Cultural Competence & Mental Health Southern Region Summit XVIII

1. Cultural Competence & Mental Health Southern Region Summit XVIII “Implementation of Evidence-Based Practices in a Rural Community” Michael W. Horn, MFT Director

2. Overview • Introduction • Description of Imperial County • ICBHS in 2000 • Challenges • Actions Taken • Panel Discussion– Clinicians and Supervisors • ICBHS in 2012 • Next Steps

3. Who We Are as a Community

4. Imperial County Located in southeastern California, 120 miles east of San Diego. Borders Arizona and Mexico.

5. Imperial County • Incorporated in 1907. The last of 58 counties in California. • Extends over 4,597 square miles. Three-fourths of Imperial County consist of mountain ranges and desert sand. Much of the county is below sea level. • Temperatures range from lows in the mid 30’s in January to highs of 110+ in July and August.

6. Imperial County • Thousands of acres of prime farmland have transformed the desert into one of the most productive farming regions in California.

7. Population by Race/Ethnicity • 2010 Census – 174,528

8. Population by City • Sixty-two percent reside in 3 main cities and 38% in smaller communities and rural areas. The largest city continues to be El Centro with a population of 42,598 followed by Calexico with 38,572 and Brawley with 24,953 people. Source: 2010 US Census

9. Population by Language Spoken • 68.5% Spanish as their first language • 29.2% English • 2.3% Other Source: 2010 US Census

10. Imperial County Poverty Statistics • When compared to the California and the United States average, Imperial County has a larger percentage of residents in poverty.

11. Imperial County Poverty Statistics • Per capita income was $16,395, compared to California which was $29,188 • Median household income was $38,685, compared to California which was $60,883 • Ranks sixth in poverty level of all California counties with 22.3 percent while the state averages 15.8 percent • About 36,000 residents lived below the poverty level Source: 2010 US Census

12. Who We Were in 2000

13. Population Served in FY 2000-2001 • Total Unduplicated Clients: 3,153 • Medi-Cal: 2,188 (69%) • Non-Medi-Cal: 965 (31%) • Penetration Rate: 5.73%

14. Medi-Cal Population Served by Ethnicity FY 2000-2001 Total – 2,188

15. Medi-Cal Population Served by Disorder FY 2000-2001 – Total 2,188

16. Available Services in 2000 • Primarily Medication Support Services • Minimal Therapy Services • Case Management Services • Crisis Interventions • Adolescent Habilitative Learning Program (AHLP) • Adult Day Treatment • Vista Sands Socialization and Behavior Modification Program

17. Clinical Staff in 2000

18. What We Were Facing • Barriers to effectively respond to the needs of our community. • Organizational Mindset • Access • Service Delivery • Staffing

19. Organizational Mindset • “One size fits all” treatment • Lack of emphasis on individualized treatment • Training without a plan • No partnership in the recovery process • No common mission

20. Barriers to Access • Centralized services • Transportation • Lack of community awareness • Availability of services • Mental Illness • Stigma

21. Service Delivery • Working in silos • Services were not integrated • Limited care coordination • Unlimited therapy sessions without outcome measurements

22. Staff Development • Majority of clinicians were not representative of the population served and were monolingual English • Insufficient clinical staff – therapists and psychiatrists • Outdated or traditional treatment methods, lacking scientific evidence

23. “The definition of insanity is doing the same thing over and over again and expecting different results” Albert Einstein

24. What We Have Done

25. Organizational Change • Culture Change • CiMH Leadership Institute • Peter Drucker (1909-2005) Management: Tasks, Responsibilities and Practices - 1973 • Establishing a common goal • Standardized Training • Retreats • Development of a common mission • Mission Statement • Values

26. Mission Statement Imperial County Behavioral Health provides quality professional services to achieve independence and community integration for individuals suffering from mental illness and substance abuse. Vision Statement Our vision is to be the “gold standard” in community-based mental health and substance abuse treatment.

27. ICBHS Values • Initiative • Adaptability • Teamwork • Decision-Making • Performance • Respect • Trust • Responsibility • Openness and Honesty • Judge and be Judged

28. Organizational Change Identifying what works • Focus on CBT • 2003 – Michelle McCormick Train the Trainer • 2008 – Beck Institute • Assessment of Population Served and Needs • 2005 - MHSA • 2008 – Contract with CiMH • 2008 – Selection of Evidence-Based Practices

29. Organizational Change • Understanding the client culture • Client Culture Training • Client Quality Improvement Committee • Client participation in key decision-making committee • “Culture Matters” Newsletter

30. “Culture Matters” Newsletter • Quarterly publication began in January 2012 as an effort to increase cultural competency and awareness in staff.

31. October 2012 Issue Love Upheaval – Martin Ortega Client art was selected to be in the MHSOAC Expressions, a special edition of the Mental Health Services Oversight and Accountability Commission (MHSOAC) newsletter.

32. Improving Access - Decentralization • Regionalization of Services • 1999 Calexico • 2002 Brawley • 2004 San Pasqual • 2004 El Centro - FRC • 2005 Niland • Integrated Services • 2011 Clinicas De Salud (FQHC)

33. Improving Access - Decentralization • Locations of service • Home-based (PEI, FFT) • School-based • 1986 El Centro Vista Sands • 1993 Brawley Vista Sands • 1995 Calexico Vista Sands • 1991 Adolescent Habilitative Learning Program (AHLP) • El Centro Community School • Brawley Community School • Calexico Community School • 2006 Betty Jo McNeece Receiving Home • 2009 Juvenile Hall

34. Improving Access – Increase Awareness and Decrease Stigma Social Media Campaign • Publications: • Imperial Valley Press • Imperial Valley Press online services • Adelante Newspaper (Spanish) • Valley Women Magazine • IV White Sheet • El Sol del Valle Newspaper (Spanish)

35. Improving Access – Increase Awareness and Decrease Stigma Social Media Campaign (Cont. ) • Television • KYMA (Channel 11) • KSWT (Channel 13) • Univision (Channel 7) • Telemundo (Channel 35) • Radio • KXO Radio & Website : www.kxoradio.com • KROP Radio & Website • KUBO Radio Bilingue (English and Spanish) • Other • Bus Stops

36. Bus Stop and Newspaper

37. Improving Access – Increase Awareness and Decrease Stigma • Community Education and Outreach • Participation in health fairs • School Presentations • Representation on collaborative committees and taskforce • Community-based outreach to community and organizations

39. Video clip in English

40. TV Video Clip in Spanish

41. Service Delivery • Creation of a multidisciplinary team • Integration of services • Improved coordination of care • Specialized clinics • Anxiety and Depression Clinic • Services for individuals with serious and chronic mental illness • Services by age • Developed a system that set structure for implementation of therapy according to specific model • Practice Guidelines • QIRC

42. Staff Development • Promoted educational opportunities for local individuals • Worked with San Diego State University (SDSU) to develop anMSW program on local campus • Developed MOU with University of Phoenix for MFT practicum placements • Career ladders • Designated as a Mental Health Professional Shortage Area and contracted psychiatrists under J1 Visas

43. Staff Development • Initial steps to enhance clinical skills • Research and selection of trainings proven effective in a clinical setting • Provided training • Cognitive Behavioral Therapy (CBT) • ASIST (Applied Suicide Intervention Skills Training) • Non Violent Crisis Intervention (NVCI) • Skilled Helper • Motivational Interviewing (MI)

44. Staff Development • 2004 - Developed and implemented • Practice Guidelines for clinicians • Standardized competencies for clinicians • 2007 Developed and implemented the Therapy Quality Improvement Review Committee (QIRC) • 2008 – Developed and implemented the MHRT and Crisis QIRC • 2008 – Contracted with CiMH to assess and identify Evidence-Based Practices (EBPs)

45. Evidence-Based Practices • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) • Intended for children 4 to 18 years of age who have been exposed to a traumatic experience • Goal is to prevent some of the long term negative effects of child traumatic stress such as increased risk of substance abuse, suicide, and social and relationship difficulties • Implemented by licensed or master level clinicians who assist children and their families in acquiring appropriate coping skills and reducing symptoms and/or problematic behaviors

46. Evidence-Based Practices • Multidimensional Treatment for Foster Care (MTFC) • Intended for children in the foster care system, ages 7 to 11, who have been separated from their parent(s) due to neglect or abuse • Goal is to provide interventions to both, the child and the parent(s) or identified after care, resulting in a successful reunification or to bring a child from a higher to a lower level of care • Children are placed in specialized foster home and a team approach is used to support the process. The child, parent(s) or after care person and the foster parents are provided with interventions by a program supervisor, skills coach and family therapist.

47. Evidence-Based Practices • Depression Treatment Quality Improvement (DTQI) • Intended for young adults ages 13 to 22 with depression • Goal is for young adults to improve coping strategies that would lead to improved mood, recovery from depression and build resistance to depression. Young adults learn to identify, evaluate, and respond to problematic or unhelpful thought and beliefs by using a variety of techniques to change thinking, mood and behaviors. • Delivered by licensed or master level clinicians in three separate modules (Activities, Thoughts and Social relationships)

48. Evidence-Based Practices • Functional Family Therapy (FFT) • Targets youth (and their families) between the ages of 11 and 18 who are at-risk or already involved in the juvenile justice system and experiencing a range of serious problems such as conduct disorder, violent externalizing behaviors, and substance-abuse • Goal is to develop family members’ inner strengths and ability to improve their situation leading to greater self-sufficiency and fewer total treatment needs • Family intervention focuses on the multiple domains and systems within which the participants live. The 3 intervention phases each have distinct goals and assessment objectives, addresses different risk and protective factors, and calls for particular skills from the interventionist or therapist providing treatment

49. Evidence-Based Practices • Aggression Replacement Training (ART) • Intended for children and adolescents ages 12 to 17 who exhibit chronic aggressive behavior • Goal is for the child/adolescent to acquire pro-social skills for effective problem solving, effective decision making, and positive social interaction • Curriculum consists of cognitive behavioral treatment and the 3 components of Skill Streaming, Anger Control Training, and Moral Reasoning. Structure includes an intensive 10 week life skills program in which youth attends 1 hour group session 3 times per week

50. Evidence-Based Practices • Nurturing Parenting Program (NPP) • Intended for youth between the ages of 13 to 18 in families who have been identified for past child abuse and neglect or who are at high risk for child abuse and neglect • Goal is to build nurturing skills as alternatives to abusive parenting and child rearing attitudes and practices • Based on psycho-educational and cognitive behavioral approaches to learning and focuses on "re-parenting," (helping parents learn new patterns of parenting to replace their existing, learned, abusive patterns). Group sessions combine concurrent separate experiences for parents and children with shared "family nurturing time."