disparities in mental health care of diverse populations: the process of elimination university of...

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


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


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


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


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


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: 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..

disparities in mental health care of diverse populations: the process of elimination university of...

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