Cultural Competence in Behavioral Health Services: NYS/USA Perspectives

Presented by: Carole Siegel, Ph.D.

Director: Nathan Kline Institute Center of Excellence in Culturally Competent Mental Health

New York State Office of Mental Health

Scottish Universities Insight Institute

April/2015

Glasgow, Scotland

Outline

Behavioral health care system of NYS/USA

Diverse cultural groups of NYS/USA

Definition and goals of CC in healthcare systems

CC domains and application areas

Examples of approaches to promote CC

Insurance/payers of services

Public Insurance Medicaid Medicare VA Affordable Care Act (ACA) supplements

Private Insurance Employers Private

Uninsured Tax under ACA

Self pay

Public insurance

Medicaid: indigent, highly disabled

Medicare: elderly, disabled who have worked

VA: veterans and their families

Private Insurance Private plans offering varying packages of services for

different premiums, copays, caps Often partially paid for by employers Recent parity laws equilibrate mental health services with health

services Available through state health exchanges

Fee for service Provider choice Selected providers

Capitated payments under managed care

Health care reform: Affordable Care Act Coverage for all

Penalty/tax for being uninsured Expansion of Medicaid population to below140% of poverty level

Promotion of integrated care models Hospital based accountable care organizations integrating health and behavioral

health For severely mentally ill

Health homes offering assistance with non-medical services such as housing and social supports

Population health/prevention focus

Enrollment in private insurance through employer sponsored plans or state health exchanges with insurers offering different level packages of service

Fee for service public insurance models moving into managed care models

Value based payments Tying of federal reimbursements to value rather than volume

Diverse cultural groups: NYS, USA Blacks

Hispanics

Asians

Whites

Other

African Americans Recent African Immigrants

Somalia, Sudanese Refugees: Ethiopians,

Afro-Caribbeans Jamaicans, Trinidadians

Puerto Rican Central Americans

Dominicans , Ecuadoreans , Mexicans Haitians

SE Asians Chinese Korean Vietnamese

Russian and former USSR immigrants

LGBT Born Deaf Rural populations

Estimate of Annual Number of Persons Receiving Community-based Services in NYC/NYS (2013) Public Mental Health System

n New York City, NY NY State

Total 279, 216 639,384

% White 23 46

% Black 30 23

% Hispanic 40 24

% Asian 2.8 1.5

% Other 5.2 5.5

In community based treatmentNYC: >73% B, H, AState: >49% B, H, A

General Pop.NYC:>67% B, H, AState: >43% B, H, A

Cultural Group/Cultural Identity Cultural group membership: Identifying with a group that subscribes to a world view,

way of life, and/or ethical system

Race/ethnicity …widest cut E.g. Caucasian, African Heritage, Hispanic/Latino, Asian, American Indian/Alaskan

Native, Native Hawaiian/Pacific Islander

Religion

Country or geographical region

Sexual orientation

Disability

Socioeconomic status

Other

Cultural Identity: Identification with one or more cultural groups

Black, Baptist, gay, professional

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Cultural Competence

The multi-pronged ability of a health care system to engage and provide high-quality care to clients with diverse values, beliefs and behaviors

At all levels of the system

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ADMINISTRATIVE ENTITYe.g., State Mental Health Authority, Managed Care Organization

Program Program

Agency A

Inpatient unit

Agency B

Clinic

CaregiverCaregiv

erCare-giver

Levels of a Mental Health System

ProgramProgram

Care-giver

Care-giver

Consumers

Cultural Competence• Organizations

• policies and procedures

• Programs • Linguistic access, program access, appropriately

adapted services, CC trained staff

Caregivers • personal attitudes (affective domain)• cultural group knowledge (cognitive domain,

generic and specific), • skills and actions (behavioral domain)

• Consumers • cultural activation • advocacy

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ADMINISTRATIVE ENTITYe.g., State Mental Health Authority, Managed Care Organization

Program Program

Agency A

Inpatient unit

Agency B

Clinic

CaregiverCaregiv

erCare-giver

Levels of a Mental Health System

ProgramProgram

Care-giver

Care-giver

Consumers

Why CC is needed In USA, there are documented disparities in receipt of

treatments and outcomes in blacks, Hispanics and Asians

In USA, large percent of persons in jails and prisons have mental illness and are black (trans-institutionalization)

CC is an approach to improving quality of care for all groups and already showing evidence of reducing disparities

What disparities can a health care systems address?

An unjust or unfair differences in health care between groups due to factors under its control

▪ Access

▪ Getting into the system E.g., insurance

▪ Availability

▪ Supplying and locating services

▪ Appropriateness

▪ Accommodating language needs▪ Modifying existing and providing new services▪ Having bilingual, bicultural staff▪ Training staff in CC

Can a health care system address social determinants of disparities?

Structural Competency

Can a consumer address cultural competency?

Cultural Activation

Cultural Group: Behavioral Health Care System Focus

A cultural group that requires special attention as its views

or values or standard approaches of the service delivery

system might impact cultural group persons’ access or

participation in services

Groups that require interpreters to communicate or translated health care materials

Recent immigrant or refugee populations LGBT communities Rural folks

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CULTURAL COMPETENCE MODELInteracting Domains of Cultural Competency

InformationExchange

InformationExchange

NeedsAssessment

NeedsAssessment

Human Resources

Human Resources

ServicesServicesPolicies/

ProceduresPolicies/

Procedures

Outcomes

Informal MH

Supports/Other

Systems

Informal MH

Supports/Other

Systems

Social Services

Housing

Clergy

……..

Mental HealthSystem

Domains Needs Assessment

Require data on cultural groups in organizations’ service areas

Information Exchange Require Input from community members

Cultural brokers e.g., religious leaders Outreach to community

Services CC staff, CC enforced through policies and procedures, culturally

appropriate (new and modified) interventions

Outcomes Track disparities to target remediation Measure parameters of culturally defined recovery

Why assessing CC at all these levels is important

Evidence is mounting that organizations, programs and clinicians that are CC:

Better engage clients in care Keep clients in care by reducing drop outs due to

Language problems

Inappropriate services

Client/clinician misunderstandings

Why CC Effects Consumer Outcomes

Policies

Staff

requirements /constraints

Clinical Team

MilieuClinical Tools

Services Care Delivery

Outcomes

Organization’s policies and procedures regarding CC

CC program milieu: atmosphere, care coordination procedures, training and supervision

Program tools to promote CC: How to adapt services

Clinician’s clinical competency to include CC

CC requirements/mandates Payers

Metrics to measure quality in state/federally funded managed care and provider group organizations will include CC metrics to insure covered programs and their providers are CC

Organizations State/federals mandates on language accessibility and training

Providers Cultural competency training

NYS Office of Mental Health:Nathan Kline Institute Center of Excellence in CC Mental Health Conducts research, develops tools and compiles resources

Portfolio highlights

NYS disparity research

Needs assessment data for state and county planners

CC assessment instruments :organizations and programs

Toolkit for clinicians to adapt EBPs for cultural groups

Religious/spiritual leader cultural/broker materials

Cultural activation tool for consumers

Educational materials for clinicians: cultural profiles

http://cecc.rfmh.org

Additional Resources

NKI Cultural Competency Assessment Scale Program Level

Program Outreach Client and family cultural assessments Engagement

Language capacity Communication skills Trust building Stigma Reduction

Culturally friendly milieu Culturally modified or new services Cultural peer member involvement Family member involvement Culturally acceptable community resources Measurement of meaningful outcomes

Service outcomes Recovery outcomes Program satisfaction Consumer input Family input

NKI Cultural Competency Scales and Tools

Organizational CC assessment scale: Policies and procedures

Program CC assessment scale: Key areas for enriching programs in CC

Toolkit for adapting EBPs for cultural groups

Consumer Cultural Activation Prompts

Commonly held clinical beliefs concerning CC

Clinical competency implies cultural competency Hopefully, but not always as cultural competency is not usually

part of clinical training curriculum

Patient-centered care implies culturally competent care It should be, but clinicians do not always know how to

communicate with the patient, ask the right questions and elicit culturally nuanced responses