disparities in mental health care of diverse populations: the process of elimination university of...
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Disparities in Mental Health Disparities in Mental Health Care of Diverse Populations: Care of Diverse Populations:
The Process of EliminationThe Process of Elimination
University of Texas Health Sciences CenterUniversity of Texas Health Sciences CenterCommittee of Advancement of Women and MinoritiesCommittee of Advancement of Women and Minorities
Distinguished Speakers SeriesDistinguished Speakers SeriesSan Antonio, TexasSan Antonio, Texas
March 27, 2009March 27, 2009
Annelle B. Primm, MD, MPHAnnelle B. Primm, MD, MPHDirector, Minority and National AffairsDirector, Minority and National Affairs
American Psychiatric AssociationAmerican Psychiatric Association
Public Health ModelPublic Health Model
Population perspective – tip of the iceberg, Population perspective – tip of the iceberg, the evidence of [people] not seenthe evidence of [people] not seen
Case findingCase finding Risk factors and protective factorsRisk factors and protective factors Prevention:Prevention:
Primary (prophylaxis)Primary (prophylaxis) Secondary (early intervention)Secondary (early intervention) Tertiary (chronic care, maintenance)Tertiary (chronic care, maintenance)
Determinants of Mental HealthDeterminants of Mental Health
Individual BiologyIndividual Biology Individual BehaviorIndividual Behavior Social EnvironmentSocial Environment Physical EnvironmentPhysical Environment Access to Quality CareAccess to Quality Care Policies & InterventionsPolicies & Interventions
MajorMajor Racial Ethnic Groups in U.S. Racial Ethnic Groups in U.S.
Latinos/Hispanics - 15%Latinos/Hispanics - 15%
African Americans - 13%African Americans - 13%
Asian American/Pacific Islanders - 5%Asian American/Pacific Islanders - 5%
American Indians/Alaska Natives - 1%American Indians/Alaska Natives - 1%
U.S. Census 2007U.S. Census 2007
US Population Percentage Change 2000-2006
0%
5%
10%
15%
20%
25%
30%
Surgeon General’s Report on Mental Health: Surgeon General’s Report on Mental Health: Race, Culture, and EthnicityRace, Culture, and Ethnicity
Striking disparities in mental health care Striking disparities in mental health care for people of colorfor people of color Less likely to receive servicesLess likely to receive services Poorer quality of care Poorer quality of care Underrepresented in mental health Underrepresented in mental health
researchresearch Disparities impose great disability burden Disparities impose great disability burden
on people of coloron people of color Culture countsCulture counts
Influence of Culture on Influence of Culture on Mental Illness and Mental HealthMental Illness and Mental Health
How patients communicateHow patients communicate How patients manifest symptomsHow patients manifest symptoms How patients copeHow patients cope Range of family and community supportRange of family and community support Willingness to seek treatmentWillingness to seek treatment
U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001
Factors in Mental Health, Factors in Mental Health, Mental Illness and Service UseMental Illness and Service Use
RacismRacism
DiscriminationDiscrimination
Economic impoverishmentEconomic impoverishment
MistrustMistrust
FearFear
Cultural and social influencesCultural and social influences
Biological, psychological and environmental factorsBiological, psychological and environmental factors
U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001
High Need PopulationsHigh Need Populations Overrepresentation of ethnically diverse
populations Homeless Chronic Disease and Disability Correctional facilities Victims of violence Child welfare Immigrants and refugeesImmigrants and refugees
U.S. DHHS, Office of the Surgeon General, SAMHSA August 2001
What Are Racial and Ethnic What Are Racial and Ethnic Health Disparities?Health Disparities?
Differences and inequalities among racial, Differences and inequalities among racial, ethnic, linguistic, and cultural groups inethnic, linguistic, and cultural groups in Risk and predisposition Risk and predisposition Disease prevalence, health status,Disease prevalence, health status,
and diagnosisand diagnosis Health care quality not due to access-related Health care quality not due to access-related
factors or clinical needs, preferences, and factors or clinical needs, preferences, and appropriateness of interventionappropriateness of intervention
Health outcomes and mortalityHealth outcomes and mortality
IOM Report: IOM Report: Unequal TreatmentUnequal Treatment
Racial and ethnic disparities exist regardless of SESRacial and ethnic disparities exist regardless of SES Higher morbidity and mortality from the leading Higher morbidity and mortality from the leading
causes of death causes of death Poorer quality of carePoorer quality of care Worse outcomesWorse outcomes
Racial and ethnic minorities tend to receive a lower Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when quality of healthcare than non-minorities, even when access-related factors, such as patients’ insurance access-related factors, such as patients’ insurance status and income, are controlled.status and income, are controlled.
Smedley et al 2003; IOM 2002Smedley et al 2003; IOM 2002
Outcomes: Higher MortalityOutcomes: Higher Mortality
African-Americans African-Americans Heart disease and stroke, cancer (breast, lung, and Heart disease and stroke, cancer (breast, lung, and
prostate), diabetes, infant mortality, HIV/AIDSprostate), diabetes, infant mortality, HIV/AIDS American Indians and Alaska Natives American Indians and Alaska Natives
Diabetes, infant mortalityDiabetes, infant mortality Asian Americans and Pacific Islanders Asian Americans and Pacific Islanders
Tuberculosis, stroke, cervical cancerTuberculosis, stroke, cervical cancer HispanicsHispanics
Diabetes, uncontrolled hypertension, HIV/AIDSDiabetes, uncontrolled hypertension, HIV/AIDS
Disparities in Seeking Disparities in Seeking Mental Health CareMental Health Care
African AmericansAfrican Americans:: more likely to use emergency services or more likely to use emergency services or primary care providers than mental health specialists. (Surgeon primary care providers than mental health specialists. (Surgeon General, 2001)General, 2001)
Asian AmericansAsian Americans:: Only 4% would seek help from mental health Only 4% would seek help from mental health specialist vs. 26 percent of whites. (Zhang et al., 1998) specialist vs. 26 percent of whites. (Zhang et al., 1998)
LatinosLatinos:: < 1 in 11 with mental disorders contact mental health < 1 in 11 with mental disorders contact mental health specialists, & < 1 in 5 contact primary care providers.specialists, & < 1 in 5 contact primary care providers. (Surgeon (Surgeon General, 2001)General, 2001)
Native AmericansNative Americans:: 44% with a mental health problem sought any 44% with a mental health problem sought any kind of help--and only 28% of those contacted a mental health kind of help--and only 28% of those contacted a mental health agency. (King, 1999)agency. (King, 1999)
Unmet NeedUnmet Need
Levels of unmet need (not receiving Levels of unmet need (not receiving specialist or generalist care in past 12 specialist or generalist care in past 12 months, with identified diagnosis in same months, with identified diagnosis in same period)period) African Americans – 72%African Americans – 72% Asian Americans – 78%Asian Americans – 78% Hispanics – 70%Hispanics – 70% Non-Hispanic Whites – 61%Non-Hispanic Whites – 61%
Alegria et al 2006Alegria et al 2006
Mental Health DisparitiesMental Health Disparities
Underuse of community outpatient careUnderuse of community outpatient care Use of alternative sources of help (faith, family, Use of alternative sources of help (faith, family,
folk) primary care and alternative medicinefolk) primary care and alternative medicine Later entry into treatment, especially at the Later entry into treatment, especially at the
crisis or emergency stagecrisis or emergency stage High drop-out rate and fewer treatment High drop-out rate and fewer treatment
sessionssessions High rates of inpatient care, especially High rates of inpatient care, especially
involuntaryinvoluntary
Cultural Competence StandardsCultural Competence Standards, , 19971997
Mental Health DisparitiesMental Health Disparities
Less access to bi-lingual services Less access to bi-lingual services More likely to be misdiagnosed More likely to be misdiagnosed Less evidence based care Less evidence based care More inpatient hospitalizationsMore inpatient hospitalizations Less follow up after psychiatric Less follow up after psychiatric
hospitalizationhospitalization
Mental Health DisparitiesMental Health Disparities
Underdiagnosis and undertreatment of Underdiagnosis and undertreatment of anxiety and mood disordersanxiety and mood disorders
Differential prescribing patternsDifferential prescribing patterns Lower metabolism of certain Lower metabolism of certain
psychotropic medicationspsychotropic medications More side effects and less adherenceMore side effects and less adherence More seclusion and restraintMore seclusion and restraint
Ethnocultural Influences onEthnocultural Influences onMental Health Care OutcomesMental Health Care Outcomes
Direct:Direct:
Cultural beliefs and preferencesCultural beliefs and preferences
PathoplasticityPathoplasticity
EthnopsychopharmacologyEthnopsychopharmacology
Ethnocultural Influences onEthnocultural Influences onMental Health Care OutcomesMental Health Care Outcomes
Indirect:Indirect:
Bias and stereotypingBias and stereotyping
Misinterpretation of behavior and beliefMisinterpretation of behavior and belief
Lack of symptom recognitionLack of symptom recognition
Misdiagnosis and inappropriate Misdiagnosis and inappropriate
treatmenttreatment
Ignorance of ethnocultural issuesIgnorance of ethnocultural issues
Substance Abuse
Poor Physical HealthSTIs, DM, CAD, CA,
etc
Poverty, Homelessness,Unemploymen
t
Unmet MentalHealth Needs
Violence and Incarceration
Vicious CycleVicious Cycle
Barriers Use of Services
Mediators Outcomes
Barriers and Mediators to Equitable Mental Health Barriers and Mediators to Equitable Mental Health Care for Diverse Racial and Ethnic GroupsCare for Diverse Racial and Ethnic Groups
Personal/FamilyPersonal/Family AcceptabilityAcceptability Cultural beliefsCultural beliefs Language/literacyLanguage/literacy Attitudes, beliefsAttitudes, beliefs PreferencesPreferences Involvement in Involvement in
carecare Health behavior Health behavior Education/incomeEducation/income
StructuralStructural AvailabilityAvailability AppointmentsAppointments How organizedHow organized TransportationTransportation
FinancialFinancial Insurance coverageInsurance coverage Reimbursement Reimbursement
levelslevels Public supportPublic support
VisitsVisits Primary carePrimary care SpecialtySpecialty EmergencyEmergency
ProceduresProcedures PreventivePreventive DiagnosticDiagnostic TherapeuticTherapeutic
Quality of Quality of providersproviders
Cultural Cultural competencecompetence
Communication Communication skillsskills
Medical Medical knowledgeknowledge
Technical skillsTechnical skills Bias/stereotypingBias/stereotyping Appropriateness Appropriateness
of careof care Efficacy of Efficacy of
treatmenttreatment Patient Patient
adherenceadherence
Health StatusHealth Status MortalityMortality MorbidityMorbidity Well-beingWell-being FunctioningFunctioning
Equity of ServicesEquity of Services
Patient Views of Patient Views of CareCare
ExperiencesExperiences SatisfactionSatisfaction Effective Effective
partnershippartnership
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. 2002;477-486.
Barriers: Attitudes and LanguageBarriers: Attitudes and Language Immigrant populations (Asian Americans and Immigrant populations (Asian Americans and
Hispanics) with limited English proficiency report Hispanics) with limited English proficiency report communication a major obstacle in addressing communication a major obstacle in addressing MH concernsMH concerns
Cultural perception of mental illness affects:Cultural perception of mental illness affects: likelihood of seeking carelikelihood of seeking care support support feelings of shame, stigma, weaknessfeelings of shame, stigma, weakness help seeking at crisis stage rather than earlierhelp seeking at crisis stage rather than earlier
Alegria et al 2006; Minski S 2003; Cooper et al 2001; Yeh & Inose 2002Alegria et al 2006; Minski S 2003; Cooper et al 2001; Yeh & Inose 2002
Barriers: LanguageBarriers: Language 18 % of the U.S. population (nearly 47 18 % of the U.S. population (nearly 47
million people) speak a language other million people) speak a language other than English at homethan English at home
28% of all Spanish speakers, 22.5% of 28% of all Spanish speakers, 22.5% of Asian and Pacific Islander speakers and Asian and Pacific Islander speakers and 13% of Indo-European language speakers 13% of Indo-European language speakers speak English either not well or not at allspeak English either not well or not at all
Limited English Proficiency (LEP) affects a Limited English Proficiency (LEP) affects a person’s ability to access and receive person’s ability to access and receive health and mental health carehealth and mental health care
National Health Law Program NNational Health Law Program NHeLP, 2006HeLP, 2006
Barriers: Attitudes and BeliefsBarriers: Attitudes and Beliefs
African Americans and Hispanics had African Americans and Hispanics had lower odds than non-Hispanic whites of lower odds than non-Hispanic whites of finding antidepressant medications finding antidepressant medications acceptableacceptable
African Americans had lower odds and African Americans had lower odds and Hispanics had higher odds than non-Hispanics had higher odds than non-Hispanic whites of finding counseling Hispanic whites of finding counseling acceptable.acceptable.
Cooper et al 2003Cooper et al 2003
Barriers: Health BehaviorBarriers: Health Behavior
Physicians were less patient-centered with Physicians were less patient-centered with African American than non-Hispanic white African American than non-Hispanic white patientspatients Less patient input is associated with less Less patient input is associated with less
information recall, treatment adherence, information recall, treatment adherence, satisfaction with care, return visits, and satisfaction with care, return visits, and suboptimal health outcomessuboptimal health outcomes
Roter et alRoter et al 1997 1997
Availability of Mental Health Availability of Mental Health Services by Race, EthnicityServices by Race, Ethnicity
African Americans account for 2% psychologists, African Americans account for 2% psychologists, 4% social workers in U.S.4% social workers in U.S.
In 2005, 16.7% of psychiatrists were from the 4 In 2005, 16.7% of psychiatrists were from the 4 major racial/ethnic groups: (Black 2.6%; Asian major racial/ethnic groups: (Black 2.6%; Asian 9.6%, Hispanic 4.4%, Native American 0.07%)9.6%, Hispanic 4.4%, Native American 0.07%)
Percentage of Spanish-speaking healthcare Percentage of Spanish-speaking healthcare professionals unknownprofessionals unknown
In 1996, only 29 psychiatrists identified as AIAN In 1996, only 29 psychiatrists identified as AIAN heritageheritage
U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001
Mediators: Cultural CompetenceMediators: Cultural Competence
Limited racial/ethnic diversity of MH providersLimited racial/ethnic diversity of MH providers Greater cultural difference may result in higher Greater cultural difference may result in higher
likelihood of misdiagnosislikelihood of misdiagnosis Cultural incompetence, including language Cultural incompetence, including language
barriers, increase likelihood of misdiagnosisbarriers, increase likelihood of misdiagnosis When needed, less than 20% of patients When needed, less than 20% of patients
seeking MH services, had interpreter services seeking MH services, had interpreter services availableavailable
Alegria et al 2006; Minski S Alegria et al 2006; Minski S et al 2003et al 2003
Culturally Competent CareCulturally Competent Care
Health and human services are offered Health and human services are offered and delivered in a way that are sensitive to and delivered in a way that are sensitive to the language, culture and traditions of the language, culture and traditions of non-native immigrants, migrants and non-native immigrants, migrants and ethnic minorities with the goal of ethnic minorities with the goal of minimizing or eliminating long standing minimizing or eliminating long standing disparities in the health status of people disparities in the health status of people with diverse racial, ethnic or cultural with diverse racial, ethnic or cultural backgrounds.backgrounds.
(www.icfdn.org)(www.icfdn.org)
Culturally Competent CareCulturally Competent Care
The ability of any health care provider of The ability of any health care provider of any cultural background in one’s any cultural background in one’s organization to effectively treat any patient organization to effectively treat any patient of any cultural backgroundof any cultural background..
(Matus, JC 2004, Health Care Manag)(Matus, JC 2004, Health Care Manag)
Cultural CompetenceCultural Competence
A set of congruent behaviors, attitudes A set of congruent behaviors, attitudes and policies that come together as a and policies that come together as a system, agency or among professionals system, agency or among professionals and enable that system, agency or those and enable that system, agency or those professionals to work effectively in cross-professionals to work effectively in cross-cultural situations. cultural situations.
(AAFP, 2001)(AAFP, 2001)
Cultural CompetenceCultural Competence
Acceptance and respect for differencesAcceptance and respect for differences Continuing self assessment regarding Continuing self assessment regarding
cultureculture Attention to the dynamics of differenceAttention to the dynamics of difference Ongoing development of cultural knowledge Ongoing development of cultural knowledge
and resourcesand resources Dynamic and flexible application of service Dynamic and flexible application of service
models to meet the needs of diverse models to meet the needs of diverse populationspopulations
SAMHSA, SAMHSA, CMHS, 1998CMHS, 1998
Outline for Cultural FormulationOutline for Cultural FormulationDSM IV-TRDSM IV-TR
cultural identity of the individualcultural identity of the individual cultural explanations of the individual’s cultural explanations of the individual’s
illnessillness cultural factors related to psychosocial cultural factors related to psychosocial
environment and levels of functioningenvironment and levels of functioning cultural elements of the relationship cultural elements of the relationship
between the individual and the clinicianbetween the individual and the clinician overall cultural assessment for diagnosis overall cultural assessment for diagnosis
and careand care
Mediators: Cultural CompetenceMediators: Cultural Competence
At least 1 in 5 resident physicians surveyed At least 1 in 5 resident physicians surveyed (from seven specialties) reported not being (from seven specialties) reported not being prepared to deal with cross-cultural issuesprepared to deal with cross-cultural issues
Approximately half of residents reported Approximately half of residents reported receiving little or no training in understanding receiving little or no training in understanding how to address patients from different cultures how to address patients from different cultures (50%), or how to identify patient mistrust (56%), (50%), or how to identify patient mistrust (56%), relevant religious beliefs (50%), and relevant relevant religious beliefs (50%), and relevant cultural customs (48%) cultural customs (48%)
Weisman et al 2005Weisman et al 2005
Mediators: Cultural CompetenceMediators: Cultural Competence
Mediators: Bias and Mediators: Bias and StereotypingStereotyping
Un-structured interviews lead to greater Un-structured interviews lead to greater variability in diagnosis, greater reliance variability in diagnosis, greater reliance on bias/stereotypeson bias/stereotypes
Psychometric validation is needed to Psychometric validation is needed to determine whether disparities in determine whether disparities in diagnoses reflect differences in diagnoses reflect differences in detection (clinical uncertainty, biases)detection (clinical uncertainty, biases)
Strakowski SM et al 2003; West et al 2006
The Ethnopsychopharmacological The Ethnopsychopharmacological ApproachApproach
AssessmentAssessment Cultural formulation for diagnosisCultural formulation for diagnosis
Choice of medicationChoice of medication Use medical history, concurrent medications, diet, Use medical history, concurrent medications, diet,
food supplements, and herbals combined with food supplements, and herbals combined with knowledge of enzyme activity in certain ethnic knowledge of enzyme activity in certain ethnic groups.groups.
Start at lower doses.Start at lower doses. Monitor patientMonitor patient
Proceed slowly - involve familyProceed slowly - involve family If side effects are intolerable - lower dosage or If side effects are intolerable - lower dosage or
choose drug metabolized through different routechoose drug metabolized through different route If no response - check adherence, raise dose and If no response - check adherence, raise dose and
monitor levels; add inhibitors; switch drugmonitor levels; add inhibitors; switch drug(Henderson, 2007)(Henderson, 2007)
Outcomes: Patient Views of CareOutcomes: Patient Views of Care Reported spending enough time with providersReported spending enough time with providers
50% of Asian Americans50% of Asian Americans 57% of Hispanics57% of Hispanics 70% of non-Hispanic Whites70% of non-Hispanic Whites
Reported having negative experience with service Reported having negative experience with service providersproviders 20% of Asian Americans and Hispanics (NLAAS)20% of Asian Americans and Hispanics (NLAAS)
Reported being treated with disrespect or looked down Reported being treated with disrespect or looked down on in their patient/provider relationshipon in their patient/provider relationship 14% of African Americans14% of African Americans 20% of Asian Americans20% of Asian Americans 19% of Hispanics19% of Hispanics 9% of non-Hispanic Whites9% of non-Hispanic Whites
Alegria et al 2006; Alegria et al 2006; Blanchard & Lurie, 2004; Blanchard & Lurie, 2004; Collins et al 2002Collins et al 2002
Outcomes: Patient SatisfactionOutcomes: Patient Satisfaction
Patients feel more involved with their care Patients feel more involved with their care when their physician is of the same racewhen their physician is of the same race
Greater involvement with care translates Greater involvement with care translates into higher patient satisfaction and better into higher patient satisfaction and better medical caremedical care
Cooper-Patrick et al 1999Cooper-Patrick et al 1999
Outcomes: Effective PartnershipOutcomes: Effective Partnership
Racial/ethnic minorities rate the quality of Racial/ethnic minorities rate the quality of interpersonal care by physicians and interpersonal care by physicians and within the health care system in general within the health care system in general more negatively than non-Hispanic whites.more negatively than non-Hispanic whites.
Collins et al 2002Collins et al 2002
Landmark Reports & Landmark Reports & National InitiativesNational Initiatives
1997 Cultural Competence Standards1997 Cultural Competence Standards 1998 President Clinton’s Presidential 1998 President Clinton’s Presidential
Initiative on Healthcare DisparitiesInitiative on Healthcare Disparities 2000 IOM Crossing the Quality Chasm 2000 IOM Crossing the Quality Chasm 2001 SG Report on MH: Culture, Race, 2001 SG Report on MH: Culture, Race,
& Ethnicity& Ethnicity 2002 IOM Unequal Treatment: 2002 IOM Unequal Treatment:
Confronting Racial & Ethnic Disparities in Confronting Racial & Ethnic Disparities in Health CareHealth Care
Landmark Reports & InitiativesLandmark Reports & Initiatives
2003 President Bush’s New Freedom 2003 President Bush’s New Freedom Commission on Mental Health Commission on Mental Health
2004 IOM In the Nation’s Compelling Interest: 2004 IOM In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Ensuring Diversity in the Health Care WorkforceWorkforce
2005 Commission to End Health Care 2005 Commission to End Health Care Disparities (AMA, NMA, NHMA)Disparities (AMA, NMA, NHMA)
2005 Sullivan Report, 2005 Sullivan Report, Missing PersonsMissing Persons AAMC Health Professionals for DiversityAAMC Health Professionals for Diversity 2005 IOM Health Care for Mental and 2005 IOM Health Care for Mental and
Substance Use ConditionsSubstance Use Conditions
Synopsis of Culturally and Linguistically Synopsis of Culturally and Linguistically Appropriate Services (CLAS) StandardsAppropriate Services (CLAS) Standards
Quality care Quality care Diverse staff Diverse staff Ongoing education and training Ongoing education and training Free and competent language assistance Free and competent language assistance
services services Patient-related materials and signage Patient-related materials and signage Strategic plan Strategic plan Organizational self-assessment Organizational self-assessment Collect data Collect data Profile and needs assessment Profile and needs assessment Collaborative partnerships Collaborative partnerships Conflict and grievance process Conflict and grievance process Publicize successesPublicize successes
Health Disparities CollaborativesHealth Disparities Collaboratives
Community of LearnersCommunity of Learners HRSA support of strategic state and national HRSA support of strategic state and national
partnershipspartnerships Improving systems of health careImproving systems of health care Planned care modelPlanned care model Model for improvement in the context of Model for improvement in the context of
community-oriented primary carecommunity-oriented primary care Improve health outcomes (diabetes, asthma, Improve health outcomes (diabetes, asthma,
depression) and organizational sustainabilitydepression) and organizational sustainability
Nat’l Network to Eliminate Disparities Nat’l Network to Eliminate Disparities in Behavioral Health - NNEDin Behavioral Health - NNED
SAMHSA in partnership with the National SAMHSA in partnership with the National Alliance of Multi-ethnic Behavioral Health Alliance of Multi-ethnic Behavioral Health AssociationsAssociations
Vision: diverse families thrive, participate and Vision: diverse families thrive, participate and contribute to healthy communitiescontribute to healthy communities
Community and ethnic-based organizations Community and ethnic-based organizations and networks, knowledge discovery centers, and networks, knowledge discovery centers, and a national facilitation centerand a national facilitation center
Equity in care is an inadequate outcome, Equity in care is an inadequate outcome, rather rather transformationtransformation is needed for behavioral is needed for behavioral health focused on culturally and linguistically health focused on culturally and linguistically competent interventionscompetent interventions
IOM Unequal Treatment: IOM Unequal Treatment: RecommendationsRecommendations
Increase public and provider awareness of Increase public and provider awareness of disparities disparities
Change financial incentives to improve Change financial incentives to improve quality, decrease fragmentation of carequality, decrease fragmentation of care
Ensure provider supply, reduce barriers Ensure provider supply, reduce barriers and promote quality evidence-based and promote quality evidence-based practicepractice
Promote civil rights enforcementPromote civil rights enforcement
Institute of Medicine, 2003Institute of Medicine, 2003
IOM Unequal Treatment: IOM Unequal Treatment: RecommendationsRecommendations
Promote provider training, cultural competence, Promote provider training, cultural competence, translation services, community health workers translation services, community health workers and multidisciplinary teamsand multidisciplinary teams
Promote patient education to enhance access Promote patient education to enhance access and participation in treatment decisionsand participation in treatment decisions
Collect data on access, utilization and quality Collect data on access, utilization and quality including race/ethnicity/language and monitor including race/ethnicity/language and monitor progressprogress
Conduct more research on sources of disparities Conduct more research on sources of disparities and interventions to eliminate themand interventions to eliminate them
Institute of Medicine, 2003Institute of Medicine, 2003
Rationale for Culturally Competent Health Care
• Responding to demographic changes
• Eliminating disparities in the health status of people of diverse racial, ethnic, & cultural backgrounds
• Improving the quality of services & outcomes
• Meeting legislative, regulatory, & accreditation mandates
• Gaining a competitive edge in the marketplace
• Decreasing the likelihood of liability/malpractice claims
Cohen E, Goode T. Policy Brief 1: Rationale for cultural competence in primary health care. Georgetown University Child Development Center, The National Center for Cultural
Competence. Washington, D.C., 1999.
Cultural Competence Cultural Competence Guiding PrinciplesGuiding Principles
QualityQuality
Data Driven SystemsData Driven Systems
OutcomesOutcomes
PreventionPrevention
Cultural Competence Cultural Competence TechniquesTechniques
Interpreter ServicesInterpreter Services Written TranslationsWritten Translations Concordant Clinicians and StaffConcordant Clinicians and Staff Education and TrainingEducation and Training Community Health WorkersCommunity Health Workers Health PromotionHealth Promotion Organizational SupportsOrganizational Supports
Brach and Fraser, Quality Management in Health Care, 2002, Brach and Fraser, Quality Management in Health Care, 2002, 10(4), 15-2810(4), 15-28
Clinician Patient Behavioral ChangeClinician Patient Behavioral Change Improved CommunicationImproved Communication Increased TrustIncreased Trust Improved Epidemiologic and Improved Epidemiologic and
Treatment Efficacy KnowledgeTreatment Efficacy Knowledge Expanded Cultural and Expanded Cultural and
Environmental UnderstandingEnvironmental Understanding
Brach and Fraser, Quality Management in Health Care, 2002, Brach and Fraser, Quality Management in Health Care, 2002, 10(4), 15-2810(4), 15-28
Reducing Health Disparities Through the Reducing Health Disparities Through the Implementation of Cultural CompetencyImplementation of Cultural Competency
Source: Brach and Fraser, Cultural Competency; 2000
Diverse Populations
• linguistically• ethnically• culturally
Diverse Populations
• linguistically• ethnically• culturally
Reduction of Health
Disparities
Reduction of Health
Disparities
Improved Outcomes for Diverse Groups
• health status• functioning• satisfaction
Improved Outcomes for Diverse Groups
• health status• functioning• satisfaction
Appropriate Services forDiverse Groups
• preventive• screening• diagnostic• treatment
Appropriate Services forDiverse Groups
• preventive• screening• diagnostic• treatment
Cultural Competency
• effective techniques• sound implementation
Cultural Competency
• effective techniques• sound implementation
+
General Strategies to Address General Strategies to Address DisparitiesDisparities
Must address all potential factors Must address all potential factors affecting disparitiesaffecting disparities
May need to address subpopulations of May need to address subpopulations of diverse ethnic and racial groups diverse ethnic and racial groups differently, dependent on how various differently, dependent on how various factors affect themfactors affect them
Include diverse communities at all Include diverse communities at all levels of research, policy, planning, levels of research, policy, planning, programs, evaluationprograms, evaluation
StrategiesStrategiesto Increase Use of Servicesto Increase Use of Services
Integration of Mental Health in Primary care Integration of Mental Health in Primary care settings settings
Increase screening and focus on preventionIncrease screening and focus on prevention Increase knowledge of ethnic and racial Increase knowledge of ethnic and racial
differences for effective diagnosis and differences for effective diagnosis and treatment (address at level of training, medical treatment (address at level of training, medical school, residency, and CME)school, residency, and CME)
Standards for screening, referral, diagnosis, Standards for screening, referral, diagnosis, and treatment and treatment
Strategies to Reduce BarriersStrategies to Reduce Barriers Policy and funding to improve/increase Policy and funding to improve/increase
(structural and personnel) MH services in (structural and personnel) MH services in human services, and other public sectors human services, and other public sectors where populations are affected (correctional, where populations are affected (correctional, child welfare, school, community health)child welfare, school, community health)
Universal health insurance to assure Universal health insurance to assure coveragecoverage
Mental health parityMental health parity Public marketing to increase population Public marketing to increase population
knowledge, change health behaviorknowledge, change health behavior Patient activationPatient activation
Strategies to Enhance Strategies to Enhance Mediating FactorsMediating Factors
Provider education on cultural competenceProvider education on cultural competence Clinicians should consider patients’ cultural Clinicians should consider patients’ cultural
and social context when negotiating and social context when negotiating treatment decisionstreatment decisions
Provider incentives (career, financial) for Provider incentives (career, financial) for successful referral and engagementsuccessful referral and engagement
Increase ethnic and racial minority Increase ethnic and racial minority representation in all clinical trials (better representation in all clinical trials (better understand environmental and biological understand environmental and biological interactions and effect on interactions and effect on symptomatology/drug interaction)symptomatology/drug interaction)
Language competency in Language competency in assessment/diagnostic instrumentsassessment/diagnostic instruments
Strategies to Improve OutcomesStrategies to Improve Outcomes
Greater public health interventions as basis Greater public health interventions as basis for correctional, child welfare, human for correctional, child welfare, human services systemsservices systems
Collecting data and reporting on race and Collecting data and reporting on race and ethnic groups’ health status (mental health, ethnic groups’ health status (mental health, functioning, co-morbidities)functioning, co-morbidities)
Clinicians to screen for suicide risk and Clinicians to screen for suicide risk and monitor carefully consumers with anxiety monitor carefully consumers with anxiety and mood disordersand mood disorders
Longitudinal studies to evaluate equity of Longitudinal studies to evaluate equity of services, patient experiencesservices, patient experiences
Office of Minority Office of Minority and National Affairsand National Affairs
(OMNA)(OMNA) APA’s nerve center for the mental APA’s nerve center for the mental health of diverse and underserved health of diverse and underserved
populationspopulations
Our MissionOur Mission
To contribute to the improvement of the To contribute to the improvement of the quality of care for diverse and underserved quality of care for diverse and underserved populations populations
To meet the professional needs of To meet the professional needs of psychiatrists from under-represented psychiatrists from under-represented (MUR) groups(MUR) groups
Our Main Issues & ConstituenciesOur Main Issues & Constituencies
People of African, Asian, Hispanic, People of African, Asian, Hispanic, Native American descentNative American descent
WomenWomen Gay, Lesbian and Bisexual IssuesGay, Lesbian and Bisexual Issues International Medical GraduatesInternational Medical Graduates Religious and Spiritual IssuesReligious and Spiritual Issues
Our PrioritiesOur Priorities
Increase diversity in psychiatryIncrease diversity in psychiatry Foster the professional well-being of Foster the professional well-being of
psychiatrists from underrepresented groupspsychiatrists from underrepresented groups Increase knowledge of the mental health Increase knowledge of the mental health
needs of underserved populations needs of underserved populations Educate communities about mental health Educate communities about mental health
disparitiesdisparities Forge alliances to prevent and eliminate Forge alliances to prevent and eliminate
disparitiesdisparities
American Psychiatric AssociationAmerican Psychiatric AssociationDisparities Elimination EffortsDisparities Elimination Efforts
Buy-in at the top: elected leaders, Board of Buy-in at the top: elected leaders, Board of Trustees, executive staffTrustees, executive staff
Support of the Office of Minority and National Support of the Office of Minority and National Affairs (OMNA)Affairs (OMNA)
Recommendations stemming from SGR Recommendations stemming from SGR Supplement passed by board of trustees: Supplement passed by board of trustees: Increase access to quality careIncrease access to quality care Support capacity development, education and Support capacity development, education and
trainingtraining Expand the science baseExpand the science base Promote collaboration and advocacyPromote collaboration and advocacy
Eliminating Mental Health Disparities Eliminating Mental Health Disparities RoundtableRoundtable
..
Fellowship ProgramsFellowship Programs
Minority Fellowships ProgramMinority Fellowships Program SAMHSA, AstraZenecaSAMHSA, AstraZeneca
Program for Minority Research Training in Program for Minority Research Training in Psychiatry (in collaboration with APIRE)Psychiatry (in collaboration with APIRE)
Spurlock Congressional FellowshipSpurlock Congressional Fellowship Medical student programsMedical student programs
Mentoring, travel scholarships, addiction Mentoring, travel scholarships, addiction and HIV psychiatry summer externshipsand HIV psychiatry summer externships
Recognition AwardsRecognition Awards
Simon Bolivar Award (Hispanic leaders)Simon Bolivar Award (Hispanic leaders) Solomon Carter Fuller Award (pioneering Solomon Carter Fuller Award (pioneering
African-Americans)African-Americans) John Fryer Award (GLBT health)John Fryer Award (GLBT health) Oskar Pfister Award (religion, spirituality, Oskar Pfister Award (religion, spirituality,
and psychiatry)and psychiatry) Kun-Po Soo Award (Asian cultural Kun-Po Soo Award (Asian cultural
heritage)heritage) George Tarjan Award (IMG advocacy)George Tarjan Award (IMG advocacy) Jeanne Spurlock Achievement Award Jeanne Spurlock Achievement Award
(MFP graduate)(MFP graduate)
OMNA ProductsOMNA Products CME curriculum, NAMI-APA effortCME curriculum, NAMI-APA effort
In Living Color: Treating Depression in Diverse In Living Color: Treating Depression in Diverse Populations for primary carePopulations for primary care
Let’s Talk FactsLet’s Talk Facts series on Mental Health of series on Mental Health of Diverse Populations available at Diverse Populations available at healthyminds.orghealthyminds.org People of African, Asian, American Indian, People of African, Asian, American Indian,
Hispanic descentHispanic descent BookBook
Disparities in Psychiatric Care: Clinical and Cross-Disparities in Psychiatric Care: Clinical and Cross-Cultural Perspectives Cultural Perspectives
DVDsDVDs Latino Mental Health DVD and GuidebookLatino Mental Health DVD and Guidebook Real Psychiatry: Doctors in ActionReal Psychiatry: Doctors in Action
OMNA Special ProjectsOMNA Special Projects Women’s Mental Health RoundtableWomen’s Mental Health Roundtable All Healers Mental Health AllianceAll Healers Mental Health Alliance OMNA on TourOMNA on Tour Community ConnectionsCommunity Connections Doctors Back to SchoolDoctors Back to School Transformational Leadership in Psychiatry Transformational Leadership in Psychiatry
AcademyAcademy National Minority Mentors NetworkNational Minority Mentors Network
Collaboration with Texas Regional Collaboration with Texas Regional Psychiatry Minority Mentorship Network Psychiatry Minority Mentorship Network (TRMMN)(TRMMN)
Diversity-Related OutcomesDiversity-Related Outcomes TRPMMN illustrates: Increased medical TRPMMN illustrates: Increased medical
school diversity is associated with white school diversity is associated with white students feeling better prepared to care for students feeling better prepared to care for diverse patients.*diverse patients.*
Compositional Diversity: proportions of URM Compositional Diversity: proportions of URM students and non-white, non-URM studentsstudents and non-white, non-URM students
Interactional Diversity: climate for interracial Interactional Diversity: climate for interracial interaction, individual exposure to diverse interaction, individual exposure to diverse perspectivesperspectives
*Saha et al, Student Body Racial and Ethnic Composition and *Saha et al, Student Body Racial and Ethnic Composition and Diversity-Related Outcomes in US Medical Schools, JAMA, Diversity-Related Outcomes in US Medical Schools, JAMA, Sept. 10, 2008, 300(10): 1135-1145Sept. 10, 2008, 300(10): 1135-1145
OMNA Future PrioritiesOMNA Future Priorities Support TRPMMN and other regional mentorship Support TRPMMN and other regional mentorship
networksnetworks Psychiatrists Back To SchoolPsychiatrists Back To School Aspiring PsychiatristsAspiring Psychiatrists Community of Scholars, national network of Community of Scholars, national network of
minority psychiatry faculty and mentors minority psychiatry faculty and mentors Collaborate with APA district branches and a Collaborate with APA district branches and a
variety of educational and ethnic medical and variety of educational and ethnic medical and psychiatric associations to foster diversity, psychiatric associations to foster diversity, recruitment, retention, advancement and leadershiprecruitment, retention, advancement and leadership
What can you do to eliminate What can you do to eliminate disparitiesdisparities??
Know your populationKnow your population DemographicsDemographics Socio-environmental conditionsSocio-environmental conditions Epidemiologic vulnerabilitiesEpidemiologic vulnerabilities
Know yourself (challenge your biases)Know yourself (challenge your biases) Listen to your patients and make a Listen to your patients and make a
concerted effort to understand cultural concerted effort to understand cultural context and belief systemcontext and belief system
What can you do to eliminate What can you do to eliminate disparities?disparities?
Notice patterns of health care delivery Notice patterns of health care delivery and question differences in quality by and question differences in quality by race, ethnicity and linguistic backgroundrace, ethnicity and linguistic background
Collect data by race and ethnicity (or Collect data by race and ethnicity (or encourage your institution to) in order to encourage your institution to) in order to uncover disparities in care uncover disparities in care
Educate your patients about what their Educate your patients about what their illness is, what to do to manage it, and illness is, what to do to manage it, and why it is important (health literacy)why it is important (health literacy)
What can you do to eliminate What can you do to eliminate disparities?disparities?
Treat your patients like they want to be Treat your patients like they want to be treated. Look for the commonalities that treated. Look for the commonalities that arise from sheer humanityarise from sheer humanity
Encourage patients to ask questions and Encourage patients to ask questions and be active participants in their health carebe active participants in their health care
Showing patients you care engenders Showing patients you care engenders trust, regardless of differencestrust, regardless of differences
Trust is key to establishing an effective Trust is key to establishing an effective patient–health professional partnershippatient–health professional partnership
Crossing the Quality Chasm: Crossing the Quality Chasm: A New Health System for the 21st CenturyA New Health System for the 21st Century
Six Aims for ImprovementSix Aims for Improvement SafeSafe EffectiveEffective Patient-centeredPatient-centered TimelyTimely EfficientEfficient EquitableEquitable
IOM, 2001IOM, 2001
Patient-centered CarePatient-centered Care
Providing care that is respectful of and Providing care that is respectful of and responsive to individual patient preferences, responsive to individual patient preferences, needs, and values, and ensuring that patient needs, and values, and ensuring that patient
values guide all clinical decisionsvalues guide all clinical decisions..
Person-centered CarePerson-centered CareHealthcare partnership among practitioners, patients, and Healthcare partnership among practitioners, patients, and their families to ensure that decisions respond to and their families to ensure that decisions respond to and respect patients' wants, needs, and preferences and respect patients' wants, needs, and preferences and solicit patients' input on the education and support they solicit patients' input on the education and support they need to make decisions and participate in their own care. need to make decisions and participate in their own care. (Adapted from Agency for Healthcare Research and (Adapted from Agency for Healthcare Research and Quality, 2002)Quality, 2002)
Six dimensions of person-centered care:Six dimensions of person-centered care:1.1. Respect for patient’s values, preferences, and Respect for patient’s values, preferences, and
expressed needsexpressed needs2.2. Coordination and integration of careCoordination and integration of care3.3. Information, communication, and educationInformation, communication, and education4.4. Physical comfortPhysical comfort5.5. Emotional supportEmotional support6.6. Involvement of family and friendsInvolvement of family and friends
(Gerteis et al, 1993)(Gerteis et al, 1993)
Recovery-oriented CareRecovery-oriented Care
““Mental health recovery is a journey of healing and Mental health recovery is a journey of healing and transformation enabling a person with a mental transformation enabling a person with a mental health problem to live a meaningful life in a health problem to live a meaningful life in a community of his or her choice while striving to community of his or her choice while striving to achieve his or her full potential.” achieve his or her full potential.”
(SAMHSA Consensus Statement, 2006)(SAMHSA Consensus Statement, 2006)
It is important to convey a sense of hope that It is important to convey a sense of hope that this is achievable for all Americans with mental this is achievable for all Americans with mental health needshealth needs..