IMPROVING BEHAVIORAL HEALTH FOR LATINO

POPULATIONS: CREATING POSITIVE CHANGE

MARGARITA ALEGRÍA, PH.D. AND GILBERTO PÉREZ, JR., MSW, ACSW

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Post-Training Evaluation

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NLBHA’S VISION AND MISSION

Our vision is to reduce the great disparities that exist in the areas of funding, access,

and quality of care for Latino consumers and families needing mental health and

substance abuse services and supports.

The mission of NLBHA is to influence national behavioral health policy, eliminate

disparities in funding and access to services, and improve the quality of services and

treatment outcomes for Latino populations.

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IMPROVING BEHAVIORAL HEALTH FOR LATINO

POPULATIONS: CREATING POSITIVE CHANGE

MARGARITA ALEGRÍA, PH.D. AND GILBERTO PÉREZ, JR., MSW, ACSW

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PRESENTERS

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Margarita Alegría, Ph.D.

Presenter

Gilberto Pérez, Jr., MSW, ACSW

Facilitator

OVERVIEW

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1. Changing demographics of the United States and persistent disparities

in behavioral health care.

2. Consistent barriers to Latino behavioral health care.

3. Cultural considerations for Latino behavioral health

4. Promising strategies for programs to improve the behavioral health

workforce for Latino populations

WHAT ARE THE CHANGING DEMOGRAPHICS OF THE

UNITED STATES?

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CHANGING DEMOGRAPHICS OF THE UNITED

STATES

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Over the next four decades:

▪ The U.S. population is projected to

grow from 326 million to 404 million.

▪ The non-Hispanic white population

remains the largest, although it is

projected to decline as a result of

falling birth rates and rising death rates.

▪ Racial/ethnic minority populations will

continue to grow, becoming more than

50 percent of total population.

U.S. Census Bureau, 2018.

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76.60%13.40%

1.30%

5.80%

0.20%

2.70%18.10%

US Population Distribution by Race/Ethnicity 2018

White Black or African American American Indian and Alaska Native

Asian Native Hawaiian and Other Pacific Islander Two or More Races

Hispanic or Latino

https://www.census.gov/quickfacts/fact/dashboard/US/PST045218

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PROJECTED U.S.

HISPANIC

POPULATION,

2017-2060

U.S. Census Bureau, Quick Facts: https://www.census.gov/library/visualizations/2018/comm/hispanic-projected-pop.html

11https://www.nielsen.com/us/en/insights/news/2016/hispanic-influence-reaches-new-heights-in-the-us.html

WHAT ARE THE CURRENT BARRIERS TO PHYSICAL AND

BEHAVIORAL HEALTHCARE FOR LATINO POPULATIONS?

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PERSISTING DISPARITIES IN HEALTHCARE

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• Despite the growing diversity of the U.S. population, disparities continue to

exist in the behavioral healthcare system for Latino populations.

• Racial/ethnic minorities represent more than 50 percent of the uninsured

population.

• Research and reports continue to show that gaining access to behavioral

health services alone does not eliminate service disparities.

• There is a need for a more collaborative, patient-centered approach to care,

including understanding patient preferences of Latinos.

• Need for in-depth understanding of social determinants of health.

DISPARITIES ACROSS PATHWAY OF CARE

Disparities persist along this entire pathway:

Across 10 states, 85% of privately insured patients could get an appointment, compared to 78% of uninsured patients (with $75 payment) and 58% of Medicaid patients (Pauly, Naylor and Weiner, 2014).

Health disparities are too frequently confused with their determinants. This has limited ability of scientific interventions and etiological studies in health disparities to demonstrate the impact in reducing health disparities.

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THE NATIONAL HEALTHCARE QUALITY REPORT: 2017

DISPARITIES IN ACCESS: 2014-2016

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• Poor individuals (at or below

100% of federal poverty line)

experienced worsening access

for 18 of 20 access measures

• Blacks experienced worse

access to care for 52% of

measures

• Hispanics experienced worse

access to care for 70% of the

measures

93.7

73.9

35.9

89.5

56.5

43.7

92.4

52.4

40.1

84

74.2

27.1

ANY INSURANCE PRIVATE INSURANCE GOVERNMENT

INSURANCE

non-Latino Whites Blacks Latinos Asians

U.S. HEALTH INSURANCE COVERAGE (%) BY RACE- 2016

Barnett, Jessica C. and Edward R. Berchick, Current Population Reports, P60-260,

Health Insurance Coverage in the United States: 2016, U.S. Government Printing

Office, Washington, DC, 2017.

https://www.census.gov/content/dam/Census/library/publications/2017/demo/p60-

260.pdf

HEALTH INSURANCE COVERAGE BY RACE

(2016)

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SYSTEMIC BARRIERS TO QUALITY HEALTHCARE FOR

DIVERSE POPULATIONS

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Low provider diversity or diversity in

leadership

Few culturally and linguistically

competent providers and/or institutions

Service silos and limited understanding of social determinants

of health and their impacts

Unequal community resources and

investments in care

Geographical differences to care

availability: urban, rural, frontier, borders

GEOGRAPHIC DISPARITIES IN BEHAVIORAL

HEALTHCARE DELIVERY

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• Residential proximity to services and availability of affordable public transportation is an

important factor in access to and utilization of health and behavioral health services.

• Farm laborers experience long work days and isolation.

• Isolated racial and ethnic minority neighborhoods are disproportionately affected by

provider shortages.

TREATMENT LEVEL BARRIERS FOR BEHAVIORAL HEALTHCARE

FOR DIVERSE POPULATIONS

19Limited access and low-quality care may lead to greater use of psychiatric ER.

Limited provider options accepting low payments.

Low geographic supply of diverse providers, particularly multilingual providers.

States limit Medicaid payments.

FACTORS INFLUENCING TREATMENT IN

RACIAL/ETHNIC MINORITY POPULATIONS

• Perception that mental health

services and systems could

not help

• Somatic interpretations of

mental illness

• Stigma, including concerns of

family dishonor, immigration

status, fears of confidentiality

breaches, and hospitalization

Aggarwal, N. K., Pieh, M. C., Dixon, L., Guarnaccia, P., Alegría, M., & Lewis-Fernández, R. (2016). Clinician descriptions of communication strategies to improve treatment engagement

by racial/ethnic minorities in mental health services: a systematic review. Patient education and counseling, 99(2), 198-209.

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Factors for

Delay in Treatment

• Discomfort discussing

emotions with

clinicians/strangers

• Diverse cultural preferences

for communication styles

(directive vs. exploratory)

• Patient concern about

clinician misuse of power

Factors for

Treatment Participation

• Interpretation that

treatments are appropriate

• Clinician communication

based on patient

expressions of illness/use of

patient vocabulary

• Discussions about patient

confidentiality and inquiry

of patient-clinician

relationship concerns

Factors for

Treatment Continuation

BARRIERS TO CARE

Desire to

handle a

problem on

one’s own

Thinking

that

treatment

would not

workBeing

unsure of

where to

go or

whom to

seeA system that requires

face-to-face engagement

while disregarding the

personal costs of

transportation, time

demands, and lack of

linguistic and cultural

competence that

minority patients

confront

Falgas I. RZ, Herrera L., Qureshi A., Chavez L., Bonal C. , McPeck, S., Wang, Y., Cook B., & Alegría, M. Barriers to and Correlates of Retention in Behavioral Health Treatment

among Latinos in Two Different Host Countries: U.S. and Spain. Journal of Public Health Management and Practice. Forthcoming 2016.

Ponce NA, Hays RD, Cunningham WE. Linguistic disparities in health care access and health status among older adults. Journal of General Internal Medicine. 2006;21(7):786-91

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DISPARITIES IN MENTAL HEALTH CARE

Aggressive outreach is at odds

with standard clinical practices

such as removing patients from a

caseload after several missed

appointments, and indicates the

need for substantial investment in

engagement and outreach.

Alegría M, Ludman E, Kafali EN, Lapatin S, Vila D, Shrout PE, et al. Effectiveness of the Engagement and Counseling for Latinos (ECLA) Intervention in Low-income Latinos.

Medical care. 2014;52(11):989-97.

Whitten P, Buis L. Private payer reimbursement for telemedicine services in the United States. Telemedicine and e-Health. 2007;13(1):15-24.

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BREAK – Q&ADEMOGRAPHICS AND BARRIERS TO HEALTH FOR LATINO POPULATIONS

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WHAT ARE CULTURAL CONSIDERATIONS FOR

ADDRESSING BEHAVIORAL HEALTH DISPARITIES IN

THE LATINO POPULATION?

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Cultural

Considerations

for Behavioral

Health Services:

Working With

Diverse

Populations

• Be familiar with cultural

conceptions of health and mental

health

• Hire and support

bilingual/bicultural behavioral

health providers

• Use interpreters who are trained

in the mental health field

• Collaborate with health care

providers through integrated care

• Infuse traditional health and

healing practices

• Use approaches such as

psychoeducation and home visits

RECOMMENDED PRACTICES

• Adapt treatments to reduce language barriers, including client manuals and scripts for

bilingual clinicians, rather than relying on ad hoc translation

• Integrate behavioral health services into existing programs that provide social

services, such as housing or employment

• Employ culturally adapted social marketing to promote health access and remove

stigma-Bring forth the idea that the earlier you get treated the better!

• Use culturally adapted interventions, collaborating with patients and family advisory

boards to enhance understanding of patient concerns and obstacles in care.

• Diversify and expand behavioral health workforces and provide behavioral health

training to community health workers

Alegría, M., Alvarez, K., Ishikawa, R. Z., DiMarzio, K., & McPeck, S. (2016). Removing obstacles to eliminating racial and ethnic disparities in

behavioral health care. Health Affairs, 35(6), 991-999.

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EXAMPLE

Delivery of services through telephone holds promise,

especially for low-income, employed Latino patients,

based on a multi-site intervention that delivered

culturally tailored counseling.

The study resulted in significant worry reduction for

those receiving the intervention, and greater worry

reduction in those who received phone intervention

over those who received face-to-face treatment.

Alcántara, C., Li, X., Wang, Y., Canino, G., & Alegría, M. (2016). Treatment moderators and effectiveness of Engagement and Counseling for Latinos intervention on worry reduction in a low-income primary care sample. Journal

of consulting and clinical psychology, 84(11), 1016.

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TELEPHONE COUNSELING

EVIDENCE-BASED PRACTICES ARE NOT READILY AVAILABLE

FOR LATINO POPULATIONS.

For example, between September 2015-June 2016, there were 36 new

evidence-based programs in SAMHSA’s National Registry.

Less than half were developed with racial and ethnic minority

populations.

Only two described treatment that was culturally-tailored to treat these

populations.

Alegria et al., 2016

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HOW CAN WE IMPROVE THE BEHAVIORAL HEALTH

WORKFORCE FOR LATINO POPULATIONS?

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Increase patient

activation,

And shared-decision

making

Improve communication

with provider

Increase provider’s

competence in EBC,

test collaborative

care w/ PCP, assertive

follow up, flexible

appointments

Increase

acceptance

of Tx/,

Augment

Community

Capacity to

Identify and

Treat Mild/

Moderate Sx.

INTERVENTION

In Patient-Provider

Interaction

INTERVENTION

In Clinical Care

INTERVENTION

in

Community

INCREASE PATIENTS

Positive Experiences in health care

And use of EBC in Txs

MULTI-SYSTEM INTERVENTIONS

IMPROVED

Minority patient outcomes

And reduced disparities

INTERVENTION

in

Policy and Market

Increase

Awareness of

Service

Disparities at

Policy Level,

Offer Data of

Role of Social

Context &

Market Forces-

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INTERVENTIONS IN THE POLICY

ARENA

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CHANGING ORGANIZATIONAL CULTURE

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• Provider organizations cannot typically become more culturally responsive

without supplemental resources and technical assistance at the federal, state, and

local levels.

• Provider’s increased cultural awareness requires explicit planning and resources, as

well as staff coaching and increased institutional support and supervision.

• Federal, state, and private insurance payers must incorporate indirect costs into

their fee schedules or find other mechanisms to pay for the expense of change,

such as technical assistance centers that offer training and support without cost to

the provider organization.

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https://data.hrsa.gov/topics/health-workforce/shortage-areas

The federal government has a formal process

for areas that have shortages of health

professionals – designated as Health

Professional Shortage Areas (HPSA).

These designations can bring opportunity for

federal or state funding for mental health

workforce development.

HEALTH PROFESSIONAL SHORTAGE

AREAS:

INTERVENTIONS IN COMMUNITY

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BEHAVIORAL HEALTHCARE DISPARITIES IN MINORITY ELDERS

Mental disorders represent 14%

of the global burden of disease

and the third cause of disability.

1 in 5 older Latino adults has 1

psychiatric or substance abuse

Dx. Minority elders appear to

be a risk for greater severity,

persistence, and recurrence of

symptoms

IOM, 201235

SUCH GREAT NEED BUT SERVICE DISPARITIES

Among older adults, NO Treatment for Linguistic Minorities:

90% of those with MH conditions (Karlin et al., 2008).

66% of older adults with MDD

72% of older adults with anxiety disorders (Garrido et al., 2011).

We found only 1 in every ten received minimally adequate care

Partly due to workforce shortages and few evidence-based treatments in community health clinics or ineffective trials in primary care.

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POSITIVE MINDS-STRONG BODIES (PM-SB)

Build collaborative research to provide disability prevention

treatments in community-based organizations (CBOs) that serve

ethnic/racial minority and immigrant elder clients.

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Positive Minds (CERED)

10 session manualized individual CBT intervention.

Based on CERED* intervention among Latinos (Alegría et al., 2014).

Adapted for use among elders, and for use with African American and Chinese elders.

Delivered by CHWs.

36-session group exercise program. 12 weeks

Resistance-based exercises to build strength and improve mobility.

Delivered by exercise trainers.

Strong Bodies (INVEST)

PM-SB INTERVENTION

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*Kafali, N., Cook, B., Canino, G., & Alegria, M. (2014). Cost-effectiveness of a randomized trial to treat depression among Latinos. The journal of mental health policy and

economics, 17(2), 41.

LATE LIFE FUNCTION & DISABILITY INSTRUMENT

(LLFDI)

Assesses function and disability

Function: Refers to individual’s ability to do

specific actions (e.g. stepping on and off a bus)

Disability: Refers to individual’s performance of

expected life tasks within a typical sociocultural

and physical environment (e.g. visit friends and

family in their home)

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RESULTS OF POSITIVE MINDS-STRONG BODIES

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• Function and Disability: The PM-SB intervention

exhibited improved scores for late life function and

lowered self-reported disability compared to the control

group

• Mood:The intervention lowered (improved) mood

symptoms, except for generalized anxiety disorder

INCORPORATING COMMUNITY HEALTH WORKERS (CHWs) IN THE

BEHAVIORAL HEALTH WORKFORCE

Frontline public health worker

Trusted member of community or one

with close understanding of community

served

Liaison between health/social services

and community

Facilitate access to services and improve

delivery of culturally competent care

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Increase knowledge about health through:

Outreach

Community education

Informal counseling

Social support

Advocacy

Who are CHWs? What do CHWs do?

https://www.apha.org/apha-communities/member-sections/community-health-workers

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HISTORY OF PROMOTORES IN THE US

The work of promotores in the US has been documented since the 1960’s.

Here is a timeline of key events:

2010 2013 2016

A workforce code for

promotores was issued by

the US Bureau of Labor

Statistics under

community health/social

services

The Centers for Medicare and Medicaid

Services created a new rule providing

state Medicaid agencies with the option

to reimburse for more community-

based preventive services, including

community health workers

Since 2016, 16 states

report having CHW

standard operating

procedures or

certification laws

in place

https://mhpsalud.org/programs/who-are-promotoresas-chws/the-chw-landscape/

STRENGTHS OF PROMOTORES DE SALUD

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EDUCATE &

SUPPORT

ABOUT

RESOURCES

ADDRESS

UNMET

HEALTH NEEDS

COORDINATE

WITH

HEALTH

SYSTEMS

• Help non-English speaking families navigate health care system

• Work towards preventative care, increasing awareness, and getting

the message out

• Help make health systems more responsive to needs in the

community

• Improve access to and quality of care within Latino communities

• Have unique ability to address unmet health needs of minorities

• Address needs of Latino immigrants, such as acceptability to

treatment and how to feel more empowered

• Provide the community and patients with an intervention that makes

sense to the patient and takes into account multicultural issues

STRENGTHS OF PROMOTORES DE SALUD

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REDUCE

BARRIERS TO

HEALTH

SERVICES

LINK

COMMUNITY

MEMBERS TO

SERVICES

• Integrate information about health into community culture,

language, and values to reduce barriers to health services

• Reduce language barriers to improve patient-provider

communication

• Adapt interventions for Latinos through culturally matched

Promotores

• Improve the health of the community by linking neighbors to health

and social services

• Take into consideration the audience’s presenting problem,

symptoms, and perspectives, including how cultural awareness and

beliefs may influence the method of treatment delivery

INTERVENTIONS IN CLINICAL CARE

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THE “CONNECTION CHASM”

• Findings from the Patient-Provider Encounter Study:

• Interpersonal factors matter (e.g., language compatibility, cultural preferences, speaking in egalitarian terms)

• Cultural preferences vary across racial/ethnic groups

• Three consistent themes: listening, understanding, and managing difference

• However, definitions for each varied across groups.

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CLINIC ENGAGEMENT

Characteristics of clinics with successful engagement with

minority patients include having dedicated outreach staff, which

reduces missed appointments.

Trainings such as DECIDE (Decide the problem; Explore the

questions; Closed or open-ended questions; Identify the who,

why, or how of a problem; Direct questions to your health care

professional; Enjoy a shared solution) can positively influence

patient activation for racial/ethnic minorities, although challenges

to engagement and retention may remain.

Alegría, M., Carson, N., Flores, M., Li, X., Shi, P., Lessios, A. S., ... & Jimenez, A. (2014). Activation, self-management, engagement, and retention in behavioral health care: a randomized clinical trial of the DECIDE intervention.

JAMA psychiatry, 71(5), 557-565.

OTHER CONSIDERATIONS

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TARGETING SDM TO REDUCE DISPARITIES IN CLINICAL VISIT

One way to improve quality and retention in behavioral health care is to implement shared decision making (SDM).

When patients and providers engage in SDM, patients’ preferences are taken into consideration for their treatment, resulting in more appropriate care, increased satisfaction, and ideally, better health outcomes.

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OPPORTUNITIES FOR SDM -PROVIDERS DECIDE-PC-4 ARM RCT OF

312 PATIENTS AND ~79 PROVIDERS

• Help providers improve patient-provider communication and therapeutic alliance as a possible underlying pathway by which shared decision making can take place.

• Consists of 3-part training sessions totaling 20 hours

• Part 1 – 3 Half-Day Workshops (14 Hours total)

• Targets the five areas of the intervention

• Consist of follow-up individual training within one month of the Part 2 training.

• Calls to coach providers regarding the training using 6 audio-recorded sessions between patients and the provider.

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QUESTIONS?

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THANK YOU!

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Disparities Research Unit Support:

• Larimar Fuentes, MS

• Marie Fukuda

• Ravali Mukthineni

Massachusetts General Hospital

Disparities Research Unit

www.massgeneral.org/disparitiesresearch