teen mental health, health equity and the affordable care act putting it all together: the “aqui...
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Teen Mental Health, Health Equity and the Affordable Care Act
Putting it all together: The “Aqui Para Ti/Here for You” story
Maria Veronica Svetaz, MD MPH
Outline Create awareness around how adolescent health has
been neglected in the health systems. Discuss youth mental health needs at the local and
global level. Identify biological and contextual factors that affect
mental health throughout adolescenthood. Briefly review barriers to deliver appropriate care and
highlight key effective interventions. Address how Affordable Care Act will allow to
implement new models of care. Snapshot of “Aqui Para Ti/ Here For you” story, a
family centered medical home for Latino teens and their families, it’s main components and successes.
Adolescence as an unequal target of care In the world of inequities, bias, stereotyping and discrimination
is a common recipe for exclusion“Research gives us no reason to fear adolescents—in fact, it
shows our negative images of teens to be largely stereotypicaland unfair—but it gives us many reasons to fear for them”.
A. Rae Sympson, Ph.D.
Rising Teen
A synthesis of research and a foundation for action Somehow, adolescent care is the most excluded of all populations, the
one that lacks the most ‘societal’ and ‘provider' empathy. Perceived as healthy, and when not, it is due to their “bad” choices:
teen pregnancy, for example. Somehow as a Society, we perpetrated the “personalization” first-time
parents of teens commonly fall for, Rae Simpsons propose that parents need a “dictionary” that translates teen
behaviors into developmental terms, and not to get tangled in “personalization” of behaviors, and I bet she will agree that this is true for every adult in our society.
Teens as “Societal Barometer”, our “symptom”(I)
Our adult lives in US are more and more complex.
That tension has a clear effect on our upcoming teens, and they are left with less guidance and support during their transition to adulthood: In average, workplace pressures have deprived
our teens from 10-12 hours of parental time per week.
Parents of teens do NOT receive the same support they did during their child first years.
Parenting 101 or Parenting vs. poverty?
What do you think? Is this relevant or not?
Teens as “Societal Barometer”, our “symptom” (II)
Our adult lives in US are more and more complex That tension has a clear effect on our teens, and they are left with
less guidance and support during their transition to adulthood. Schools are structured in a way that, most of the time, don’t meet
student learning needs. Resources are also scarce where diversity is aggregated.
Media keeps feeding negative messages about teens in general and diversity in particular.
Social media enabling extremely aggressive and negative communication, thanks to anonymity, or detachment from negative behavior.
Medical services are over-compartmentalized and structured to respond to acute bio-medical needs and “refer”, with specialized spaces for teens in decline. Coordinated care is not a common service for teens.
Teens as “Societal Barometer”, our “symptom”
“As a society, we both fear adolescents and fear for them.
We fear their rashness,their rudeness, and their rawness; and
we fear for their safety, their future, and their very lives ”.
A. Rae Sympson, Ph.D.Rising Teen
A synthesis of research and a foundation for action
A Local Health Priority During 1970-1980 teen suicide rates for 15-19 y.o. had
doubled. 10% of today’s teens are estimated to attempt suicide
each year. 20% had seriously considered doing so (suicide attempt).
Rates of all of these are much higher for Native Americans and Latino youth.
Half of all US teens do not feel safe in one of their environments (home, school or community).
Most of them feel unvalued and don’t have a role model in their lives.
An unequally met need Kataoka, Sheryl H. M.D., M.S.H.S.; Zhang, Lily M.S.; Wells, Kenneth B. M.D., M.P.H.
Institution Department of Psychiatry and Bio-behavioral Sciences, Child and Adolescent Psychiatry Division, and the Research Center on Managed Care for Psychiatric Disorders, University of California, Los Angeles; and RAND, Santa Monica, Calif.
Journal of Psychiatry. 159(9):1548-1555, September 2002
Unmet Need for Mental Health Care Among U.S. Children:
Variation by Ethnicity and Insurance Status
The authors conducted secondary data analyses in three nationally representative household surveys fielded in 1996-1998: the National Health Interview Survey, the National Survey of American Families, and the Community Tracking Survey.
Of children and adolescents 6-17 years old who were defined as needing mental health services, nearly 80% did not receive mental health care.
Controlling for other factors, the authors determined that the rate of unmet need was greater among Latino than white children among uninsured than publicly insured children.
A Global Health Priority Highly biomedical approaches relying on scarce resources,
combined to low levels of help-seeking and very low levels of research from developing countries mean that probably <5% of the mental health care needs of adolescents are addressed.
Very poor mental health resources: 1 out of 10 of all mental health resources (beds, professionals, dollars) are allocated to countries housing about 9 out of 10 of the global population. 10% of resources allocated toward 90 % of the global population
Developmentally appropriate interventions integrated with youth friendly services and promoting global research are key strategies for the future.
The global iniquity of evidence
No item for 42 countries – where 76 million children and adolescents live
Adolescent mental disorders: A global perspectiveVikram Patel, Wellcome Trust Senior Research Fellow - Professor of International Mental Health
The vulnerabilities of biology The proportionate burden of mental disorders
in childhood rises with age, reaching 15% to 30% in adolescence.
The interaction of the features of neurodevelopment in adolescence and rapidly changing environments predispose to a range of risk behaviors and mental illness.
nature PLUS nurture: this is a clear leverage developmental stage:
you can help them thrive or sink them
The vulnerabilities of an unequal context
The vulnerabilities of an unequal context
•Babies Born at normal Birth weight•Children ages 3 and 5 enrolled in nursery school, preschool or kindergarten
•Fourth graders who scored at or above proficient in reading•Eight graders who scored at or above proficient in math
•Females ages 15 to 10 who delay childbearing until adulthood•High school students graduating on time•Young adults ages 19 to 25 who are in school or working•Young adults ages 19 to 25 who have completed an associate’s degree or higher
•Children who live with a householder who has at least a high school diploma
•Children who live in two parent families•Children who live in families with incomes at or above 200% of poverty
•Children who live in low-poverty areas (poverty < 20 %)
The 12 Measures in the Race for Results Index
The vulnerabilities of an unequal context
Data “illusion”: most of these two parents are trapped in a two low-wages job, away from their children, unable to escape poverty. “The New Neighbors” Urban Institute and Annie E. Casey Foundation 2003
The majority of the 18 million children in immigrant familiesIn the US are children of color. Those children face obstacles to opportunities, including poverty, lack of health insurance, parents with lower levels of educational attainment, substandard housing and language barriers. Most vulnerable are the 5.5 million children who reside with at least one unauthorized immigrant parent.
Adverse Childhood Experiences (ACE): How this got translated into action?
Adverse Childhood Experiences Definition :
The following categories all occurred in the participant's first 18 years of life
1- Abuse2- Neglect3- Household dysfunction
Translated into clear action to target children
1-3
Vulnerable household?Household in need?
What are the challenges to care, when do you want to care? Teen mental health is not always clearly identified as a
developmental need, and as an inequity in health policies. Thanks so much, School of Public Health for putting this on the
spot!
There is not enough training in primary care to do that properly.
Settings not designed to fit these behavioral need: highly biomedical approaches relying on scarce resources.
Low levels of help-seeking: teens don’t know how success or depression feels: less than 5% of the mental health care needs of adolescents are addressed.
Some positive thinking please! What does help to care?
Some positive thinking please! What does help to care?
A paradigm shift in the field
Shifting gears: ACA and ACOAffordable Care Act and Accountable Care Organizations
Bringing the Chronic Care Model to front for mental health care in/and primary care.
Standardized screening to ALL: leveling the “care” field.
New models of team care and coordinated care.
Bundle of payments, more developmentally appropriate services integrated in one stop.
Family interventions: prioritizing context.
Affordable Care Act: new models of careHealth Homes (or Behavioral Health Homes, based in the Patient
Centered Medical Home Model – PCMH-) A health home — as defined in Section 2703 of
the Affordable Care Act — offers coordinated care to individuals with multiple chronic health conditions, including mental health and substance use disorders. The health home is a team-based clinical approach that includes
the consumer, his or her providers, and family members, when appropriate.http://www.chcs.org/usr_doc/Health_Homes_FAQs_101211.pdf
Putting all together: Aqui Para Ti/Here for You
A family centered MN certifiedmedical home for Latino youth and their families.
Funded partially through EHDI(Eliminating Health DisparitiesInitiative-MDH)
Our Outstanding Staff: Is bicultural and bilingual in English and Spanish. Collaborates with other community organizations and
sustains long-term partnerships. Has experience and interest in working and serving
young Latino immigrants in MN. Has successfully secured a a diverse funding structure to ensure the continuity of our program. Is compassionate and
understanding of the needs and assets of the Latino community.
1) Presence of a trained adolescent care team (provider, health educator, care manager)
2) Family parallel care (needs of both parents and youth are addressed in a parallel fashion).
3) Family and patient centeredness 4) Structured approach to screening, utilizing
nationally established clinical practice guidelines
5) Case management.6) Dual approach: Intervention-prevention 7) Connecting
Core intervention components (since 2002)
Uncovering unmet needs
Culturally concordance
Honoring cultural values: Familism &
Personalism
Increasing social capital
Increasing social connectedness
Parallel Family Care
Figure 1: APT Conceptual Model
Improved Family Functioning
Connection Expectations Participation Communication
Youth Assets Pos. ethnic identity Empathy Problem solving Self-awareness Goal orientation School orientation
Parents Parenting self-efficacy
Parenting Knowledge/skills Monitoring Discipline
Cognitive Participation
Youth/Family Connection to
Resources
Coaching modules Case Management
Youth Knowledge and
skills
Maintenance of Positive Youth
Behavior or Decreased Risk:
Depression Substance use Sexual
behaviors School
engagement
Cultural literacy/ Youth friendliness /Parallel family care
Collective Action
Cultural literacy/ Youth friendliness /Parallel family care Coherence
Reflexive Monitoring
Patient – provider factors
Youth Behavioral self-efficacy
Emotional self-regulation
IN PROGRAMDEVELOPMENT:
Managing budgets
Managing reports
Writing grants
Doing presentations
Teaching medical workforce and the giving back to the community
Doing advocacy in Health Disparities, etc
Working in system change, etc
1) Program Coordinator
2) Program Developer
YOUTHBoys/girls10-24 y.o.
PARENTS
CommunityHealth Workers (2)Main Tasks:EDUCATECOORDINATE
FamilyEducator (1)Main tasks: EDUCATECOORDINATEHOME VISITS
Parallel Family Care
Physician
School-College
Connector (1)
IN ACTION IN THE CLINIC
TEEN ADVISORY BOARD PARENT ADVISORY BOARD
WEEKLY Case Management (all the team plus residents plus medical students)
National Model Adolescent Care Program
Our Results: Mental Health: Teens Mental Health – Beck Depression Inventory
Overall, patients exhibited significantly fewer
depressive symptoms at their final assessment (M = 11.09), compared to their first assessment (M = 14.07) (paired t-test = 2.20, p = .03).
For those whose depressive symptoms were above the clinical cut-off (higher than 17) (n=20), there was a clinically significant decrease in symptoms over the time period from a mean of 25 to a mean of 15 , that was also statistically significant (p = .003).
Our Results: Mental Health : Parents
Parents’ depressive symptoms were also assessed:78 parents completed one or more Beck Depression
Inventories. At the time of the first assessment, total scores ranged from 0-43 (M = 13.58, SD = 11.50) and 19 parents (24.1%) had depression scores that exceeded the clinical cut-off (>17).
This highlights the appropriateness of the program's model, providing parallel care during
adolescents years to the Latino families is critical.
Parents’ Experiences – Beck Depression Inventory, and Parenting Styles and Efficacy
CONCLUSIONS
Yes, You CAN
For those whose depressive symptoms were above the clinical cut-off (higher than 17) (n=20), there was a clinically significant decrease in symptoms over the time period from a mean of 25 to a mean of 15 , that was also statistically significant (p = .003).
Refreshed ACA Care Models