CabassaLJ NYAPRS Ex 04 27 11 FinalNN by 45GhV20m


									 The Role of Culture in the Integration of
Physical Health Services in Mental Health

         Leopoldo J. Cabassa, PhD
NYS Center of Excellence for Cultural Competence
      New York State Psychiatric Institute
 Department of Psychiatry, Columbia University

        NYAPRS 7th Annual Executive Seminar
                   April 27, 2011

       Discuss racial/ethnic
        health disparities
        among people with

       Illustrate how culture
        impacts the
        integration of physical
        health services in
        mental health settings
     Public Health Crisis
    Among People with SMI

               People with serious
                mental illness die, on
                average, 25 years
                earlier than the general
                population largely due
                to preventable medical
        Racial/Ethnic Health Disparities in the
                   SMI Population

         Compared to non-Hispanic whites with SMI,
          African Americans and Latinos with SMI face
          serious health inequities due to:
           Higher rates of obesity, diabetes, metabolic
            syndrome, and cardiovascular disease

             Poorer access and quality of medical care

    Cabassa et al., 2011; Chwastiak et al., 2008; Dixon et al., 2000; Frayne et al., 2005
    Hellerstein et al., 2007; Lambert et al., 2005; Kato et al., 2004; Stecker et al., 2006
              Racial/Ethnic Differences in Diabetes
                    by Psychiatric Disorders

                                        NHW vs. AA               NHW vs. H
                                      OR    (95% Cl)          OR   (95% Cl)
    No psychiatric disorders          1.49 1.22, 1.83         1.48 1.18, 1.84
    Any psychiatric disorders         1.79     1.45, 2.20     2.05     1.61, 2.61
    Any substance use                 1.89     1.36, 2.61     2.54     1.67, 3.86
    Any mood disorders                1.89     1.19, 2.99 1.96         1.27, 3.01
    Any anxiety disorders             1.58     1.13, 2.20 1.76         1.24, 2.51
    Note: NHW: Non-Hispanic Whites; AA: African Americans; H: Hispanics; all
    models are adjusted for socio-demographic variables and diabetes risk factors
    Source: Cabassa et al., (In Press). Gen Hosp Psych.
        Possible Reasons for Health Disparities among
            Racial and Ethnic Minorities with SMI

           Higher rates of obesity and insulin resistance place
            African Americans and Latinos at increased risk for
            the negative metabolic abnormalities associated
            with second-generation antipsychotics

           Social/cognitive deficits associated with psychiatric
            disabilities may amplify the communication
            problems minorities face in the medical encounter

           Mistrust due to racism may be compounded by

           Higher enrollment in fragmented health care
    Ader et al., 2008; IOM, 2006; Kraokowski et al., 2009;
           Determinants of
        Health Care Disparities

    -Service fragmentation   Provider
    -Resources               -Training             Consumer
    -Location                - Knowledge/        -Health insurance
    -Reimbursement             Skills            -Language
    policies                 -Stigma             -Competing demands
    -Organizational          -Bias/Stereotypes   -Comorbdities
    culture                  -Professional       -Health literacy
    -Cultural competence     boundaries          -Norms & attitudes
    policies and practices                       -Body image
                   Culture Influences Health

       Culture shapes:
           how consumers, providers, and organizations
            perceive, define, label, and cope with physical and
            mental disorders
           body image, dietary practices, and the value
            consumers and providers place on certain foods
           consumer-provider interactions; the expectations and
            preferences each brings to these interactions
            how people interact with the healthcare system

Caprio et al., 2008; Kleinman et al., 2006, Cross et al., 1989; Guarnaccia et al., 1996;
Whitley, 2007
                 Culture and Service Integration

           Culture = what is most at stake for consumers,
            providers, and organizations in the receipt and
            delivery of health care services

           Culture exists at multiple levels of the health care

           Service integration entails a cultural exchange or
            transformation process of ideas, norms, values,
            policies, and practice among different stakeholders
    Kleinman, 1995; Palinkas et al., 2005
     Qualitative Study of Service Integration

        Study Aim:
            Identify cultural factors in
             the integration of physical
             health services in
             behavioral health
        Sample:
            Purposive sample of 6
             behavioral health
             organizations in Northern
        Methods:
            Multi-stakeholder approach
            Combination of qualitative
     What is most at stake for organizations?

         Service integration strategies must fit with the
          organization’s culture and local context

         Integration efforts must use existing resources,
          structures, and partnerships

         High priority to help reduce service fragmentation
          and improve care coordination

         Service integration is not a one-size-fits all
          approach. Instead it is a highly local process
         What is most at stake for providers?

        Clarification of professional roles to reduce
         providers’ ambivalence about delivering physical
         health services
            Who should do what and when?

        Improve care coordination to mitigate providers’
         frustration of working in a broken system

        Access and quality of care efforts must address
         primary care providers’ stigma and bias toward
         consumers with SMI
         What is most at stake for consumers?

        The combination of stigma and racism contributes to
         consumers’ mistrust of the medical system and results in
         their disengagement from care

        Medical care must be sensitive to cultural variations of
         body image and diets

        Patient-centered care should not ignore cultural norms
         that shape the medical encounter

        Attention to community factors should inform healthy
         lifestyle recommendations

        Cultural factors at multiple levels of the health care
         system should be considered in service integration
         efforts to improve the physical health of people with

        Service integration should focus on what is most at
         stake for organizations, providers, and consumers

        Future research is needed to examine the
         effectiveness and sustainability of culturally
         appropriate physical health interventions in mental
         health settings
     “Physical Health is Integral to Recovery”

                         “There are multiple
                         strategies to pursue in
                         addressing morbidity and
                         mortality . . . But for any
                         of these strategies to be
                         successful, our principal
                         partnership must be with
                         the people we serve”

        Funding Sources
            New York State Office of Mental Health
            National Institute of Mental Health (K01MH091108)

        Research Team
            Roberto Lewis-Fernández, MD; Andel Nicasio, MS Ed;
             Ron Turner, BA; Jerel Ezell, MPH; Madeline Tavarez,
             BS; Angela Parcesepe, MPH; MSW;Rebeca Aragon, BS

        Consultants
            Peter Guarnaccia, PhD; Benjamin Druss, MD, MPH;
             Pamela Collins, MD
                 Thank You // Gracias

             Leopoldo J. Cabassa, Ph. D.
                       Assistant Director
      NYS Center of Excellence for Cultural Competence
              New York State Psychiatric Institute
     Assistant Professor of Clinical Psychiatric Social Work
                    Department of Psychiatry
                      Columbia University

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