Gary Haugland

Performance measures of cultural competency in mental health organizations.

The authors utilized numerous documents created by advisory groups, expert panels and multicultural focus groups to develop performance measures for assessing the cultural competency of mental health systems. Competency was measured within three levels of organizational structure: administrative, provider network, and individual care-giver. Indicators, measures and data sources for needs assessment, information exchange, services, human resources, plans and policies, and outcomes were identified. Procedures for selection and implementation of the most critical measures are suggested. The products of this project are broadly applicable to the concerns of all cultural groups.

Performance measures and their benchmarks for assessing organizational cultural competency in behavioral health care service delivery.

A project is described in which performance measures of cultural competency in behavioral health care were selected and benchmarked. Input from an Expert Panel representing the four major ethnic and racial groups in the U.S. and persons with extensive experience in implementing cultural competency in health care, along with survey data from 21 sites were used in the process. Measures and benchmarks are made specific to organizations that administrate care networks, and to service entities that deliver care. Measures were selected to parallel an implementation process, and benchmarks were set at “gold standard” levels.

Treatment patterns of young chronic schizophrenic patients in the era of deinstitutionalization

A retrospective longitudinal treatment utilization study of 56 young chronic schizophrenic patients who began their treatment careers during the deinstitutionalization era was carried out covering all psychiatric services provided to each patient since first treatment. The group was primarily male and was characterized by histories of drug abuse and violence. Treatment utilization was heavy, discontinuous, and episodic with these patterns intensified for patients with histories of drug abuse. The majority of the group became “long-stay” hospital residents. The clinical and mental health policy implications of these findings are discussed and further research is suggested.

Mental Health Screening in Addiction, Corrections and Social Service Settings: Validating the MMS

ObjectiveThis paper tests the validity of a simple and easy to use scale, the Modified Mini Screen (MMS) to identify people with mental health problems in the treatment ecology for chemical dependency, including specialty sector substance abuse treatment settings, and shelters, jails and street community outreach programs.MethodsFour hundred and seventy-six individuals in chemical dependency treatment and in jails, shelters and outreach settings completed a set of 22 items to screen for mental disorders—the MMS—and a validation interview—the Structured Clinical Interview for Diagnosis (SCID). ROC curve analysis was used to (1) determine the optimal range of cut points for identifying mental health problems in this culturally heterogeneous sample and wide range of treatment and community settings, and (2) calculate overall accuracy, sensitivity, specificity, and positive and negative predictive values for the MMS.ResultsForty three percent of the sample met criteria for a DSM-IV diagnosis of anxiety, mood or psychotic disorder. At cut points of 6–9, the sensitivity of the MMS ranged from 0.63–0.82, its specificity ranged from 0.61–0.83, and its overall accuracy ranged from 70–75%. At these cut points, the MMS screen performed equally well for men and women, and for African Americans and Caucasians, and is comparable to the performance of other screens validated for less compromised populations. A decision tool has been developed based on these results that is available from the authors.ConclusionThe MMS performs well in naturalistic chemical dependency treatment settings, jails, shelters and street outreach programs across gender and ethnic groups, and can provide a useful tool in service systems developing a “No Wrong Door” policy for persons with co-occurring mental health and substance abuse problems.

Components of Cultural Competence in Three Mental Health Programs

OBJECTIVE The aim of this study was to identify components of cultural competence in mental health programs developed for cultural groups by community and mental health professionals from these groups. METHODS Three programs were studied: a prevention program primarily serving African-American and Afro-Caribbean youth, a Latino adult acute inpatient unit, and a Chinese day treatment program in a community-based agency. Nine study-trained field researchers used a semistructured instrument that captures program genealogy, structure, processes, and cultural infusion. Program cultural elements were identified from field notes and from individual and group interviews of consumers and staff (N=104). A research-group consensus process with feedback from program staff was used to group elements by shared characteristics into the program components of cultural competence. RESULTS Components included communication competencies (with use of colloquialisms and accepted forms of address); staff in culturally acceptable roles; culturally framed trust building (such as pairing youths with mentors), stigma reduction, friendly milieus (such as serving culturally familiar foods and playing music popular with the culture), and services; and peer, family, and community involvement (including use of peer counselors and mentors, hosting parent weekends, and linking clients with senior center and community services). CONCLUSIONS Incorporating these components into any program in which underserved cultural populations are seen is recommended for improving cultural competence.

The Nathan Kline Institute Cultural Competency Assessment Scale: Psychometrics and Implications for Disparity Reduction

The NKI Cultural Competency Assessment Scale measures organizational CC in mental health outpatient settings. We describe its development and results of tests of its psychometric properties. When tested in 27 public mental health settings, factor analysis discerned three factors explaining 65% of the variance; each factor related to a stage of implementation of CC. Construct validity and inter-rater reliability were satisfactory. In tests of predictive validity, higher scores on items related to linguistic and service accommodations predicted a reduction in service disparities for engagement and retention outcomes for Hispanics. Disparities for Blacks essentially persisted independent of CC scores.

Access to and Use of Non-Inpatient Services in New York State Among Racial-Ethnic Groups

OBJECTIVE Nationwide studies contrasting service use of racial-ethnic groups provide an overview of disparities, but because of variation in populations and service systems, local studies are required to identify specific targets for remedial action. The authors report on the use of non-inpatient services regulated in New York State (NYS) and report use by the states larger cultural groups. METHODS Data from the NYS Patient Characteristics Survey were used to estimate annual treated prevalence and treatment intensity, defined as the average number of annual weeks in service for non-Hispanic blacks, Hispanics, Asians, and non-Hispanic whites. The latter rates were obtained for specific types of treatment use, by persons age and diagnosis, for the state and for population density-defined regions. Statistical methods contrasted rates of whites with other groups. RESULTS A total of 578,496 individuals in these racial-ethnic groups were served in 2,500 programs, and 51% of those served were nonwhite. Treated prevalence rates of whites were lower than those of blacks and Hispanics and were substantially higher than prevalence rates for Asians. Statewide treatment intensity rates of all racial-ethnic and age groups were comparable except for lower use among Asians >65. Key findings from granular analyses were lower treatment intensity rates for black youths with disruptive disorders, Hispanic adults with anxiety disorders, and Asians >65 with depression compared with white counterparts. In upstate metropolitan areas, black youths and Hispanic adults received services in fewer weeks than whites, and in the New York City metropolitan area, whites >65 had higher treatment intensity rates than contrast groups. CONCLUSIONS Findings suggest a need for assistance to black families in negotiating the multiple systems used by their children, clinical training focusing on cultural symptom presentation, screening of Asians in community settings, and mandated cultural competency assessments for all programs.

Mental health service needs assessment

A method is presented for identifying populations in need of mental health services in states, counties, and subcounty areas, using social indicators for zip codes within the areas. Three common approaches to needs assessment are presented, and limitations of each approach are discussed. The zip code method highlights homogeneous subareas of both high and low risk within heterogeneous counties. Using the method targets high risk need areas more efficiently.A method is presented for identifying populations in need of mental health services in states, counties, and subcounty areas, using social indicators for zip codes within the areas. Three common approaches to needs assessment are presented, and limitations of each approach are discussed. The zip code method highlights homogeneous subareas of both high and low risk within heterogeneous counties. Using the method targets high risk need areas more efficiently.

CHARACTERIZING THOSE IN MENTAL HEALTH TREATMENT: THE PLANNER'S PERSPECTIVE

A hierarchical classification scheme intended to categorize patients receiving mental health services into groupings useful for planning purposes is presented. A patient in treatment is assigned one of four levels jointly defined by an assessment of the patients current level of disability and expected long-term service requirements. To illustrate the operationalization of the scheme, using data collected as part of a one week survey of patients in treatment in the New York State mental health service system in 1985, patients are classified on long-term residency, probable source of funding for service received in the week (used as a surrogate measure of level of disability) and diagnoses. Several applications of the scheme are given including crossregional comparisons of service systems and examining service use of targeted minority and age subgroups.

Making the cut: Depression screening in urban general hospital clinics for culturally diverse Latino populations

OBJECTIVES We examined whether the cut-point 10 for the Patient Health Questionnaire-9 (PHQ9) depression screen used in primary care populations is equally valid for Mexicans (M), Ecuadorians (E), Puerto Ricans (PR) and non-Hispanic whites (W) from inner-city hospital-based primary care clinics; and whether stressful life events elevate scores and the probability of major depressive disorder (MDD). METHODS Over 18-months, a sample of persons from hospital clinics with a positive initial PHQ2 and a subsequent PHQ9 were administered a stressful life event questionnaire and a Structured Clinical Interview to establish an MDD diagnosis, with oversampling of those between 8 and 12: (n=261: 75 E, 71 M, 51 PR, 64 W). For analysis, the sample was weighted using chart review (n=368) to represent a typical clinic population. Receiver Operating Characteristics analysis selected cut-points maximizing sensitivity (Sn) plus specificity (Sp). RESULTS The optimal cut-point for all groups was 13 with the corresponding Sn and Sp estimates for E=(Sn 73%, Sp 71%), M=(76%, 81%), PR=(81%, 63%) and W=(80%, 74%). Stressful life events impacted screen scores and MDD diagnosis. CONCLUSIONS Elevating the PHQ9 cut-point for inner-city Latinos as well as whites is suggested to avoid high false positive rates leading to improper treatment with clinical and economic consequences.