1. No category

A Federal Perspective on
Community Defined Evidence
Practices & Reducing Disparities
Larke Nahme Huang, Ph.D.
Director, Office of Behavioral Health Equity
With Assistance from Krystle Canare
Best Practices in Our Communities Conference
Pacific Clinics
San Gabriel, CA October 8, 2014
Key Questions
2
Overarching Question: How Can CDEP reduce
disparities in behavioral health care?
1. Are we making progress in reducing disparities in
behavioral health?
2. Why do we need Community defined evidence
practices (CDEP) and access strategies?
3. SAMHSA supported CDEP activities
4. CDEP and the Affordable Care Act
2
Definition of Health Disparity
(Healthy People 2020)
3
Health disparity, “a particular type of health difference
that is closely linked with social, economic, and/or
environmental disadvantage.
Health disparities adversely affect groups of people who
have systematically experienced greater obstacles to health
based on their racial or ethnic group; religion;
socioeconomic status; gender; age; mental health;
cognitive, sensory, or physical disability; sexual orientation
or gender identity; geographic location; or other
characteristics historically linked to discrimination or
exclusion.”
What is a health disparity?
4
“A particular type of
health difference that is
closely linked with social,
economic, and/or
environmental
disadvantage.”
Healthy People 2020
5
1. ARE WE MAKING PROGRESS IN
REDUCING BEHAVIORAL HEALTH
DISPARITIES?
Suicide rates by ethnicity and age group
-- United States, 2007-2011
6
35
25
20
Eur-Amer NonLatino
Afr-Amer NonLatino
Native American
Asian-PI
Latino
15
10
5
65
+
-6
4
60
-5
9
55
-5
4
50
-4
9
45
-4
4
40
-3
9
35
-3
4
30
-2
9
25
-2
4
20
-1
9
15
-1
4
10
-0
9
05
-0
4
0
00
Rate per 100,000 population
30
Age Group in years
Unadjusted crude rates per 100,000 population; A. Crosby, CDC, 2014
Latina/o Adolescent Suicidal Risk
Behaviors
7
Percentage of Students by Race/Ethnicity and Sex
45
41.4
40
34.3
35
31.4
30
25
Latino Female
24.4
Latino Male
20.7
20
21
18
15
18.4
17.4
12.8
12.6
9
10
Black Female
17.6
Black Male
13.9
13.5
13.7
11.1
White Female
10.6
8.4
8.8
6.9
White Male
7.7 7.9
4.6
5
0
Felt Sad or Hopeless
Seriously Considered
Attempting Suicide
Made a Suicide Plan
Attempted Suicide
Source: Center for Disease Control, 2011 . Data from: self-report survey. 15,425
students, grades 9-12: administered September 2010- December 2011; 43 states
http://www.cdc.gov/healthyyouth/yrbs/pdf/us_disparityrace_
Major Depressive Episode (MDE) in the Past Year,
Age12-17 by Race and Hispanic Origin
8
Had at Least One MDE in the Past Year, Age 12-17,
by Race and Hispanic Origin: 2009-2010
Percentage (%) with MDE in the
Past Year, Age 12-17
10
9
8.3
8.5
8
9.4
7.9
6.8
7
7.5
7.9
7.6
7.4
7.7
7.8
5.6
6
5
4
2009
3
2010
1.8
2
1
0
0
White
Black or African American Indian or Native Hawaiian or
American
Alaskan Native
Other Pacific
Islander
Race and Hispanic Origin
Asian
Two or More Races Hispanic or Latino
Note: Where no estimate was reported due
to low precision 0.0 was used.
SAMHSA, National Household Survey on Drug Use and Health (NSDUH), 2009 and 2010
≥1 MDE in Past Year and Receipt of Treatment in the
Past Yr for Depression, Age 12-17
9
Received Treatment in the Past Year, Age 12-17 with MDE,
by Race and Hispanic Origin: 2009-2010
45
Percentage (%) with MDE that
Received Treatment in thePast Year,
Age 12-17
40
41.2
38.6
37.6
33.1
35
30
25.4
23.1
25
20
2009
15
2010
10
7.5 7.4
5
0
0
0
0
0
0
0
White
Black or African American Indian Native Hawaiian
American
or Alaskan Native or Other Pacific
Islander
Race and Hispanic Origin
Asian
Two or More
Races
Hispanic or Latino
Note: Where no estimate was reported due
to low precision 0.0 was used.
SAMHSA, National Household Survey on Drug Use and Health (NSDUH), 2009 and 2010
Trends in Disparities
2000-2002—2008-2010 (AHRQ,NHDR)
10
Quality of Care
Access to Care
Disparities in 2012
(AHRQ, Natl Health Disparities Report, 2012)
11
Quality of Care
Access to Care
Neighborhood
and Built
Environment
Economic
Stability
Health and
Health Care
Social
Determinants
of Health
Education
12
Social and
Community
Context/Justice
Involvement
Demographics of the JusticeInvolved Population
13
High Rates of Illness Among JusticeInvolved Population
14
Health Disparities Upon Release
15
• Increased mortality following release (12x higher)
• High rates of hospitalization for former inmates at reentry
2.5x higher within a week of release (1 in 70)
1.8x higher within 90 days of release (1 in 12)
• Chronic health and behavioral health conditions are often
exacerbated by lack of accessibility to health care after
release
• In a majority of states, imprisonment leads to termination of
Medicaid benefits
Housing: Moving to Opportunity Study
16
• HUD/NIMH Study
• Randomized moving families in concentrated
poverty, public housing to lesser poverty
areas.
• Results:
– Decrease in mother’s depression
– Decrease in mother’s diabetes
– Findings associated with sleep
patterns/hypervigilance?
– Mixed result for youth, academics, mental health
17
2. WHY DO WE NEED COMMUNITY
–DEFINED EVIDENCE
STUDIES/PRACTICES?
“Clozapine, gold standard for treatment-resistant
schizophrenia…a different story for African Americans”
18
• Key risk: agranulocytosis, a condition defined by white blood cell (WBC)
counts dropping to extremely low levels that place a person at high risk for
infection
• Key disparity involved in clozapine re the ANC ranges, which are currently
normed to White patients
• Normative ANC levels vary among racial and ethnic groups, and some have
normatively lower ANC than White Americans, including African
Americans
• Deficit in mean ANC across racial/ethnic groups  benign ethnic
neutropenia (BEN) doesn’t reduce ability to resist infection
• But, given lack of “evidence-testing” across groups An estimated 20% of
African Americans may be ineligible to begin clozapine because of BEN,
and another 25% who begin may discontinue due to normal hematologic
variation
“Study finds a racial gap in
benefits of exercise”
19
• “At equal rates of activity with whites, black adolescent
females were more likely to be obese”
• Among black girls who were most active at age 12, obesity at
age 14 was nearly as likely as for those who had far lower
activity rates. This did not hold true for white female
adolescents.
• Findings point to a significant metabolic disadvantage for
African American girls
• Thus, obesity prevention interventions need to be adapted to
account for less sensitivity to effects of physical activity
among black girls
White & Jago, Archives of Pediatrics and Adolescent Medicine, 2012
“… it is unsurprising that preliminary data on applying
current interventions to couples targeted by federal
initiatives have been disappointing.”
20
• Healthy Marriage Initiative: based on linkage between marriage and
well-being; decreasing poverty, improve child outcomes
• A decade of federal initiatives to promote marital interventions for poor
couples and couples of color
• Focus: help couples access marriage education services, acquire
skills/knowledge to form healthy marriages
• However, most interventions studies based on mostly white and middle
class couples
• Since 2007 ~ $100M appropriated to these programs; findings are mixed,
little impact
• For poor families: paying rent, keeping children safe, finding better schools
are urgent matters; “focusing on marriage seems self-indulgent” when
working hard to raise children
M Johnson, American Psychologist, May-June 2012
“Disparities in use of mental health services persist
for Black and Latino children”
21
• “About 10% of white youth are using mental health care
compared to 4 - 5% of Black and Latino youth”
• “That 2-to-1 ratio is giant disparity compared to other areas of
health care”
• Money spent for MH care increased for white children;
decreased significantly for Latino children (2002-2003 and
2006-2007)
• “…the amount of dollars the system is spending on Latino
users relative to white users is shrinking.”
• But, when strategies are used to engage these families
access to MH care increases.
B. Cook, Health Services Research, 2012; Dataset:
30,000 youth, Medical Expenditure Panel Surveys.
Special Analysis for Surgeon General’s Report
on Culture, Race and Ethnicity
22
• Between 1986 and 2001, ~ 10,000 participants were
included in randomized controlled trials
evaluating the efficacy of interventions for four mental
health condition (bipolar disorder, schizophrenia,
depression and ADHD) and included only:
–
–
–
–
561 African Americans (5.6%)
99 Latinos (.01%)
11 Asian Americans and Pacific Islanders (.001%)
0 American Indians and Alaska Natives were available
for analysis.
– Not a single study analyzed the efficacy of the treatment by
ethnicity or race. (Miranda et al., 2003)
22
Most Commonly Spoken Languages
Other than English or Spanish (2014)
23
24
3. SAMHSA SUPPORTED
CDEP ACTIVITIES
(1)SAMHSA’s Community-defined
Evidence Project
25
Purpose:
• Identify “effective” community and/or culturally based
practices, who is doing them and how they are being done
• Determine common characteristics or “essential elements”
among these practices
• Identify formal or informal measurement of effectiveness that
is being used with such practices; document the measures
• Identify culturally-informed methodologies and measurement
practices that involve the community
25
Community Defined Evidence
26
• A research model that emphasizes investigation “from the
ground up”
• Key assumption: service recipients have knowledge based
upon life experience and learned expertise that is rarely
tapped to inform scientific study and develop behavioral
health practices.
• Identify and affirm alternative and existing forms of
knowledge about behavioral health and wellness
• Use traditional and indigenous ways of knowing to develop
and implement practices that are acceptable and useful to the
populations that are expected to use them
Kenneth J. Martinez, Psy.D.
26
Community Defined Evidence
27
• CDE is a set of practices that have been found
to yield positive results as determined through
ongoing efforts to achieve community
consensus, and which have reached a level of
acceptance by service recipients despite
varying degrees of empirical measurement of
practice effectiveness. (Martinez, et al. 2010; 2012)
27
Criteria Used to Review
Identified Practices in CDEP Project
28
1) 1. A process that includes the community
2) 2. Develop a practice with community involvement and
expertise
3) 3. Test and implement the practice, including community
input
4) 4. Assess implementation and utilization of the practice
5) 5. Continuous quality improvement process
Kenneth J. Martinez, Psy.D.
28
Essential Elements in CDEP Practices
(K. Martinez, et al.)
29
1. Acknowledging the centrality of the family
2. Creating and encouraging a collective healing
process
3. Addressing needs holistically
4. Addressing stigma and using culturally relevant
terms
29
Essential Elements In CDEP Practices
(K. Martinez, et al.)
30
5. Engaging in dialogue about the practice with
community members and service recipients on an
ongoing basis
6. Increasing community connections by partnering
with organizations important to local ethnic
communities
7. Implementing practice in comfortable and familiar
practice settings
30
California Reducing Disparities Project
31
• Build on CDEP Concept
• Response to Surgeon General’s 2001 Report and 2003
President’s New Freedom Commission Report
• Investment from Mental Health Services Act (former DeptMH)
• 5 Strategic Planning Workgroups(SPW) formed to serve 5
populations (African Americans, AAPI, Latinos, LGBTQ, Native
Americans)
• Phase 1: Develop strategic plan to reduce mental health
disparities in 5 populations and ID promising practices
• Outcome: Population Reports
• Phase 2: Fund and evaluate promising practices/communitydefined evidence programs
(2) SAMHSA’s Service to
Science Initiative (STS)
32
• Goal: Build evaluation capacity of locally
developed programs to demonstrate more
credible evidence of their program’s
effectiveness
• Support innovative local interventions
• 243 programs have participated
What is provided in STS?
33
• Evaluation training and Technical assistance
– Feasibility study; improving staff/community
evaluation capacity and use of data; plans for data
analysis; develop/improve evaluation instruments;
process and outcome evaluations with
stakeholder input
• Seed money to CBOs; $30,000
• Preparation of manual
(3) National Network to Eliminate Disparities
in Behavioral Health (NNED)
34
34
To join the NNED: www.nned.net
http://share.nned.net/
35
NNED Workforce Focus:
Communities of Practice
36
• Bienvenido Program – Mental Health Promotion for Latino
Communities (Spanish-speaking)
• Project Youth Venture – Tribal Youth Substance Abuse Prevention
• Latino Multi-Family Group Therapy
• Motivational Interviewing
• Developing Diverse Peer Specialists
• Strengthening Families
• Cognitive Behavioral Therapy, Adapted for Latinos
• Project ASIST for Tribal Suicide Prevention
• Health Reform: Outreach and Enrollment
• NNEDLearn Training Meeting
(4) Grant- making: RFA Language
37
• “SAMHSA’s services grants are intended to fund services or practices
that have a demonstrated evidence base and that are appropriate for
the population(s) of focus. An evidence-based practice (EBP) refers to
approaches to prevention or treatment that are validated by some
form of documented research evidence.”
• “SAMHSA recognizes that EBPs have not been developed for all
populations and/or service settings.”
• “Applicants proposing to serve a population with an intervention
that has not been formally evaluated with that population are
required to provide other forms of evidence that the practice(s) they
propose is appropriate for the population(s) of focus. Evidence for
these practices may include unpublished studies, preliminary
evaluation results, clinical (or other professional association)
guidelines, findings from focus groups with community members,
etc.”
(5) What is the Disparity Impact
Strategy? (DIS)
38
Systems change process in response to policies
aimed to improve health outcomes by:
– Creating a more strategic focus on racial and
ethnic populations in SAMHSA investments
– Using a data-informed quality improvement
approach to address racial and ethnic disparities
in SAMHSA programs; including CDEP approaches
– Utilizing this secretarial priority to influence how
SAMHSA does it work, e.g., its grant-making
operations
HHS Action Plan to Reduce Racial and
Ethnic Health Disparities (2011)
39
Secretarial Priority #1
1. Assess and heighten the impact of
all HHS policies, programs, processes,
and resource decisions to reduce
health disparities. HHS leadership will
assure that:
(c)Program grantees, as
applicable, will be required to submit
health disparity impact statements
as part of their grant applications.
Such statements can inform future
HHS investments and policy goals,
and in some instances, could be used
to score grant applications if
underlying program authority permits
What Does the Disparity Impact
Strategy Mean for Grantees?
40
• No new data burden; uses the required performance
measures
• No change in primary programmatic intent
• Focus on how programs engage/perform in regard to
racial/ethnic subpopulations (LGBT, where data collected)
• Data on racial/ethnic subpopulations used for quality
improvement (QI) in the program (LGBT, where available)
• Strategies implemented for how grant programs can improve
performance for racial/ethnic subpopulations
• Required “Disparity Impact Statement” linked to funding
Disparity Impact Strategy:
Operational Framework
41
Access
Use
Outcomes
Disparity Impact Strategy:
Initial Observations
42
• Increase attention to vulnerable populations
• Increase access to federal resources and involvement
in federally-funded programs for disparity
populations
• Identify better outreach, engagement, retention
and interventions to improve access, interventions
and outcomes for disparity-vulnerable populations
• Greater intent to seek out harder-to-reach
populations
• Aligning DIS w TA and strategic plans
43
4. CDEP AND AFFORDABLE CARE ACT
CDEP and Affordable Care Act
44
The Affordable Care Act brings:
*reforms to the insurance industry
*increases affordability;
*increases access;
*promotes health equity.
FamiliesUSA, 2010
Nonelderly Health Coverage by
Race/Ethnicity, 2014
45
Private
12%
Public
Uninsured
15%
13%
17%
27%
18%
16%
34%
41%
34%
72%
71%
39%
46%
52%
Non-Hispanic white, Hispanic or Latino Non-Hispanic black, Non-Hispanic Asian, Non-Hispanic other
single race
single race
single race
races and multiple
races
DATA SOURCE: CDC/NCHS, National Health Interview Survey, 2009–2014, Family Core component.
Importance of Within Group Variation:
Percentage of Uninsured Among AAPIs
46
30
25.5
25
20
20
16.7
15
10
11.3
11.8
13.9
6.7
5
0
Source: Assistant Secretary for Planning and Evaluation, based on U.S. Census figures
15.7
Expanded Coverage
47
Expanded Coverage
• Medicaid coverage will be expanded to cover more legally
present, non-elderly children and adults, approx:
• 1.3 million Asian Americans
• 90,800
Native Hawaiians and Pacific Islanders
• 4 million
African Americans
• 7 million
Latinos
• 277,800
American Indians
FamiliesUSA, 2010
Prevalence of Behavioral Conditions Among
Medicaid Expansion Population, US
48
18.0%
16.0%
14.9%
14.0%
14.2%
12.0%
10.0%
8.0%
7.0%
6.0%
4.0%
Percent with a Serious
Mental Illness (1,283,000)
CI: 6.3%-7.7%
Percent with Serious
Psychological Distress
(2,731,742)
CI: 14.0%-15.9%
CI = Confidence Interval
Sources: 2008 – 2010 National Survey of Drug Use and Health
2010 American Community Survey
Percent with a Substance
Use Disorder (2,603,405)
CI: 13.2%-15.2%
Prevalence of Behavioral Conditions Among
Exchange Population, US
49
18.0%
16.0%
14.6%
14.0%
13.3%
12.0%
10.0%
8.0%
6.0%
6.0%
4.0%
Percent with a Serious Mental
Illness (1,195,600)
CI: 5.5%-6.6%
Percent with Serious
Psychological Distress
(2,650,247)
CI: 12.4%-14.2%
CI = Confidence Interval
Sources: 2008 – 2010 National Survey of Drug Use and Health
2010 American Community Survey
Percent with a Substance Use
Disorder (2,909,294)
CI: 13.7%-15.6%
SAMHSA’s Office of Behavioral Health Equity: HR
Outreach/Engagement Community of Practice
50
•
•
•
•
•
•
•
Lack of trust of unknown entities, public programs
Low health literacy, limited English proficiency
Disproportionate rates of behavioral health (BH) conditions
among uninsured
BH symptoms and income/housing volatility
Periods of un-insurance lead to increased inpatient and
emergency visits, longer lengths of inpatient stays, poorer
psychiatric outcomes, and higher healthcare expenditures
BH providers have limited enrollment experience
Traditional outreach workers have limited training on working
with individuals with BH conditions
Reaching & Enrolling Diverse Populations:
Community-defined Approaches
51
• Involve community members in outreach
• Use language familiar to the community
• Partner with community and faith-based
organizations
• Use broad range of outreach sites
• Provide a personal approach
• Integrate your message into community events
• Use ethnic-specific media as a resource
OBHE & Partners: Informational Webinars for
Diverse Community Leaders and CBOs
52
• ACA Outreach and Enrollment Challenges in Asian American,
Native Hawaiian, and Pacific Islander Communities: Some
Findings
• Health Insurance Basics
• Outreach and Enrollment Promising Practices for the AAPI
Community –
• Persistent Barriers to Outreach and Enrollment for the Latino
Community
• Understanding the ACA and Engagement of African
American Subpopulations
• Affordable Care Act for Immigrants and Refugees
• Best Practices in Outreach and Enrollment for Latino
Communities
Strategy Briefs for Behavioral Health Organizations to
Promote New Health Insurance Opportunities
http://store.samhsa.gov/product/SMA14-4820
53
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