Raymond Alberts, LMSW

Jason Cheng, MD

Institute for Community Living, Inc.

Wednesday October 23, 2013

NYC not-for-profit agency

>100 programs, 10,000 consumers, majority in Brooklyn: housing, case management, ACT, clinics, homeless shelters, health home, and PROS

Founded Health Care Choices FQHC

In housing and case management:

◦ >70% schizophrenia / schizoaffective

Primarily paraprofessional workforce

Behavioral health medical homes: Integrating approaches to physical health, mental health and substance use

Collaborating for health: Disease management for individuals and families

Decision support tools: Optimizing health records for integrated care

Culture, spirituality and community: Reaching out to address health disparities

At the end of this webinar, participants will be able to:

◦ Describe how individual, cultural, structural, and community factors contribute to health disparities

◦ Approach individuals’ whole health in a culturally humble and spiritually sensitive way, with the context of community

◦ Strategize interventions at the individual, program and community levels that can help address health disparities in your area

Health disparities

Individual level

Program or clinic level

Community / contextual level

• People with serious mental illness (SMI) die an average of 25 years earlier than those in the general population

• 60% of mortality is due to treatable and preventable medical conditions (i.e. heart disease, stroke, diabetes)

• A rough estimate suggests that 40,000 people with SMI die prematurely each year

There is extensive research on racial and ethnic disparities related to physical health

Hypertension is experienced at a 40% greater rate in African Americans compared to Caucasians

African Americans, Native Americans, and Latinos are each at least 1.7 times as likely to have diabetes as Caucasians

Racial/ethnic minority populations in United States receive less mental health care overall, especially for mood and anxiety disorders.

Disparities have not improved over the past few decades.

Minority groups receive less psychotherapy, have shorter visit duration, and receive poorer quality care.

This leads to worse mental health and physical health outcomes.

Preferences

Provider bias

“Structural” access barriers (e.g., insurance, geographic location of services, historical settings for care)

“Cultural” access barriers (e.g., language, provider race/ethnicity, cultural humility)

Childhood poverty is associated with problems with cognition, school achievement, behavior, delinquency, and both childhood and adult mental disorders.

Adult poverty is associated with depressive disorders, anxiety disorders, and suicide.

Poor neighborhoods are typically characterized by high rates of unemployment, crime, adolescent delinquency, social disorder, physical disorder, single parent households, and residential mobility.

11% of all immigrants in the U.S. live in New York State

22% of the state’s population are immigrants

Of residents 5 years and older, 13% speak English less than “very well”

2.3 million New Yorkers are limited English proficient

Rates of uninsurance: 27% of Latinos, 16% of Blacks, 14% of Asian Pacific Americans, 9% of Caucasians

One particular model of depression care provided in primary care settings, collaborative care, has been shown to address both access to depression care and depression outcomes for ethnic minorities

Those who feel more comfortable in primary care settings may be more likely to get mental health treatment if it is offered in those settings

We hope providing primary care in behavioral health settings can also address health disparities

1. The individual/clinical level – cultural humility and spiritual sensitivity

2. The program/clinic level – integrated care with Culturally and Linguistically Appropriate Services (CLAS)

3. The community/contextual level – awareness and ability to address community and social factors

Lifelong learning Ongoing critical self-

reflection (biases) Recognizing &

challenging power imbalances

Respectful partnerships Institutional

accountability Feeling comfortable with

& enjoying not knowing

Being unfamiliar with nuances of individuals’ cultural frame of reference can cause incorrect judgment of normal variations in behavior, belief, or experience

Cultural identity of the individual

Cultural conceptualizations of distress

Psychosocial stressors and cultural features of vulnerability and resilience

Cultural features of the relationship between the individual and the clinician

Overall cultural assessment

Age Gender Sexual orientation Region within

country or state Rural vs. urban Language(s) Lifestyle (e.g. diet,

activity level)

Religious/Spiritual Aspects

Literacy Socioeconomic

status Political orientation Disabilities Migration,

acculturation, bi-culturality

What are the main problems your mental health concern has caused you? What do you think caused them?

What do you fear most about your problem?

What kind of intervention do you think you should receive?

What are the most important results you hope to receive from this intervention?

Alternative medicine (e.g., naturopathy, acupuncture, cupping, coining)

Mind-body interventions (e.g., meditation, hypnosis, music/art therapy, prayer, mental healing, Shamanism)

Biologically-based therapies (e.g., herbs, Atkins/Pritkins diets, vitamins)

Manipulative/ body-based methods (e.g., osteopathic manipulations, chiropractic, massages)

Energy Therapies (e.g., qi gong, reiki,

therapeutic touch, magnets)

Stresses vs. sources of support in the local environment

Role of religion & kin networks

Immigration and acculturative stress

(De La Rosa et. al, 2000)

How does one navigate the cultural differences?

The clinician also has a culture from training.

Similarities can facilitate the relationship. However, they can also result in incorrect assumptions and blind spots.

Listen with sympathy

Explain your perceptions of the problem

Acknowledge and discuss differences and similarities in explanation of illness

Recommend treatment

Negotiate treatment

Spirituality is about one’s relationship with the transcendent questions (including those of meaning) that confront one as a human being and how one relates to these questions.

A religion is a set of texts, practices, and beliefs about the transcendent, shared by a particular community.

The distinction is blurry!

Spirituality can offer: ◦ Better self control.

◦ Faster or easier recovery, as it focuses on strengths.

Religious practices can offer: ◦ Access to a sacred space.

◦ Access to connection with others through activities and feelings of self-worth.

◦ A resource for the mental health provider working with the client. One dramatic example is spirit possession.

What keeps you going in hard times?

What role does forgiveness of yourself and others play in your life?

How do you see your life and where do you wish to go with it?

What religion did your family follow?

Do you practice presently?

Do you believe in God or a higher power?

Do you believe God is forgiving, punishing or understanding?

Do you follow any spiritual practice or tradition? Examples include prayer, meditation, breathing, yoga and chanting.

Ever have a spiritual experience, an aha moment, or an awakening from meditation?

Any groups or clubs give y0u a sense of grounding, purpose, or connection? That help you in recovery from a problem?

What are your beliefs around self care?

Idea of the body as a temple or gift

Does your spiritual community offer support around wellness and health care?

Based on your answers, how can we use them in your recovery or treatment?

By looking at the person in totality, therapists can assist the whole person in treatment and recovery.

PCP

Person

Psychiatrist

Peer health coach

Specialists

Nurse

Care

Manager

Entitlements

The Program Level: Integrated Care

Reimbursement

Regulatory

Health

Records

https://www.thinkculturalhealth.hhs.gov/includes/downloadpdf.asp?pdf=EnhancedNationalCLASStandards.pdf

Or just Google “CLAS Standards”

Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

All ICL employees receive cultural training during orientation.

ICL hires staff with cultural and language abilities reflective of the populations served.

Psychosocial assessments at intake identify our clients’ cultural background and needs, as well as linguistic needs, to begin treatment with a culturally humble outlook.

The ICL Rockaway Parkway Clinic has a written notice in Russian of the right to receive language services. A similar notice in Spanish was developed for the ICL Highland Park Clinic. These are integrated care sites.

ICL’s self-management workbooks and other health-related materials are available in Russian and Spanish.

Phone translation services are available when staff cannot speak the language of a person served.

Focus groups occur regularly at integrated health sites, with a majority of participants of minority background.

Integrated health outcomes are tracked by race/ethnicity.

ICL’s has a Diversity Council that is involved in trainings, cultural events, oversight of policies and paperwork, and creation of an open and respectful work environment. Membership includes a consumer.

Try to help consumers and their families “break the links” between various types of poverty and mental illness.

In addition to providing clinical services, refer to psychosocial programs, community development organizations, social service agencies, and sources of economic support.

Care management for the whole person

Wellness programming in every program

Linking wellness to housing and employment goals

Entitlements specialists as an access point to health care and wellness

Community partnerships ◦ Healthy Bodegas Initiative or Farmers’ Markets

◦ Wellness programming in churches, mosques, community centers

Trauma-Informed Care, everywhere, all the time

Integrated care can help reduce health disparities by improving access to care and accounting for the whole person

Cultural humility improves engagement with a client’s reality

Spirituality and religion are relatively neglected in traditional assessments, but guides are available

Community outreach and advocacy creates sustainable change

The enhanced CLAS standards are a good starting point for assessing an organization’s approach to meeting the cultural and linguistic needs of its clients

ICL’s Integrated Health Team: Please feel free to contact us at MedHomes@ICLinc.org

• Shivonne Blake, CDM

• Carissa Caban-Aleman, MD

• Jason Cheng, MD • Ruth Chiles, RD

• Judy Chong, CASAC • Elisa Chow, PhD

• Elizabeth Cleek, PsyD

• Bernadette Kwitonda, NPP • Elissa Lapide, MD

• Eduard Levy, MD

• Marc Manseau, MD

• Rosemarie Sultana-Cordero, MA, LMHC

• Marcia Titus-Prescott, RN

• Jeanie Tse, MD

• Dana Tuqan, LMHC

• and numerous program staff

• Special thanks to Raymond Alberts, LCSW-R, Courtney Policano, LMSW, & Alan Tishler, PsyD

www.ICLinc.org Please visit our Behavioral Health Medical Homes page at:

At the Brink of Transformation: restructuring the Healthcare Delivery System in Brooklyn: report of the Brooklyn Health System Redesign Team, 2011.

Betancourt JR, Green AR, Carrillo JE, Park ER. Cultural competence and health care disparities: key perspectives and trends. Health Aff (Millwood). 2005;24:499–505.

Chow J, Johnson M, Austin M. The status of low-income neighborhoods in the post-welfare reform environment: mapping the relationship between poverty and place. Journal of health and Social Policy 2005 2005;21(1):1-32.

De La Rosa, et al., The role of acculturation in the substance abuse behavior of African-American and Latino adolescents: Advances, issues, and recommendations, Journal of Psychoactive Drugs, vol. 32, 2000.

FG Castro & EH Alarcón , Integrating cultural variables into drug abuse prevention and treatment with racial/ethnic minorities, Journal of Drug Issues, 2002

Interian A, Lewis-Fernández R, Dixon LB. Improving treatment engagement of underserved U.S. racial-ethnic groups: a review of recent interventions. Psychiatr Serv. 2013 Mar 1;64(3):212-22.

Li Z, Page A, Martin G, Taylor R. Attributable risk of psychiatric and socio-economic factors for suicide from individual-level, population-based studies: A systematic review. Social science & medicine. 2011;72(4):608-616.

Ludwig J, Duncan GJ, Gennetian LA, et al. Neighborhood Effects on the Long-Term Well-Being of Low-Income Adults. Science 2012 September 21, 2012;337(6101):1505-1510.

National Association of State Mental Health Program Directors Medical Directors Council. Morbidity and Mortality in People with Serious Mental Illness. October 2006.

Manseau MW, Case BG. Racial/Ethnic Disparities in Outpatient Mental Health Visits to US Physicians, 1993-2008." Psychiatric Services. Online ahead of print October 15, 2013.

McLoyd V. Socioeconomic disadvantage and child development. The American Psychologist 1998 February 1998;53(2):185-204.

New York State Department of Health Medication Redesign Team, Health Disparities Work Group. Final Recommendations. October 20, 2011.

Sulmasy DP. Spiritual issues in the care of dying patients: ". . . it's okay between me and god". JAMA. 2006 Sep 20;296(11):1385-92.

Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9: 117–125.

Yoshikawa H, Aber J, Beardslee W. The effects of poverty on the mental, emotional, and behavioral health of children and youth: implications for prevention. The American Psychologist 2012 May-June 2012;67(4):272-284.

November 8, 2013 (Friday), 12:00-1:00p: Suicide Prevention, Part II with Aruna Jha, PhD

For more information, please check the CTAC website at www.ctacny.com

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