Engaging Latinos in Depression Treatment: Why the warm handoff may not be best Elizabeth Horevitz, MSW, PhD Collaborative Family Healthcare Association 16 th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Session #G3b Friday, October 17, 2014

Faculty Disclosure I have not had any relevant financial relationships during the past 12 months.

Learning Objectives At the conclusion of this session, the participant will be able to: Critique the warm handoff as a “one size fits all” approach in referral practices. Consider how the warm handoff is utilized in their own practice setting. Discuss factors that influence effective engagement of Latinos into depression treatment.

Bibliography / Reference 1.Fernandez y Garcia E, Franks P, Jerant A, Bell RA, Kravitz RL. Depression Treatment Preferences of Hispanic Individuals: Exploring the Influence of Ethnicity, Language, and Explanatory Models. J Am Board Fam Med. 2011;24(1):39–50. 2.Cortes DE, Mulvaney-Day N, Fortuna L, Reinfeld S, Alegría M. Patient—Provider Communication Understanding the Role of Patient Activation for Latinos in Mental Health Treatment. Health Educ Behav. 2009;36(1):138– Zhang W, Creswell J. The Use of “Mixing” Procedure of Mixed Methods in Health Services Research: Med Care Dwight Johnson M, Apesoa-Varano C, Hay J, Unutzer J, Hinton L. Depression treatment preferences of older white and Mexican origin men. Gen Hosp Psychiatry. 2013;35(1):59–65 5.Ell K, Lee PJ, others. Depression Care for Low-Income, Minority, Safety Net Clinic Populations With Comorbid Illness. Research on Social Work Practice. 2010;20(5):467.

Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

overview Research background and driving questions Methodology Results Implications for integrated primary care

Research background  Latinos & Depression  Depression is debilitating and costly for all populations  Latinos experience comparable rates of MDD as Whites (14% for immigrants; 20% for US-born Latinos)  Disparately low rates of MH treatment-seeking  Mexican Americans half as likely to seek mental health treatment as Whites  Typically seek care for depression in medical settings (stigma, access issues, lack of culturally competent care)  Disparately low rates of follow-up on referrals to MH services (MH treatment “uptake”)  “Our patients are simply lost to follow-up”  Estimates as low as 3%-6% (Ishikawa, 2011).

background The Former Landscape of Health Care in the US: -High costs and frequent use of “safety nets” -Fractured care (social services down the street?) -Dichotomy: mind/body -Primary care: de-facto MH system HEALTH CARE MENTAL HEALTH CARE

Post-ACA FUTURE landscape of healthcare “A team-based model of care wherein medical and mental health providers partner to facilitate the detection, treatment, and follow-up of psychiatric disorders in the primary care setting. It is an appropriate model for treating mild to moderate psychiatric disorders and for maintaining the treatment of severe psychiatric disorders (e.g., bipolar disorder, schizophrenia) that have been stabilized” (Hogg Foundation for Mental Health, 2008) “Collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety” Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews 2012, Issue 10.

THE PROMISE OF THE WARM HANDOFF The best thing since sliced bread?

The promise of ibh for latinos  Access  Acceptability  Research has assessed treatment outcomes, but we don’t know whether or how IBH may improve MH treatment uptake  Is it really better than the old “silo” model? In what way?  Is the warm handoff everything it is cracked up to be? “The importance placed on the relationship Latino patients have with their primary care providers supports a service model that seamlessly extends and generalizes this relationship to the behavioral health specialist. This is the so-called warm handoff model… This extension forms the basis for engagement of clients into behavioral health services via the primary care clinic.” --Manoleas, P., (2007), p. 443.

Purpose  PHASE I: To identify specific sociodemographic and contextual factors in the referral process that predict mental health treatment initiation for depressed Latinos within a naturalistic IBH setting.  Ho1: Patients who receive a warm hand-off referral type will be more likely to attend an initial behavioral health visit than those who receive a cold hand-off.  Ho2: Patients higher in acculturation will be more likely to attend an initial behavioral health visit than those lower in acculturation.  Ho3: Patients with comorbid anxiety will be more likely to attend an initial behavioral health visit than those without comorbid anxiety.

Purpose PHASE II: To qualitatively understand why Latino patients decide to follow up or not with behavioral health services for treatment of depression upon referral. Study results have implications for reducing mental health utilization disparities in Latinos, as well as illuminating factors that compose effective IBH models.

Community health clinic ole “The medical and dental home for Napa County’s underserved, providing high-quality, affordable, compassionate and culturally sensitive primary health care”. Behavioral Health Services  Targeted  Non-Specific

Predisposing Enabling Need Background: Process of care PHQ-9 9+ (theoretically) triggers referral to BH All medical patients screened for depression/anxiety sx Warm Hand-Off (WHO) or Cold Hand-Off (CHO) Referral to BH by PCP Show (uptake/initiate) No-Show Behavioral health treatment initiation ?

Methodology: Sequential mixed methods  PHASE I:  Retrospective cohort design  Medical records review (N= 431)  Predictor analysis: Show/no show to initial BH visit (dichotomous)  PHASE II: in-depth semi-structured interviews to “dig deeper” into the decision to follow-up or not with BH (60-90 minutes each)  Thematic analysis

Methodology PHASE I  Key predictor variable of interest:  Warm handoff vs cold handoff  Severity of depression (score on PHQ-9: 9-27)  Length of time between PCP visit and BH visit  Acculturation (language)  Co-morbid anxiety  Anti-depressants  Eth/Gen match PCP & pt; Eth/Gen match BHC & pt  PCP/Patient Alliance (proxy)  Income level  Insurance status  Sex  Age

Sample PHASE I (N=431) 73% Female; 27% Male Age: x̄ = 43.5; range: % Spanish-speaking; 19% English-speaking 78% Moderate depression-Moderately severe depression; 22% Severe Depression 36% Warm handoff; 64% Cold handoff 52% on psychotropic medication 16% Co-morbid anxiety 79% at or below federal poverty level Days to initial BH appointment: Mean= 15 days (range: 1-56)

Findings PHASE I TThe Good News: 52% attend initial BH visit. TThe Surprising News: WWarm handoff, acculturation and comorbid anxiety not predictors of depression treatment uptake but… SSignificant negative interaction effect between English language and warm handoff (OR= 0.271, p =.01).

In plain english  English speaking Latinos who received a warm handoff were 4x less likely to attend an initial BH visit than those who received a cold handoff referral. MOMENT OF SILENCE TO LET THAT SINK IN…

PHASE I: Other findings of interest

Sample Phase II (N=16) 9 Spanish-speaking; 7 English-speaking 13 women; 3 men Depression scores: – 11 Moderate; 4 moderately severe; 2 severe 9 Warm handoff; 7 Cold handoff 7 attended; 9 did not attend first visit

FINDINGS PHASE II  Depression narrative matters (meaning & healing)  Patients’ relationship with Clinic Ole matters  Patient-provider relationship is crucial  English-speakers more likely to report negative relationship with provider and/or Clinic Ole  Experience of referral matters  Wide range of experience  Education about depression + match service to need is critical  Psychosocial barriers  *Readiness* and cost/benefit analysis (wait time)  Financial concerns  Confusion/misunderstanding  Health literacy issues

Depression narrative Gendered Influences beliefs about healing: MATCHING Well, uh, well depression that is to say, s- they sen-, the s- I felt it, like in itself, powerless to resolve my problems, that I would try to resolve my economic problems, my problems of f- family, well let's say to survive, of where to live, and uh, oh, and I felt like I had to hide in a place where no one could see me. Well if I owed anyone money, that they didn't see me, because I did not have a way of paying them back. Or, uh, or, or to be thinking "Tomorrow how am I going to come up with so much money to pay what is the, the, the rent, food, and all of that?" And uh, and, and at times I would think about, to myself I would say, I'm thinking of sleeping and not waking up tomorrow. -Matias, age 49, Spanish-speaker, Attended first visit Q: How should one treat depression? The medication because the doctor prescribes it to us. And counseling – because you can talk, like me that I'm talking to you, and, and, well, like you need to let out everything that you feel inside, like, all of our feelings, what you want, what you, uh, don't want, what has happened to us, what we, what we have lived, like, yes, I feel like that gives us relief… -- Anabel; 45; Spanish-speaker; Did not attend first visit

CHCO experience It's convenient for me. As I told you, this clinic gives me confidence, mostly because we are, there are Latinos, Latino people like us, people – well yes, Latino people that speak Spanish and everything, right? So I feel a confident coming here. - Anabel

CHCO EXPERIENCE Provider-patient relationship Q: Tell me about your relationship with your primary care provider. It's good, it's really good we have really good communication with each other um it all happened, I had never seen her until um I had my appendix taken out in November and she came to Queen of the Valley and um it was the first time I ever met her and then from there you know she you know ah referred me to come back and come see her, let her know how it went so it went really good it was like an instant um I guess you want to say like connection, really I, I trusted her. - Paola; 31; English-speaker; Attended first visit Well I don’t think that, at least with the first doctor, he understood the whole depression part of it all.… because I don’t think he cared. I guess that’s the best way to put it. Like, I tried to tell him … you know they ask you these questions when you first come in, you know, “Have you been down for like two weeks?” or, you know, and all of the answers were pretty much “Yes”… And I guess I kind of thought maybe he would elaborate on that, you know, like, “This isn’t normal,” you know, “How long have you been feeling this way?” And it was never a conversation of anything like that. - Claudia; 32; English-speaker; Did not attend first visit.

REFERRAL EXPERIENCE Extreme variability of referral experience Impression of BH services is crucial Well, I, so, just, what I should do, well, cry and cry and then get out everything I have inside. Like that I, well, it hit me like that. Well, they don’t give me medicine to calm me down or anything. When I went they, they didn’t want to attend to me. They gave me medicine for – for another thing, but not for depression. … The nurse just told me that they gave me a little piece of paper… She told me, here the, here she said “you are going to see this one”… - Lola; 45; Spanish-speaker; CHO; Did not attend first visit Can you tell me about your experience being referred to behavioral health? I don’t know, I just kind of feel like the girls ask those questions just to ask them. Like, maybe not for the benefit of them, but if feels like it’s just something they have to do… You know what I mean?...And, um, because when I’ve come in the past they ask you them, and they never filled out a piece of paper. So, I was like, “Why are you asking me these things? Are you gonna… really gonna remember them when you go back and fill out the top of my paperwork?... It feels like something they have to do. Like protocol. I’m like, is anyone even going to ask me about this?... Next thing I know some girl walks in the room… Claudia; 32; English; WHO; Did not attend first visit Q: It says here that you saw the counselor that same day… tell me more about that meeting. Well I felt goo- good, it’s just that, that that was what I should have done, to have come, because at that moment I had the courage to tell her my problem, I felt comfortable, and from the moment I told the doctor, not the counselor, so then I, I felt comfortable, and with, and with the idea to see her [the counselor]. Well it was perfect, I felt more, well with more desire to come and to tell her more about what it is that was upsetting me. -Matias; 49; Spanish-speaker; warm handoff; attended first visit

The referral process was... from [my doctor] was, um, excellent. She was very indulging and, she was very... attentive and... you know, she really wants me to come to the appointment. And, um Alicia was very nice. She was very understandable just like [my doctor]. Um, they both like, try to help you whenever they can, and they try to give you advice on the knowledge that they have. And I just think that [my doctor] and Alicia like they're... they really want to help you with um... depression. They really want you to get better and feel better and do better in life, and not get stuck with depression, like, for a long time. -Sandra;19; English-speaker; Warm Handoff; Did not attend first visit Because, um, they cancelled it on me. Because I apparently, she wasn't gonna make it. So um, they never rescheduled another one with me. Uh they said they were, but they never did. They just cancelled it, so I never came to talk to her. Psychosocial barriers & Pathways They called me to say to come to my appointment, not to forget about it. I said yes, but they said it was going to be twenty dollars. I said, no, [my doctor] told me I didn’t have to pay because I can’t right now; I can’t; I don’t have enough. She said, you can pay later. I said, no… If I feel bad and I want to keep talking to that person to feel better, I won’t be able to do it. Why? Because I have to be paying and paying. So it’s better to cancel the appointment; I don’t want anything. Cancel it. And my son said, well, mom, if they’re charging you, why do you go? Instead of that, go for a walk. So I cancelled it, and I haven’t been able to see any counselor. I haven’t. - Rodelia; 56; Spanish-speaker; cold handoff; did not attend first visit. Q: Why did you decide to attend the visit with the counselor? Because I didn’t … I don’t want it to get worse. I’m hoping that it don’t get worse and I know that some medications are just … you know they don’t work or some do, so I’m at the point where I don’t even want to take … I don’t want to take no kind of medication for what I’m feeling, because I’m already on a ton for my illness. So I’m just … you know I don’t know, I just … I think talking is good you know. -- Maria; 39; English-speaker; Warm Handoff; Attended first visit.

summary Compared to silo model, our follow-up rate is good, but could be better; English-speakers don’t seem to respond well to WHO, but qualitative findings suggest that the experience varies tremendously Several simultaneous factors appear to influence follow-up… Follow- up predisposingenablingneed

summary Depression narrative (meaning and healing) Relationship with clinic and medical provider Referral experience (hand-off or hand-hold? Matching services to symptoms/narrative) Readiness & expectations/symptom acuity Everyday barriers ($, misunderstanding, scheduling conflict)

Implications & Discussion -(Re)-Consider the Warm Handoff as a “best practice” -What works, for whom, under what circumstances? -Role of acculturation when we consider cultural compatibility of the IBH model -Centrality of the PCP-patient relationship (making the PHQ-9 a meaningful tool) -Check for understanding & motivation (health literacy, reinforce plan); assess additional access barriers

Questions? Thank you to Clinic Ole, and especially to the participants in this study, who generously shared their stories with me. They, like I do, hope their stories will help improve care for all. This study was generously supported by funding from: UC MEXUS, The Fahs Beck Fund for Dissertation Research, and The Center for Latino Policy Research at the University of California, Berkeley. I am also grateful for funding from UC Berkeley’s Dissertation Year Fellowship, which supported me in my final year of research. Contact:

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