1. Addressing Mental Health Disparities with Latino and Russian Clients- A Project Overview Graham Harriman, MA, Marcela Dixon, CHW, Sergiy Barsukov, CHW A Project Supported by the Center for Mental Health Services of the Substance Abuse & Mental Health Services Administration (SAMHSA)

2. Multnomah County Health Department  County-run system of primary care safety net clinics – part of public health department  Portland, Oregon and suburbs – 675,000  7 clinics serving approximately 26,000 patients/year, 99% below 200% of poverty

3. Patients  Racial/Ethnic mix 44% Hispanic 38% Caucasian (includes Eastern European) 9% African American 11% of clients identify Russian as their first language

4. Environment  Health Information System indicated we were significantly under-diagnosing mental disorders in ethnic population of patients  High levels of psychosocial stressors (violence, social & cultural isolation, poverty, family disruption)  When mental disorders identified, great resistance to being referred to community system of care

5. In Their Own Words  Acculturative stress is common- isolation the paramount concern  Many Latina attendees of focus groups reported issues of domestic violence  Language and culture are barriers to care Focus group results August 2003

6. Action Plan  Integrate mental health into primary care setting  Utilize Chronic Care Model (Wagner)  Bicultural-bilingual therapist staff placed in primary care clinics  Emphasize Community Health Worker interventions  Utilize the Stanford Chronic Disease Self Management Program (Lorig et al.)

7. Data  Service Utilization  Patient Satisfaction  Outcome Data Patient Satisfaction Assessment Outcomes Provider Satisfaction

8. SERVICE UTILIZATION

9. CLIENTS SEEN TO DATE Average Number of New Clients Per Month = 26.5

10. CHW VISIT LOCATION

11. FOCUS OF CHW VISITS

12. REFERRAL SOURCES

13. RESULTS TO DATE

14. Patient Satisfaction Focus Group Results  6 Focus Groups (3 in Spanish, 3 in Russian)  24 Participated in Spanish Groups  26 Participated in Russian Groups  Participants were asked about migration, acculturation, system access, experiences with County services, and suggestions for improvement

15. Latino Focus Groups Report  Participants stated they use many coping skills to manage mental health concerns, including walking, seeing a therapist, therapy groups, taking medication, going to church and being active  Tomando Control de Su Salud (Spanish version of CDSMP) received positive statements  Therapy sessions well regarded  Referral system to MH Disparities Project is “seamless” from clients’ point of view  Comments on Project Personnel were positive overall

16. Russian Speaking Focus Group Report  Positive statements on provider care, including Russian Speaking CHW in project, assistance with translation, access to care, and compassionate demeanor mentioned  Concerns raised about interpreters- language difficulties, biases towards mental health

17. OUTCOME DATA

18. SF – 12 Mental Health Functioning

19. PHQ-9 Depression Score

20. Clinical Outcomes Therapist vs No Therapist Intervention

21. PROVIDER Satisfaction  49 out of 65 responded to survey  75% response rate  Survey handed out at provider meetings at clinic sites

22.  93% “agreed” that CHWs were “perceived as valuable members of the clinical support staff.”  Of providers aware of project, % “satisfied” or “very satisfied”: 83% with the CHWs, 75% with project therapists 71% with the Chronic Disease Self-Management Program Provider Response

23. LESSONS LEARNED  Involvement of therapists produces significantly enhanced outcomes  Many of the services are not reimbursable  Mental health carve outs increase difficulty of providing services in primary care settings  Religious/cultural beliefs create special challenges to delivering mental health treatment

24. LESSONS LEARNED  Mental health services in primary care clinics produces clinically significant results for Latino patients and Russian-speaking refugees diagnosed with depression  CHWs are a recognized and valued component of clinical support  Marketing of program services is essential  Some providers have difficulty identifying clients who may benefit from CHW services

25. GOING FORWARD  Investigate FQHC reimbursement mechanisms for CHW-delivered services.  Advocate with state Medicaid Office about fiscal strategies  Integrate depression and anxiety treatment with other chronic conditions and investigate “incident to” billing methodologies  Work closely with ethnic population advocacy groups to demand reimbursement for services.  Seek more immediate support from foundations