Transcript CC can Predict Disparity Reduction

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
Acknowledgments


New York State Office of Mental
Health
Nathan S. Kline Institute Center of
Excellence in Culturally Competent
Mental Health.
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

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).
Levels of a Mental Health System
In which CC needs to operate
ADMINISTRATIVE ENTITY
e.g., State Mental Health Authority,
Managed Care Organization
Agency A
Agency B
Inpatient unit
Clinic
Program
Program
Program
Caregiver
Caregiver
Caregiver
Agency C
Rehab
Program
Program
Program
Caregiver
Caregiver
Caregiver
Consumers
Caregiver
NKI Cultural Competency
Assessment Scale (CCAS)
Organizational Level
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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
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.
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.
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
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.
Why was disparity reduction
predicted for Hispanics and not
for Blacks?

Language related items more relevant to
Hispanics than Blacks

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Modified programs for Blacks may not have been
in place in studied agencies.

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Difficulties in adapting services when adaptation is
more than ‘translation’
Scale may not contain organizational items of
relevance to Blacks


Communication competencies for Blacks need to be
differently addressed.
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
Ensuring CC under State
Health Care Reform

Reimbursements to participating organizations
should take into account dollars required to set up
CC activities,

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
e.g., for interpretation services
e.g., to support a CC specialist
Participating Managed Care Organizations:
Medicaid or Other

Contracts should require

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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
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
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


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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.org