-Ortega, C., Sánchez-Lorente, M. M., Sosa-Palanca, E. M., GarcíaMartínez, P., & Mármol-López, M. I. (2021). Health Inequities in LGBT People and Nursing Interventions to Reduce Them: A Systematic Review. International Journal of Environmental Research and Public Health, 18(22), Article 22. https://doi.org/10.3390/ijerph182211801 Roth, L. T., Garcia, M., Soren, K., & Catallozzi, M. (2021). An unmet need for pediatric LGBTQ training. Clinical Teacher, 18(5), 547–551. https://doi.org/10.1111/tct.13407 14 2023 U.S. National Survey on the Mental Health of LGBTQ Young People. The Trevor Project. Retrieved June 18, 2023, from https://www.thetrevorproject.org/ 15 Tables and Figures Table 1 Pre-intervention Surveys and Post-intervention Surveys Pre Post N=8 N=10 How comfortable are you with 0 0 providing mental health services to Comfortable 5 4 LGBTQ+ youth (ages 12-21)? Neutral 2 1 Somewhat comfortable 3 3 Not comfortable at all 0 0 Very knowledgeable 0 0 about the LGBTQ+ youth (ages 12- Knowledgeable 0 2 21) population culture (such as 3 2 history, terminology, specific health Somewhat 6 4 challenges, etc.)? 1 0 0 0 providing mental health services to Experienced 2 2 LGBTQ+ youth (ages 12-21)? Neutral 2 1 Somewhat experienced 3 5 Not experienced at all 3 0 How knowledgeable do you feel Very Comfortable Neutral knowledgeable Not knowledgeable at all How experienced are you in Very experienced 16 How much training do you feel like Extensive training 0 0 you have received to work with Good amount of training 0 2 LGBTQ+ youth (ages 12-21)? Neutral 0 1 Some training 6 5 No training at all 4 0 How likely would you be to use a Very likely 4 NA toolkit to learn more about the Likely 6 LGBTQ+ youth (ages 12-21) Neutral 0 population? Somewhat likely 0 Not likely 0 How important is it to you to provide Very important 10 7 culturally sensitive care to LGBTQ+ Important 0 1 youth (ages 12-21)? Neutral 0 0 Somewhat important 0 0 Not important 0 0 From your professional experience, Highly at-risk 10 8 how at-risk do you feel members of At-risk 0 0 the LGBTQ+ youth (ages 12-21) Neutral 0 0 Somewhat at-risk 0 0 17 population are for mental health Not at-risk 0 0 NA 1 disorders? How often have you referenced this Every time toolkit in working with your Most of the time 1 LGBTQ+ youth (12-21) clients? Some of the time 2 Not often 3 Not at all 1 How feasible was it to implement Very feasible NA this toolkit into your practice? Feasible 3 Neutral 1 Somewhat feasible 2 Not feasible 0 How useable was this toolkit for Very useable your practice? Useable 2 Neutral 1 Somewhat useable 2 Not useable 0 How satisfied were you with this Very satisfied toolkit? Satisfied NA 2 NA 3 3 2 18 Neutral 2 Somewhat satisfied 1 Not satisfied 0 19 Table 2 Pre-intervention and Post-intervention Survey Responses Pre Post It doesn't help that our state is so anti.... I'd I forget how to access it...please remind us love any education you could provide is to help thanks! provide better care to these vulnerable populations.... I forget how to access it. If I had it as a bookmark or physical copy in my office then I would remember better. 20 Table 3 Bi-weekly Surveys #1 #2 #3 #4 How often have you Not at all 1 referenced this toolkit Not often in the past two weeks Some of the time 1 1 working with your Most of the time 1 2 LGBTQ+ youth (12- Every time 21) clients? 1 21 Appendix A Pre-Intervention Survey 1) How comfortable are you with providing mental health services to LGBTQIA+ youth (ages 12-21)? Not comfortable at all Somewhat comfortable Neutral Comfortable Very Comfortable 2) How knowledgeable do you feel about the LGBTQIA+ youth (ages 12-21) population culture (such as history, terminology, specific health challenges, etc.)? Not knowledgeable at all Somewhat knowledgeable Neutral Knowledgeable Very knowledgeable 3) How experienced are you in providing mental health services to LGBTQIA+ youth (ages 1221)? Not experienced at all Somewhat experienced Neutral Experienced Very experienced 4) How much training do you feel like you have received to work with LGBTQIA+ youth (ages 12-21)? No training at all Some training Neutral Good amount of training Extensive training 5) How likely would you be to use a toolkit to learn more about the LGBTQIA+ youth (ages 1221) population? Not likely Somewhat likely Neutral 22 Likely Very likely 6) How important is it to you to provide culturally sensitive care to LGBTQIA+ youth (ages 12-21)? Not important Somewhat important Neutral Important Very important 7) From your professional experience, how at-risk do you feel members of the LGBTQIA+ youth (ages 12-21) population are for mental health disorders? Not at-risk Somewhat at-risk Neutral At-risk Highly at-risk 8) Please share any more relevant thoughts, experiences, or concerns pertaining to providing mental health care to LGBTQIA+ youth (ages 12-21). 23 Appendix B PowerPoint Presentation and Resource Documents 24 25 26 27 28 29 30 31 32 33 34 35 36 Professional Contacts ● Mental Health Prescribing ○ Deven Jennings, PMHNP-BC ■ [phone] ○ Scott Salomone, MD ■ [phone] ○ Collin Riley, PMHNP-BC ■ [phone] ○ Utah LGBTQ+ Affirming Prescribers Psychology Today ■ https://www.psychologytoday.com/us/psychiatrists/utah?category=gay ● Therapy ○ Encircle ■ https://encircletogether.org/therapy ○ The LGBTQ-Affirmative Psychotherapist Guild of Utah ■ https://lgbtqtherapists.com/directory.html ● Clinics ○ Encircle ○ UAF Legacy Utah ■ https://uafhealth.org/ ○ Pathways ■ https://pathwaysreallife.com/lgbtq-counselor-in-utah/ ○ University of Utah ■ https://healthcare.utah.edu/lgbtqia ○ University of Utah Transgender Health Program ■ https://medicine.utah.edu/trans-health-program ○ Intermountain Health ■ https://intermountainhealthcare.org/medical-specialties/lgbtq-health/ 37 Resources ● Organizations ○ The Trevor Project ■ https://www.thetrevorproject.org ○ NASP ■ https://www.nasponline.org/resources-and-publications/resources-andpodcasts/diversity-and-social-justice/lgbtq-youth/organizationssupporting-lgbtq-youth ○ GLAAD ■ https://glaad.org/resourcelist/?gclid=Cj0KCQjwntCVBhDdARIsAMEwA Ck2c1wumDiaqAaCYCv5Ik6Hm1TPwu8cN7eSgDaru7vCxyD2w1sigkaAn_nEALw_wcB ○ CDC ■ https://www.cdc.gov/lgbthealth/youth-resources.htm ○ Encircle ■ https://encircletogether.org/ ○ Utah LGBTQ+ Chamber of Commerce ■ https://www.utahlgbtqchamber.org/lgbtq-safezone-resources/ ○ Utah Afterschool Network ■ https://utahafterschool.org/program-resources/resource-library/item/452lgbtq-resources ○ Visit Salt Lake ■ https://www.visitsaltlake.com/plan-your-visit/communitydiversity/lgbtq/lgbtq-community-resources/ ○ Numinus ■ https://numinus.com/blog/lgbtqyouth-mental-health-support-resources/ ○ University of Utah LGBT Resource Center ■ https://lgbt.utah.edu/ ○ Live On Utah ■ https://liveonutah.org/lgbtq-2/ ○ Utah Pride Center ■ https://utahpridecenter.org/ ● Parents ○ The Family Acceptance Project ■ https://familyproject.sfsu.edu/ ○ Child Welfare Information Gateway ■ https://www.childwelfare.gov/topics/systemwide/diversepopulations/lgbtq/lgbt-families/ ○ The Trevor Project 38 ■ https://www.thetrevorproject.org/resources/article/friends-family-supportsystems-for-lgbtq-youth/ ● Trainings ○ The LGBTQ-Affirmative Psychotherapist Guild of Utah ■ https://latgou.wildapricot.org/page-1786455 ○ Encircle ■ https://form.typeform.com/to/adzdYG?typeformsource=encircletogether.typeform.com ● Books ○ Pocket Guide to LGBTQ Mental Health: Understanding the Spectrum of Gender and Sexuality: Petros Levounis and Eric Yarbrough ○ Finding Your Inner Strength: A Guide to Mental Health for LGBTQ+ Youth ○ The Queer Mental Health Workbook: A Creative Self-Help Guide Using CBT, CFT and DBT: Brendon J Dunlop ○ A Guide for How to be LGBTQ Parents - Frank Dixon ● Podcasts ○ Inside Mental Health Podcast: Transgender and LGBTQIA+ Mental Health ○ LGBT youthline ○ Science Vs - Trans Kids: The Misinformation Battle ○ Stories from Encircle with Stacey Harkey ● Films ○ Believer ○ Dog Valley ○ Damn These Heels Film Festival ■ https://damntheseheels.org/ 39 Appendix C Bi-weekly Survey 1) How often have you referenced this toolkit in the past two weeks working with your LGBTQIA+ youth (12-21) clients? Not at all Not often Some of the time Most of the time Every time 2) Please share any more relevant thoughts, experiences, or concerns pertaining to providing mental health care to LGBTQIA+ youth (ages 12-21). 40 Appendix D Post-intervention Survey 1) How comfortable are you with providing mental health services to LGBTQIA+ youth (ages 12-21)? Not comfortable at all Somewhat comfortable Neutral Comfortable Very Comfortable 2) How knowledgeable do you feel about the LGBTQIA+ youth (ages 12-21) population culture (such as history, terminology, specific health challenges, etc.)? Not knowledgeable at all Somewhat knowledgeable Neutral Knowledgeable Very knowledgeable 3) How experienced are you in providing mental health services to LGBTQIA+ youth (ages 1221)? Not experienced at all Somewhat experienced Neutral Experienced Very experienced 4) How much training do you feel like you have received to work with LGBTQIA+ youth (ages 12-21)? No training at all Neutral Some training Good amount of training Extensive training 41 5) How often have you referenced this toolkit in working with your LGBTQIA+ youth (12-21) clients? Not at all Not often Some of the time Most of the time Every time 6) How important is it to you to provide culturally sensitive care to LGBTQIA+ youth (ages 1221)? Not important Somewhat important Neutral Important Very important 7) From this toolkit and your professional experience, how at-risk do you feel members of the LGBTQIA+ youth (ages 12-21) population are for mental health disorders? Not at-risk Neutral Somewhat at-risk At-risk Highly at-risk 8) How feasible was it to implement this toolkit into your practice? Not feasible Somewhat feasible Neutral Feasible Very feasible 9) How useable was this toolkit for your practice? Not useable Somewhat useable Neutral Useable Very useable 42 10) How satisfied were you with this toolkit? Not satisfied Somewhat satisfied Neutral Satisfied Very satisfied 11) Please share any more relevant thoughts, experiences, or concerns pertaining to providing mental health care to LGBTQIA+ youth (ages 12-21). 43 Appendix E Executive Summary: Implementation of a LGBTQ+ Evidenced Based Toolkit in an Outpatient General Psychiatry Clinic: A Quality Improvement Project Situation LGBTQ+ youth in Utah are at a high risk of developing mental health disorders and are at an elevated risk of dying by suicide. This has been shown through national and local research. This population is also hesitant to try to access mental health care despite the higher need for it. This summary is designed to provide information about the results of the recent scholarly project that took place at Lone Peak Psychiatry to address improving mental health care provided to this population. Background LGBTQ+ youth exist in an environment that invalidates their existence in Utah, including sometimes when they seek mental health treatment. As a result, this can lead to an increase in mental health disorders for this population along with some reluctance to want to get mental health treatment. Mental health providers have reported lacking education to work with this population. Due to this, LGBTQ+ youth can inadvertently feel invalidated by mental health providers. It has been shown that evidence-based toolkits designed to provide resources on how to provide culturally sensitive care have improved treatment mental health providers feel they give to LGBTQ+ youth. I developed such an evidence-based toolkit for providers at Lone Peak Psychiatry to provide more knowledge on how to work with this population. Assessment A pre-intervention assessment was conducted before the administration of the evidencebased toolkit. The toolkit was administered along with a presentation at a provider meeting. Biweekly surveys were conducted during the intervention. Weekly office hours were offered for cases along with general questions. A post-intervention survey was conducted after the toolkit was implemented. The results did not show that providers grew in confidence or knowledge levels to work with LGBTQ+ youth. However, it was determined that providers agreed it was feasible to implement a toolkit into their practice, along with they were satisfied with it and felt like it was usable. Not enough providers did the bi-weekly surveys to determine how often most of them used the toolkit. Recommendation Based on the feedback from the toolkit, it was determined that an evidence-based toolkit is a feasible and usable way to address concerns with providing care for LGBTQ+ youth. However, with the format of this toolkit, it was not determined that providers grew in their knowledge and confidence levels. A needs assessment could be conducted to determine a better way to approach implementing a toolkit. Toolkits in the future could also focus more on buy-in to participate in intervention, such as offering weekly classes or an online structured training. Additionally, more incentives to participate in surveys such as potential rewards for completing them could be offered.