1. 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

2. 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

3. Insurance/payers of services  Public Insurance  Medicaid  Medicare  VA  Affordable Care Act (ACA) supplements  Private Insurance  Employers  Private  Uninsured  Tax under ACA  Self pay

4. Public insurance  Medicaid: indigent, highly disabled  Medicare: elderly, disabled who have worked  VA: veterans and their families

5. 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

6. 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

7. 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

8. Estimate of Annual Number of Persons Receiving Community-based Services in NYC/NYS (2013) Public Mental Health System nNew York City, NYNY State Total279, 216639,384 % White2346 % Black3023 % Hispanic4024 % Asian2.81.5 % Other5.25.5 In community based treatment NYC: >73% B, H, A State: >49% B, H, A General Pop. NYC:>67% B, H, A State: >43% B, H, A

9. 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 9

10. 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 10

11. 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 11

12. 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

13. 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

14. Can a health care system address social determinants of disparities?  Structural Competency

15. Can a consumer address cultural competency?  Cultural Activation

16. 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 16

17. CULTURAL COMPETENCE MODEL Interacting Domains of Cultural Competency Information Exchange Information Exchange Needs Assessment Needs Assessment Human Resources Human Resources Services Policies/ Procedures Policies/ Procedures Outcomes Informal MH Supports/ Other Systems Informal MH Supports/ Other Systems Social Services Housing Clergy …….. Mental Health System

18. 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

19. 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

20. Why CC Effects Consumer Outcomes Policies Staff requirements /constraints Clinical Team MilieuClinical ToolsServices 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

21. 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

22. 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

23. http://cecc.rfmh.org Additional Resources

24. 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

25. 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

26. 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