1. Hazelette Crosby-Robinson, LLMSW Katie Kettner, LLMSW Florence Roberson Khalila King Outreach & Engagement in Physical Health Care Services For Racially, Ethnically & Socially Disadvantaged Populations with Mental Health Problems 1 Slides property of WCHO Community Organization & Development Team

2. Workshop Objectives Participants will be able to:  Identify the health disparities that affect racially, ethnically and socially disadvantaged populations  Describe how a community-based method can improve health outcomes for racially, ethnically and socially disadvantaged populations  List at least 3 outreach methods used to reach and inform minority populations who have physical and mental health care needs 2 Slides property of WCHO Community Organization & Development Team

3. WHAT YOU SHOULD KNOW ABOUT US… 3 Washtenaw Community Health Organization Slides property of WCHO Community Organization & Development Team

4. Washtenaw Community Health Organization 4 Community Mental Health Services Program (CMHSP) for Washtenaw County Member of the Community Mental Health Partnership of Southeast Michigan Prepaid Inpatient Health Plan (PIHP) with Lenawee, Livingston & Monroe Counties Designated Substance Abuse Coordinating Agency for Lenawee, Livingston and Washtenaw counties Slides property of WCHO Community Organization & Development Team

5. Washtenaw County Demographics 5 2010 Population – 344, 291 2 large cities and several towns & villages  Ann Arbor  Ypsilanti  Chelsea  Saline  Milan  Dexter  Manchester 2 major universities & 1 community college  University of Michigan  Eastern Michigan University  Washtenaw Community College 2 large health systems  University of Michigan Health System  St. Joseph Mercy Hospital Slides property of WCHO Community Organization & Development Team

6. Washtenaw County Health & Income Disparities 6 Profound disparities exist in lifespan for Washtenaw County residents. There is over a 15 year gap between the shortest and longest average lifespan across Washtenaw County cities, townships and villages. Slides property of WCHO Community Organization & Development Team Data Source: Adreanne Waller, MPH – Project Epidemiologist, Washtenaw County Public Health

7. Washtenaw County Health & Income Disparities 7 Washtenaw County adults with health insurance who have less education have higher diabetes rates than more educated adults with health insurance Regardless of overweight status, Washtenaw County adults who have more education are much less likely to have heart attacks African-American/Black population have worst diabetes rate in Washtenaw County – 7.3% The poorest Washtenaw County African American adults are 3 to 4 times more likely to have diabetes than the poorest Washtenaw County white adults African American/Black population have worst Infant Mortality rate in Washtenaw County – 11.5 per 1,000 (compared to 4.4 per 1,000 for White population) The wealthiest 20% of Washtenaw County residents possess 50% of the total income in the County. The poorest 20% possess only 2.9% of the total income There is a disproportionate share of minorities on Medicaid and they do not receive access to services as they need (local and national issue) Data Source: Adreanne Waller, MPH – Project Epidemiologist, Washtenaw County Public Health Slides property of WCHO Community Organization & Development Team

8. Mental Health Disparities 8 Racial and ethnic minorities have less access to and less availability of mental health care; are less likely to receive needed services; and often receive poorer quality mental health care. Additional studies have identified the role of socioeconomic disadvantage in exacerbating disparities in mental health. Source: Mental Health: Culture, Race, and Ethnicity – A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md, US Department of Health and Human Services, US Public Health Service, 2001 Slides property of WCHO Community Organization & Development Team

9. 9 Project History Slides property of WCHO Community Organization & Development Team

10. Project History: The Issue 10 Startling info revealed in 2010 at a WCHO Board meeting:  50% of inpatient psychiatric admissions for Washtenaw Co. were coming from 2 zip code areas of Ypsilanti – 48197 & 48198 Zip code # Hosp Adm % Hosp Adm # Inpatients % Inpatients # Male # Female # CMH # Non- CMH 4819729929%23430%10811560176 4819822322%17022%689642132 4810311311%8911%39463064 48108717%527%26 1243 48104636%436%23191133 Slides property of WCHO Community Organization & Development Team

11. Project History: The Issue 11 Why was this a problem?  Community members are seeking emergency care as first line alternative when in need of mental health care  48197 & 48198 hold just 20% of the County’s population  WCHO has clinical & administrative offices located in the 48198 zip code area  Extremely costly for our organization Slides property of WCHO Community Organization & Development Team

12. Project History: The Issue 12 48197 & 48198 zip code areas:  Lie within the City of Ypsilanti  Are subject to cumulative social disadvantages; have high rates of poverty, social disadvantage & racial/ethnic minority residents  Have the highest rates of high school dropouts – 20.1% in Willow Run district (compared to 2.8% in Manchester)  Have the highest rates of poverty – 15.6% in City of Ypsilanti (compared to.8% in Lima Township)  Hold 67% of Washtenaw County’s Black/African American population Slides property of WCHO Community Organization & Development Team

13. INITIATING THE MEDICAID MATCH PROJECT 13 Addressing the Issue Slides property of WCHO Community Organization & Development Team

14. Addressing the Issue 14 WCHO applied for and received a Medicaid Match grant to identify and remedy perceptions and practices that might inhibit access and utilization of Medicaid mental health services within the population of interest Slides property of WCHO Community Organization & Development Team

15. Outreach & Engagement with Racial & Ethnic Socially Disadvantaged Populations 15 Goal:  Partner with community members & community agencies in efforts to remove & reduce access barriers for beneficiaries in target areas who are eligible for/need mental health & substance abuse services  Contracted with a Community Organizer Secret Shopper Street outreach  Faith-Based Outreach  Focus groups Slides property of WCHO Community Organization & Development Team

16. Focus Groups 16 Held 11 focus groups to collect feedback/opinions of internal staff & external human service providers, community members, and primary/secondary consumers We have learned that potential consumers in the 48197 & 48198 zip codes here in Ypsilanti are more likely to receive inpatient psychiatric treatment than to come in to see us. As someone working with the consumers we want to engage, what are some of the reasons that you think potential consumers don’t get services from us? Hired an independent focus group facilitator to encourage honest responses from participants Reported results back to internal staff Utilized results for Community Outreach and Engagement plan as part of the Medicaid Match project Slides property of WCHO Community Organization & Development Team

17. Focus Group Responses 17 Structural Issues  Lobby is a cold environment  When clients have to face a bank-like security glass, it makes one wonder if mental health = criminality  Close proximity to DHS is problematic  Limited human interaction and no welcoming triage system; clients are told to call Access from a pay phone in the lobby rather than talking to someone at the front desk Slides property of WCHO Community Organization & Development Team

18. Focus Group Responses 18 Cultural Factors  There is a stigma of mental illness as being different than other illnesses; issues of responsibility & blame  There are various issues which arise within a number of ethnic, racial, cultural groups on mental health issues and their treatment; mistrust of authorities  Some tension exists around treatment within the intersection of faith & science  Many African Americans lean first to family, friends, and pastors before turning to professionals  There needs to be an ongoing, stronger dialogue between the faith and professional mental health communities to explore how best to work together, and when to hand-off  Starting in schools, African American/Black males have often been the targets of diagnosis and medication  Culturally, there are many who cannot accept that they could face mental illness Slides property of WCHO Community Organization & Development Team

19. Focus Group Responses 19 Systemic Issues  There should be a ‘no wrong door’ policy  Access is regarded as the ‘Just Say No’ agency  We must improve our service model and move beyond lip service  Branding and marketing are problematic; is WCHO health or mental health? No name recognition and not ‘on the radar’  There is a general lack of good information on mental health in the hands of consumers  Public transportation, telephones, and access to computers/the web are not equally distributed across the current and/or potential client base  “We need to go where they are” Slides property of WCHO Community Organization & Development Team

20. Focus Group Responses 20 Suggestions for Improvement  Resolve the branding issue by ensuring that WCHO’s info can be found and accessed  Focus on making service center more inviting  Build a closer relationship and dialogue with the faith community  Work more closely with other human service organizations on mental health issues  Articulate an ‘outer-county’ strategy to reach outer edges of County  Work on making the intake system more client-friendly  Ensure that clients can always talk to a person  Consider alternative concerning hours of operation to accommodate working adults Slides property of WCHO Community Organization & Development Team

21. “WE NEED TO GO WHERE THEY ARE” 21 Addressing the Issue – Year Two Slides property of WCHO Community Organization & Development Team

22. Addressing the Issue – Year Two 22 Goal:  Identify and develop specific interventions that seek to minimize/eliminate identified barriers to access in the 48197 and 48198 zip codes Slides property of WCHO Community Organization & Development Team

23. Addressing Structural Issues 23 Lobby issues  Community organizer spent time in lobby with refreshments  Better signage posted  Eliminated pay-phone process; people are now able to speak face-to-face with Access staff after very short wait time  Computer kiosks with security screens installed by Community Support and Treatment Services (CSTS) so consumers can access their medical record and view Individual Plan of Service Slides property of WCHO Community Organization & Development Team

24. Addressing Systemic Issues 24 Improvements to CSTS Access System made by Access staff:  Reviewed and rewrote Access eligibility criteria; removed outdated and inappropriate criteria for services  Implemented a presumptive eligibility model  Individuals may call one single Access number and will be triaged, assessed and/or referred to services; educated on options  Access expanded in 02/13 to include 24/7 Mandated Functions for 4 County Affiliates  Moved Mandated Functions out of U of M Psychiatric Emergency Services; individuals no longer directed towards Emergency Room for after hours mental health crises Slides property of WCHO Community Organization & Development Team

25. Addressing Branding & Marketing Issues 25 Outreach and Engagement campaign to 48197 & 48198 zip code areas  Purchased and distributed WCHO products to all ages and populations  Street-level outreach  Utilization of local printing company that’s recognizable to community and experienced in reaching community of interest  Direct mail campaign  Heavy involvement in coalitions, and planning/participating in community events  6 week “Building Healthy Communities” curriculum at Willow Run Youth Summer Camp  Collaborated with other Human Service Organizations Slides property of WCHO Community Organization & Development Team

26. Addressing Cultural Factors 26 Efforts to reduce stigma of mental illness Faith-based outreach  Working individually with faith-based organizations  Church fans Building trust and rapport with community members and stakeholders Working with African American/Black male youth  Ballin’ In the Boulevard  Camp outreach Slides property of WCHO Community Organization & Development Team

27. HOW OUR WORK HAS PAID OFF 27 2 nd Year Results Slides property of WCHO Community Organization & Development Team

28. Number of Community Hospital Admissions Fiscal Years 11, 12 & 13 (through July 2013) 28 If current admission trend continues, approximately 490 admissions are anticipated resulting in a 22% decrease in admissions from FY 12 Slides property of WCHO Community Organization & Development Team

29. Number of Walk-Ins to 48198 Service Center (through July, 2013) 29 Walk-ins to the Towner service center in the 48198 zip code area have increased by about 40% since FY 11 Slides property of WCHO Community Organization & Development Team

30. 2 nd Year Results 30 Willow Run Summer Camp survey results indicated curriculum was effective in increasing knowledge about the WCHO and the importance of mental/physical health Community Support and Treatment Services (CSTS) created 39 positions to keep up with increased service demand WCHO administrative staff moved to new location to create more room for direct care providers at 48198 service center Increased recognition, trust building and networking with community members and stakeholders Gained ideas and experience for outreach and engagement expansion Slides property of WCHO Community Organization & Development Team

31. ADDING PRIMARY HEALTH CARE COMPONENT 31 Addressing the Issue – Year 3 Slides property of WCHO Community Organization & Development Team

32. Addressing the Issue – Year 3 32 WCHO learned that disadvantaged individuals with mental health issues in the 48197/48198 zip codes in Ypsilanti do not have regular primary care providers and may be seeking emergency care rather than seeking ongoing preventive care and regular follow-up Americans with major mental illness die 14 to 32 years earlier than the general population as they are more likely to suffer from chronic diseases, obesity and poverty and they may suffer the adverse health consequences earlier Slides property of WCHO Community Organization & Development Team

33. Addressing the Issue – Year 3 33 Goals:  Survey community members to assess barriers to primary health services  Develop & implement education and outreach program to improve access to physical health care in this underserved area  Share our findings with others Slides property of WCHO Community Organization & Development Team

34. Addressing the Issue – Year 3 34 Creation and distribution of Community Health Survey  Likert Scale for satisfaction of healthcare systems and resources in the community  Questions regarding barriers to access, what prevents community members from seeking services, where people receive health services when needed, and familiarity with WCHO  Distributed in Spanish and made available via Survey Monkey Slides property of WCHO Community Organization & Development Team

35. Addressing the Issue – Year 3 35 Survey Results  260 respondents  Majority reported adult and child dental care is difficult to receive in the county; other health care services that are difficult to receive include:  Counseling  Vision care  Substance Use  63% reported that having no regular source of health care keeps people from getting healthcare they need; other prevalent barriers to healthcare include:  lack of trust in doctors/clinics  Childcare  Fear  lack of evening and weekend services  Transportation  high co-pay or deductible  don’t know what type of services are available Slides property of WCHO Community Organization & Development Team

36. Addressing the Issue – Year 3 Slides property of WCHO Community Organization & Development Team 36 Survey Results, continued  57% reported that most people in our county likely receive their healthcare in the ER  48% reported that they were previously aware of the WCHO and the services they provide; 23% have heard of the WCHO, but not of their services  The majority reported they are satisfied with the quality of life, healthcare systems, and networks of support within Washtenaw County

37. Addressing the Issue – Year 3 37 Outreach Activities  Primary health-focused outreach and event, coalition participation  Parkridge Community Center Youth Summer Camp Building Healthy Communities curriculum presentation  Primary health-related WCHO product distribution Slides property of WCHO Community Organization & Development Team

38. OUTREACH VIDEO 38 Outreach Events Slides property of WCHO Community Organization & Development Team

39. Addressing the Issue – Year 3 39 Behavioral Health and Wellness Symposium  Medicaid Match project capstone event created to inform community members and human service organizations of the efforts being made locally and state-wide to integrate behavioral and physical health care  Featured keynote presentation by Senator Rebekah Warren and panel including State Representative David E. Rutledge and WCHO Board members, County Commissioner, and WCHO Executive Staff and Medical Director Slides property of WCHO Community Organization & Development Team

40. Addressing the Issue – Year 3 40 Sharing our work with the community and receiving recognition  Poster presentation at the University of Michigan Dept. of Psychiatry 24 th Annual Albert J. Silverman Research conference  2013 WCHO Behavioral Health and Wellness Symposium  2013 MACMHB Conference – Building Culturally Competent and Diverse Organizations and Systems of Care  WCHO staff and Board meetings  Substance Abuse Coordinating Agency Town Hall  Newsletters  Formal reports Slides property of WCHO Community Organization & Development Team

41. NEXT STEPS 41 Conclusion Slides property of WCHO Community Organization & Development Team

42. WCHO Community Development & Organization 42 Success of program has allowed us to create a Community Development & Organization team within the WCHO Expanding outreach efforts  Expanding our team  Extending outreach and engagement efforts to entire county  Additional focus on opiate use issue  Continue to share our work and findings with others  Consideration regarding how our work has improved health outcomes for our community Slides property of WCHO Community Organization & Development Team

43. COMMENTS? QUESTIONS? GROUP DISCUSSION 43 Thank You! Slides property of WCHO Community Organization & Development Team

44. References 44 Agency for Health Care Research and Policy. National Health Care Disparities Report, 2003 http://archive.ahrq.gov/qual/nhdr03/fullreport/index.html http://archive.ahrq.gov/qual/nhdr03/fullreport/index.html Mental Health: Culture, Race, and Ethnicity – A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md, US Department of Health and Human Services, US Public Health Service, 2001 McGuire TG, Miranda J: New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Affairs 27: 393-403, 2008 National Healthcare Disparities Report, 2004. Rockville, Md, Agency for Healthcare Research and Quality, 2004 National Institute of Mental Health Smedley BD, Stith AY, Nelson AR: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC, Institute of Medicine, National Academies Press, 2003 Snowden LR, Hu TW, Jerrell JM. Emergency care avoidance: Ethnic matching and participation in minority-serving programs. Community Mental Health Journal, 31(5), 463-473, 1995. Waller, A. Ten Things to Know About Health Equity in Washtenaw County. 2010 Waller, A. Opening the Window of Opportunity to Health for All. 2012 Slides property of WCHO Community Organization & Development Team