1. Latino Access Study Report to the California Mental Health Planning Council Department of Mental Health October 2009

2. Latino Access Study (LAS) Background Information LAS Requirements LAS Details Challenges LAS Methodology Access Barriers County Examples LAS Promising Strategies

3. Background Information In 2001, the Statewide Quality Improvement Council (SQIC) and the Cultural Competence Advisory Committee made a recommendation to the Department of Mental Health (DMH) to include a Latino Access Study (LAS) as a part of the quality improvement plans required in the Mental Health Plan (MHP) contracts for FY2002-03. DMH agreed with this recommendation and issued a letter to counties requiring the county mental health plans to conduct the LAS (May 2002).

4. Latino Access Study Requirements All county Mental Health Plans with Medi-Cal eligible populations of 10,000 or more and/or counties with Spanish identified as a threshold language were required to complete the LAS. Nine small counties were exempt because they did not meet the population and/or language requirements at the time: Alpine, Amador, Calaveras, Mariposa, Nevada, Plumas, Siskiyou, Trinity, and Tuolumne.

5. Latino Access Study Requirements The SQIC recommendations focused on two areas for examination: initial access and secondary access  Initial access studies could include: outreach efforts to increase access, stigma, and/or healthcare/mental health partnerships  Secondary access studies could include: retention issues, the effects of extended clinic hours, and/or barriers for Latinos with Limited English Proficiency (LEP)

6. Latino Access Study Details 37 county MHPs submitted a copy of their LAS to DMH The focus of the studies varied greatly from county to county:  47% Barriers for Latinos with LEP  28%Outreach efforts to increase access  28% Retention  25% Stigma  22% Utilization Rates  19% Penetration Rates  14%Health/Mental Health partnerships  8% Miscellaneous (e.g. organizational self-assessment)  6% Effects of extended hours  6% Cultural competence training for staff

7. Challenges of the LAS Limited direction/guidance on how to conduct the study No funding for the studies or to implement strategies Limitations on the data that were available Small sample sizes (small counties) Very few counties were able to substantiate a significant increase in Latino access as a direct result of the LAS Some counties limited the scope of the LAS to a review of penetration and/or utilization rates County MHPs were not initially required to submit copies of their studies to DMH

9. LAS Methodology The study methodology also varied from county to county  46% Data Review  43% Interview/ Focus Groups  22% Outreach Efforts  16% Consumer Satisfaction Surveys  14% Organizational Self-Assessment  11% Increase Bilingual Staff/ Interpreters  06% Chart Reviews  06% Cultural Competence Training for Staff  06% Partner with Healthcare/Primary Care

11. LAS identified these barriers to access for Latino populations: Limited staff resources to make services more widely available General lack of information or understanding of mental illness/ mental health services Stigma Language barriers/lack of bilingual staff/lack of trained interpreters Transportation barriers Restricted hours of service Fear related to immigration/residency status

12. LAS County Examples: San Mateo County Data review, including: penetration rates by location and language; an analysis of the correlation of penetration rates and other indicators of access with available data on the ethnic and language distribution of staff; and a cultural competence self-study completed by CMH staff Review of all policies, procedures, and practices affecting Latino access at primary points of access Analysis of available summary data on satisfaction and complaints concerning Latino consumers

13. LAS County Examples: San Mateo County Analysis of MHP staff satisfaction surveys Interviews and focus groups with Latinos representing mental health consumers and family members, community members not involved with the mental health system, key contacts in the Latino community, and local Latino mental health clinicians San Mateo County’s LAS resulted in key recommendations to improve access for Latino mental health consumers.

14. LAS County Examples: Sacramento County Initiated an 18-month study to examine and identify barriers to community based mental health services for the Latino community Multi-tier approach included a large countywide study and individual LAS for each agency or program A system-wide committee, the Latino Access Study Focus Group, was convened to develop the countywide study

15. LAS County Examples: Sacramento County The Latino Access Study Focus Group committee conducted five countywide focus groups representing current and former clients, family members, community leaders, and Healthy Start Coordinators Focus group questions were developed in both English and Spanish The goal of each focus group was to identify barriers for the Latino community in the county and design strategies to remove those barriers In response to the focus groups’ findings, Sacramento County planned a second phase of the LAS to develop strategies and interventions to address the barriers identified.

16. LAS County Examples: Los Angeles County (LACDMH) LAS conducted as a multiple phase project Conducted an extensive literature review regarding available research on Latino access to mental health services Assessed quality of data collection (both Medi-Cal and non Med-Cal) and procedures which impact data collection Convened focus groups with mental health consumers and clinicians As a result of data review and focus groups, LACDMH focused on addressing one of the most critical barriers identified: language access

17. LAS County Examples: Los Angeles County (LACDMH) Developed a pilot study to evaluate Interpreters’ Training outcomes with a goal to increase cultural competence of the providers when working with monolingual or Limited English Proficiency populations The data indicated a significant improvement of knowledge from the pre-instruction time point to the post- instruction time point. The interpreters’ attitudes toward interpretation did not change significantly as a result of the training. LACDMH continues to evaluate the Interpreter Training Program and has dedicated resources from the MHSA Workforce Education and Training component to increase the capacity for the Interpreter Training Program.

18. LAS County Examples: Small Counties, Small Steps, Big Results Both Madera and Imperial counties were able to improve access for Latino consumers by offering flexible clinic hours:  Imperial County MHP regularly allows consumers to access services on a “walk-in” basis. They also provide information (about mental health services, intake, and referrals, etc.) via telephone Monday-Friday, evenings, holidays, and weekends.  Similarly, the Madera County MHP found that having open clinic hours during which time clients could “walk-in” and receive an assessment made it easier for consumers to overcome barriers (i.e., restricted clinic hours, child care, lack of transportation, stigma, shame for missing appointments, etc.), and increased access to mental health services.

19. LAS Promising Strategies Engagement: Engaging local community leaders and community members in the development of local anti-stigma campaigns. Organizational Structure: Latino access was increased by offering flexible service hours and “walk-in” appointments. Workforce: Identified need for increasing the number of bilingual staff to address needs of large Spanish-speaking communities in counties. Training: Funding interpreter training increases competency and is a beneficial investment. Program: Practicing “enhanced case management” as an outreach strategy between first contact and the initial assessment and building “relationship–based connections” grew Latino access. Welcoming Environment: Providing comfortable, culturally appropriate surroundings (i.e., use of Latino art, Spanish language videos, brochures, posters, etc.)

20. Contact Information Department of Mental Health Office of Multicultural Services Rachel Guerrero Autumn Valerio Autumn.Valerio@dmh.ca.gov (916) 651-3865 www.dmh.ca.gov/Multicultural_Services