cultural competence principles in achieving equity in mental … · 2015-03-18 · • 70% of...

© 2015 American Psychiatric Association. All Rights Reserved.

Cultural Competence Principles in Achieving Equity in Mental Health

Care March 21, 2015

Ranna Parekh, MD, MPH Director, Division of Diversity and Health Equity American Psychiatric Association

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Cultural Competence            It  is  the  ability  of  mental  health  professionals  and  services  to  provide  pa5ent-­‐centered  care  by  taking  into  account  the  mul5ple,  changing  and  individualized  cultural  iden55es  of  each  person  receiving  care.  

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Culture and Mental Health

•  Culture  includes  place  of  origin,  race,  ethnicity  and  others  iden6fiers  such  as  gender,  age,  educa6onal  level,  income,  sexual  orienta6on,  religious  beliefs  

•  Culture  is  dynamic  and  evolving  

•  Cultural  iden6ty  varies  from  person  to  person  

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DSM 5 Definition of Culture •  Values,  orienta6ons,  knowledge  and  prac6ces  that  

individuals  derive  from  membership  in  diverse  social  groups  (ie,  ethnic  groups,  faith  communi6es,  occupa6onal  groups,  veterans  groups,  etc.)  

•  Aspects  of  individual’s  background,  developmental  experinces,  current  social  contexts  that  affect  his/her  perspec6ve(ie,  geographical  origin,  migra6on,  language,  religion,  sexual  orienta6on,  race/ethnicity)  

•  The  influence  of  family,  friends  and  other  community  members  (social  network)  on  the  individual’s  illness  experience.  

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U.S. Population Changes

Majority minority by 2043 Minority births exceeded white births as of 2011

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Population Diversity Kentucky and US

Kentucky   US  

White   86%   63%  Black/African  American   8%   13%  Hispanic/La6no   3%   17%  Two  or  more  races   2%   2%  Asian   1%   5%  

Source:    US  Census  2014  

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Kentucky and US

Kentucky   US  

Foreign  born   3%   13%  With  disability  (under  age  65)   13%   8%  

Median  income   $43,000   $53,000  

Source:    US  Census,  2014  

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Uninsured Rates for the Nonelderly by Race/Ethnicity, 2013

Kentucky US

White 13% 12% African American 11% 17% Hispanic N/A 26% Other N/A 15%% Total 14% 15%

Sources:Kaiser  Family  Founda6on  

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Appalachia •  Higher  prevalence  of  mental  health  disorders  in  

Appalachia  than  US  (more  report  psychological  distress  and  MDD)  

•  Higher  rates  of  serious  psychological  stress    and  MDD  in  central  Appalachia    (vs  northern  and  southern)  

•  Alcohol  is  predominant  substance  of    abuse  in  US  and  Appalachia  

•  Methamphetamine  use  is  rising,  but  rates  lower  in  Appalachia  than  US   Source:    ARC,  2008  

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Reasons People Do Not Seek Help for Mental Health Concerns

•  S6gma  

•  Low  Perceived  Need  

•  Cost/Insurance  

•  Structural  Barriers  

•  Do  Not  Believe  Services  Would  Help  •                                                           NSHUD  2011  

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Stigma and Mental Health

The  s6gma  associated  with  mental  illness  prevents  many  individuals  and  families  from  seeking  help  and/or  ge`ng  treatment.      Mental  health  providers  need  to  be  cognizant  and  sensi6ve  to  the  shame  associated  with  mental  illness  and  respect  individuals,  families  and  communi6es  concerns  (oben  related  to  saving  face).      Utmost  assurance  and  acen6on  must  be  paid  to  maintain  confiden6ality.  

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Access Challenges for Underserved Populations

•  Shortage of behavioral health providers in some areas

•  Major cutbacks in public mental health services

•  Severe lack of mental health workforce diversity

•  Transportation (physical access)

© 2015 American Psychiatric Association. All Rights Reserved. Source: SAMHSA, 2013

© 2015 American Psychiatric Association. All Rights Reserved. 17 Source: SAMHSA, 2013

© 2015 American Psychiatric Association. All Rights Reserved. 18 Source: SAMHSA, 2013

© 2015 American Psychiatric Association. All Rights Reserved. 19 Source: SAMHSA, 2013

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Mediators Outcomes

Barriers and Mediators to Access to Equitable Health Care for Diverse Racial and Ethnic Groups

Quality of providers n Cultural competence n Communication skills n Medical knowledge n Technical skills n Racial bias/

stereotyping n Appropriateness of

care n Efficacy of treatment n Adherence to

treatment

Health Status n Mortality n Morbidity n Well-being n Functioning

Equity of Services Consumer Views of Care

n Experiences n Satisfaction n Effective

partnership

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 Use of Services Personal/Family

n Language/literacy n Attitudes, beliefs n Preferences n  Involvement in care n Health behavior n Education/income

Structural n Availability n Appointments n How organized n Transportation

Financial n  Insurance coverage n Reimbursement

levels n Public support

Visits n Primary care n Specialty n Emergency

Procedures n Preventive n Diagnostic n Therapeutic

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Mental Health Parity

Parity Law (Mental Health Parity and Addictions Equity Act, 2008) mandates that employer-based health plans must provide benefits similar to those provided for medical/surgical conditions.

Final Rule issued in November 2013

Affordable Care Act builds on this and requires all new plans to offer coverage for mental health and substance use disorders at parity as a core benefit.

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ACA and Mental Health: Expanding Access to Treatment Provide coverage for mental health and substance use disorder services for all plans sold through state exchanges

Patients can’t be denied coverage because they have had a psychiatric illness

Eliminate the lifetime limits on services or coverages

Closing Medicare’s drug benefit “doughnut hole”  

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Health Care Reform Contributions to Eliminating Disparities Integrated care between primary care and mental health

•  People with severe mental illness die 25 years sooner than those in the general population

•  70% of individuals with significant MH/SUD had at least 1 chronic health condition, 45% have 2, and almost 30% have 3 or more

•  Ethnically and racially diverse populations have high rates of chronic disease and premature death

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Health Care Reform Contribution to Eliminating Disparities

•  Mental health parity

•  Expanding health coverage

Employer mandate, health exchanges, Medicaid expansion

•  Improving access to care

Community health centers, Indian Health Care Improvement Act, HRSA NHSC, workforce development, behavioral health services reimbursable in primary care

•  Culturally and linguistically appropriate information to Medicaid and health exchange enrollees

Kaiser Family Foundation, 2010

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Future Trends Increasing Access

•  Peer  Support  Specialists  •  Community  Health  Workers  •  Promotoras  •  Mental  Health  Navigators  •  Cultural  Brokers  

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What is the APA Doing to Eliminate

Mental Health Disparities in the context of

Health Care Reform?  

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APA and Diversity Working  to  

•  Eliminate  mental  health  dispari6es  among  minority  and  vulnerable  popula6ons    

•  Advance  professional  interests  of  psychiatrists  from  minority  and  underrepresented    (MUR)  groups    

•  Educate  public  about  mental  health  and  s6gma  affec6ng  assessment  and  6mely  treatment  

•  Train  culturally  competent  psychiatrists    

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APA Approach •  Components/Governance  •  Professional  Educa6on/  Career  Development  

•  Recruitment  •  Public  Educa6on    Accomplished  through  

•  Division  of  Diversity  &  Health  Equity  •  Alliance  building  &  collabora6ons  

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Career Development

Fellowships

•  APA SAMHSA Minority •  Diversity Leadership •  Public Psychiatry •  Jeanne Spurlock Congressional

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•  Council  on  Minority  Mental  Health  and  Health  Dispari6es  

•  MUR  Trustee  on  the  Board  of  Trustees  (began  2013)  

•  MUR  Caucuses  (7)  

•  Assembly  Commicee  of  MUR  Reps  

Components/ Governance Support

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Books

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Mental  Health  and  Faith  Community  Partnership    •  American  Psychiatric  

Founda6on  •  American  Associa6on  for  

People  with  Disabili6es/    Interfaith  Disability  Advocacy  Coali6on  

•  American  Psychiatric  Founda6on  

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Public Education APA On Tour Community Meetings

Regional  forums  in  areas  with  high  propor6ons  of  underserved  popula6ons  hosted  by  APA’s  Division  of  Diversity  and  Health  Equity    

Discussions  about    mental  health  dispari6es    and  the  impact  on  overall    health,  economic  produc6vity    and  societal  well-­‐being  

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APA Diversity Mental Health Month

Bringing attention to mental illness needs and services in culturally diverse communities

APA will celebrate in July 2014 for the 1st time

www.psychiatry.org/diversity-­‐month  

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Public Education

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 American  Psychiatric  Associa6on      www.psychiatry.org    Ranna  Parekh,  MD,  MPH        rparekh@psych.org