Practice Modification to Embrace Multiculturalism: Balancing the Individual

and the Evidence

Samantha Pelican Monson, PsyD, Clinical Psychologist

KC Lomonaco, PsyD, Clinical Psychologist

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session #G3cFriday, October 17, 2014

We have not had any relevant financial relationships

during the past 12 months.

Faculty Disclosure

#1 Describe the impact of multicultural patient presentations on current integrated primary care models.

#2 Identify viable solutions to preserve efficiency and population-based care while embracing patient diversity.

#3 Cite relevant evidence to support practice innovation to incorporate multiculturalism.

Learning Objectives

At the conclusion of this session, the participant will be able to:

Bibliography / References

1. Manoleas, P. (2008). Integrated primary care and behavioral health services for Latinos: A blueprint and research agenda. Social Work in Health Care, 47, 438-454.

2. Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88, 251-258.

3. Bass, J.K., Annan, J., Murray, S.M., Kaysen, D., Griffiths, S., Cetinoglu, T., … Bolton, P.A. (2013). Controlled trial of psychotherapy for Congolese survivors of sexual violence. The New England Journal of Medicine, 368, 2182-2191.

4. Crosby, S.S. Primary care management of non-English-speaking refugees who have experienced trauma. The Journal of the American Medical Association, 310, 519-528.

Bibliography / References

5. Bridges, A.J., Andrews, A.R., Villalobos, et.al. (2014). Does integrated behavioral health care reduce mental health disparities for Latinos? Initial findings. Journal of Latina/o Psychology, 2, 37-53.

6. Kirmayer, L.J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A.G., Guzder, J., … Pottie, K. (2011). Common mental health problems in immigrants and refugees: General approach in primary care. The Canadian Medical Association Journal, 183, E959-E967.

7. Sue, D.W., & Sue, D. (2007). Counseling the culturally diverse: Theory and practice (5th ed.). New York, NY: John Wiley & Sons, Inc.

8. Hays, P. (2013). Connecting across cultures: The helpers toolkit. Thousand Oaks, CA: Sage Publications, Inc.

A learning assessment is required for CE credit.

Questions and answers will be conducted throughout this presentation.

Learning Assessment

Linguistic, cultural, acculturation, and age diversity

FQHC with Refugee Patients

ENGLISH; 7,788

NEPALI; 2,623 SPANISH; 2,512

AMHARIC; 1,364

ARABIC; 1,335

BURMESE; 1,231

SOMALI; 866

RUSSIAN; 661

KAREN; 618

TIGRINYA; 450

NULL; 441

OTHER; 285

SWAHILI; 282 FRENCH; 198 BERMESE CHIN; 111 FARSI; 66 Language with less than 50 visits; 360

Linguistic, cultural, acculturation, and age diversity

FQHC with Refugee Patients

UNITED STATES; 10,809

NULL; 1,919

ETHIOPIA; 1,407

MEXICO; 1,174

NEPAL; 871

SUDAN; 645

SOMALIA; 590

THAILAND; 520

RUSSIAN FEDERATION; 503

IRAQ; 339 ERITRIA; 255

MALAYSIA; 132 GHANA; 131

MOROCCO; 128

CONGO, DEMOCRATIC REPUBLIC OF; 117

BURUNDI; 83

CHINA; 71

UZBEKISTAN; 62

CONGO; 59

IRAN, ISLAMIC REPUBLIC OF; 58

BERMUDA; 56

Countries with Less than 50 Visits; 1,094

Linguistic, cultural, acculturation, and age diversity

FQHC with Refugee Patients

Linguistic, cultural, acculturation, and age diversity

FQHC with Refugee Patients

Linguistic, cultural, acculturation, and age diversity—messy!

FQHC with Refugee Patients

ENGLISH; 7,788

NEPALI; 2,623 SPANISH; 2,512

AMHARIC; 1,364

ARABIC; 1,335

BURMESE; 1,231

SOMALI; 866

RUSSIAN; 661

KAREN; 618 TIGRINYA; 450

NULL; 441

OTHER; 285

SWAHILI; 282 FRENCH; 198 BERMESE CHIN; 111 FARSI; 66 Language with less than 50

visits; 360

UNITED STATES; 10,809

NULL; 1,919

ETHIOPIA

; 1,407

MEXICO; 1,174

NEPAL; 871

SU-DAN; 645

SOMALIA; 590

THAILAND;

520

RUSSIAN FEDER-

ATION;

503

IRAQ;

339 ERI-TRIA

; 255

MALAYSIA;

132

GHANA; 131 MO

ROCCO; 128

CONGO, DEMOCRATIC RE-PUBLIC OF; 117

UKRAINE

; 101

BU-RUNDI; 83

CHINA; 71

EL SALVADOR; 67

UZBEKISTAN; 62

CONGO; 59

IRAN, ISLAMIC REPUBLIC OF; 58 BERMUDA; 56

Countries with Less than 50 Visits; 1,094

Some staff and providers are bilingual in English/Spanish, and some are not

Our organization is retrofitted to provide care to Latino patients, not built explicitly for this purpose

FQHC with Latino Patients

Issues that arise in clinic: Beliefs about heath and illness differ from

culture to culture Acculturation – Families that straddle two (or

more) different worlds Disparities in care increase stressors, health

issues

FQHC with Latino Patients

How do we look outside our Western frame of reference to offer culturally sensitive care while maintaining model fidelity?1

What do you think caused the problem? What kind of treatment do you think you

should receive? What are the most important results you

hope to get from treatment? Acknowledge the differences in the room

Is there a place for these questions in your model of integrated primary care?

Clinical Pearl #1: Add culture-based questions to standard practice.2

Validated modifications of evidence-based treatments often: Bring patients together in groups Utilize a trusted community leader Host at a non-clinical site

Is your model of integrated primary care flexible enough to incorporate alternative

modalities?

Clinical Pearl #2: De-individualize assessments and interventions.3

Micro—within the care team: Promote cultural competence through

education Mutual feedback among colleagues about

stereotyping or prejudice Macro—outside the care team:

Encourage flexibility of policies (e.g., inclusion of non-Western approaches) to align with multicultural patient populations

Is there “space” for this in your model of integrated primary care?

Clinical Pearl #3: Advocate for social justice to decrease biases in care.4,5

Prevalence of common mental health problems is lower immediately after migration and increases over time

Patients may not be prepared for the racism and discrimination they will face

Does your model of integrated primary care accommodate this?

Clinical Pearl #4: Acculturation may bring new or increased symptoms.1,6

How do ethical principles adapt to be culturally responsive? Dual relationships/conflict of interest Touch Self disclosure

How have you changed/challenged your ethical practice to work in a culturally sensitive

manner within your model of integrated primary care?

Clinical Pearl #5: When ethics are unclear, consult!7

Please complete and return theevaluation form to the classroom monitor before

leaving this session.

Thank you!

Session Evaluation