1. HEALTH CARE REFORM AND ORGANIZATIONAL LEVEL CULTURAL COMPETENCY Carole Siegel Gary Haugland Eugene Laska Lenora Reid-Rose Dei-In Tang Joseph Wanderling Ethel Chambers Brady Case NKI Center of Excellence in Cultural Competency NYAPRS: April 27, 2011

2. Acknowledgments  New York State Office of Mental Health  Nathan S. Kline Institute Center of Excellence in Culturally Competent Mental Health.

3. Outline  Cultural Competency (CC) at the Organizational Level What it covers/what it does not  NKI Cultural Competence Assessment Instrument: Organizational Level  Can we show that organizational level CC reduces disparities? Partial successes Study results  Integration with health care reform Where should it operate How to ensure that it operates

4. Definition of CC An integrated set of behaviors, attitudes and skills, policies and procedures that come together to enable caregivers to work effectively and efficiently in multicultural situations. It is an attribute of a system, an agency or an individual (New York State Office of Mental Health 1998, adapted from Cross et al. 1989).

5. ADMINISTRATIVE ENTITY e.g., State Mental Health Authority, Managed Care Organization Program Agency A Inpatient unit Agency B Clinic Agency C Rehab Caregiver Levels of a Mental Health System In which CC needs to operate Program Caregiver Consumers Caregiver

6. NKI Cultural Competency Assessment Scale (CCAS) Organizational Level  Organizational commitment to CC  Collecting needs assessment data  Receiving community input  Infusing CC throughout an organization  Training staff  Making language accommodations  Interpreters  Bi-lingual Staff  Key Forms, Service Descriptions, Educational Materials  Hiring and retention policies  Adapting and creating new services

7. Study design  Agencies studied:  25 contract outpatient mental health service agencies Monroe County Office of Mental Health  Agency CC data: Assessed from CCAS instrument  Client data:  Characteristics and service use of agency users Recorded in County mental health information system.

8. Measures and Models  Service Event Measures  Engagement: Second visit occurs in first month post admission.  Retention: At least 4 visits in 6 months post admission  Statistical Model: Hierarchical logistic model on service outcomes.  Level 1 person regression: on dx, age, gender, race/ethnicity, interaction terms.  Level 2 agency regression: on size, ethnic mix and CCAS score.  Disparity measure  Odds ratio: odds of event for Whites divided by odds of event for racial/ethnic group.

9. What CC items predicted lower disparity rates between Hispanics and Whites ? For Hispanics with mood, anxiety, other non-psychotic disorders: at least one of following Agency has Interpreters Bilingual staff Hiring, retention policies Translated forms, educational and service material Modifies and/or has new services  For Blacks with mood disorders Agency has interpreters

10. What CC items did not predict disparity reduction?  Administrative items  Agency commitment, plan, CC committee, CC integrated in agency, having data Comment: Items are distant from direct care. However, they are necessary prerequisites  Training Comment: Mixed quality of training materials has been cited. Materials are not relevant to direct care Often unrelated to populations being served.

11. Why was disparity reduction predicted for Hispanics and not for Blacks?  Language related items more relevant to Hispanics than Blacks  Communication competencies for Blacks need to be differently addressed.  Modified programs for Blacks may not have been in place in studied agencies.  Difficulties in adapting services when adaptation is more than ‘translation’  Scale may not contain organizational items of relevance to Blacks  E.g., transportation and hours  Disparity reduction for Blacks may be more related to program delivery and therapeutic alliances  E.g, trust building, stigma reduction

12. Ensuring CC under State Health Care Reform  Reimbursements to participating organizations should take into account dollars required to set up CC activities,  e.g., for interpretation services  e.g., to support a CC specialist  Participating Managed Care Organizations: Medicaid or Other  Contracts should require MCO has a CC Plan MCO has financial commitment to CC MCO conducts annual CC assessment  Participating Agencies under Managed Care  Contracts should require MCO has a CC Plan MCO has financial commitment to CC MCO conducts annual CC assessment

13. Conclusion  The business case still needs to be made for CC, since it can be expensive to implement.  Cost Benefit Ratios  CC Costs/Disparity Reduction Savings

14. For your interest  Siegel C, Haugland G, Laska E, Reid-Rose L,, Tang D-I, Wanderling J, Chambers ED, Case B. (2011) The Nathan Kline Institute Cultural Competency Assessment Scale: Psychometrics and Implications for Disparity Reduction Adm Policy Ment Health 38:120–130, DOI 10.1007/s10488-011-0337-0   Siegel C, Haugland G, Reid-Rose L, Hopper K. Program Components of Cultural Competency, to appear Psychiatric Services, June 2011.  NYS OMH Nathan Kline Institute Center of Excellence in Culturally Competent Mental Health  Website: http://cecc.rfmh.orghttp://cecc.rfmh.org