Carol Carstens, PhD, Scott Wingenfeld, MPA, Kwok Tam, MSocSci Ohio Department of Mental Health Office of Research & Evaluation First Meeting on Patient Reported Outcomes in Mental Health September 30, 2012 Washington DC

Objective: To look at the relationship between patient self- reported experience of care and measures of clinical care. Data Source/Collection: Data were collected in a mail survey of minority consumers (N = 311). Design/Methods: In this cross-sectional study, Likert-type scales were used to collect information on client perception of providers’ cultural competence and self-report measures of functioning, quality of life, and social connectedness. Hierarchical regression was used to examine the relationship between cultural competence and the independent variables. Principal Findings: After controlling for subject-related factors, consumer perception of provider cultural competence was significantly related to self-reported outcome measures. Conclusions: Cultural competence is a specific approach to patient centered care that can improve the outcomes of mental health services. Ohio Department of Mental Health Office of Research & Evaluation 2

 Research Question  What is Cultural Competence?  Measuring Cultural Competence  Measuring Self-Reported Outcomes  Adult Consumer Sample  Linear Regression Models  Limitations & Sources Cited Ohio Department of Mental Health Office of Research & Evaluation 3

Does consumer perception of the service providers’ cultural competence have any association with self- reported treatment outcomes? Ohio Department of Mental Health Office of Research & Evaluation 4

 Culture falls under the umbrella of person- centered care. It provides a framework for understanding human experience. Personal & Group Identity Beliefs & Values Customs & Traditions Language & History Otherness: Minority versus Majority Ohio Department of Mental Health Office of Research & Evaluation 5

 Ignorance  Indifference  Mistrust  Fear  Discrimination  Difference Beliefs & Values Language Communication patterns Ohio Department of Mental Health Office of Research & Evaluation 6

 Inquire about cultural identity — race, ethnicity, gender, sexual orientation, religion, spirituality, disability status & other self-defining characteristics  Explore cultural explanations of the problem  Consider cultural factors in psychosocial environment and level of functioning  Examine cultural elements in the client- provider relationship  Overall cultural assessment goes into diagnosis and individual treatment plan Ohio Department of Mental Health Office of Research & Evaluation 7

Very little research  looks at the relationship between provider’s cultural competence & the patient’s symptoms, functioning or social support (Griner & Smith, 2006)  evaluates cultural competence from the consumer perspective (Cornelius et al, 2004) Ohio Department of Mental Health Office of Research & Evaluation 8

Experimental 52-item Inventory developed by L.J. Cornelius & others in Maryland in  Awareness of patient culture  Respectful behaviors  Language interpreters  Understanding indigenous practices  Consumer involvement  Acceptance of cultural differences  Community outreach  Patient-provider-organization interactions Ohio Department of Mental Health Office of Research & Evaluation 9

 20 items from CBCCI tested & analyzed by ODMH- ORE staff in 2012 Ohio administration Reduced administrative burden Conceptual & statistical considerations  10 items from CBCC survey adopted to analyze consumer-reported treatment outcomes Factor loadings >.4 Two factor solution explains 59.4% s² Staff level (8 items) Organizational level (2 items) Cronbach’s α =.91 Ohio Department of Mental Health Office of Research & Evaluation 10

Survey Item # Question Factor 1 Factor 2 2 The staff listen to me and my family when we talk to them The staff who work directly with me on my mental health needs respect my belief in God, a supreme being, or higher power Some of the staff at my agency understand the difference between their culture and mine Staff understand that people of my racial or ethnic group are not all alike When I first called or came to the agency, it was easy to talk to the staff Most of the time, I feel I can trust the staff who work with me Staff understand some of the different ideas that I, my family, and others from my minority group may have about mental illness Staff are willing to be flexible and provide alternative approaches or services to my cultural/ethnic treatment needs The agency waiting room has pictures or reading material that show people from my minority group The agency’s reading materials and handouts are in other languages as well as English..603 Ohio Department of Mental Health Office of Research & Evaluation 11

Self-rated  Perception of Care General Satisfaction (3 items) Access to Care (4 items) Quality & Appropriateness (8 items) Participation in Treatment (2 items)  Outcomes (8 items)  Functioning (5 items)  Social Connectedness (4 items) Ohio Department of Mental Health Office of Research & Evaluation 12

DomainItems Outcomes of Services I deal more effectively with daily problems I am better able to control my life I am better able to deal with crisis I get along better with family I do better in social situations I do better in school and/or work My housing situation has improved My symptoms don’t bother me as much Ohio Department of Mental Health Office of Research & Evaluation 13

DomainItems Functioning I am able to do things that are more meaningful to me My symptoms don’t bother as much I am better able to take care of my needs I am better able to handle things when they go wrong I am better able to do things I want to do Social Connected- ness I am happy with the friendships I have I have people with whom I can do enjoyable things I feel I belong in community In a crisis, I would have the support I need from family or friends Ohio Department of Mental Health Office of Research & Evaluation 14

 Adult survey: 4,740 randomly selected adult consumers with serious mental illness (SMI)  Minority subsample: 1,325 consumers selected if race code indicated person of color OR ethnicity code indicated hispanic origin  175 individuals selected where race = White without hispanic qualifier  Total subsample = 37% of adult consumer sample received cultural competence survey Ohio Department of Mental Health Office of Research & Evaluation 15

 ♀ = 61% ♂ = 39%  46.8 X Age Range 17.9 – 88.2 SD = 11.8  91% Medicaid 9% other public coverage  88% long term 12% new in 2011  87% still in treatment 6.5% terminated 7% unknown status Ohio Department of Mental Health Office of Research & Evaluation 16

Some people belong to minority groups because their race, country of origin, history, language, religion, or sexual orientation is different than most people. Do you consider yourself a cultural, racial, ethnic, religious, or sexual minority group member? Yes No If you answered YES, what is your minority group? (Specify cultural, racial, ethnic, religious and/or sexual identity)______________________ Ohio Department of Mental Health Office of Research & Evaluation 17

 About 37% of the sample who were people of color or hispanic ethnicity said No to the question about minority status.  The US is becoming more racially and ethnically diverse.  Many people in the sample do not appear to see themselves as “other” or set apart from mainstream society because of race or ethnicity. Ohio Department of Mental Health Office of Research & Evaluation 18

 Age  Race  Gender  Ethnicity  Geographic Profile  Diagnosis  Service Longevity  Service Continuity  Perception of Care  General Satisfaction  Access  Quality & Appropriateness  Participation in Treatment*  Cultural Competence Ohio Department of Mental Health Office of Research & Evaluation 19

Significant Variables βtp Bipolar DO Major Depression Small City Geo Type Participation in Tx Cultural Competence Ohio Department of Mental Health Office of Research & Evaluation R² =.422, F = ,293, p <

Significant Variablesβtp Bipolar DO Major Depression Small City Geo Type Participation in Tx Cultural Competence Ohio Department of Mental Health Office of Research & Evaluation R² =.381, F = ,299, p <

Significant Variablesβtp Major Depression Small City Geo Type Access Participation in Tx Cultural Competence Ohio Department of Mental Health Office of Research & Evaluation R² =.325, F = ,287, p <

 Cultural Competence: Confounded Construct  Minority status  Race & Ethnicity  Group vs Individual identity  Scale Development:  Limited psychometric testing on CBCC  Dependent Vars:  Post-hoc outcome measures  Diversity of Service Population Unknown:  Sample religious/spiritual identification = 8%  Sample GLBT identification = 2% Ohio Department of Mental Health Office of Research & Evaluation 23

 Griner, D, & Smith, TB Culturally Adapted Mental Health Interventions: A meta-analytic review. Psychotherapy: Theory, Research, Practice, Training 43(4):  Cornelius LJ, Booker NC, Arthur TE, Reeves I & Morgan O The Validity and Reliability Testing of a Consumer-Based Cultural Competency Inventory. Research on Social Work Practice 14(3): Ohio Department of Mental Health Office of Research & Evaluation