Mapping Progress in Mental Health Disparities in a Transformed California Mental Health System

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Mapping Progress in Mental Health Disparities in
a Transformed California Mental Health System

• University of California Davis Health System
• Sacramento, CA
• May 22, 2009
• Annelle B. Primm, MD, MPH
• Director, Minority and National Affairs
• American Psychiatric Association

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Overview

• Significance of disparities
• Landmark reports and initiatives
• Public health and prevention approach
• Current challenges
• Unmet need
• Barriers, mediators and outcomes
• Interplay of social determinants, public health
  interventions and outcome
• Recommendations
• Call to action

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Significance of Disparities

• In the context of growing demographic diversity
  in U.S.
• Significant burden of unmet mental health needs
  among diverse racially, ethnically, culturally
  and linguistically diverse populations
• Translates into ill health, premature death,
  diminished productivity and social potential,
  wasted resources
• A major U.S. problem

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Landmark Reports National Initiatives

• 1997 Cultural Competence Standards
• 1998 President Clintons Presidential Initiative
  on Healthcare Disparities
• 2000 IOM Crossing the Quality Chasm
• 2001 SG Report on MH Culture, Race, Ethnicity
• 2002 IOM Unequal Treatment Confronting Racial
  Ethnic Disparities in Health Care

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Landmark Reports Initiatives

• 2003 President Bushs New Freedom Commission on
  Mental Health
• 2004 IOM In the Nations Compelling Interest
  Ensuring Diversity in the Health Care Workforce
• 2005 Commission to End Health Care Disparities
  (AMA, NMA, NHMA)
• 2005 Sullivan Report, Missing Persons
• AAMC Health Professionals for Diversity
• 2005 IOM Health Care for Mental and Substance Use
  Conditions
• 2009 IOM Preventing Mental, Emotional and
  Behavioral Disorders among Young People

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Public Health Model

• Population perspective tip of the iceberg, the
  evidence of people not seen
• Case finding and outreach
• Risk factors and protective factors
• Prevention
• Universal
• Selected
• Indicated

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Health Care ReformKey Principles

• Universal coverage
• Sharing the burden of affordable, portable,
  quality coverage
• Controlling costs
• Health information technology
• Prevention and early intervention as the
  foundation of the health care system

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Mental Health ParityImplications for Diverse
and Underserved Populations

• Large gaps in access to mental health care
  services may remain unless addressed in upcoming
  healthcare reform efforts
• Severe access problems to mental health services
  for low income uninsured
• Shortage of mental health providers in some areas
• High rates of mental health problems being
  treated in the general medical sector

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Determinants of Mental Health

• Individual Biology
• Individual Behavior
• Social Environment
• Physical Environment
• Access to Quality Care
• Policies Interventions

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Unmet Need

• Levels of unmet need (not receiving specialist or
  generalist care in past 12 months, with
  identified diagnosis in same period)
• African Americans 72
• Asian Americans 78
• Hispanics 70
• Non-Hispanic Whites 61
• Alegria et al 2006

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Vicious Cycle
Violence and Incarceration
Poverty, Homelessness, Unemployment
Substance Abuse
Unmet Mental Health Needs
Poor Physical Health STIs, DM, CAD, CA, etc
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Barriers and Mediators to Equitable Mental Health
Care for Diverse Racial and Ethnic Groups
Barriers
Mediators
Outcomes
Use of Services

• Personal/Family
• Acceptability
• Cultural beliefs
• Language/literacy
• Attitudes, beliefs
• Preferences
• Involvement in care
• Health behavior
• Education/income
• Structural
• Availability
• Appointments
• How organized
• Transportation
• Financial
• Insurance coverage
• Reimbursement levels
• Public support

• Quality of providers
• Cultural competence
• Communication skills
• Medical knowledge
• Technical skills
• Bias/stereotyping
• Appropriateness of care
• Efficacy of treatment
• Patient adherence

• Health Status
• Mortality
• Morbidity
• Well-being
• Functioning
• Equity of Services
• Patient Views of Care
• Experiences
• Satisfaction
• Effective partnership

• Visits
• Primary care
• Specialty
• Emergency
• Procedures
• Preventive
• Diagnostic
• Therapeutic

Modified from Institute of Medicine. Access to
Health Care in America A Model for Monitoring
Access. Washington, DC National Academy Press
1993. Cooper LA, Hill MN, Powe NR. J Gen
Internal Med. 2002477-486.
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Outcomes Higher Mortality

• African-Americans
• Heart disease and stroke, cancer (breast, lung,
  and prostate), diabetes, infant mortality,
  HIV/AIDS
• American Indians and Alaska Natives
• Diabetes, infant mortality
• Asian Americans and Pacific Islanders
• Tuberculosis, stroke, cervical cancer
• Hispanics
• Diabetes, uncontrolled hypertension, HIV/AIDS

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Crossing the Quality Chasm A New Health System
for the 21st Century

• Six Aims for Improvement
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable
• IOM, 2001

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Person-centered Care

• Providing care that is respectful of and
  responsive to individual patient preferences,
  needs, and values, and ensuring that patient
  values guide all clinical decisions.

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Person-centered Care

• Healthcare partnership among practitioners,
  patients, and their families to ensure that
  decisions respond to and respect patients' wants,
  needs, and preferences and solicit patients'
  input on the education and support they need to
  make decisions and participate in their own care.
  (Adapted from Agency for Healthcare Research and
  Quality, 2002)
• Six dimensions of person-centered care
• Respect for patients values, preferences, and
  expressed needs
• Coordination and integration of care
• Information, communication, and education
• Physical comfort
• Emotional support
• Involvement of family and friends
• (Gerteis et al, 1993)

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Recovery-oriented Care

• Mental health recovery is a journey of healing
  and transformation enabling a person with a
  mental health problem to live a meaningful life
  in a community of his or her choice while
  striving to achieve his or her full potential.
• (SAMHSA Consensus Statement, 2006)
• It is important to convey a sense of hope that
  this is achievable for all Americans with mental
  health needs.

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Outcomes

• Morbidity
• Mortality
• Functioning
• Well-being
• Resilience
• Equity of services

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Social Determinants

• Income (poverty)
• Housing
• Physical environment
• Education
• Social forces (racism, discrimination,
  xenophobia)
• Access to resources
• Stress
• Institutionalization

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Public Health Interventions

• Equity
• Quality of care
• Stigma reduction efforts
• Evidence based treatment approaches and
  community-defined evidence
• Person-centered, culturally and linguistically
  competent, recovery oriented, trauma informed
  care
• Audiovisual tools and social marketing campaigns
  to combat stigma of mental illness

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Synopsis of Culturally and Linguistically
Appropriate Services (CLAS) Standards

• Quality care
• Diverse staff
• Ongoing education and training
• Free and competent language assistance services
• Patient-related materials and signage
• Strategic plan
• Organizational self-assessment
• Collect data
• Profile and needs assessment
• Collaborative partnerships
• Conflict and grievance process
• Publicize successes

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Health Disparities Collaboratives

• Community of Learners
• HRSA support of strategic state and national
  partnerships
• Improving systems of health care
• Planned care model
• Model for improvement in the context of
  community-oriented primary care
• Improve health outcomes (diabetes, asthma,
  depression) and organizational sustainability

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Natl Network to Eliminate Disparities in
Behavioral Health - NNED

• SAMHSA in partnership with the National Alliance
  of Multi-ethnic Behavioral Health Associations
• Vision diverse families thrive, participate and
  contribute to healthy communities
• Community and ethnic-based organizations and
  networks, knowledge discovery centers, and a
  national facilitation center
• Equity in care is an inadequate outcome, rather
  transformation is needed for behavioral health
  focused on culturally and linguistically
  competent interventions

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IOM Unequal Treatment Recommendations

• Increase public and provider awareness of
  disparities
• Change financial incentives to improve quality,
  decrease fragmentation of care
• Ensure provider supply, reduce barriers and
  promote quality evidence-based practice
• Promote civil rights enforcement

Institute of Medicine, 2003
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IOM Unequal Treatment Recommendations

• Promote provider training, cultural competence,
  translation services, community health workers
  and multidisciplinary teams
• Promote patient education to enhance access and
  participation in treatment decisions
• Collect data on access, utilization and quality
  including race/ethnicity/language and monitor
  progress
• Conduct more research on sources of disparities
  and interventions to eliminate them

Institute of Medicine, 2003
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General Strategies to Address Disparities

• Must address all potential factors affecting
  disparities
• May need to address subpopulations of diverse
  groups differently, dependent on how various
  factors affect them
• Include diverse communities at all levels of
  research, policy, planning, programs, evaluation

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Strategiesto Increase Use of Services

• Integration of mental health in primary care
  settings
• Increase screening and focus on prevention
• Increase knowledge of population differences for
  effective diagnosis and treatment (address at
  level of training, medical school, residency, and
  CME)
• Standards for screening, referral, diagnosis, and
  treatment

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Strategies to Reduce Barriers

• Policy and funding to improve/increase
  (structural and personnel) MH services in human
  services, and other public sectors where diverse
  populations are located (correctional, child
  welfare, school, community health)
• Universal health insurance to assure coverage
• Mental health parity
• Public marketing to increase population
  knowledge, change health behavior
• Patient activation

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Strategies to Enhance Mediating Factors

• Provider education on cultural competence
• Clinicians should consider patients cultural and
  social context when negotiating treatment
  decisions
• Provider incentives (career, financial) for
  successful referral and engagement
• Increase representation of diverse populations in
  all clinical trials (better understand
  environmental and biological interactions and
  effect on symptomatology/drug interaction)
• Language competency in assessment/diagnostic
  instruments

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Strategies to Improve Outcomes

• Greater public health interventions as basis for
  correctional, child welfare, human services
  systems
• Collecting data and reporting on diverse groups
  health status (mental health, functioning,
  co-morbidities)
• Longitudinal studies to evaluate equity of
  services, patient experiences

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Other Strategies

• Collaboration of health and mental health
  agencies at the federal, state, county and local
  level (CDC, Offices of Multicultural Services
  Health, Departments of Health and Mental Health,
  etc.)
• Increased surveillance to monitor changes in
  prevalence and needs of disparate populations
• Data collection beyond prevalence to focus on
  impairment, outcomes and access to treatment

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Research

• Risk and resilience models that elucidate causal
  pathways for mental distress and mental illness
  in vulnerable populations
• Evaluate differential impact of race, culture,
  language, mental disorder and chronic disease on
  morbidity and mortality outcomes
• Integrate focus on mental health into the public
  health system

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Research

• Engagement models that work for diverse
  populations and focus on community defined
  evidence (community-based programs that work)
  February 2009 American Journal of Public Health
  Chung et al paper on collective efficacy and
  community engagement using Talking Wellness group
  and art events to address depression in LA
  African American community

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Office of Minority and National
Affairs(OMNA)

• APAs nerve center for the mental health of
  diverse and underserved populations

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Our Mission

• To contribute to the improvement of the quality
  of care for diverse and underserved populations
• To meet the professional needs of psychiatrists
  from under-represented (MUR) groups

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Our Main Issues Constituencies

• People of African, Asian, Hispanic, Native
  American descent
• Women
• Gay, Lesbian and Bisexual Issues
• International Medical Graduates
• Religious and Spiritual Issues

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Our Priorities

• Increase diversity in psychiatry
• Foster the professional well-being of
  psychiatrists from underrepresented groups
• Increase knowledge of the mental health needs of
  underserved populations
• Educate communities about mental health
  disparities
• Forge alliances to prevent and eliminate
  disparities

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American Psychiatric AssociationDisparities
Elimination Efforts

• Increase access to quality care
• Support capacity development, education and
  training
• Expand the science base
• Promote collaboration and advocacy

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Fellowship Programs

• Minority Fellowships Program
• Program for Minority Research Training in
  Psychiatry (in collaboration with APIRE)
• Spurlock Congressional Fellowship
• Medical student programs
• Mentoring, travel scholarships, addiction and HIV
  psychiatry summer externships

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OMNA Products

• CME curriculum, NAMI-APA effort
• In Living Color Treating Depression in Diverse
  Populations for primary care
• Lets Talk Facts series on Mental Health of
  Diverse Populations available at healthyminds.org
• People of African, Asian, American Indian,
  Hispanic descent and Gay Lesbian and Bisexual
• DVDs
• Latino Mental Health DVD and Guidebook
• Real Psychiatry Doctors in Action

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Disparities in Psychiatric Care Clinical and
Cross-cultural Perspectives

• Gay Men
• Lesbians
• Bisexuals
• Transgender Persons
• Rural
• African Americans
• Asian Americans
• American Indians, Native Alaskan, Native Hawaiian
• Women
• Incarcerated Populations

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Disparities in Psychiatric Care Clinical and
Cross-cultural Perspectives

• Children and Adolescents
• Adulthood
• Older Adults
• Migrant and Refugee Populations
• Addicted Populations
• Chronically Mentally Ill Populations
• Disabled Populations
• Mentally Ill Populations

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Disparities in Psychiatric Care Clinical and
Cross-cultural Perspectives

• Addressing Disparities
• Culturally sensitive evaluation
• The Role of Cultural Competence
• The Role of Emergency Care
• The Role of Providers
• The Role of Quality Care
• The Role of Education
• The Role of Continuing Medical Education

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Disparities in Psychiatric Care Clinical and
Cross-cultural Perspectives

• Addressing Disparities
• The Role of Non-medical Human Services and Human
  Medicine
• Ethnic and Racial Group-Specific Considerations
• The Role of Parity
• Global Perspectives
• The Need for Universal Access to Care

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OMNA Special Projects

• Womens Mental Health Roundtable
• All Healers Mental Health Alliance
• OMNA on Tour
• Community Connections
• Doctors Back to School
• Transformational Leadership in Psychiatry Academy
• National Minority Mentors Network
• Collaboration with Texas Regional Psychiatry
  Minority Mentorship Network (TRMMN)

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Call to Action

• Public health approach to eliminating disparities
• Public policy makers and planners to claim this
  problem, set specific targets, design strategies,
  and track outcomes
• Seek solutions that involve diverse communities
  and grow and utilize community-defined evidence

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Congratulations to California!

• On the cutting edge of addressing disparities
  head on
• Developing a transformational process
• Making it real and making it happen
• Involving leaders from community, consumers,
  academics and policy makers to collaborate
• Using your vast human and financial resources and
  technological ingenuity to actualize your vision