Addressing Mental Health Disparities through Integrated Care

1. Eliminating Mental Health Disparities through a Culturally and Linguistically, Patient-Centered, Integrated Health Care Approach Camille D. Miller Honorary Lecture 6th Annual Texas Primary Care and Health Home Summit April 5, 2018 Katherine Sanchez, LCSW, PhD Associate Investigator Center for Applied Health Research

4. 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/

5. 1O most costly medical conditions Soni, A. Top 10 Most Costly Conditions among Men and Women, 2008: Statistical Brief #331. July 2011. AHRQ,. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st331/stat331.pdf

6. Texas 2017 OVERALL RANKING: Texas was 34th last year. It was 31st in 2014 Strengths: Low rate of drug deaths Low prevalence of smoking Challenges: High percentage of population without insurance Low number of primary care physicians High prevalence of diabetes and obesity

7. Texas 2017 Highlights:

8. Distribution of US Population by Race/Ethnicity 2015 Source: U.S. Census Data. People Quick Facts. Retrieved February 2017 from: http://quickfacts.census.gov

9. Demographic Shift:Projected US Population Source: Census.gov

10. Distribution of Uninsured by Race/Ethnicity, 2014 Half of the nation’s uninsured are from minority communities Source: U.S. Census Bureau, Current Population Survey, 2009 to 2012 Annual Social and Economic Supplements.

11. Health Disparities 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.

12. 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.

14. The systemic barrier removed

15. Social Determinants of Health • The conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life: • economic policies and systems, • development agendas, • social norms, • social policies and • political systems.

16. Educational attainment http://www.pewhispanic.org

17. Percent of Working Families Below 200% Poverty (by race/ethnicity) The Working Poor Families Project Policy Brief. Winter 2014-2015. www.workingpoorfamilies.org

18. Health Impact Pyramid Frieden, 2010

19. These are politically loaded issues that are difficult to address: • Low educational attainment • Racial segregation • Low social support • Individual poverty • Income inequality • Area level poverty

20. Depressive symptoms by race (%) in the U.S. Population SOURCE: CDC/NCHS National Health and Nutrition Examination Survey, 2009–2012

21. Mental Health Disparities Mental Health: Culture, Race & Ethnicity 2001; President’s New Freedom Commission on Mental Health, 2003 • Poor treatment engagement • Less likely to receive evidence-based interventions, • Persistent stigma around issues of mental illness • 20-50% less likely to initiate behavioral health care • 40-60% less likely to fill prescriptions • 40-80% more likely to end treatment prematurely

22. Lack of English fluency is an independent predictor of Fernandez A, et al. J Gen Intern Med. 2011;26(2):170-176. • 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

23. Other factors that affect access for immigrants and minority populations Bauer AM, Chen C-N, Alegría M. Medical Care. 2010;48(12):1097-1104. • Limited health literacy • geographic inaccessibility • lack of medical insurance • citizenship status • level of acculturation • duration of residence in the U.S.

24. Depression and Hispanics Interian A, Ang A, Gara MA, Rodriguez MA, Vega WA. Gen. Hosp. Psych. Mar-Apr 2011;33(2):94-101. Somatic presentation of symptoms impedes accurate and timely detection. Initiate anti-depressant medication treatment at low rate and are more likely to discontinue their treatment for depression without consulting their physician. Cultural treatment preferences for counseling. Relapse rates are high and slow response to treatment. Intractable symptoms and slow response result in considerable disease burden.

25. Cultural effectiveness • socioeconomic status • ethnicity • health beliefs • attitudes • accessibility to medical care Bernal, Jiménez-Chafey, & Domenech Rodríguez, 2009 • understanding the cultural and historical experiences of different groups' and • examining how patient characteristics influence the utilization of services:

26. Implicit bias among health care professionals • Implicit attitudes are thoughts and feelings that exist outside of conscious awareness, and are difficult to consciously acknowledge and control. • Negative implicit attitudes about people of color may contribute to racial/ethnic disparities in health and health care. • Low to moderate levels of implicit racial/ethnic bias were found among health care professionals significantly related to patient–provider interactions, treatment decisions, treatment adherence, and patient health outcomes. • Hispanic/Latino/Latina patients were viewed as unlikely to accept responsibility for their own care and more likely to be noncompliant with treatment recommendations. • NO literature on evidence-based efforts on how to REDUCE an individual health care provider’s bias. Hall, Chapman, et al. (2015). American Journal of Public Health

27. Primary Care Pippins JR, Alegria M, Haas JS. Medical Care. Nov 2007;45(11):1020-1025. • More than half of people with mental health disorders are served in primary care, without referral to specialty mental health, de facto mental health system (Regier, 1993). • Hispanics are more likely to receive mental health care in primary care settings. • However, multiple factors contribute to the poor quality of treatment in primary care. • Linguistic barriers are even more pronounced in primary care settings.

28. Depression Education Intervention Cabassa LJ, Molina GB, Baron M. Depression fotonovela: development of a depression literacy tool for Latinos with limited English proficiency. Health promotion practice. 2012;13(6):747-54. • Uses a unique, culturally adapted depression fotonovela titled “Secret Feelings” developed by Cabassa, Molina and Baron (2012). • Popular comic-book style pamphlet that portrays a dramatic story using photographs and dialogue bubbles, which has become an effective tool for engaging Hispanic audiences and increasing knowledge about specific health issues • Designed to enhance the awareness and understanding of depression, its role in chronic disease, its impact on Hispanic populations and the multitude of barriers to effective treatment • Provided in English or Spanish and in the presence of family members or loved ones if desired

29. Dialogue bubbles Cabassa LJ, Molina GB, Baron M. Depression fotonovela: development of a depression literacy tool for Latinos with limited English proficiency. Health promotion practice. 2012;13(6):747-54. doi:10.1177/1524839910367578.

30. Project DESEO: Depression Screening and Education: Options to Reduce Barriers to Treatment To systematically screen all adult primary care patients using innovative iPad Depression Screening application (developed for Medicaid 1115 waiver project). To implement a Depression Education Intervention (DEI) to increase disease literacy, and dispel myths about depression and its treatment among Hispanic patients in a community health center thus reducing stigma and increasing treatment engagement.

31. METRIC: Measurement, Education and Tracking inIntegrated Care: Strategiesto Increase Patient Engagement and Reduce Mental Health Disparities among Hispanics • Funded by National Institute on Minority Health and Health Disparities, 2015 • Randomized control trial that will assess the effects of a three-part design to improve detection, diagnosis and treatment of depression in a community based health center, reduce stigma and increase disease literacy, and increase uptake in treatment • Depression Education Fotonovela compared to standard education • Measurement-based integrated care model with LCSW • iPad Depression Screening and Monitoring technology

32. Lessons learned • Behavioral Health Disorders may not be easily understood as biopsychosocial illnesses. • It is critically important to ask patients and their families about their explanatory (health belief) models. • As healthcare providers, we need to examine our own views about stigma and behavioral health disorders and examine for our own intracultural and intercultural biases. • Universal or targeted condition screening can help mitigate patient stigma. • BUT screening without systematic care supports is largely ineffective for improved outcomes.

33. Future research: How to measure and impact the social determinants of risk and outcomes of disease: • Health delivery system testing of EBP in safety net settings to align the necessary logistics for quality care (e.g. emergency room settings, coordination w PCP, outcome assessment). • Providers might not welcome activated patients suggesting importance of integrating system change linked to patient activation and self-management but also provider training and quality outcomes measurement. • Studies to eliminate disparities in the clinical encounter-bias, stereotypes, unconscious bias, and quality of care. • Studies of integrated care to meet needs and life circumstances of disparity populations, to make sure services will be of use. Alegria, et al, NIMHD Health Disparities Institute, 2015.

34. Questions? Thank you!! Katherine Sanchez • Katherine.Sanchez@BSWHealth.org