Transcript 42x72 poster template

Resident Training in Latino Mental Health Care
Rachel Molander, MD 1,2,3; Pancho Oyarbide, LCSW 3; Ronald Diamond, MD 2,3; Art Walaszek, MD 2
1. William S. Middleton Memorial Veterans Hospital. Madison, WI; 2. University of Wisconsin School of Medicine & Public Health; 3. Mental Health Center of Dane County. Madison, WI
Figure 1
US Census Projected Hispanic Population Growth
30
25
20
17.8
15.5
22.3
20.1
Developing a resident elective in La Clinica Latina:
24.4
Figure 3
12.6
15
Lifetime Prevalence of DSM IV Dx
Mexican American Prevalence and
Services Survey (MAPSS) and
National Comorbidity Survey (NCS)
10
5
0
2000
2010
2020
2030
2040
2050
Year
40
35
Figure 2
Percentage
50
10
20
5
•Between 1990 and 2000, Dane County’s Latino population grew
150%. (US Census Bureau 2008)
•25% of clinic visits to the UW family practice clinic are from
Spanish-speaking clients. Primary care providers report that they
have few places to refer Spanish-speaking clients for bilingual
psychiatric services.
•In 2002 DCMHC started a Latino/a clinic in an attempt to
increase availability of mental health services in the Latino/a
community - Fig 2.
References:
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Origins of La Clinica Latina of the Mental Health
Center of Dane County
•
19.5
14.3
10.8
Barriers:
For the resident:
•Training site with a culturally/ethnically/racially diverse patient
population.
•Opportunity for continuity care experience with diverse
population rather than discreet encounters in ER/inpatient unit.
Financial:
•Need funding for portion of resident stipend for time
spent at the Latino Clinic ~ $3000/year
•The Mental Health Center of Dane County had drastic
cut backs 2002-2009 with limited funding available to pay
for resident stipends.
For the Mental Health Center of Dane County (MHCDC):
•Culturally/linguistically competent psychiatrist for the Latino
Clinic.
•Expose/train residents in order to increase numbers of future
culturally competent psychiatrists and providers of care to
underserved populations (feed the pipeline to decrease
shortage).
Mexican Immigrants
(MAPSS)
Affective d/o
Anxiety d/o
US Born Mexican
Americans (MAPSS)
Supervision:
•Need adequate resident trainee supervision for
prescribing, cross-cultural learning, psychotherapy.
Elective Time:
•Need adequate elective time available for continuity in
clinical experience.
Total US Population
(NCS)
Substance Abuse or Dependence
Any d/o
Process: Met individually and as a group with
Percentages add to > 100 b/c of comorbidity.
•Barriers to mental health services access include (3-6):
•Language
•Low socioeconomic status and high rates of uninsured
•Cultural factors: stigma; somatization; alternative explanatory models of
psychiatric symptoms.
•Inadequate numbers of linguistically and culturally competent mental
health care professionals
•
•
18.5
17.1
Goals/needs:
0
0
•Latinos (US born and immigrants) are much less likely to seek mental health
care (2).
•
•
28.2
25
24.1
20
30
M
D
•Rates of mental illness among adult Latino immigrants are generally lower
than that of Caucasians. US born Latino adults have rates of mental illness
roughly equal to that of Caucasians. US born Latino youth have higher rates
of depression, anxiety disorders, and suicide than Caucasian youth (2) Fig 3.
29.3
25
15
10
32.3
30
40
A
(The term "Latino(s)," as used in this presentation, refers to all persons of
Mexican, Puerto Rican, Cuban, or other Central and South American or
Spanish origin).
48.6
45
DSM IV Diagnsoses in the Latino Clinic
Mental Health Care in the Latino Population
48.7
50
Percent
Latinos are the fastest growing ethnic group in the United States and are projected to make up
~ ¼ of the US population by 2050 (Fig 1). Rates of mental illness for US Latinos are roughly
equivalent to that of Caucasians and are even higher in Latino youth. Latinos face a number of
barriers in accessing mental health care; one of which is the limited number of providers who
are culturally and linguistically competent to provide quality care to this population. Training in
cross-cultural care is an increasingly important priority of psychiatry residency programs.
Residents need access to training sites with ethnically, racially and culturally diverse patient
populations in order to have adequate training in cross-cultural care. This poster reviews issues
related to Latino mental health and residency training in cross-cultural care, and then describes
the process of establishing an elective rotation for psychiatry residents in the Latino Clinic of the
Mental Health Center of Dane County.
% of US population
Abstract
U.S. Census Bureau, Population Division. http://www.census.gov/
US Department of Health and Human Services. Office of the Surgeon General. Substance Abuse and Mental Health Services
Administration (2001). Chapter 6. Health Care for Hispanic Americans, In: Mental Health: Culture Race and Ethnicity. A Supplement to
Mental Health : A report of the surgeon general. (SMA) – 013613.
Ruiz,P. “Hispanic Access to Mental Health Services.” Psychiatric Quarterly, Vol 73, no.2, Summer 2002.
Brown, E.R.,Ojeda, V.D., Wyn, R.,Levan R. (2000). “Racial and ethnic disparities in access to health insurance and health care.” Los
Angeles: UCLA Center for Health Policy Research and The Henry J. Kaiser Family Foundation.
Brown, E.R., Wyn R., Hongjian, W., Valenzuela, A., Dong, l. (1999). “Access to health insurance and health care for children in immigrant
families.” In DJ Hernandez (Ed.) Children of immigrants. Washingto, DC: National Academy of Sciences.
Hanson, K.L. (2001). Patterns of insurance coverage within families with children.” Health Affairs, 20, 240-46.
Center for Mental Health Services. (2000). Cultural competence standards in managed care mental health services: Four
underserved/underrepresented racial/ethnic groups. http://www.mentalhealth.org/publications/allpubs/ SMA00–3457/.
APA Website: http://www.psych.org/Resources/OMNA.aspx
Weissman, J.S., Betancourt, J., Campbell, E.G., Park, E.R., Kim, M., Clarridge, B., Blumenthal, D., Lee, K.C., Maina, A.W. “Resident
Preparedness to Provide Cross-Cultural Care.” JAMA. 2005.Vol 294(9).1058-1067.
pychiatry program director, MHCDC medical director, and
staff at the Latino clinic to develop structure and learning
goals for the rotation, and to problem-solve issue of
funding resident stipend.
Residency Training in Cross –Cultural Care
Residency Training in Cross-Cultural Care is a Priority
•ACGME requires residency training in cross-cultural care and experience in the
evaluation and treatment of patients “of different ages and gender from across
the life cycle, and from a variety of ethnic, racial, sociocultural, and
economic backgrounds.”
•JAMA 2005 - National study of resident perceptions about preparedness to
provide cross-cultural care (9):
•Residents think it’s impt to address cultural issues in providing care
•Residents report little clinical time allotted in residency to address
cultural issues, and little training formal evaluation or role modeling.
•Resident self-reported preparedness to provide cross cultural care
lags well behind preparedness in other clinical and technical areas.
Limited Access to Public Sector Training Sites
•Public sector training sites frequently offer better opportunities for treating
populations from diverse ethnic, racial, sociocultural, and economic
backgrounds.
•Medicare reimburses GME institutions only for time resident spends at the
sponsoring institution.
•Many GME institutions (including UW) require training sites outside the
sponsoring institution to pay for residents training time.
•Financial strain and cutbacks are increasingly common in both public and
private sector health care. This is resulting in more limited public sector training
opportunities and may limit resident training experience in providing cross
cultural care.
University of Wisconsin Psychiatry Residency Training Program
Location: Madison, Wisconsin (Dane County)
•2008 Latino population in Dane County 5%.
•2008-09 UW resident clinical logs report 3.3% of patients seen by residents were
Latino. Most were acute ER or inpatient contacts w/o continuity.
Solutions:
Financial:
•Wrote an Evjue grant to cover portion of stipend for time spent in Latino Clinic
(not funded).
•Department of psychiatry and MHCDC ultimately split cost of resident stipend
50/50.
Supervision:
•Medical Director at MHCDC supervises medication management, and Latino
Clinic director (LCSW) and psychologist supervise cross cultural learning and
psychotherapy.
Elective Time:
•Program director approves ½ day per week for > 1 year elective time for
resident to rotate in Latino Clinic.
Outcome:
Resident does elective in Latino Clinic ½ day per week 2007-09:
•Saw over 83 new patients in 3 years
•Continuity of > 1 year with 20 patients
•Participated in weekly Latino Clinic team meetings with social workers, nurses, and
psychologists.
•Weekly supervision with Latino Clinic director for case review and discussion of readings related
to Latino mental health. Supervision with medical director PRN for med management issues.
•Resident becomes fluent, able to see Spanish speaking clients without interpreter assistance.
•In 2009, staff psychiatrist position established in the Latino Clinic and filled by former resident.
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