Teen Mental Health, Health Equity and the Affordable Care Act

1. Teen Mental Health, Health Equity and the Affordable Care Act Putting it all together: The “Aqui Para Ti/Here for You” story Maria Veronica Svetaz, MD MPH Maria.Svetaz@hcmed.org

2. Outline • Create awareness around how adolescent health has been neglected in the health systems. • Discuss youth mental health needs at the local and global level. • Identify biological and contextual factors that affect mental health throughout adolescenthood. • Briefly review barriers to deliver appropriate care and highlight key effective interventions. • Address how Affordable Care Act will allow to implement new models of care. • Snapshot of “Aqui Para Ti/ Here For you” story, a family centered medical home for Latino teens and their families, it’s main components and successes.

3. Adolescence as an unequal target of care • In the world of inequities, bias, stereotyping and discrimination is a common recipe for exclusion “Research gives us no reason to fear adolescents—in fact, it shows our negative images of teens to be largely stereotypical and unfair—but it gives us many reasons to fear for them”. A. Rae Sympson, Ph.D. Rising Teen A synthesis of research and a foundation for action • Somehow, adolescent care is the most excluded of all populations, the one that lacks the most ‘societal’ and ‘provider' empathy. • Perceived as healthy, and when not, it is due to their “bad” choices: teen pregnancy, for example. • Somehow as a Society, we perpetrated the “personalization” first-time parents of teens commonly fall for, • Rae Simpsons propose that parents need a “dictionary” that translates teen behaviors into developmental terms, and not to get tangled in “personalization” of behaviors, and I bet she will agree that this is true for every adult in our society.

4. Teens as “Societal Barometer”, our “symptom”(I) • Our adult lives in US are more and more complex. • That tension has a clear effect on our upcoming teens, and they are left with less guidance and support during their transition to adulthood: • In average, workplace pressures have deprived our teens from 10-12 hours of parental time per week. • Parents of teens do NOT receive the same support they did during their child first years.

5. Parenting 101 or Parenting vs. poverty?

6. What do you think? Is this relevant or not?

7. Teens as “Societal Barometer”, our “symptom” (II) • Our adult lives in US are more and more complex • That tension has a clear effect on our teens, and they are left with less guidance and support during their transition to adulthood. • Schools are structured in a way that, most of the time, don’t meet student learning needs. Resources are also scarce where diversity is aggregated. • Media keeps feeding negative messages about teens in general and diversity in particular. • Social media enabling extremely aggressive and negative communication, thanks to anonymity, or detachment from negative behavior. • Medical services are over-compartmentalized and structured to respond to acute bio-medical needs and “refer”, with specialized spaces for teens in decline. Coordinated care is not a common service for teens.

8. Teens as “Societal Barometer”, our “symptom” “As a society, we both fear adolescents and fear for them. We fear their rashness, their rudeness, and their rawness; and we fear for their safety, their future, and their very lives ”. A. Rae Sympson, Ph.D. Rising Teen A synthesis of research and a foundation for action

9. A Local Health Priority • During 1970-1980 teen suicide rates for 15-19 y.o. had doubled. • 10% of today’s teens are estimated to attempt suicide each year. • 20% had seriously considered doing so (suicide attempt). • Rates of all of these are much higher for Native Americans and Latino youth. • Half of all US teens do not feel safe in one of their environments (home, school or community). • Most of them feel unvalued and don’t have a role model in their lives.

10. An unequally met need • Kataoka, Sheryl H. M.D., M.S.H.S.; Zhang, Lily M.S.; Wells, Kenneth B. M.D., M.P.H.Institution Department of Psychiatry and Bio-behavioral Sciences, Child and Adolescent Psychiatry Division, and the Research Center on Managed Care for Psychiatric Disorders, University of California, Los Angeles; and RAND, Santa Monica, Calif. • Journal of Psychiatry. 159(9):1548-1555, September 2002 Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status • The authors conducted secondary data analyses in three nationally representative household surveys fielded in 1996-1998: the National Health Interview Survey, the National Survey of American Families, and the Community Tracking Survey. • Of children and adolescents 6-17 years old who were defined as needing mental health services, nearly 80% did not receive mental health care. • Controlling for other factors, the authors determined that the rate of unmet need was greater • among Latino than white children • among uninsured than publicly insured children.

11. A Global Health Priority • Highly biomedical approaches relying on scarce resources, combined to low levels of help-seeking and very low levels of research from developing countries mean that probably <5% of the mental health care needs of adolescents are addressed. • Very poor mental health resources: 1 out of 10 of all mental health resources (beds, professionals, dollars) are allocated to countries housing about 9 out of 10 of the global population. • 10% of resources allocated toward 90 % of the global population • Developmentally appropriate interventions integrated with youth friendly services and promoting global research are key strategies for the future.

12. The global iniquity of evidence No item for 42 countries – where 76 million children and adolescents live Adolescent mental disorders: A global perspective Vikram Patel, Wellcome Trust Senior Research Fellow - Professor of International Mental Health

13. The vulnerabilities of biology • The proportionate burden of mental disorders in childhood rises with age, reaching 15% to 30% in adolescence. • The interaction of the features of neurodevelopment in adolescence and rapidly changing environments predispose to a range of risk behaviors and mental illness. nature PLUS nurture: this is a clear leverage developmental stage: you can help them thrive or sink them

14. The vulnerabilities of an unequal context

15. The vulnerabilities of an unequal context The 12 Measures in the Race for Results Index

16. The vulnerabilities of an unequal context The majority of the 18 million children in immigrant families In the US are children of color. Those children face obstacles to opportunities, including poverty, lack of health insurance, parents with lower levels of educational attainment, substandard housing and language barriers. Most vulnerable are the 5.5 million children who reside with at least one unauthorized immigrant parent. Data “illusion”: most of these two parents are trapped in a two low-wages job, away from their children, unable to escape poverty. “The New Neighbors” Urban Institute and Annie E. Casey Foundation 2003

17. Adverse Childhood Experiences (ACE): How this got translated into action? Adverse Childhood Experiences Definition : The following categories all occurred in the participant's first 18 years of life 1- Abuse 2- Neglect 3- Household dysfunction Vulnerable household? Household in need? Translated into clear action to target children 1-3

18. What are the challenges to care, when do you want to care? • Teen mental health is not always clearly identified as a developmental need, and as an inequity in health policies. • Thanks so much, School of Public Health for putting this on the spot! • There is not enough training in primary care to do that properly. • Settings not designed to fit these behavioral need: highly biomedical approaches relying on scarce resources. • Low levels of help-seeking: teens don’t know how success or depression feels: less than 5% of the mental health care needs of adolescents are addressed.

19. Some positive thinking please! What does help to care?

20. Some positive thinking please! What does help to care? • A paradigm shift in the field

21. Shifting gears: ACA and ACOAffordable Care Act and Accountable Care Organizations • Bringing the Chronic Care Model to front for mental health care in/and primary care. • Standardized screening to ALL: leveling the “care” field. • New models of team care and coordinated care. • Bundle of payments, more developmentally appropriate services integrated in one stop. • Family interventions: prioritizing context.

22. Affordable Care Act: new models of care Health Homes (or Behavioral Health Homes, based in the Patient Centered Medical Home Model – PCMH-) • A health home — as defined in Section 2703 of the Affordable Care Act — offers coordinated care to individuals with multiple chronic health conditions, including mental health and substance use disorders. The health home is a team-based clinical approach that includes the consumer, his or her providers, and family members, when appropriate. http://www.chcs.org/usr_doc/Health_Homes_FAQs_101211.pdf

23. Putting all together: Aqui Para Ti/Here for You Afamily centered MN certified medical home for Latino youth and their families. Funded partially through EHDI(Eliminating Health DisparitiesInitiative-MDH)

24. Our Outstanding Staff: • Is bicultural and bilingual in English and Spanish. • Collaborates with other community organizations and sustains long-term partnerships. • Has experience and interest in working and serving young Latino immigrants in MN. • Has successfully secured a a diverse funding structure to ensure the continuity of our program. • Is compassionate and understanding of the needs and assets of the Latino community.

25. Core intervention components (since 2002) • Presence of a trained adolescent care team (provider, health educator, care manager) • Family parallel care (needs of both parents and youth are addressed in a parallel fashion). • Family and patient centeredness • Structured approach to screening, utilizing nationally established clinical practice guidelines • Case management. • Dual approach: Intervention-prevention • Connecting Culturally concordance Honoring cultural values: Familism & Personalism Uncovering unmet needs Increasing social capital Increasing social connectedness

26. Parallel Family Care

27. TEEN ADVISORY BOARD PARENT ADVISORY BOARD Physician IN PROGRAMDEVELOPMENT:Managing budgets Managing reports Writing grants Doing presentations Teaching medical workforce and the giving back to the community Doing advocacy in Health Disparities, etc Working in system change, etc 1) Program Coordinator 2) Program Developer Parallel Family Care YOUTH Boys/girls 10-24 y.o. PARENTS Community Health Workers (2)Main Tasks:EDUCATECOORDINATE Family Educator (1)Main tasks: EDUCATECOORDINATE HOME VISITS School-College Connector (1) IN ACTION IN THE CLINIC WEEKLY Case Management (all the team plus residents plus medical students)

28. National Model Adolescent Care Program

29. Our Results: Mental Health: Teens • Mental Health – Beck Depression Inventory Overall, patients exhibited significantly fewer depressive symptoms at their final assessment (M = 11.09), compared to their first assessment (M = 14.07) (paired t-test = 2.20, p = .03). For those whose depressive symptoms were above the clinical cut-off (higher than 17) (n=20), there was a clinically significant decrease in symptoms over the time period from a mean of 25 to a mean of 15 , that was also statistically significant (p = .003).

30. Our Results: Mental Health : Parents Parents’ depressive symptoms were also assessed: 78 parents completed one or more Beck Depression Inventories. At the time of the first assessment, total scores ranged from 0-43 (M = 13.58, SD = 11.50) and 19 parents (24.1%) had depression scores that exceeded the clinical cut-off (>17). This highlights the appropriateness of the program's model, providing parallel care during adolescents years to the Latino families is critical. Parents’ Experiences – Beck Depression Inventory, and Parenting Styles and Efficacy

31. CONCLUSIONS Yes, You CAN Refreshed ACA Care Models For those whose depressive symptoms were above the clinical cut-off (higher than 17) (n=20), there was a clinically significant decrease in symptoms over the time period from a mean of 25 to a mean of 15 , that was also statistically significant (p = .003).