Katherine Sanchez, L.C.S.W., Ph.D. Assistant Professor University of Texas at Arlington

1. Session # C4a October 6, 2012 Charting a True Course for the Frontier of Integration: Eliminating Racial and Ethnic Disparities through Integrated Health Care Katherine Sanchez, L.C.S.W., Ph.D. Assistant Professor University of Texas at Arlington Rick Ybarra, M.A. Program Officer Hogg Foundation for Mental Health Octavio N. Martinez, Jr., M.D., M.P.H., M.B.A., F.A.P.A. Executive Director Hogg Foundation for Mental Health Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A.

2. Faculty Disclosure I/We have not had any relevant financial relationships during the past 12 months.

3. Objectives • At the conclusion of this presentation, the participant will be able to identify three barriers experienced by racial and ethnic minorities that result in health care disparities • At the conclusion of this presentation, the participant will be able to delineate three principles and components in the delivery of integrated health care to racial and ethnic minorities • At the conclusion of this presentation, the participant will be able to describe three practice-based examples in the delivery of integrated care to reduce/eliminate health disparities

4. Learning Assessment A learning assessment is required for CE credit. Audience interaction through a brief Question & Answer period at the conclusion of presentation.

5. Health Disparities and Health Equity Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008. Health disparities - differences in the incidence and prevalence of health conditions and health status between groups. Health equity - when everyone has the opportunity to “attain their full health potential” and no one is “disadvantaged from achieving this potential because of their social position or other socially determined circumstance.”

6. Health Disparities Racial and ethnic minority populations are less likely to receive a variety of medical services, from routine procedures to appropriate cardiac medications and bypass surgery. MORE likely to have limb amputations as a result of diabetes and experience a lower quality of health services overall. Findings held even when controlling for insurance status, income, age and education level.

7. Behavioral Health Disparities • Poor doctor patient communication (DPC) • Persistent stigma around issues of mental illness • Racial and ethnic minority populations initiate medication treatment at a much lower rate than whites • low use of anti-depressant medication • more likely to discontinue their treatment without consulting their physician

8. What Factors Contribute to Racial and Ethnic Health Disparities • Socioeconomic status • Residential segregation and environmental living conditions • Occupational risks/exposures • Health risk and health seeking behavior • Differences in access to care • Differences in health care quality Smedley, 7/21/09

9. Relationship between Social Determinants and Mortality (2000) Galea et al, Estimated Deaths Attributable to Social Factors in the United States, AJPH, August 2011, Vol. 101, No. 8.

10. Populations at risk for low health literacy Elderly (age 65+) - Two thirds of U.S. adults age 60 and over have inadequate or marginal literacy skills, and cannot read or understand basic materials such as prescription labels. “Minority” populations Immigrant, non-English speaking populations Low income - Approximately half of Medicare/Medicaid recipients read below the fifth-grade . People with chronic mental and/or physical health conditions Low educational attainment

11. Lack of English fluency is an independent predictor of Poor control of chronic disease Poor quality of primary care, An absence of a source of care Lack of continuity Lack of patient satisfaction Poor quality patient education and understanding of their disorder Reduced health care use

12. Other factors that affect access for immigrants and minority populations Limited health literacy Geographic inaccessibility Lack of medical insurance Citizenship status Level of acculturation Duration of residence in the U.S.

13. Eliminating Racial and Ethnic Disparities through Integrated Health Care Literature review Consensus Meeting Consensus Statements Recommendations Innovations from the field http://www.hogg.utexas.edu/

14. Recommendation: Patients/Consumers • Key Strategies Identified • Conduct comprehensive assessments that are culturally and linguistically competent to understand cultural values, beliefs and constructs • Develop patient/consumer-driven treatment plans • Example: Charles B. Wang Community Health Center • Mental Health Bridge Program (New York City) • No distinction between treatment rooms • Combined electronic health record • Informal communication encouraged

15. Recommendation: Practice • Key Strategies Identified • Develop and share appropriate tools that go beyond just the standard measurement of symptoms • Build understanding by cross-training providers and exposing them to other systems • Example: Center for Native American Health (NM) • Use of focus groups and vignettes • Women wanted a CHW to make home visits • Men preferred to meet and talk with other NA men at a neutral location

16. Recommendation: Communities • Key Strategies Identified • Create culturally responsive, asset-based environments • Use community-based participatory approaches • Identify and empower leaders from within the community • Provide health/behavioral health education • Example: Project Brotherhood (Chicago) • Hired and trained a barber to provide health education • Provide fatherhood classes • Produced a comic book that teaches conflict resolution

17. Recommendation: Health Care Systems • Key Strategies Identified • Provide services where needed • Ensure institutions reflect the populations they serve • Address cultural and linguistic diversity • Evaluate practice for efficacy • Example: Connecticut Latino Behavioral Health System • The Cultural Competency Index: instrument designed to evaluate cultural responsiveness of their clinical services • Staff pre- and post-training evaluations • Satisfaction with trainings • Random tape ratings to assess language fluency and the integration of Latino cultural values in treatment

18. Recommendation: Workforce • Key Strategies Identified • Build a diverse multidisciplinary workforce • Attract and retain bilingual/bicultural providers • Identify and engage health care workers early in their studies/careers • Provide in-culture and in-language supervision • Build and support diverse, empowered leadership • Example: Cherokee Health Systems (Tennessee) • Employed a full-time Burundi interpreter to work at the front desk of their largest inner city clinic • Retained a multilingual psychologist (Spanish, French, Portuguese) who works via tele-health technology • Offers advanced training to bilingual staff to become certified CNAs

20. Learning Assessment Questions & Answers

21. Thank you for your attendance and participation! Katherine Sanchez, LCSW, PhD Assistant Professor University of Texas at Arlington ksanchez@uta.edu Rick Ybarra, MA Program Officer Hogg Foundation for Mental Health Rick.ybarra@austin.utexas.edu Octavio N. Martinez, Jr., M.D., M.P.H., M.B.A., F.A.P.A. Executive Director Hogg Foundation for Mental Health Hogg-ED@austin.utexas.edu

22. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!