Elimination of Disparities in Mental Health Care: An Overview Read Comments | Post Your Own Comment
This segment of the TA Call Series on the Elimination of Disparities in Mental Health Care has provided an overview of the issues that cause and perpetuate disparities. Now let's examine solutions! Cultural and linguistic competence of service providing organizations is one critical component required to correct these disparities. Please see the following brief prepared by the Louis de la Parte Florida Mental Health Institute, University of South Florida. This brief and the accompanying monographs provide guidance and example of what can be done at the organizational level. Next month, the focus will be at the level of local and state systems.
In order to be effective, a system of care for children with serious emotional disturbances and their families must be accessible to the local community. Communities facing disparities in access to care and wishing to reduce those disparities must begin by increasing their understanding of the populations they serve and the existing community and organizational barriers. Increasing access to services for culturally and linguistically diverse children and their families is particularly challenging and requires attention to the influence of culture on the help-seeking process and the design and delivery of mental health services (Hernandez, Nesman, Isaacs, Callejas, & Mowery, 2006). The Accessibility of Mental Health Services study was designed to identify and operationalize culturally competent organizational practices that can be implemented within systems of care to improve access to services for diverse children and their families. In this issue brief we will present a conceptual model that defines organizational cultural competence in terms of increased access and reduced disparities. For our purposes, access to mental health services is described as the direct service and organizational mechanisms that facilitate a person’s ability to enter into, navigate, and exit the appropriate services and supports as needed. Disparities have been defined as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States” (Carter-Pokras, & Baquet, 2002). We add to this definition the notion that disparities must be considered within the community context in which diverse children and families live. When placed in this context, disparities can include differences in access, quality, appropriateness, and outcomes of care as well as over-representation of children and youth of color in other service sectors such as juvenile justice, child welfare, and special education. Community context is fundamental to the organizational cultural competence conceptual model developed by the Accessibility of Mental Health Services study. The model is based on a literature review of strategies for serving diverse children and their families (Hernandez, Nesman, Isaacs, Callejas, & Mowery, 2006), a review of organizational assessment instruments (Harper, Hernandez, Nesman, Mowery, Worthington, & Isaacs, 2006), and field-based research with exemplary organizations (Callejas, Nesman, Mowery, & Hernandez, 2008). This brief will describe the model and illustrate each component with examples from participating organizations serving African American, Asian/Pacific Islander, Latino, and Native American children and families. The Conceptual Model At the most macro level, the conceptual model illustrates the relationships between a community’s populations, the organization or system’s characteristics, and existing disparities in services as they are embedded within an overall community context (Figure 1). The linkage between cultural competence and access is made through the concept of compatibility between the community’s diverse populations and the organization.
Community and Population Characteristics The conceptual model shows how a targeted population and organizations that serve that population are embedded within a community context (1) For example, the context might include policies such as Medicaid reimbursement practices, community infrastructure elements such as transportation options, or availability of services and businesses within targeted neighborhoods. The community context might also include state and federal policies, and international trends such as immigration streams or stock market fluctuations. These contextual factors can influence both characteristics of the community population and organizational functioning. The model highlights the importance of understanding the target population’s cultural and linguistic characteristics in order to increase organizational compatibility (2) Population characteristics that impact access might include attitudes and beliefs about mental health, linguistic preferences, experiences with racial or ethnic discrimination, socioeconomic level, and other social factors that impact help-seeking and perceptions about mental health organizations and systems. Population characteristics may also impact utilization factors such as dropout rates or satisfaction with services. Developing cultural competence in an organization involves understanding and adapting the organization’s policies, structures, and procedures to a target population (3) These characteristics of the organization influence the ways in which it interacts with the community’s populations, and are also influenced by the populations’ characteristics as well as the overall community context. The level of compatibility between a target population’s cultural and linguistic characteristics and the organization (4) is related to the level of organizational cultural competence, as shown by the vertical arrow on the far left of the diagram. The model also illustrates that increasing compatibility is thought to result in the ultimate outcome of reduced mental health disparities (5) This outcome can be shown in many ways, including through organizational, community, or individual and family level measures. For example, disparities might be measured by showing reduced incidence of abuse or juvenile arrests in certain zip codes within the community. System level outcomes might include increased use of outpatient/voluntary services compared to crisis, inpatient, and involuntary services for the target population across the system of care. Organizational level outcomes might be measured in terms of reduced disparities in access, dropout, or no show rates for the target population compared to the general population. At the individual and family level, outcomes might include decreased disparities in clinical status compared to the general population, or increased improvement in child/family functioning within the target population. Outcomes can be considered individually at each of these levels and can also be compared across levels to better understand how disparities are being affected by adaptations that are being made in organizations. Organizational Characteristics In a more detailed illustration of the organization, practices in infrastructure and direct service domains are differentiated (Figure 2). Adaptations are needed in both of these domains for an organization to become more culturally competent in serving a specific population. These adaptations must be informed by that population’s cultural and linguistic characteristics, history, and worldview, as well as community context issues. The infrastructure domain includes multiple functions that are typical of organizations, each of which must be adapted for cultural competence (3a). Organizational infrastructure strategies are implemented or developed at an administrative level within organizations or systems—and do not usually involve direct interaction with children and families needing services. These strategies are most often implemented by administrators, working closely with funders and policymakers. Such strategies are frequently reflected in mission statements, established governance policies, human resources procedures, and other components associated with the infrastructure of an agency. However, implementation of these organizational strategies can shape whether and how direct service strategies are used to address the needs of racially/ ethnically diverse children and families. The direct service domain includes functions related to direct service such as accessibility, availability, and utilization (3b). The strategies associated with this domain address barriers whose impacts are most often experienced by diverse children and families seeking services. These strategies tend to be implemented by direct service personnel such as outreach workers, case managers, and therapists, and often involve immediate interaction with children and families.
As shown in the conceptual model, compatibility is needed within each organizational domain and between the infrastructure and direct service domains in order to serve the target population in a culturally competent manner (3c). An example of compatibility would be developing infrastructure supports such as staff training and longer initial appointment times that promote communication of mutual respect and genuine concern for family needs and preferences. Such practices operate best when implemented in an open and flexible organizational environment that allows personnel to use their knowledge of ethnically and racially diverse communities to further develop strategies and practices for engaging families and responding to their needs. Culturally competent organizations can be characterized as setting a foundation of culturally competent practice that direct service personnel can build upon through their more personal interactions with children and families seeking services. Such strategies set the stage for an organization to further develop a broad service array that can address specific needs as they emerge and that can be tailored to those needs by trained staff, which are able to implement the mission and vision of their organization and have the flexibility to make decisions that will further address the needs of diverse children and families. Organizations that make this investment in their agencies and staff are considered to be illustrative of compatibility between direct service functions and organizational functions. Using the Model The organizational cultural competence conceptual model presented in this brief can be used as a guide for adapting key components of an organization to serving specific target populations. For example, an organization might identify an underserved population through comparison of service data with community demographics. The organization can then begin to build awareness and knowledge about the population through community assessments and information collected through relationships with community representatives. Organizational infrastructure analysis and data on service access and use can provide planners with a snapshot of areas needing adaptation within the organization and strategies can be developed that incorporate knowledge about the targeted population. Although this model emphasizes making adaptations within organizations, diverse communities can also simultaneously develop strategies for increasing awareness and knowledge about service systems among their members. Therefore, development of compatibility might best be described as involving reciprocal knowledge development and communication between a specific population and mental health organization in order to ensure an appropriate and acceptable continuum of services. The desired impact of these strategies can then be monitored based on outcomes such as increased use, increased satisfaction, or improved functioning. Broader outcomes might look for decreased disparities in the burden of mental health problems for families in the target population. For further information on the conceptual model visit http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/default.cfm |
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