A Cultural Competency Primer Centers of Excellence in CC Mental Health

1. A Cultural Competency Primer Centers of Excellence in CC Mental Health NYS Psychiatric Institute Nathan Kline Institute for Psychiatric Research

2. Outline of talk • Mental health care disparities • Cultural competence matters • Cultural competence within system levels • NYS cultural competence plan

3. What is a health disparity? • An unjust or unfair difference in health status or health care between groups. • Reasons for difference that are not unjust • ‘biology’ e.g., age* • Reasons that may or may not be unjust • treatment preferences* • appropriateness of intervention* • Reasons that are unjust • socioeconomics and its concomitants • service access • racism • treatment biases * from IOM report

4. Disparity occurs when difference is: Unnecessary and avoidable Unfair and unjust Biology Tmt preference Socioeconomics …………… Treatment related

5. What disparities can OMH address? • An unjust or unfair difference in mental health status or mental health care between groups that is due to mental health service system factors under its control: • access • availability • appropriateness • treatment biases

6. Examples of Mental health care disparities • Racial and ethnic disparities in mental health care occur across the pathways of care: • Access • Treatment Engagement and Use • Quality of Care

7. Disparities in Access People with depression who did NOT ACCESS mental health treatment in the past year (N=8,762) p<.001 Percentage of people Alegría et al., Psych Services, 2008

8. Disparities in Service Use Mean # of sessions: patients w/ schizophrenia (N=2,239) p<.05 Mean # day treatment sessions Mark et al., MH Serv Res 2003

9. Disparities in Quality of Care: Schizophrenia Odds of receiving only 1st-gen anti-psychotics (N=2,239) 95%CI:1.27-2.12, p<.001 Odds Ratio (OR) Mark et al., MH Serv Res, 2003

10. NYS OMH Service Utilization: Access and visits Treated prevalence and average weeks per year (2007) in non residential service Persons with schizophrenia (one week sample = 31,640 (28% of total))

11. Reducing disparities • Surgeon General’s Report suggests a solution: • Cultural Competency in the delivery of mental health care

12. One Definition of CC • An attribute of a system, agency or individuals that describes the integration of behaviors, attitudes and skills, policies and procedures that come together to enable mental health caregivers to work effectively and efficiently in multicultural situations.

13. Culturally Competent Mental Health Care • Considers culture-specific elements of consumers’ lifestyle (e.g., emotional expression, familial living arrangements, social context) to facilitate accurate diagnosis and treatment planning that reaches across cultural boundaries and is acceptable to consumers and their families.

14. Cultural competence matters:Expected outcomes of culturally competent mental health care • Increased engagement • Increased retention • Provision of more appropriate and patient centered care • Greater consumer and family engagement • More community involvement • Reduced access barriers by improving coordination across sectors of care

15. The Challenge • Limited empirical data are available on • Key ingredients of cultural competency (CC) • Developing and implementing culturally adapted program activities, e.g, EBPs • The impact of CC on service outcomes (e.g., symptom reduction, functioning, recovery)

16. Levels of a Mental Health System ADMINISTRATIVE ENTITY e.g., State Mental Health Authority, Managed Care Organization Agency A Inpatient unit Agency B Clinic Program Program Program Program Caregiver Caregiver Caregiver Caregiver Caregiver Consumers

17. Measuring Organizational CCfromNKI CC Assessment Scale 1. Organization’s Actionable Commitment to Cultural Competency 2. Assessment of Service Needs to Identify Cultures and Languages 3. Cultural Input into CC Activities: CC Committee 4. Integration of CC Committee within Organization

18. Criteria (continued) 5. Training Activities to Ensure Culturally Competent Staff 6. Recruiting, Hiring and Retaining Culturally Competent Staff (For major cultural groups) 7. Language Capacity of Agency: Interpreters

19. Criteria (continued) 8-10: Language Capacity of Agency 8. Bilingual Staff 9. Translation of Vital Forms 10.Service Descriptions & Educational Materials in Languages of Cultures 11. Service Review and Adaptation

20. CCAS scale distinguishes agencies on CC

21. Factor Analysis • Factor 1: Foundational • agency commitment • having a CC committee • integration of CC committee in agency • conducting staff training • Factor 2: Fundamentals • having data • recruiting/hiring/retention • having translated /formatted service and educational materials • Factor 3: Direct care • having interpreters • having bilingual staff • having translated key forms • assessing/adapting/having new services Scores: Factor 1 > Factor 2 > Factor 3

22. Increasing CC Predicts Disparity Reduction for Hispanics (from Siegel, et al., under review)

23. CC Specifics: Program level elements From two NKI CECC EBP projects • Client and family cultural assessments • Identity, Re-diagnosis • Trust building • Language accessibility • Interpreters, brokers, forms, educational materials • Communication/relationship building • Stigma Reduction • Culturally friendly milieu • Culturally modified services • Consumer input • Family input • Staff • Bilingual/bicultural • CC training with respect to program • Supports • Community linkages • Other service linkages • Outcomes • Disparity measures tracked • Cultural group outcomes

24. Ethnicity-Specific Program Outcomes • Asian Americans in ethnicity-specific programs had 15x the odds of returning after first session • Mexican Americans in ethnicity-specific programs had 11x the odds of returning after first session • Retention among African Americans • 77% in ethnicity-specific programs • 60% in mainstream programs Takeuchi et al, AJPH, 1995

25. CC Specifics: Caregivers/Providers-Level • Focus on developing providers’ knowledge, attitudes, and skills in delivering culturally competent care. • Targets: • Language barriers • Consumers-provider communication • Cultural norms of consumer/provider interaction • Alternate views of illness and treatments • Therapeutic alliance

26. Provider Level Example: Motivational Antidepressant Therapy • New manualized treatment to improve retention and adherence in ADT • Promotes participatoriness / negotiation • Targets motivation / ambivalence • Assesses cultural understandings and expectations • Provides a platform for psychoeducation • Motivational Interviewing (MI) + ADT Lewis-Fernández et al, In preparation

27. Retention in Motivational ADT vs. SADT Lewis-Fernández et al, under review

28. Provider Level Example:Interpreters and Cultural Brokers

29. CC Specifics: Consumer Level • Focus on developing consumers’ knowledge, attitudes and skills in order to improve • Treatment engagement • Self-efficacy • Illness self-management • Recovery

30. Consumer Level Example:Right Question Project • Intervention focused on patient empowerment to raise questions for clinician and participate in decision making • Based on practice-based evidence • 3 patient trainings by care managers, 30 min each • Incorporated CBT strategies, role-play, homework, and cultural components • Parallel sites, N=231 Alegría et al, Medical Care,2008

31. Right Question Project • Retention • Participants had 2x the odds of remaining in treatment • Attendance • Participants had 3x the odds of attending at least 1 scheduled follow-up visit • 29% more likely to attend scheduled visits Alegría et al, Medical Care,2008

32. Patient Level Example:Depression Fotonovela • Culturally and linguistically tailored mentalhealth literacy tool for depressed Latinos in primary care Cabassa et al, In preparation

33. Conclusions • Racial/ethnic disparities occur across the pathways of mental health care • Cultural competence matters in reducing these disparities • Cultural competence needs to be addressed at multiple levels of the service system

34. CC Plan for NYS OMHKey ingredients • Action oriented • Leadership buy-in • Focus on integration of cultural competence throughout the agency • Supports organizational change throughout the system • Mechanisms for review and modification of plan

35. Necessary Commitments • Agency agenda vs. individual agenda • Leadership champions the cause • Acknowledgement of outcome disparities • Proactive agenda to address disparities • Community/Stakeholder involvement

36. Integration • Consistent bridge to agency initiatives • Focus on service equity • Responsibility is infused throughout the agency

37. Community • Stakeholders • Recipient and family • Involvement • Support • Education • Multicultural Advisory Committee • Guidance • Advocacy • Support • Mentoring