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

1. The Role of Culture in the Integration of Physical Health Services in Mental Health Settings 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

2. Outline • Discuss racial/ethnic health disparities among people with SMI • Illustrate how culture impacts the integration of physical health services in mental health settings

3. Public Health Crisis Among People with SMI 3 • People with serious mental illness die, on average, 25 years earlier than the general population largely due to preventable medical conditions

4. Racial/Ethnic Health Disparities in the SMI Population 4 • 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

5. Racial/Ethnic Differences in Diabetes by Psychiatric Disorders 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.

6. 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 stigma • Higher enrollment in fragmented health care services Ader et al., 2008; IOM, 2006; Kraokowski et al., 2009;

7. Determinants of Health Care Disparities • Organization • Service fragmentation • Resources • Location • Reimbursement • policies • -Organizational • culture • Cultural competence • policies and practices • Provider • -Training • - Knowledge/ • Skills • -Stigma • -Bias/Stereotypes • Professional • boundaries Consumer -Health insurance -Language -Competing demands -Comorbdities -Health literacy -Norms & attitudes -Body image

8. Culture Influences Health 8 • 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

9. 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 system • 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

10. Qualitative Study of Service Integration • Study Aim: • Identify cultural factors in the integration of physical health services in behavioral health organizations • Sample: • Purposive sample of 6 behavioral health organizations in Northern Manhattan • Methods: • Multi-stakeholder approach • Combination of qualitative methods

11. 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

12. 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

13. 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

14. Conclusion 14 • 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 SMI • 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

15. “Physical Health is Integral to Recovery” 15 “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”

16. Acknowledgements 16 16 • 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

17. 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 cabassa@pi.cpmc.columbia.edu 17