Resident Training in Latino Mental Health Care

1. Resident Training in Latino Mental Health Care Rachel Molander, MD 1,2,3; Pancho Oyarbide, LCSW 3; Ronald Diamond, MD 2,3; Art Walaszek, MD 2 1. William S. Middleton Memorial Veterans Hospital. Madison, WI; 2. University of Wisconsin School of Medicine & Public Health; 3. Mental Health Center of Dane County. Madison, WI Figure 1 Developing a resident elective in La Clinica Latina: Abstract Figure 3 • Goals/needs: • For the resident: • Training site with a culturally/ethnically/racially diverse patient population. • Opportunity for continuity care experience with diverse population rather than discreet encounters in ER/inpatient unit. • For the Mental Health Center of Dane County (MHCDC): • Culturally/linguistically competent psychiatrist for the Latino Clinic. • Expose/train residents in order to increase numbers of future culturally competent psychiatrists and providers of care to underserved populations (feed the pipeline to decrease shortage). • Barriers: • Financial: • Need funding for portion of resident stipend for time spent at the Latino Clinic ~ $3000/year • The Mental Health Center of Dane County had drastic cut backs 2002-2009 with limited funding available to pay for resident stipends. • Supervision: • Need adequate resident trainee supervision for prescribing, cross-cultural learning, psychotherapy. • Elective Time: • Need adequate elective time available for continuity in clinical experience. Latinos are the fastest growing ethnic group in the United States and are projected to make up ~ ¼ of the US population by 2050 (Fig 1). Rates of mental illness for US Latinos are roughly equivalent to that of Caucasians and are even higher in Latino youth. Latinos face a number of barriers in accessing mental health care; one of which is the limited number of providers who are culturally and linguistically competent to provide quality care to this population. Training in cross-cultural care is an increasingly important priority of psychiatry residency programs. Residents need access to training sites with ethnically, racially and culturally diverse patient populations in order to have adequate training in cross-cultural care. This poster reviews issues related to Latino mental health and residency training in cross-cultural care, and then describes the process of establishing an elective rotation for psychiatry residents in the Latino Clinic of the Mental Health Center of Dane County. Figure 2 Mental Health Care in the Latino Population • (The term "Latino(s)," as used in this presentation, refers to all persons of Mexican, Puerto Rican, Cuban, or other Central and South American or Spanish origin). • Rates of mental illness among adult Latino immigrants are generally lower than that of Caucasians. US born Latino adults have rates of mental illness roughly equal to that of Caucasians. US born Latino youth have higher rates of depression, anxiety disorders, and suicide than Caucasian youth (2) Fig 3. • Latinos (US born and immigrants) are much less likely to seek mental health care (2). • Barriers to mental health services access include (3-6): • Language • Low socioeconomic status and high rates of uninsured • Cultural factors: stigma; somatization; alternative explanatory models of psychiatric symptoms. • Inadequate numbers of linguistically and culturally competent mental health care professionals Process: Met individually and as a group with pychiatry program director, MHCDC medical director, and staff at the Latino clinic to develop structure and learning goals for the rotation, and to problem-solve issue of funding resident stipend. Percentages add to > 100 b/c of comorbidity. Residency Training in Cross –Cultural Care • Residency Training in Cross-Cultural Care is a Priority • ACGME requires residency training in cross-cultural care and experience in the evaluation and treatment of patients “of different ages and gender from across the life cycle, and from a variety of ethnic, racial, sociocultural, and economic backgrounds.” • JAMA 2005 - National study of resident perceptions about preparedness to provide cross-cultural care (9): • Residents think it’s impt to address cultural issues in providing care • Residents report little clinical time allotted in residency to address cultural issues, and little training formal evaluation or role modeling. • Resident self-reported preparedness to provide cross cultural care lags well behind preparedness in other clinical and technical areas. • Limited Access to Public Sector Training Sites • Public sector training sites frequently offer better opportunities for treating populations from diverse ethnic, racial, sociocultural, and economic backgrounds. • Medicare reimburses GME institutions only for time resident spends at the sponsoring institution. • Many GME institutions (including UW) require training sites outside the sponsoring institution to pay for residents training time. • Financial strain and cutbacks are increasingly common in both public and private sector health care. This is resulting in more limited public sector training opportunities and may limit resident training experience in providing cross cultural care. • Solutions: • Financial: • Wrote an Evjue grant to cover portion of stipend for time spent in Latino Clinic (not funded). • Department of psychiatry and MHCDC ultimately split cost of resident stipend 50/50. • Supervision: • Medical Director at MHCDC supervises medication management, and Latino Clinic director (LCSW) and psychologist supervise cross cultural learning and psychotherapy. • Elective Time: • Program director approves ½ day per week for > 1 year elective time for resident to rotate in Latino Clinic. • Origins of La Clinica Latina of the Mental Health Center of Dane County • Between 1990 and 2000, Dane County’s Latino population grew 150%. (US Census Bureau 2008) • 25% of clinic visits to the UW family practice clinic are from Spanish-speaking clients. Primary care providers report that they have few places to refer Spanish-speaking clients for bilingual psychiatric services. • In 2002 DCMHC started a Latino/a clinic in an attempt to increase availability of mental health services in the Latino/a community - Fig 2. • Outcome: • Resident does elective in Latino Clinic ½ day per week 2007-09: • Saw over 83 new patients in 3 years • Continuity of > 1 year with 20 patients • Participated in weekly Latino Clinic team meetings with social workers, nurses, and psychologists. • Weekly supervision with Latino Clinic director for case review and discussion of readings related to Latino mental health. Supervision with medical director PRN for med management issues. • Resident becomes fluent, able to see Spanish speaking clients without interpreter assistance. • In 2009, staff psychiatrist position established in the Latino Clinic and filled by former resident. • References: • U.S. Census Bureau, Population Division. http://www.census.gov/ • US Department of Health and Human Services. Office of the Surgeon General. Substance Abuse and Mental Health Services Administration (2001). Chapter 6. Health Care for Hispanic Americans, In: Mental Health: Culture Race and Ethnicity. A Supplement to Mental Health : A report of the surgeon general. (SMA) – 013613. • Ruiz,P. “Hispanic Access to Mental Health Services.” Psychiatric Quarterly, Vol 73, no.2, Summer 2002. • Brown, E.R.,Ojeda, V.D., Wyn, R.,Levan R. (2000). “Racial and ethnic disparities in access to health insurance and health care.” Los Angeles: UCLA Center for Health Policy Research and The Henry J. Kaiser Family Foundation. • Brown, E.R., Wyn R., Hongjian, W., Valenzuela, A., Dong, l. (1999). “Access to health insurance and health care for children in immigrant families.” In DJ Hernandez (Ed.) Children of immigrants. Washingto, DC: National Academy of Sciences. • Hanson, K.L. (2001). Patterns of insurance coverage within families with children.” Health Affairs, 20, 240-46. • Center for Mental Health Services. (2000). Cultural competence standards in managed care mental health services: Four underserved/underrepresented racial/ethnic groups. http://www.mentalhealth.org/publications/allpubs/ SMA00–3457/. • APA Website: http://www.psych.org/Resources/OMNA.aspx • Weissman, J.S., Betancourt, J., Campbell, E.G., Park, E.R., Kim, M., Clarridge, B., Blumenthal, D., Lee, K.C., Maina, A.W. “Resident Preparedness to Provide Cross-Cultural Care.” JAMA. 2005.Vol 294(9).1058-1067. • University of Wisconsin Psychiatry Residency Training Program • Location: Madison, Wisconsin (Dane County) • 2008 Latino population in Dane County 5%. • 2008-09 UW resident clinical logs report 3.3% of patients seen by residents were Latino. Most were acute ER or inpatient contacts w/o continuity.