Addressing the Needs of Culturally and Linguistically Diverse Communities

through Integrated Health Care Katherine Sanchez, LCSW, PhD

Assistant ProfessorThe University of Texas at Arlington

Lynda Frost, JD, PhDDirector of Planning and Programs

Hogg Foundation for Mental Health The University of Texas at Austin

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session # D1October 28, 201110:30 AM

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Objectives

This session will:• Discuss early findings from a collaborative effort to build a

culturally and linguistically competent integrated health care model.

• Identify challenges and strategies of participants in addressing the needs of ethnic and racial minorities in integrated settings.

• Describe a socio-culturally adapted model for providing comprehensive health services.

Expected OutcomesUpon completion of this presentation, participants will be able to:

• Summarize the current state of the literature and expert opinion on generally-accepted principles, components and best practices in integrated health care that address cultural and linguistic competency.

• Identify lessons learned from a multi-year project designed to make key cultural adaptations to several evidence-based practices.

• Describe findings and differential outcomes from a case study of a low-income, uninsured Hispanic population at a community-based clinic providing integrated health care services.

• Identify challenges and strategies in addressing the needs of ethnic and racial minorities in integrated settings and describe a socio-culturally adapted model of integrated health care services to those challenges and strategies.

Why do cultural and linguistic competence matter?

Overview and demographics,with a focus on Latinos

U.S. Population Projections: 2005–2050 Pew Research Center (2008)

• Nearly one in five Americans (19%) will be an immigrant in 2050, compared with one in eight (12%) in 2005.

• By 2025, the immigrant, or foreign-born, share of the population will surpass the peak during the last great wave of immigration a century ago.

www.pewresearch.org

Foreign bornForeign born

• Estimates for the foreign-born population reached an all-time high of 38.1 million in 2007, representing 12.6 percent of the U.S. population.

• About 12 million people, or 31 percent of all foreign-born, were born in Mexico.

• California (27.4 percent), New York (21.8), New Jersey (19.9), Nevada (19.4) and Florida (18.9) had the highest percentage of foreign-born.

www.census.gov

U.S. Population Projections: 2005–2050 Pew Research Center (2008)

• The Latino population, already the nation’s largest minority group, will triple in size and will account for most of the nation’s population growth from 2005 through 2050.

• Texas became a “majority-minority” state in 2004, meaning various ethnic minority populations now outnumber Whites.

• 8.6 million Hispanics in Texas, 36% of the state’s population.

• Hispanics will make up 29% of the U.S. population in 2050, compared with 14% in 2005.

www.pewresearch.org

Language other than English

• 19.7 percent of the population age 5 and over spoke a language other than English at home in 2007.

• That figure was 17.9 percent in 2000 and 13.8 percent in 1990.

• Among those families speaking a language other than English in their home, 60% indicated that they spoke Spanish.

• Primary language spoken at home for 6.2 million Texans

www.census.gov

Settlement trends

Historically, Hispanics have been largely concentrated in the South and West, and in a few major metropolitan areas.

In 2000, over half of the nation's Latinos resided in just two states, California (11 million) and Texas (6.7 million).

Census 2000 data indicates that over the past decades Latino immigrants have been attracted to new areas of the country and to mid-sized cities and small towns.

(de Haymes, M. V., & Kilty, K. M., 2007)

Workforce issues• It is estimated that 40% of Hispanics in the U.S. are not proficient in English, and this

number is likely to increase as the population grows.

• Lack of language proficiency is a significant determinant of disparities in mental health care.

• The magnitude of the language barrier as it contributes to disparities in health and mental health care is likely to persist.

• There exists a persistent shortage of Spanish-speaking clinicians.

• There is a need to train culturally diverse, bilingual clinicians in evidence-based interventions proven effective for depression in Hispanic populations.

• A 2001 Surgeon General’s report on mental health stated that “Racial and ethnic minorities continue to be badly underrepresented, relative to their proportion of the U.S. population, within the core mental health professions – psychiatry, psychology, and social work, counseling, and psychiatric nursing.”

Workforce issues

Assuring the Sufficiency of a Frontline Workforce Project: NASW Center for Workforce Studies (2006)

• Social work, like most health care professions, is less ethnically diverse than the U.S. population.

• Licensed social workers are predominantly non-Hispanic White (86%).

• Forty-one percent of survey respondents report that more than half of their caseloads belong to a non-White minority group.

www.socialworkers.org

Hogg Foundation for Mental HealthThe Mental Health Workforce in Texas:

A Snapshot of the Issues (2007)• The lack of minority representation in professional training

programs and in the workforce is an important factor in mental health disparities.

• Two distinct challenges:

– Increasing the number of racial and ethnic minority mental health professionals

– Creating a culturally and linguistically competent mental health workforce

• As professional licensing boards in Texas are not required to collect data on race, ethnicity, or languages spoken by licensees, it is hard to plan for the future

www.hogg.utexas.edu

Why does integratedhealthcare matter?

Co-occurring mental and medical illness are common.

• Adults with common medical disorders have high rates of depression and anxiety which often impair self-care and compliance with treatment of their chronic disease.

• The prevalence of chronic medical conditions (diabetes, hypertension, obesity) continues to rise.

• Low-income minority patients with diabetes experience a high level of depressive disorder associated with socioeconomic stressors and clinical severity.

• Depression is often unrecognized and untreated in approximately two thirds of patients with both conditions.

• Major depression increases the burden of chronic illness by increasing perception of symptoms, causing additional impairment in functioning, and increasing medical cost through over utilization of the healthcare system.

• Poverty and poor health are associated with higher rates of mental disorders.

Primary care: the ‘de facto’ mental health care system

• Primary care physicians care for more than half of depressed individuals, without referral for psychiatric consultation.

• Hispanics and other ethnic minorities experience a disproportionate burden of disability associated with mental disorders because of disparities in mental health care.

• Complicating the diagnosis is the fact that as many as 75 percent of patients with a mental health disorder have as a chief complaint a predominantly somatic symptom.

• Even with well documented prevalence of common mental disorders in primary care, and their associated substantial morbidity, most treatments for mental disorders fall below the minimal standards of quality.

• Undertreatment is particularly common in Hispanics and other ethnic minorities

Treatment preferences among racial and ethnic minorities, LEP individuals

• Many patients, especially the Hispanic population, prefer to receive treatment from the trusted relationship with their primary care provider, the majority of whom use language services (interpreters or bilingual providers).

• Hispanic populations, particularly LEP individuals, initially preferred psychotherapy over anti-depressant use, citing fears of becoming addicted to antidepressants, worries about taking too many pills, and the stigma associated with medication for depression.

• Latino patients in primary care were more likely to receive their preferred treatment if they were offered individual education, telephone sessions, assistance with transportation and family involvement

• Attention to patient preferences in mental health care is essential to improve the quality of treatment and may improve outcomes.

Collaborative Care for the Treatment of Depression with a Low-Income, Uninsured, Spanish-speaking Population

• In 2006, the Hogg Foundation for Mental Health launched a three-year demonstration project on implementing collaborative care practices for the treatment of depression and anxiety in primary community clinics.

• Hogg awarded $2.6 million in 3-year grants to 5 organizations to provide integrated healthcare in primary care or pediatric settings.

• In this discussion, the focus will be on assessing the clinical impact of integrated care through data collected as part of an evaluation of a 3-year integrated behavioral health care program for adults in a primary care clinic whose population is primarily low-income, underserved Hispanics.

• In particular, the study sought to examine the effectiveness of the collaborative care model for the treatment of depression with a sub-population of Hispanics who primarily speak Spanish.

Practice Gaps in the literature

• Collaborative care model as an effective strategy for providing mental health care to a low-income, uninsured adult population in a primary care setting.

• Collaborative care model as an effective strategy for providing mental health care to a Spanish-speaking preferred population

• Patient preferences on linguistically competent services as measured by outcomes.

Collaborative Care for the Treatment of Depression with a Low-Income, Uninsured, Spanish-speaking Population

Research questions:Do low-income patients in a primary care clinic, who screen positive for mental

health disorders, and receive intensive, multi-disciplinary collaborative care, demonstrate improved scores on measures of mental health?

Additionally, is an integrated health care model an effective strategy for providing mental health services to a sub-population of Spanish speaking patients?

It will be important to determine if there are significant differences in clinical outcomes by race, language, and ethnicity in the clinic’s low-income clients.

The study also sought to describe the characteristics of the sample population including demographics, types of mental disorders, perceived health related quality of life, and frequencies and types of services received.

Methods

Setting and Sample:

People’s Community Clinic, Austin, Texas.

N= 269 adults served during the 3-year demonstration project of integrated health care

Community-based clinic, which provided care to uninsured and underinsured

Clinic’s patients were predominantly Hispanic (71%) or African-American (10%).

79.6%, lived in households whose annual income was at or below the federal poverty guidelines.

Quantitative Measures:

PHQ-9 and OASISage, ethnicity, gender, language preference, number of visits with MD, SW, care

manager

ResultsSample characteristics:

• 27.9%, (n=75 ) Spanish-speaking Hispanics,

• 26.8%, (n=72) English-speaking Hispanics,

• 34.9%, (n=94) non-Hispanic whites and

• 10.4%, (n=28) Other.

Depression outcomes:

• There were no differences between groups in severity of depression at initial assessment.

• Significant differences between groups were found in the percent of patients that exhibited a >50% reduction in baseline PHQ-9 scores at three-month follow-up:

• Specifically, Spanish-speaking Hispanic patients had a particularly high level of recovery (77%), followed by English-speaking Hispanics (51%), non-Hispanic whites (50%), and other racial/ethnic groups (46%).

• The finding for greater improvement in the Spanish-speaking population remained even after controlling for age, gender, medical comorbidities, prior treatment, and baseline depression scores.

USDHHS Office of Minority Health• Vision to eliminate behavioral health disparities through

integration of behavioral health and primary care services for racial and ethnic minorities and limited English proficient (LEP) populations

• Initiated collaboration with Hogg Foundation for Mental Health in 2010

• Purpose: Define & recommend cultural and linguistic competency elements, strategies & approaches to incorporate into existing models of IHC delivered to racial and ethnic minorities and LEP populations & identify effective strategies for implementing changes

USDHHS OMH / Hogg Foundation Activities and Deliverables

• Literature review• Stakeholder interviews• Web-based survey of providers & consumers• National consensus meeting• Consensus report• Pilot kick-off meeting• National funders meeting• Issue brief for funders

Questions and Answers

Feel free to contact us:Katherine Sanchez, LCSW, PhD

Ksanchez@UTA.edu

Lynda Frost, JD, PhDlynda.frost@austin.utexas.edu

References• Passel J, Cohn DV: U.S. Population Projections: 2005 - 2050. In: Pew Research Center Social and Demographic Trends.

Washington, DC: Pew Research Center; 2008: 55.

• U.S. Population Projections http://www.census.gov/population/www/projections/index.html

• Language spoken at home and ability to speak English http://www.census.gov/population/www/projections/index.html

• McGuire T, Miranda J: New Evidence Regarding Racial and Ethnic Disparities in Mental Health: Policy Implications . Health Affairs 2008, 27(2):393-403.

• Jackson-Triche ME, Greer Sullivan J, Wells KB, Rogers W, Camp P, Mazel R: Depression and health-related quality of life in ethnic minorities seeking care in general medical settings. Journal of Affective Disorders 2000, 58(2):89-97.

• U.S. Department of Health and Human Services: Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report to the Surgeon General. In. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 2001.

• Unutzer J, Schoenbaum M, Druss BG, Katon WJ: Transforming Mental Health care at the interface with general medicine: Report for the President's Commission. Psychiatric Services 2006, 57(1):37-47.

• Ell, K., Katon, W., Cabassa, L. J., Xie, B., Lee, P. J., Kapetanovic, S., et al. (2009). Depression and diabetes among low-income Hispanics: Design elements of a socio-culturally adapted collaborative care model randomized controlled trial . International Journal of Psychiatry in Medicine, 39(2), 113-132.

• Wagner EH, Austin BT, Von Korff M: Organizing care for patients with chronic illness. Milbank Quarterly 1996, 74(4):511-&.

• Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ: Collaborative care for depression - A cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 2006, 166(21):2314-2321.

• Williams JW, Gerrity M, Holsinger T, Dobscha S, Gaynes B, Dietrich A: Systematic review of multifaceted interventions to improve depression care. Gen Hosp Psych 2007, 29(2):91-116.

Session Evaluation

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