A Novel Collaborative Mental Health Practice Model for the Treatment of Mental Illness of the Spanish Speaking Indigent and Uninsured

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A Novel Collaborative Mental Health Practice
Model for the Treatment of Mental Illness of the
Spanish Speaking Indigent and Uninsured

• Davor Zink, Margie Hernandez, Hannah Lindsey,
  Vala Burton, Tara Jackman and Antonio E. Puente
• University of North Carolina Wilmington
• Jennifer Buxton and Allison Altendorf
• New Hanover Regional Medical Center
• Presented at the annual meeting of the
• Southeastern Council of Latin American Studies
• March 17, 2011
• Wilmington, NC

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U.S. Population Hispanic

• US
  301,621,159 (100.0)
• US Hispanics
  46,943,613 (15.4)
• Largest Fastest Ethnic Minority Group in the
  United States (and undercounted). Will be the
  Largest Group in the United States by
  Approximately 2050.

Source U.S. Census Bureau, 2007 American
Community Survey, Pew 2009
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Percent Latino of the Total Population in the
United States 1970 to 2050
Projections
Census
Projected Population as of July 1
Source U.S. Census Bureau, 1970, 1980, 1990, and
2000 Decennial Censuses Population Projections,
July 1, 2010 to July 1, 2050
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Expected Growth Hispanics in the U.S.

• 
  Projections of Hispanic Population 2009-2050
• Source U.S. Census Bureau figures

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Top Five States by Latino Growth Rate 2000 to
2006
(For states with 100,000 or more Latinos in 2006)
Rank State Growth Rate (percent)
1 Arkansas 60.9
2 Georgia 59.4
3 South Carolina 57.4
4 Tennessee 55.5
5 North Carolina 54.9
Source U.S. Census Bureau, Population Estimates
July 1, 2000 to July 1, 2006
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NC Population Hispanic

• NC
  9,061,032 (100)
• Hispanics (or Latino any race) 639,623 (7.1)
• Mexican 408,782
  (4.5)
• Puerto Rican 51,867
  (0.6)
• Cuban
  14,876 (0.2)
• Other Hispanic or Latino 164,098 (1.8)
• Current/Expected Growth 400-500 annually
• Second fastest growing after Alabama
• (due to increasing US and foreign born migration
  birth rates)

Source U.S. Census Bureau, 2007
American Community Survey
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Latest Figures

• North Carolina Growth 111 (2000-2010)

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Main Problems in the Hispanic Population

• Low education
• Poverty
• Language barriers
• Mental Health/Health Problems

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U.S. Hispanic Educational Attainment

• Graduate or Professional Degree
  10.1
• Bachelors Degree
  17.4
• Associate Degree
  7.4
• Some College (no degree) 19.5
• High School Graduate
  30.1
• 9th-12th grade (no diploma)
  9.1
• Less than 9th grade
  6.4
• Note Nationwide, 47 of undocumented Hispanics
  have less than a high school degree

Source U.S. Census Bureau, 2007 American
Community Survey
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Language Poverty Co-variates

• People who speak only English at home
  (219,092,969) are
• below (11.2) poverty line
• above (88.8) poverty line
• People who only speak Spanish or any other
  language at home (33,833,322) are
• below (20.0)
• above (80.0)

Source U.S. Census Bureau, 2007 American
Community Survey
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Language Concerns

• Variation of Spanish
• Spanish as a Second or Even Third Language
• Limits and Perils of Translations
• Importance of Non-Verbal Communication
• Difficulties With Learning English

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Typical Mental Health Problems

• Depression
• Anxiety
• Substance Abuse
• Domestic Violence
• (from literature and 5 years of clinical service
  at Tileston Mental Health Clinic)

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Origins Of Mental Health Problems

• Acculturation Isolation
• Language Limitations
• Health Disparities
• Decreased Social Support
• Financial Limitations
• Poor Education
• Lack of Religious Affiliation

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The Tileston Health Clinic

• A non-profit clinic that has been serving
  low-income and uninsured patients in southeastern
  North Carolina for 20 years.
• Mission
• Provide quality health services at no cost
• No form of health insurance
• Income falls within the federal poverty
  guidelines
• English and Spanish

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The Tileston Health Clinic

• Medical services
• Dental services
• On-site pharmacy
• Staff
• Healthcare professionals (MAs, CPPs, PhDs and
  MDs)
• Support staff (undergraduate, graduate)
• All volunteers
• Budget
• Grants, donations, and money collected from
  fundraisers
• All services and medications provided by the
  clinic and its affiliates are free of charge to
  all of the clinics patients.
• Daily (8-5)

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The Mental Health Clinic

• Founded by A. E. Puente, a clinical
  neuropsychologist and UNCW professor, 10 years
  ago.
• Psychotherapy and Counseling
• Clinical Psychologists, counselors
• Medication Management
• PharmD./CPP, Clinical Psychologist, MD
• Psychological and neuropsychological testing
• Graduate students
• Administration
• Undergraduate and graduate students

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By the Numbers

• Number of patients 56 (2009)
• Total served
• Total per night 20 approx.
• Number of hours per month clinic is open on
  average 10 hrs
• Number of volunteers 12
• Number of psychotherapy encounters 200
• Average encounter 30 mins
• Average of sessions per pt
• Number of testing encounters 100 (including
  treatment outcome)
• Average testing protocol 6 hrs/patient

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The Collaborative Pharmacy Practice Model (CPPM)

• Clinical Pharmacist Practitioner (CPP) license.
• Allowed the pharmacist to prescribe medications
  based on the psychologists working diagnosis.
• Overseeing physician
• Review all clinic notes
• Endorse the pharmacists medication
  recommendations

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The Collaborative Pharmacy Practice Model (CPPM)

• Clinical psychologist and the clinical pharmacist
  see patients together
• Pharmacist prescribes psychotropic medications
  based on psychologist diagnoses
• Initial evaluation
• Psychotherapy
• Medication management
• Testing

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Typical presenting problems

• Depression
• Anxiety
• Substance Abuse Disorder/Alcoholism
• Children- Learning Disability, ADHD

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The Collaborative Pharmacy Practice Model (CPPM)

• Most patients receive psychotherapy in
  conjunction with pharmacotherapy
• Patients with substance abuse disorders and
  actively suicidal and/or psychotic are ineligible
  for mental health clinic services

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Testing

• Diagnostic purposes
• Psychological and neuropsychological testing
• Facilitate diagnosing the patients and to
• Acquire standardized data for the patients
  records
• Research purposes
• Treatment outcome
• Pre-test data is
• Gathered upon the initial clinic appointment
• Provide an overall picture of the patients
  current physical and mental health status
• Post-test data is
• Gathered approximately six months after the start
  of therapy
• Evaluate the patients response to therapy

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Treatment Outcome

• Alcohol Use Disorders Identification Test (AUDIT)
• quantity and frequency of alcohol or substance
  use
• detect dependence as well has harmful or
  hazardous drinking
• Patient Health Questionnaire for depression
  (PHQ-9)
• assesses and monitors depression severity
• Short Form-12 (SF-12)
• assesses quality of life

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Pre and Post Testing

• No significant results were found
• Measures were not sensitive enough
• Small sample size
• amount of time between pre and post tests
• Lack of staff
• Limited hours
• Patients did not follow-up with their treatment
  plan
• Became employed or insured
• Moved
• No exit interview
• Attrition

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Pre and Post Testing

• Anecdotal evidence suggest patients are improving
  with treatment
• The biopsychosocial well being of the patients
  was the primary reason for termination of
  treatment
• The effectiveness of treatment was evident to the
  staff

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Case Study T.P.

• Depression and Anxiety
• Patient has no energy, cannot get out of bed,
  very anxious, helpless, physical pain,
  unemployed, marital problems cannot function in
  society
• Medication Psychotherapy
• Paroxetine
• Individual and couples psychotherapy sessions
• CPPM sessions
• All treatment was provided in Spanish
• After a year no depression, anxiety under
  control, no physical pain, patient familial
  situation is stable, patient has a stable job.

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Economic Impact In 2009

• 56 patients for a total of 316 visits.
• A total of 165 hours of free care, total
  estimated value of 15,580.88.
• A total of 775 prescriptions were issued by the
  CPP, total patient cost savings of 123,699.29.
• Clinic patients received over 139,000 in free
  mental health care and prescription medications.

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Limitations

• More patients than available volunteers
• Large waiting list
• Volunteers availability
• Funding

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The Tileston Mental Health Clinic

• Is one of the few institutions in the state of NC
  that is able to provide free medical and mental
  care for uninsured Hispanics and only one that
  provides bilingual services.
• The CPPM used in the clinic is a novel approach
  worth of replication and further improvements.
• Only psychiatrists prescribe medications,
  limiting the availability of this kind of
  treatment, especially for the clinics patient
  population (low income, uninsured, Hispanics).
• Volunteering and learning opportunity for
  students and professionals in the community.

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Problems for North Carolina

• Number of Hispanics in North Carolina (111
  growth)
• Some SE NC counties have over 50 of the
  population that are Hispanics
• Number of Doctoral Level Psychologists that are
  Hispanic in North Carolina 1
• Major mental health crisis looming in the horizon
• One possible solution Proposed UNCW PhD program
  (requires knowledge of Spanish)

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Conclusion

• Wilmington, we have a problem
• Gracias!
• Preguntas?