Developing Culturally-Competent Individual Service Plans for Wellness, Recovery and Resilience

1. Developing Culturally-CompetentIndividual Service Plansfor Wellness, Recovery and Resilience Neal Adams MD MPH California Department of Mental Health Sacramento CA 916.651.6742 Nadams@dmhhq.state.ca.us

2. Learning Objectives • At the completion of the training, participants will be better able to use service plans as an effective clinical tool by being able to… • develop a culturally competent service plan in collaboration with the person served and family as appropriate • understand role of culture in assessing needs • understand relationship between service planning, culture and outcomes • identify elements of an individual service plan • explain concepts of medical necessity • critically review, update and revise a plan

3. Overview • Service planning is both a process and a product • builds alliance with the person served (and family as appropriate) • assures that assessment and services are culturally competent • describes preferences and role of the person served • establishes directions and methods • identifies expected outcomes and transitions or discharge • documents medical necessity • supports service documentation / billing

4. Plan Development • Acquired skill / Art form • not often taught in professional training • often viewed as administrative burden and paper exercise • requires flexibility • Opportunity for creative thinking • Integrates information about person served • derived from formulation and prioritization • information transformed to understanding • Strategy for managing complexity

5. Functions of the Service Plan • Specifies intended outcomes / transitions / discharge criteria • clearly elaborates expected results of services • includes perspective of person served and family in the context of the person’s culture • promotes consideration and inclusion of alternatives and natural supports / community resources

6. Functions of the Service Plan • Identifies responsibilities of team members--including person served and family • increases coordination and collaboration • decreases fragmentation and duplication • coordinates multidisciplinary interventions • prompts analysis of available time and resources • Establishes role of person served and family in their own recovery / rehabilitation • assures that services are person-centered • enhances collaboration between person served and providers

7. Functions of the Service Plan • Supports utilization management • services authorization, communication with payors and payment for services • allocation of limited resource • Provides assurance / documentation of medical necessity • anticipates frequency, intensity, duration of services • Promotes culturally competent services

8. Components of Culture • Shared set of beliefs, norms and values • language is a key factor • also includes ethnicity, race, sexual orientation, disability and other self defined characteristics • Culture • is learned, taught and reproduced • refers to systems of meanings • acts as as a shaping template • exists in a constant state of change • includes subjective / experienced and objective /observed components of human behavior

9. The Importance of Culture • Culture and social contexts shape individual's mental health • symptoms, presentation and meaning • coping styles • family influences • help seeking • stigma • trust

10. Cultural Elements • Person / provider relationship shaped by differences in culture and social status • Impact clinical encounter • communication • rapport • disclosure • privacy • trust • power • dignity • respect

11. Cultural Barriers • There are significant ethnic and cultural disparities in mental health and access to services related to • lack of promotion and prevention of mental health • acculturation and immigration stress • identity • racism / marginalization / discrimination • assimilation • alienation and trauma • access, service setting and organization • language • provider bias and stereotyping

12. Models of Cultural Competence • Assuring the provision of effective services for culturally diverse populations is the responsibility of the system not the person served • participation of persons served and their families in design and delivery of culturally appropriate services • tailor services to person’s culture • remove barriers • promote access • improve outcomes • Requires leadership, policies, skills, knowledge and abilities at all levels of the system

13. Multicultural Competencies • Providers must have • awareness • of their own culture and social status • power differentials in relationship • knowledge • how theory and practice are culturally embedded • history and manifestation of racism • sociopolitical influences on lives of persons served • culture specific diagnosis • difference in family structures and roles across cultures

14. Multicultural Competencies continued • Providers must have • skills • understand the persons conceptualization of their illness • self-assess their own cultural competence / bias • modify assessment techniques / tools • design and implement non-biased effective service plans

15. Goal Directed Outreach Persons’ / families’ request for assistance Understanding the individual Response in context of their culture Assessment Services or treatment CULTURE Prioritization of needs Goals and objectives Desired change Service plan

16. Person Centered • There is agreement on • goals • tasks • participation and roles • The relationship with the provider is experienced as • collaborative • empathic • respectful • trusting • understanding • hopeful • encouraging • empowering

17. Collaborative Approach • Team approach is key • must be culturally competent • Each participant / partner brings own area of expertise • Synergistic effect • Participation of person served and support system (and family as appropriate) as team members is essential

18. What’s Critical • Service plans must • developed with the person served and family as a partner • identify the person's own expectations • be consistent with culture and personal (and family as appropriate) preferences • recognize that participation may vary • personal style • age and development • cultural traditions and expectations • severity of needs

19. Range of Perspectives • Some call it… • recovery • rehabilitation • wellness • reintegration • empowerment • community integration • discovery • family harmony • resiliency

20. Examples of Models / Frameworks • Recovery (Ohio) • dependent on system / unaware of possibilities • dependent on system / aware of possibilities • non-dependent and able to make choices / aware • interdependent with community / aware • Rehabilitation / Motivation • pre-contemplative • contemplative • determined • active

21. What do people want? • Commonly expressed goals of persons served • manage their own lives  quality of life • work  education • activity / accomplishment  social opportunities • transportation  housing • spiritual fulfillment  health and well being • satisfying relationships  fun • family • peers • sexual satisfaction ... to be part of the life of the community

22. A Plan is a Road Map • Provides hope by breaking a seemingly overwhelming journey into manageable steps for both the provider and the person served B C D A E “life is a journey…not a destination”

23. Building a Plan Outcomes Services Objectives Goals Prioritization Understanding Assessment Request for services

24. Medical Necessity • History • Current application • Standard of service and quality • Five elements • indicated • appropriate • consider issues of culture • efficacious • effective • efficient

25. A plan is only as good as the assessment

26. Assessment • Initiates helping relationships • ongoing process • Comprehensive domain based data gathering • Identifies strengths • abilities and accomplishments • interests and aspirations • recovery resources and assets • unique individual attributes • Considers stage / phase of change process • Must be culturally competent • include cultural formulation

27. Cultural Factors in Assessment • Begin with cultural and demographic factors • clarify identity • “how do you see yourself?” • race, ethnicity, sexual orientation, religion, color, disability reference group • family may be source of cultural information • specify language • fluency • literacy • preference

28. Cultural Factors in Assessment continued • Include history of person’s and family’s • immigration • assimilation • acculturation • trauma • immigration • country of origin • Consider • linguistic differences in description of distress • symptom expression / somatic concerns • culture bound syndromes

29. Cultural Factors in Assessment continued • Use assessment tools and forms that are culturally competent • reliable • validated with ethnic groups and families • linguistically appropriate • Involve racially / ethnically / culturally specific providers when possible and appropriate • assist in gathering and understanding data • directly or through consultation

30. Cultural Factors in Assessment continued • Consider person served’s preference for linkages with racial / ethnic / cultural community • Evaluate the psychosocial environment • interaction of social stressors • multiplicity of stressors • available supports • levels of functioning and disability • issues related to gender

31. Cultural Factors in Assessment continued • Understand the individual’s • beliefs and practices • mental health • stigma, shame • gender bias in seeking help • attribution of condition • family composition, relational roles, and dynamics • culturally identified stressors • poverty • discrimination based upon race ethnicity and / or sexual orientation • spirituality and religious affiliation

32. Cultural Explanations of Illness • Important to explore • idioms of distress • e.g. the physical manifestation of somatization • meaning and perceived severity of symptoms in relation to cultural group norms • current preferences and past experiences with professional and ‘popular’ or traditional sources of services

33. Outline for Cultural Formulation • DSM-IV • Inquire about cultural identity • Explore possible cultural explanations of illness • Consider cultural factors related to psychosocial environment and levels of functioning • Examine cultural elements in the client provider relationship • Include overall cultural assessment in diagnosis and service plan

34. The Importance of Understanding • Data collected in assessment is not sufficient for service planning • Formulation/ understanding is essential • requires clinical skill and experience • moves from what to why • sets the stage for prioritizing needs and goals • the role of culture and ethnicity is critical to true appreciation of the person served • Recorded in a chart narrative • shared with person served

35. Prioritization by Person Served • What comes first? • personal / family values need to be considered • cultural nuances are significant • Must be the driving force • consistent with concerns / perspective of person served (and family as appropriate) • builds upon person served's own expertise Negotiation and dialogue with person served is essential

36. Provider Perspectives in Prioritization • Basic health and safety • Maslow • food, clothing, shelter • affection, self esteem • freedom, beauty, goodness, justice • self-actualization • self-transcendence • Harm reduction • Legal obligations and mandates

37. Statement of Needs / Concerns • Reflect balance between understanding of person served and provider • opportunity for dialog and partnership • sharing and modification of provider understanding • negotiation is OK • Prerequisite to formulating broad goals • “As evidenced by …” Diagnosis cannot be considered a need or concern

38. Statement of Needs / Concerns continued • Three “formal” elements • need / concern statement • behavioral evidence • identification of stressors / precipitants • Anticipate transition / discharge • May be included in formulation / narrative

39. Goals • Long term, global, and broadly stated • perception of time may be culture bound • may influence expectations and participation • may need to explain type and / or level of service • Life changes as a result of services • focus of alliance / collaboration • readily identified by each client

40. Goals continued • Person centered • ideally expressed in person served’s / family’s words • easily understandable • language may be an issue • appropriate to the person’s culture • reflect values, life-styles, etc. • consistent with desire for self-determination and self-sufficiency • may be influenced by culture and tradition

41. Goals continued • Essential features • attainable • one observable outcome per goal • realistic • written in positive terms • built upon abilities / strengths, preferences and needs • embody hope • alternative to current circumstances

42. Barriers • What is keeping the person from their goals? • need for skills development • intrusive or burdensome symptoms • lack of resources • need for assistance / supports • problems in behavior • challenges in activities of daily living • threats to basic health and safety • Challenges / needs as a result of a mental disorder

43. Objectives • Culture of persons served shapes setting objectives • address culture bound barriers • Expected near-term changes to meet long-term goals • works to remove barriers • divide larger goals into manageable tasks • provide time frames for assessing progress • maximum of two or three per goal

44. Objectives continued • Essential features • measurable • behavioral • achievable • understandable for the person served • Services are not an objective

45. Objectives continued • Appropriate to the setting / level of care • Responsive to the person’s individual disability, challenges and recovery • Appropriate for the person’s age, development and culture • “(The individual) will …” • changes in behavior / function / status of person served • described in action words

46. Interventions • Actionsby person served, family, peers, staff and and the entire system of care • may include family, support network, etc. • Specific to an objective • Cultural efficacy must be considered • Availability and accessibility of services may be impacted by cultural factors

47. Six Critical Elements • Interventions must specify • provider and clinical discipline • staff member’s name • modality • frequency /intensity / duration • purpose / intent / impact • Clarifies who does what

48. Evidence Based Practices • Should be considered in specific conditions and interventions • cultural and other factors may “over-ride” • tend to be organized by diagnosis and not sensitive to context • lack of research in application to ethnic to specific cultural groups • Psychopharmacology issues • ethnopsychopharmacology • efficacy • side effects • co-administration of traditional therapies

49. Review / Evaluation • Reassess plan at clinically appropriate intervals • determine effectiveness • re-evaluate appropriateness • input of person served / family essential • Plan revisions • concerns / needs • goals • objectives • interventions / modalities • time frames and target dates

50. Outcomes • Object of provider / client contract • explicitly identified in service plan • The result of services • multiple aspects • clinical status and symptom reduction • self-management • quality of life • experience of services / satisfaction • overall recovery goals • meaningful activity / work