Marilyn Laila Sampilo, PhD, MPHHealth Equity &

Cultural Competency Administrator

Review equity and related concepts

Provide data on behavioral health disparities

Discuss integration of behavioral health in primary care

Case study/model of integrated primary care

Discussion

• Health equity: Everyone has the opportunity to be as healthy as possible.

• Health disparity: Differences in health outcomes and their causes among groups of people

CDC, 2016

• Behavioral health equity: the right to access quality health care for all populations regardless of the individual’s race, ethnicity, gender, socioeconomic status, sexual orientation, geographical location and social conditions through prevention and treatment of mental health and substance use conditions and disorders

• Behavioral health disparity: Systemic difference in substance use or mental health outcomes between segments of the population

SAMHSA, 2018

76.679.1

13.4 12.918.1

3.8

0

10

20

30

40

50

60

70

80

90

United States Ohio

Race and Hispanic Origin

White, Non-Hispanic Black or African American Hispanic or Latino

Asian Two or More Races American Indian or Alaskan Native

Native Hawaiian and Other PI

30.2

17.3

12.6

6.1

29.2

14.712.9

9.8

33.7

16.4

13.5

8.2

0

5

10

15

20

25

30

35

40

Sadness/Hopelessness Seriously consideredattempting suicide

Made a suicide plan Attempted suicide

YRBS: Mental Health Variables

White Black Hispanic

9.70

12.2

14.1

4.9

10

8.5

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

Severe difficultiesw/emotional/behavioral health

Attention Deficit & HyperactivityDisorder (ADHD)

Learning disability

Emotional and behavioral problems and learning disabilities among poor and nonpoor children, 2009

Poor Nonpoor

NCCP calculations based on the National Health Interview Survey (NHIS) 2009

• Physical and structural barriers

• Cognitive barriers

• Affective barriers

• Value orientation barriers

Leong & Kalibatseva, 2011

• Most children are healthy and receive health care services through outpatient primary care settings

• Physician orientation towards screening and early intervention

• Physical health status behavioral health issues

Stancin & Perrin, 2014

• Increases access to BH services

• Reduces stigma

• Care coordination

• Improved adherence

• Supports the medical home, family-centered care

• Emphasizes screening and early intervention

American Academy of Child and Adolescent Psychiatry, 2009

• “Health promotion refers to a wide range of activities designed to enhance individual and family functioning. Health promotion and disease prevention programs use behavioral and environmental factors to advance physical and mental functioning.”

• Pediatric health promotion and problem prevention refers to “enhancing the status of healthy children, taking action to avoid the development of problems, and identifying problems early enough to minimize their potential negative outcomes.”

Black, 2002; Roberts, 1986

Stancin & Perrin, 2014

• “The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of people’s lives… This unequal distribution of health damaging experiences… is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics. Together, the structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries (p. 1).”

CSDH, 2008

Bay Area Regional Health Inequities Initiative, 2016

Turning Inward

• Identify/consider aspects of cultural identity, lived experience

• Consider privilege and power structures

• Identify/consider biases and assumptions

• Commit to self-evaluation and self-critique

Turning Outward

• Consider health equity in the context of intersectionality

• Focus on systems of power/privilege rather than seek to change those marginalized or oppressed by systems of power

• Develop partnerships with community, groups who advocate for vulnerable populations

Turning Outward

• Clinical care integration with initiatives to address structural factors

• Improvements in access to treatment (structural advantages in access)

• Advocate for social change

References

• Bay Area Regional Health Inequities Initiative (2016). What are social determinants of health. Retrieved from https://letsgethealthy.ca.gov/sdoh/• Black, M. M. (2002). Society of Pediatric Psychology presidential address: Opportunities for health promotion in primary care. Retrieved from

https://academic.oup.com/jpepsy/article/27/7/637/888800• Center for Disease Control (2016). Strategies for reducing health disparities. Retrieved from

https://www.cdc.gov/minorityhealth/strategies2016/index.html• Center for Disease Control (2017). Youth risk behavior survey: Data summary & trends report. Retrieved from

https://www.cdc.gov/healthyyouth/data/yrbs/pdf/trendsreport.pdf• Commission on Social Determinants of Health, (2008). Closing the gap in a generation: Health equity through action on the social determinants of

health. Retrieved from https://www.who.int/social_determinants/thecommission/finalreport/en/• Henry J Kaiser Family Foundtion (2013). Distribution of U.S. population by race/ethnicity, 2010 and 2050. Retrieved from

https://www.kff.org/disparities-policy/slide/distribution-of-u-s-population-by-raceethnicity-2010-and-2050/• Leong, F. T. L., & Kalibatseva, Z. (2011). Cross-cultural barriers to mental health services in the United States. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3574791/• Lopez, N. and V. L. Gadsden. 2016. Health Inequities, Social Determinants, and Intersectionality. NAM Perspectives. Discussion Paper, National

Academy of Medicine, Washington, DC. doi: 10.31478/201612a• Ohio Development Services Agency (2018). Ohio county indicators, July 2018. Retrieved from

https://development.ohio.gov/reports/reports_countytrends_map.htm• Ohio Development Services Agency (2019). The Ohio poverty report, February 2019. Retrieved from

https://development.ohio.gov/reports/reports_pop_proj_map.htm• Roberts, M. (1986). Health promotion and problem prevention in pediatric psychology: An overview. Retrieved from

https://academic.oup.com/jpepsy/article-abstract/11/2/147/924224?redirectedFrom=fulltext• Seith, D., & Isakson, E. (2011). Who are America’s poor children? Examining health disparities among children in the United States. Retrieved from

http://www.nccp.org/publications/pdf/text_995.pdf• Stancin, T., & Perrin, E. C. (2016). Psychologists and pediatricians: Opportunities for collaboration in primary care. Retrieved from

https://academic.oup.com/jpepsy/article-abstract/11/2/147/924224?redirectedFrom=fulltext• Substance Abuse and Mental Health Services Agency (2018). Behavioral health equity. Retrieved from https://www.samhsa.gov/behavioral-health-

equity• Task Force on Mental Health, American Academy of Child and Adolescent Psychiatry (2009). Improving mental health services in primary care:

Reducing administrative and financial barriers to access and collaboration. Retrieved from https://pediatrics.aappublications.org/content/123/4/1248

• US Census Bureau (2018). QuickFacts Ohio: Population estimates, July 1, 2018. Retrieved from https://www.census.gov/quickfacts/fact/table/oh/PST045218

………………..……………………………………………………………………………………………………………………………………..

Advancing Behavioral

Health Equity: The

Role of Integrated

Pediatric Primary Care

Catrina C. Litzenburg, Ph.D.

@clitzenburgphd

………………..……………………………………………………………………………………………………………………………………..

Definition of Primary Care

“Primary Care is the provision of integrated, accessible

health care services by clinicians who are accountable for

addressing a large majority of personal health care needs,

developing a sustained partnership with patients and

practicing in the context of family and community.”

Donaldson et al. (1996)

………………..……………………………………………………………………………………………………………………………………..

Hilltop Primary Care Center

………………..……………………………………………………………………………………………………………………………………..

Greater Hilltop Area Commission

https://www.columbus.gov/areacommissions/greaterhilltop/

………………..……………………………………………………………………………………………………………………………………..

Greater Hilltop Area

• Estimated population (2018): 77,789

• ↓ 4,996 residents in past 5 years

• Largest age group: 0 to 4 years (8.6%)

• 35% of households live below poverty level

The City of Columbus &

Hilltop Business Association

(2019)

………………..……………………………………………………………………………………………………………………………………..

Greater Hilltop Area

1%2%

9%

16%

72%

Racial Distribution

American Indian Asian or Pacific Islander Other or Mixed Black White

………………..……………………………………………………………………………………………………………………………………..

Primary Care Services

• Complete health care including checkups for infants,

children and teenagers

• Care for sick children including same-day sick, walk-in

appointment clinic

• Specialized services for asthma, obesity, and ADHD

• Osteopathic Manipulative Medicine (OMM) Clinic

• Social services

• Reach Out and Read Program

………………..……………………………………………………………………………………………………………………………………..

Integrated Primary Care

• Same-day consultation

• Brief follow-up (i.e., 3 to 5 sessions per episode of care)

• Curbside consultation

• Co-precepting for medical learners

………………..……………………………………………………………………………………………………………………………………..

Primary Care Screening

• Edinburgh Postpartum Depression Scale (EPDS)

• Ages & Stages Questionnaire (ASQ)

• Modified Checklist for Autism in Toddlers (M-CHAT)

• Patient Health Questionnaire (PHQ-9)

• Generalized Anxiety Disorder 7-Item (GAD-7)

Sriraman et al. (2017); Schonhaut et al. (2013);

Zwaigenbaum et al. (2015); Richardson et al.

(2010); Mossman et al. (2017)

………………..……………………………………………………………………………………………………………………………………..

Hilltop PCC – January 2019

• 89 unique patients

• 103 encounters

• 14 patients seen twice

………………..……………………………………………………………………………………………………………………………………..

Patient Demographics

7

17

57

19

Age in years

0 to 2 3 to 5 6 to 12 13+

………………..……………………………………………………………………………………………………………………………………..

Patient Demographics

60

40

Sex

Male Female

………………..……………………………………………………………………………………………………………………………………..

Patient Demographics

81

10

9

Insurance

Public Private None

………………..……………………………………………………………………………………………………………………………………..

Type of Encounter

50

9

41

Same-day consultation Medical follow-up Psychology-only

………………..……………………………………………………………………………………………………………………………………..

Presenting Concern Count Percent

Psychosocial Adjustment 31 33.33

ADHD 15 16.13

Sleep 12 12.90

Disruptive Behavior 9 9.68

Anxiety 6 6.45

Mood Disturbance 5 5.38

Developmental Delay 4 4.30

Trauma 3 3.23

Toileting 2 2.15

Academic Functioning 2 2.15

Feeding 1 1.08

Healthy Weight 1 1.08

Caregiver Depression 1 1.08

Crisis 1 1.08

………………..……………………………………………………………………………………………………………………………………..

Case Presentation

• “John”

• 6 year-old Latinx male

• Presented for well-child check on 12/20/2018

• Presented for primary care psychology appointment on

1/11/2019

• Psychosocial adjustment

• Family disruption

• Recent moves

• Peer relations

• Acculturation

………………..……………………………………………………………………………………………………………………………………..

Case Presentation

• “James”

• 10 year-old White male

• Presented for med check on 1/03/2019 and 1/24/2019

• ADHD

• Prescribed 27mg Concerta every morning, and 5mg

Ritalin every afternoon

• Engaged in behavior management with community-

based provider

• 3rd grade with current Individualized Education Plan

(IEP)

………………..……………………………………………………………………………………………………………………………………..

Case Presentation

• “Mary”

• 18 month-old Asian female

• Presented for 12-month well-child check on 12/18/2018,

psychology-only visit on 1/03/2019, and 15-month well-

child check on 3/18/2019

• Sleep

• Sleep-onset-association

• Age-inappropriate bedtime

• Inconsistent daytime napping

………………..……………………………………………………………………………………………………………………………………..

References

• The City of Columbus & Hilltop Business Association (2019). Market analysis, small business opportunity

study: Hilltop USA, West Broad Street & Sullivant Avenue. Retrieved from

http://www.hilltopbusinessassociation.org/87-news/134-hilltop-market-analysis.

• Donaldson, M. S., Yordy, K. D., Lohr, K. N., & Vanelow, N. A. (1996). Primary care: America’s health in a

new era. Washington, DC: National Academy Press.

• Mossman, S. A., Luft, M. J., Schroeder, H. K., Varney, S. T., Fleck, D. E., Barzman, D. H., … Strawn, J.

R. (2017). The Generalized Anxiety Disorder 7-item (GAD-7) scale in adolescents with generalized

anxiety disorder: Signal detection and validation. Annals of Clinical Psychiatry, 29(4), 227-234A.

• Richardson, L. P., McCauley, E., Grossman, D. C., McCarty, C. A., Richards, J., Russo, J. E., … Katon,

W. (2010). Evaluation of the Patient Health Questionnaire (PHQ-9) for detecting major depression among

adolescents. Pediatrics, 126(6), 1117-1123. doi: 10.1542/peds.2010-0852.

• Schonhaut, L., Armijo, I., Schönstedt, M., Alvarez, J., & Cordero, M. (2013). Validity of the Ages and

Stage Questionnaires in term and preterm infants. Pediatrics, 131, e1468-e1474. doi:

10.1542/peds.2012-3313

• Sriraman, N. K., Pham, D., & Kumar, R. (2017). Postpartum depression: What do pediatricians need to

know? Pediatrics in Review, 38(12), 541-550.

• Zwaigenbaum, L., Bauman, M. L., Fein, D., Pierce, K., Buie, T., Davis, P. A., … Wagner, S. (2015). Early

screening for autism spectrum disorder: Recommendations for practice and research. Pediatrics,

136(S1), S41-S59. doi: 10.1542/peds.2014-3667D