Session #G3b Friday, October 17, 2014 Engaging Latinos in Depression Treatment: Why the warm handoff may not be best Elizabeth Horevitz, MSW, PhD Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Faculty Disclosure • I have not had any relevant financial relationships during the past 12 months. Learning Objectives At the conclusion of this session, the participant will be able to: • Critique the warm handoff as a “one size fits all” approach in referral practices. • Consider how the warm handoff is utilized in their own practice setting. • Discuss factors that influence effective engagement of Latinos into depression treatment. Bibliography / Reference 1. Fernandez y Garcia E, Franks P, Jerant A, Bell RA, Kravitz RL. Depression Treatment Preferences of Hispanic Individuals: Exploring the Influence of Ethnicity, Language, and Explanatory Models. J Am Board Fam Med. 2011;24(1):39–50. 2. Cortes DE, Mulvaney-Day N, Fortuna L, Reinfeld S, Alegría M. Patient—Provider Communication Understanding the Role of Patient Activation for Latinos in Mental Health Treatment. Health Educ Behav. 2009;36(1):138–154. 3. Zhang W, Creswell J. The Use of “Mixing” Procedure of Mixed Methods in Health Services Research: Med Care. 2013 4. Dwight Johnson M, Apesoa-Varano C, Hay J, Unutzer J, Hinton L. Depression treatment preferences of older white and Mexican origin men. Gen Hosp Psychiatry. 2013;35(1):59–65 5. Ell K, Lee PJ, others. Depression Care for Low-Income, Minority, Safety Net Clinic Populations With Comorbid Illness. Research on Social Work Practice. 2010;20(5):467. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation. overview • • • • Research background and driving questions Methodology Results Implications for integrated primary care Research background Latinos & Depression Depression is debilitating and costly for all populations Latinos experience comparable rates of MDD as Whites (14% for immigrants; 20% for US-born Latinos) Disparately low rates of MH treatment-seeking Mexican Americans half as likely to seek mental health treatment as Whites Typically seek care for depression in medical settings (stigma, access issues, lack of culturally competent care) Disparately low rates of follow-up on referrals to MH services (MH treatment “uptake”) “Our patients are simply lost to follow-up” Estimates as low as 3%-6% (Ishikawa, 2011). background The Former Landscape of Health Care in the US: -High costs and frequent use of “safety nets” -Fractured care (social services down the street?) -Dichotomy: mind/body -Primary care: de-facto MH system HEALTH CARE MENTAL HEALTH CARE Post-ACA FUTURE landscape of healthcare “A team-basedcare model of care wherein medical and “Collaborative is associated with significant mental health in providers partner facilitate the improvement depression and to anxiety outcomes detection, of psychiatric compared treatment, with usual and care,follow-up and represents a useful disorders in the primary care setting. It is an addition to clinical pathways for adult patients with appropriate model for treating mild to moderate depression and anxiety” psychiatric disorders and for maintaining the treatment of severe psychiatric disorders (e.g., bipolar disorder, Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for depression and been anxiety problems. Cochrane Database of schizophrenia) that have stabilized” (Hogg Systematic Reviews 2012, Issue 10. Foundation for Mental Health, 2008) THE PROMISE OF THE WARM HANDOFF • The best thing since sliced bread? The promise of ibh for latinos “The importance placed on the relationship Latino patients have with their primary care providers supports a service model that seamlessly extends and generalizes this relationship to the behavioral health specialist. This is the so-called warm handoff model… This extension forms the basis for engagement of clients into behavioral health services via the primary care clinic.” --Manoleas, P., (2007), p. 443. Access Acceptability Research has assessed treatment outcomes, but we don’t know whether or how IBH may improve MH treatment uptake Is it really better than the old “silo” model? In what way? Is the warm handoff everything it is cracked up to be? Purpose PHASE I: To identify specific sociodemographic and contextual factors in the referral process that predict mental health treatment initiation for depressed Latinos within a naturalistic IBH setting. Ho1: Patients who receive a warm hand-off referral type will be more likely to attend an initial behavioral health visit than those who receive a cold hand-off. Ho2: Patients higher in acculturation will be more likely to attend an initial behavioral health visit than those lower in acculturation. Ho3: Patients with comorbid anxiety will be more likely to attend an initial behavioral health visit than those without comorbid anxiety. Purpose • PHASE II: To qualitatively understand why Latino patients decide to follow up or not with behavioral health services for treatment of depression upon referral. • Study results have implications for reducing mental health utilization disparities in Latinos, as well as illuminating factors that compose effective IBH models. Community health clinic ole “The medical and dental home for Napa County’s underserved, providing high-quality, affordable, compassionate and culturally sensitive primary health care”. Behavioral Health Services Targeted Non-Specific Background: Process of care • PHQ-9 • 9+ (theoretically) triggers referral to BH All medical patients screened for depression/anxiety sx Referral to BH by PCP • Show (uptake/initiate) • No-Show • Warm Hand-Off (WHO) or • Cold Hand-Off (CHO) Behavioral health treatment initiation ? Predisposing Enabling Need Methodology: Sequential mixed methods PHASE I: Retrospective cohort design Medical records review (N= 431) Predictor analysis: Show/no show to initial BH visit (dichotomous) PHASE II: in-depth semi-structured interviews to “dig deeper” into the decision to follow-up or not with BH (60-90 minutes each) Thematic analysis Methodology PHASE I Key predictor variable of interest: Warm handoff vs cold handoff Severity of depression (score on PHQ-9: 9-27) Length of time between PCP visit and BH visit Acculturation (language) Co-morbid anxiety Anti-depressants Eth/Gen match PCP & pt; Eth/Gen match BHC & pt PCP/Patient Alliance (proxy) Income level Insurance status Sex Age Sample PHASE I (N=431) • 73% Female; 27% Male • Age: x̄ = 43.5; range: 19-86 • 81% Spanish-speaking; 19% English-speaking • 78% Moderate depression-Moderately severe depression; 22% Severe Depression • 36% Warm handoff; 64% Cold handoff • 52% on psychotropic medication • 16% Co-morbid anxiety • 79% at or below federal poverty level • Days to initial BH appointment: Mean= 15 days (range: 1-56) Findings PHASE I The Good News: 52% attend initial BH visit. The Surprising News: Warm handoff, acculturation and comorbid anxiety not predictors of depression treatment uptake but… Significant negative interaction effect between English language and warm handoff (OR= 0.271, p = .01). In plain english English speaking Latinos who received a warm handoff were 4x less likely to attend an initial BH visit than those who received a cold handoff referral. MOMENT OF SILENCE TO LET THAT SINK IN… PHASE I: Other findings of interest Table 1.5. Group differences by Language. Characteristics Anti-depressants Yes No Co-morbid Anxiety Yes No Depression Severity (PHQ-9) Insurance Status Uninsured Insured Total N = 431 n 223 208 % (52%) (48%) Primary Spanish N = 349 Primary English N= 82 n 167 182 n 56 26 % (48%) (52%) % (68%) (32%) P-Value *.001 .057 67 (16%) 364 (84%) Mean (SD) 15.64 4.75 49 (14%) 300 (86%) Mean (SD) 15.21 4.66 18 64 Mean 17.50 (22%) (78%) (SD) 4.70 *.000 *.033 222 176 (72%) (44%) 191 131 (59%) (41%) 31 45 (41%) (59%) Sample Phase II (N=16) • 9 Spanish-speaking; 7 English-speaking • 13 women; 3 men • Depression scores: – 11 Moderate; 4 moderately severe; 2 severe • 9 Warm handoff; 7 Cold handoff • 7 attended; 9 did not attend first visit FINDINGS PHASE II Depression narrative matters (meaning & healing) Patients’ relationship with Clinic Ole matters Patient-provider relationship is crucial English-speakers more likely to report negative relationship with provider and/or Clinic Ole Experience of referral matters Wide range of experience Education about depression + match service to need is critical Psychosocial barriers *Readiness* and cost/benefit analysis (wait time) Financial concerns Confusion/misunderstanding Health literacy issues Depression narrative • Gendered • Influences beliefs about healing: MATCHING Well, uh, well depression that is to say, s- they sen-, the s- I felt it, like in itself, Q: How should one treat depression? powerless to resolve my problems, that I would try to resolve my economic problems, my problems f- doctor family, prescribes well let's say tous. survive, of where to–live, and uh, The medication becauseof the it to And counseling because oh, can and talk, I felt like like me I had to I'm hidetalking in a place where onewell, could Well if I out owed you that to you, and,no and, likesee youme. need to let anyone money, thatfeel they didn'tlike, see all me,ofbecause I did what not have way what of paying everything that you inside, our feelings, you a want, you, uh, themwant, back.what Or, uh, or to be thinking "Tomorrow I going come with don't hasor, happened to us, what we, whathow we am have lived, to like, yes,up I feel so much money pay what is the, the, the rent, food, and all of that?" And uh, and, like that gives us to relief… and at times I would think about, to myself I would say, I'm thinking of sleeping and not waking up tomorrow. -- Anabel; 45; Spanish-speaker; Did not attend first visit -Matias, age 49, Spanish-speaker, Attended first visit CHCO experience It's convenient for me. As I told you, this clinic gives me confidence, mostly because we are, there are Latinos, Latino people like us, people – well yes, Latino people that speak Spanish and everything, right? So I feel a confident coming here. - Anabel CHCO EXPERIENCE • Provider-patient relationship Q: Tell me about your relationship with your primary care provider. Well I don’t that, at least withreally the first doctor, he understood whole It's good, it'sthink really good we have good communication withthe each other um it depression part of it never all.… because don’tum think hemy cared. I guess that’s all happened, I had seen her Iuntil I had appendix taken outthe in best way to put it. tried to him … youValley know and they um askityou questions November andLike, sheIcame to tell Queen of the wasthese the first time I ever when you first come in, you know, “Have you been down for like two weeks?” met her and then from there you know she you know ah referred me to come or, back you all oflet the answers were prettyso much “Yes”… I guess kindanof and know, come and see her, her know how it went it went reallyAnd good it was Ilike thought maybe he would elaborate you know, like,I,“This isn’ther. normal,” you instant um I guess you want to say on likethat, connection, really I trusted know, “How long have you been feeling this way?” And it was never a conversation of anything that. - Paola; 31;like English-speaker; Attended first visit - Claudia; 32; English-speaker; Did not attend first visit. REFERRAL EXPERIENCE • Extreme variability of referral experience • Impression of BH services is crucial Can you tell just, me about experience referred tothen behavioral Well, I, so, what Iyour should do, well, being cry and cry and get outhealth? everything I have Q: It says here that you saw that same day…give tell me me medicine more about that inside. Like that I, well, it hit the me counselor like that. Well, they don’t to calm Imeeting. don’t know, just kind When of feel Ilike thethey, girlsthey ask didn’t those want questions just to ask Like, me down or Ianything. went to attend me. them. They gave maybe not for for the–benefit of them, butbut if feels likedepression. it’s just something have do… me medicine for another thing, not for … The they nurse just to told me Well Ithey felt gooit’s just that, that was what I should have done, to said have come, You whatgood, I mean?...And, um, because when come thehere pastshe they ask“you you thatknow gave me a little piece ofthat paper… She toldI’ve me, herein the, because moment I had courage to tell So, her Imy problem, I feltare comfortable, them, andatthey never out the a piece of paper. was like, “Why you asking are going tothat see this filled one”… andthese from the moment toldgonna… the doctor, notgonna the counselor, sothem then I, I feltyou comfortable, me things? Are Iyou really remember when go back and with, and with themy idea to CHO; see her [the counselor]. feltLike more, fill out the top of paperwork?... Itnot feels like something they perfect, have to Ido. - Lola; 45; Spanish-speaker; Did attend firstWell visit it was well with I’m more desire to come andgoing to telltoher aboutthis?... what it Next is that wasI upsetting protocol. like, is anyone even askmore me about thing know some me.walks in the room… girl - Matias; 49; Spanish-speaker; warm handoff; attended first visit Claudia; 32; English; WHO; Did not attend first visit Psychosocial barriers & Pathways The referral process was ... from [my doctor] was, um, excellent. She was very indulging and, she was very ... attentive and ... you know, she really wants me to come to the appointment. And, um Alicia was very nice. She was Q: Why did you decide attend the visit Um, with they the counselor? very understandable just to like [my doctor]. both like, try to help you They called mecan, to say tothey come appointment, to forget about that it. I they said yes, whenever they and trytotomy give you advice not on the knowledge Because I Ididn’t … going I don’t want it to get worse. hoping that it don’t getwant worse but they said it was bedoctor] twenty dollars. said, no, [my told me I didn’t have. And just think that to [my and AliciaI I’m like they're ... doctor] they really and Itoknow that some medications areI just … Iyou know work orfeel some have paywith because can’t right now; can’t; don’t havethey She youdo, can to help you um ...I depression. They really want you toenough. getdon’t better andsaid, so I’m at the point where I and don’t even … talking I don’t to want take notokind pay later. Ido said, no… I feel bad and I wanttowith totake keep thatto person feel of better and better in If life, not get want stuck depression, like, for a long medication forbewhat because I’m already a ton for my I’mit’s better, I won’t ableI’m to feeling, do it. Why? Because I have on to be paying andillness. paying.SoSo time. just …toyou know I don’t know, I just … I want think anything. talking is good youit.know. better cancel the appointment; I don’t Cancel And my son said, well, mom, if they’re charging you, why do you go? Instead of that, go for a walk. So -Sandra;19; English-speaker; Warm Handoff; Did not attend first visit Maria; 39; Warm Attended first visit. I--cancelled it, English-speaker; and I haven’t been able Handoff; to see any counselor. I haven’t. Because, um, cancelled it on me. Because I apparently, she wasn't gonna make - Rodelia; 56;they Spanish-speaker; cold handoff; did not attend first visit. it. So um, they never rescheduled another one with me. Uh they said they were, but they never did. They just cancelled it, so I never came to talk to her. summary • Compared to silo model, our follow-up rate is good, but could be better; • English-speakers don’t seem to respond well to WHO, but qualitative findings suggest that the experience varies tremendously • Several simultaneous factors appear to influence follow-up… enabling predisposing need Followup summary • Depression narrative (meaning and healing) • Relationship with clinic and medical provider • Referral experience (hand-off or hand-hold? Matching services to symptoms/narrative) • Readiness & expectations/symptom acuity • Everyday barriers ($, misunderstanding, scheduling conflict) Implications & Discussion - (Re)-Consider the Warm Handoff as a “best practice” - What works, for whom, under what circumstances? - Role of acculturation when we consider cultural compatibility of the IBH model - Centrality of the PCP-patient relationship (making the PHQ-9 a meaningful tool) - Check for understanding & motivation (health literacy, reinforce plan); assess additional access barriers Questions? Thank you to Clinic Ole, and especially to the participants in this study, who generously shared their stories with me. They, like I do, hope their stories will help improve care for all. This study was generously supported by funding from: UC MEXUS, The Fahs Beck Fund for Dissertation Research, and The Center for Latino Policy Research at the University of California, Berkeley. I am also grateful for funding from UC Berkeley’s Dissertation Year Fellowship, which supported me in my final year of research. Contact: Elizabeth.firstname.lastname@example.org Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!