CHUNG: Good morning.
CHUNG: How you guys going? It’s cold, it’s very cold. So, my name is
Bowen Chung, I am a psychiatrist and I am both the Chair and presenter. And
today, we’re going to be talking about from Community Partners in Care to the Health
Neighborhood Initiative translating NIH Funded Science into Policy and Public Health Impact.
And we’ve had a number of funders over the years. The IMH, the National Library Medicine,
the National Institute of Minority Health and
Health Disparities, UCLA Clinical Translational Science Institute throughout with Johnson
Foundation, California Community Foundation and the Patient Center, Arkansas Research
Institute. None of the speakers have any disclosures? And basically, we’re — I’m going to sort
of have everybody — I’ll introduce everybody and we’re going to go through the presentations
and then sort of safe time with the end for some questions and discussion.
My name is Bowen Chung, I’m a Child Psychiatrist by training and I’m in the County of Los Angeles
Department of Mental Health employee. I also worked at UCLA in my faculty role and then
I run corporation and a research role. I’m going to be talking a little bit about the
study and talk about some 36 months client outcomes from a randomized trial.
Beth Bromley is an associate professor now. She officially got to associate. She is a
Psychiatrist Anthropologist who is also at UCLA but works at the West L.A. V.A. Healthcare
System and she’s going to be talking about the whole person care for depress clients
and under a resource communities where we look that stakeholder interviews about what
client with depression may potentially need both for depression care as well as social
determines as well and to sort of summarize some of the qualitative interviews with our
community partners and care participants about what they felt they needed to address their
depression and also what they needed from the social determine side to help them as
well. Enrico Castillo is a Public Health Psychiatrist
who is with the Department of Mental Health, but he’s also at UCLA as Robert Wood Johnson
Clinical scholar. And he is going to talk about, since they’ve called interviews we
did at the Department of Mental Health where we talked to a lot of administrators and leaders
in the healthcare system publicly fund healthcare system in Los Angeles about how they would
take something like the findings from an NIH funded study and sort of think about how we
put it — be put into something called the “Health Neighborhood Initiative” which is
a policy initiative at the Department of Mental Health. And our discussion at the end most
importantly is Dr. Marvin Southard. He is currently a
professor of Social Work Practice at USC, but for many, many years, I think 17 years? SOUTHARD: 17, yes.
CHUNG: 17 years was City Director of the Los Angeles County Department of Mental Health
which I believe is the largest public mental health system in the world. And before that,
he was in more over all county, current county as a Mental Health Director now. And he was,
you know, wow. A lot of our work who’s taken place, he was directly just step down last
year. Before I start and I’m going to do this just
because I have to channel my community partners and actually, I have no keys. But, one of
the things we do is, you know, a lot of our work is actually a version of community bar
— based participatory research. I don’t know if people know what that is. People know?
So, basically, community participatory research is a form of research that is done in public
health where one creates a partnerships with communities, usually, under resource minority
communities or sort of I guess — no, I’m about to spend, but the sort of marginalized
communities that often don’t participate in research because of lack of trust, right.
And usually, actually, I do this presentation. We do these presentations together with our
community partners, right. And one the things we like to do which is a little bit different
than your usual scientific talk. This will try to give you a flavor of what it would
be like to work in the community. And so, I’m going to do with something called the
community engagement exercise that we used it in a lot of our meetings where we bring
together, you know, community partners, other stakeholders as well as, you know, researchers
to sort of do a warm up. Do — anybody open to pulling up their keys? You know, anybody
who want to pull up their keys? CHUNG: Yeah, you’ve got a key, yeah. I don’t
have a key yet, I’m homeless right now. OK. Everybody pull out their key and I’m going
to randomly ask people on the audience. Why don’t you — to pull up a key and tell me
a little bit about it? CHUNG: So as my community partner say, you
have a house and have ride, OK. So, what about you? Anybody else you want to prove?
(UNKNOWN): This is the key to my apartment and my dorm.
CHUNG: Oh you got — so, you have — you’re on a school.
CHUNG: Oh great. What are you getting? A college degree, have you what?
CHUNG: OK, wonderful. Let’s go over here. Let’s do — what’s your key?
(UNKNOWN): I have one key from my friend’s house; we’re going to take care of her cat.
CHUNG: What are the other keys? (UNKNOWN): And my house key and my car key
and this is — these are keys to a safe. CHUNG: OK. So, you have friends who trust
you enough to have a key to their house, such pretty important, right? And then, let’s go
to Enrico. CASTILLLO: I have hotel key because I have
the honor presenting here. CHUNG: So, we have somebody here. So, one
of the things that we always like to do with this talk is just a sort of — with this particular
exercise is to remember that we’re doing a lot of this work for the people who don’t
have keys or it’s one of my sort of community partners always says, you know, the people
with a card board condos who are PHDs in the sidewalk. So, all our work is really about,
you know, sort of helping, sort of improve the lots of people who mean unsurely always
have the opportunity to sort the effective by a good care, good science.
And last, that would be very well miss if I didn’t discuss the fact the P.I. for the
studies was Ken Wells who is Psychiatrist and Health Services Researcher at UCLA and
our community partner Loretta Jones who is a Community Health Advocate with an organization
called, “Healthy African American Families”. And we will go through quickly because I’m
already behind. So, one of the things about our work is that we’ve been doing it for a
long time. We do all of our work in partnership with our community partners. We’ve been working
in Los Angeles with funded work and basically, some narration of the same project for about
12 or 13 years. We started off with a private called, “Witness for Wellness” which was actually
part of NIMH-Funded Research, Health Services Research Center.
In 2003, we had a number of projects funded by different organizations like the California
Diamond. The results from the study are funded by the NIMH, it was a randomized 12 and the
dissemination implementation portfolio. And we’ve had sort
of three year follow up funded by the Patient-Centered Outcome Research Institutes. And actually,
some funding by the National Institute on Minority Health and Health Disparity to study
how this particular study are sort of translated into science and policy.
One of the things we always want to talk about and this is from our community partners is
that, you know, they told us many years ago that the, you know, this is about wellness,
it’s not about mental health meaning we don’t want to deficit in the base model of health.
We want something based in resiliency. And so, it’s really not just a — for done work.
And we sort of came up with this — we kind of came full circle when we started looking
at the World Health Organization Definition of Health — or Mental Health is not just
the absence of mental disorders but the state of well-being where people are actually able
to realize their own potential, cope with the normal stresses of life and make a contribution
with their community. And I think that’s something that really infuses all of our work. Another
thing that I think everybody is talking about here at this conference is how those — the
social determinants affect to how people sort of people’s mental health in particular?
And how that sort of, then, once again going to just a policy and the politics?
So, a lot of our work is really based on the fact that we know that depression is treatable.
Depression care and primary care has been shown to improve outcomes for minorities after
our American, Latinos. This is slide from Dr. Wells’ study partners
and care which is one of the First Depression Collaborated Care Studies. It was done in
the late ’90s, paper started to coming out in 2001 or 2002 which randomized 55 primary
care clinics across the country to either quality improvement or collaborative care
for depression versus usual care. And what they found was is that before, the study took
place that basically, minorities were not getting any good quality care and have four
block comes for depression. And after this quality improvement program
sort of was implemented. They randomized 55 clinics. They found that African-Americans,
Latinos actually got better quality of care but also did much better in terms of depression
outcomes. In fact, African-Americans, Latinos sit about
five times better that whites over five years in terms of the outcomes with some sort of
impact on employment, in other words, people are less likely to be unemployed as well as
improvements in that work about 15 percent for five year. Dr. Wells being sort of very
earnest man, as I said, well let’s go to do this in minority communities because minority
is the better, right? But one thing we figured out very quickly when we did started doing
the study was that we really don’t know a lot about community linkages and a lot of
the places in places like South of Los Angeles or how it would. There’s none in the primary
care or mental health even begin to take care of the – beyond that need there.
So, what we did was through not using our community engage approach. We developed a
study and a partnership with about 50 organizations in Los Angeles County. Everything from churches,
the barbershops, the beauty salons, the County Kaiser, senior centers and we asked them to
sort of participate in a randomize trial. All this is based on something we called,
“Community Partnered Participatory Research” which is this sort of a variation in Community
Based Participatory Research. We’ve really engages community’s patience — when I said,
community, I mean, sort of community health advocates, just interested individuals, takes
a really grasp to this approach. Other types of organizational stakeholders like heads
of clinics, providers, ministers and brings them around the table and engages some around
sort of principles of community engagement. Transparency, respect, part sharing, sharing
leadership to a knowledge exchange, it’s a very classic principles for community based
participatory research. And also, they’re put into a memorandum of understanding with
our partners about data ownership who has papers, you know, who owns papers, disagreements
about things, who owns the data and this is all built into sort of a model of our community
to weigh capacity development. So, one of the things that we always like
to talk about is that not the — we don’t just empower individuals in the community,
in fact, the academic partners are – have a lot of capacity development as well. So, if community partners or patient or somebody
who is homeless can make an eco-contribution that somebody like the director of Mental
Health could, a famous professor, researcher or a doctor because often times, the knowledge,
that’s most important. Whom we’re trying to sort of help with is a person who is homeless,
right? Sort of we improve their out. And so they are, a little bit experiences is really
important. There are three stages in our stages in our study. We call that the vision, the
value and the victory. With — the vision is a sort of the partner planning process
where we develop the study together, look at outcomes together. If I bring in one of
notes for Corey (ph), this is very similar to kind of the way that they are thinking
about things. We do a partner clause, so we do the randomize trial together. We did a,
you know, compared two conditions which I’ll explain later. And we look that one year outcomes
in three rock. And so now we’re disseminating, we call it the victory.
So, what was Community Partners and Care? Community Partner and Care was basically just
a version of the dissemination implementation study that was done under community engagement
conditions. We’ve work in two communities with about 2 Million residences. We had 95
programs in 50 agencies and the programs are quite diverse. As I mentioned, they could
be barbershops, beauty salons, senior centers, exercise clubs and within the agencies and
programs we’ve recruited patients. The inclusion criterion was PHQ weight over 10 or above,
18 years or older, English or Spanish speaking and reliable contact deformation, that’s it.
About 90, 70 and 98 percent of the people we approached their way to be screened. We
had about — we screened about 4440 clients. We enrolled about 1200. We had 981 complete
baseline and you see the numbers sort of over three years. And, well, this is actually not
bad if you think about — we’ll show you the demographics for something like 60 percent
on — we’re under the federal poverty level. The family outcomes of the client level was
poor mental health related quality of life, MCS 12 scores, 12 item, the mental health
subscores of the — as of 12 and the PHQ-8 . And then, we have the provider organizational
outcomes training participation rate. Why do we randomize organizations to? We randomize
some of the two things; one was a depression collaborative care training or quality improvement
training. We invited the programs that were randomized. We randomized program to two conditions
by type, one was called resource for services
which roughly matched with the County Los Angeles did for depression primary care behavioral
integration where we had a conference, introduce people to tool kits, had a webinars and trainings,
and provided technical support in person and over the phone. Todd (ph) implements these
tools. The second one was something we called community
engagement or planning. We’re basically – we train people up but also engaged in each community
for 6 months. All of these agencies and patients and community members in a planning process
where you — we adapted the tool kits for the particular agencies. So for example, we
adapted something like care management which is detection, education, care coordination
within the clinic, sometimes even therapy, and that something that administered to do
for example or none license person. So a lot of task shifting.
We simplified things. We created something called the resiliently class which was basically
a 15 session group CBT class based on something called, “We care” what was published in Gemini
with low income Latino and African-America went for depression. And we adapt to something
so that none professional could do. And that has done seven sessions in a church or with
or whatever. We also encourage the networks to work together and I’m going to go through
this much more quickly. These were all the sort of tools that we had. You know, we had
CBT with care management. We have patient education resources. Clients that were screened
were incredibly diverse 65 percent and had a family income over below 10,000 a year,
85 percent were African-American, Latino half; this has taken placed before ACA had no insurance.
One of the things that we found, this is PHQ score grade of in 10 was the depression was
— depressive symptoms were quite common in both none healthcare and healthcare settings.
And primary care for example is about 35 percent and sort of your average, sort of HMO manage
care population, it’s about 15 percent in primary care. So, depression was really high.
One of the things that happened actually was that, you know, in the community engaged condition
we plan with people. We retained them up and ended about 6 months of sort of problem-solving
on how things were working in this virtual network for depression care. We distributed
the task. And our community engaged condition, we — the provider participation in these
trainings and planning was just off the chart. And we only provided people with lunch or
food and continue indication if they needed it. We didn’t pay them a dime, none of the
agencies. One of the things we found was at six months
both community engagement on planning and research for services improve quite mental
health, they’re quite mental health related post (ph) like depression supports did not
change. This was in — as essence that compare of effectiveness study. But community engagement
of planning was more effective than resource for services and improving mental health related
quality of life physical activity and reducing homelessness risk. We reduced behavioral health
customizations by about 50 percent. Also, the community engagement condition did
an interesting thing where it shifted outpatient depression services away from specialty mental
health towards the primary care of face to face services and part of services for depression.
So, if we ask people not only, where they went for services over six month period for
anything, we also ask them that something that looked like depression or emotional support
services within these different places. The improvements were not due to what you
would usually think about is quality metrics for depression. So the mechanism maybe something
around that’s not consistent with the normal treatment which is kind of — or sort of interesting
finding as well as behavioral health hospitalization reductions. And in 12 months, we showed continuing
matters improvements and mental health really quality of life community engage – community
engagement of planning seem like it did a little bit better than resource for services.
It was actually published in the Annals of Internal Medicine in 2014. The six month findings were publish in the
journal of JAMA Internal Medicine. We had continued reductions of behavioral health
hospitalizations for the community engaged condition over 12 months. And then,
three years what we started looking at was whether there was some long-term patient learning
from the community engaged networks or patients or clients who are exposed to this community
engagement networks in terms of reduced barriers, increase self-advocacy, service shifts, the
service shifts from formal health care to none healthcare studies continue especially
in the community sector. We, you know, sort of continued on with our intended treat analysis.
And the regression results for linear regression odds ratios for logistic comes in incidents
rate ratios, purpose one sort of like — for continuous outcomes you can put on transformations.
We use two sided T test and use the faults discovery rate adjusted for P value 0.05.
At baseline, because we had a lot of patrician, our community engages group was about two
years older than the resource for services but otherwise there are no differences. Our,
you know, group continue to be majority ethnic minority under
the federal poverty level with lot of multiple chronic health conditions. So what we found
at three years was that there was no difference in community engagement planning and reaches
out for services on poor mental health related quality of life for depression. But we did
found some small physical health related quality of life improvements in the community engaged
group compared that resource for service group. The sort of the trajectory towards your behavioral
health hospital nights continued. There were greater sort of percentage of community sector
visits for depression or greater faith-based services business for depression, so those
seemed to continue. So these are the sort of the findings. And
I’m going to go through. And then, they’re very quickly in the interest of time. Oh,
and with stabilizers seemed to have increased use not sure why. So, the interpretation we
had was that long-term changes and utilization from the beginning, networks activation, with
hour use of services from the alternative sectors from which the clients were identified.
So within these sectors we didn’t actually specify where people should get care. The
providers were — an organization for free to use it on anybody. And that, we
didn’t actually didn’t tell them for the most part where these — who were these people.
So the shift sort of word like, we didn’t push it one way or another. And
that we just had them sort of — we just have them trained, and then we track clients through
there, and we didn’t sort of asking to specify this intervention on particular individuals.
Well, what’s interesting is that it hopefully they’re quality, seemed to improve consistently.
And the three — and the reductions in hospitalization seem to persist overtime. The positive impact
has been that, you know, one of the things that we were able to do was work with Dr.
Southard when he was a Director of Department of Mental Health to actually add this as part
of the strategic plan for L.A. County to do something called the Healthy Neighborhood
Initiative which other people will talk about to coordinate behavioral health services across
social determinants on an eight pallet neighborhoods. We also had, you know, the State of California
funded a behavioral center — a Center of Excellence for Behavioral Health. And we also
had simple query (ph) funding as a result of this.
One of things we were very proud about and we always like to talk to people about this
fact that we won the 2014, Association for Clinical and Translational Science Team Science
Award. This is basically the clinical translation on science awardees sort of, big sort of impact
award for team science. And we’re the only applied research team to have won it usually
given to geneticists or biochemist. We also won the 2015 Community-Campus Partnerships
for Health Annual Award which is a public health organization that sort of — as an
international award that celebrates a groups that you — on this kind of work with adherence
to social justice, principles and we won the 2015 UCLA Community Program of the year. So,
we’ve had a lot of sort of good acknowledgements for a work.
Anyway, so, that was quick. Next step, let me see. There you go. Dr. Bromley.
BROMLEY: Thank you Bowen. OK, it’s nice to be here with you today. My name is Elizabeth
Bromley. I’m associate professor in the center with Bowen. And really representing much larger
partnership. The results I’m going to talk to you about
today were co-led by myself, my colleague Dmitry Khodyakov at Grant and with the leadership
of Felica Jones, the Healthy African-American families and a Team of Community and Academic
Researchers that work in this data from beginning to end. Study design, data collection, and
analysis, write up, we have a really active team.
So, my talk today will address issues of client and provider priorities for health and social
service outcomes at 36 month follow up in the — lets see that (ph) sample. So, we understand
that socio-cultural factors and depression intersect and interact in multiple ways. First,
of course, depress of symptoms and depression are associated with functional impairment.
Depressed individuals often also, have unmet social needs, oops — simultaneously, poverty,
housing stability, social isolation, violence and other social factors may adversely affect
mental health. And we know that social and economic factors may compound ethnic disparities
in care and outcome in depression. So it follows that to achieve clinical outcomes, depressed
individuals may require help from different service providers working in different sectors
to address interrelated health and social service needs. These social service and clinic
providers may work to address the impact of issues like housing instability or neighborhood
violence at the level of the individual client, or these providers may be engaged in efforts
at the population or community level that aim to alleviate some of the social factors
that impact mental health. A 36-month follow-up in CPIC — our community
partners were particularly interested in understanding how the intersection and interaction of health
and social factors shaped the service experiences of clients and of the providers that serve
them in their communities. So the data we’ll present here asks how do depressed clients
and their providers in under-resourced communities prioritize diverse health and social outcomes.
And what strategies do providers use to achieve these diverse outcomes?
It’s the case that the answers to these questions could inform the implementation of several
current efforts to transform service delivery in public and community settings in order
to address health and social factors. We heard about some examples in Philadelphia this morning.
Some other efforts that aim to integrate services for health and social factors include California’s
Whole Person Care Initiative and the Health Neighborhood Initiative; the Centers for Medicaid
and Medicare’s Accountable Care Communities Program; the Robert Wood Johnson Foundation’s
Culture of Health Initiative; and the Thrive NYC efforts in New York City, all of which
describe cross-sector collaboration as key to achieving improved health outcomes and
health equities. So just for these research questions, we use
semi-structures telephone interviewing, a 36-month follow-up in CPIC. We enrolled for
interviewing from among the clients that completed 36-month follow up surveys, and we sampled
from client — providers and administrators at the agencies that were enrollment sites
for CPIC. We used purposes-stratified sampling strategies for both clients and providers.
For clients, we sought to achieve diversity in our sample on the variables of ethnicity,
gender, CPIC study arm, so resources for services as well as community engagement and planning,
and also depression status at 36 months as measured by the PHQ-8, and I’ll show more
on that sampling approach later. For providers and administrators from agencies
enrolled in CPIC, we sought diversity on the service sector and looked for both health
and community and social service providers in CPIC communities. We used closed and open
interview items for both clients and providers. The interviews
had a number of similarities and were intended to overlap so that the data could be compared.
For clients, they were asked to describe the importance of various needs, including health
and social factors. So clients were asked to consider at the outset of the interview
all the issues they were working on and to identify those issues they most wanted help
with. So, we asked them: What’s your most important problem or need right now? And after
this open-ended question, we asked clients to specify if they wanted help, yes or no,
with preselected specified needs, physical health, mental health, and housing. We identified
these pre-specified needs based on the literature, discussions with our partners and feedback
from our study team. So we asked them: Would you say you would like help now with your
housing? Would you say you’d like help now with finding food? Went through a set of 10
items in that manner. And then at the end, we asked clients to name for us their top
three needs — the number one most important need, the number two and the number three. For providers, and just to say for clients,
we also then explored each of those top three needs, asking clients’ efforts that they’d
made to get help for that need, what had worked, what hadn’t worked? All of those were open-ended
responses from clients. I’m not today going to present for you any of the open-ended responses
from clients, but I will show you some of the open-ended responses from providers. So
the provider interviews followed that same plan. We asked providers about the clients
they serve in their communities and the sorts of needs those clients confront. What are
their top three needs their clients describe, and then what do providers and agencies do
to try to respond to various needs that clients bring. So we used some simple descriptive
statistic to tally the rates of — the reported rates of particular needs from clients and
agency providers. So, simply the percent of clients and providers (inaudible) each need,
which needs were named most often in the top three.
We used (inaudible) test to determine the association between clients’ depression status
and their needs, which I’ll show you, and (inaudible) test to explore differences in
ranking of needs reported by providers and administrators from different sectors. So
this is our sample. You see we have clients and then providers over on your right. So
again, this is a (inaudible) stratified sample we wanted to get diversity from different
particular variables in the study sample at 36 months. So we enrolled 104 clients, about
half of them were in each study arm. We had focused on Latino and African American clients
solely from the 36 month follow up. We got a good mix of genders and we intended
to sample those whose depression had improved and those whose depression had persistence.
So, we ended up taking the top third and bottom third, based on the PHQ-8 score at 36 months.
So it turned out in the top third of those with the PHQ-8 scores that indicated a PHQ-8
of 15 or higher. So those are individuals who screened positive three years before,
went through the intervention and at three years still had PHQ score above 15. And then
we had in the bottom third those whose depression was PHQ-8 score of 10 or less at 36 months.
I don’t show it here, but it does turn out that there is a substantial improvement in
PHQ-8 scores for those in the resolved depression group and no change much — basically, much
smaller, very little change in the persistent depression group that we sampled here. And
then you see the service sectors that we sampled from the 50 providers and administrators that
we included in the interviews. So, first we walk through the client data.
We ask clients to write their most important needs, and most often clients rated mental
and physical health as their most important needs. Their next most important needs were
help with housing, caring for others and employment. There was a difference in the priorities of
clients with and without persistent depression at 36-month to follow-up. Those clients with
PHQ-8 scores of 15 or higher ranked mental health as their highest priority need. While
those in the resolved depression group, improved depression group with PHQ scores of 10 or
lower, ranked caring for others as their highest priority need. I should say here that in their
open-ended descriptions of their needs, this category of caring for others included both
issues of caring for elderly relatives, caring for
children, trying to access services for children and other family members.
And also help for interpersonal conflict or family challenges, because there’s actually
number of things that are grouped into that caring for others category. So this is a chart
that shows just the frequencies with which each need was mentioned by clients as one
of their top three needs. So for all of the needs listed on the left, the percent and
the number of clients who named it as one of their top three needs. So you see, physical
health was most commonly in the top three. Improving low (inaudible) or help for mental
health was number two. And below that, we see this other range of social factors that
clients report need for help with — housing, caring for others, finding work, improving
spiritual health and finances — all quite common needs, and then a relatively
high rate of need for help with finding food for yourself and your family.
So the “P” values on the right-hand side show you where there were some significant differences
between those with and without persistent depression at 36 months. So improving low
mood was more common among those who still were depressed at 36 months, and as I said,
caring for others. Then you also see the difference in the finding food category — much more
common in those with persistent depression at 36 months. So we asked then providers to
describe their clients’ top needs and providers in administration CPIC agencies named housing,
mental health and employment as clients’ top needs. And here we see similarly how providers
and administrators included each of these needs in their understanding
of their clients’ top three needs. There was no statistically significant difference in
the ranking of clients’ top three needs between representatives from healthcare or social
community sector agencies. So while I break them down here, they were
very similar. So providers ranked mental health, here called improving low mood, and physical
health less highly than their clients, not as frequently naming physical and mental health
as top client concerns. So for instance, only 10 of 50 providers included physical health
as one of their clients’ top three needs. You see that here in this row 10. (inaudible)
50 named improving physical health, while for clients that was the most frequently mentioned
need. Nonetheless, these aren’t identical, but these results suggest that providers and
administrators have a good understanding of the kinds of needs that their clients bring.
And there’s a great deal of overlap between the kinds of needs mentioned as important
by providers, administrators and those the clients’ named.
So in our opened-ended interview, we asked providers and administrators to talk about
how they address this range of needs. So all of these agencies have a primary focus, a
fairly focused agenda mission. Nonetheless, they clearly are working with clients to bring
a large range on that needs with them to their care. So in their responses, providers and
administrators really named three main strategies that they use to address the array of needs
of their clients. First, they very frequently mentioned using needs assessments of some
sort. These were often unstructured or informal needs assessments, but they all mentioned
the importance in-take and early-on in treatment, getting a broad understanding of the kinds
of needs the clients were dealing with in their everyday life. As one said, we do assessments;
we meet them where they’re at, where they are on the front line.
They also — providers and administrators also describe the importance of a client-centered
approach, so it was often a term they used. And what they meant by that was that they
focus not just on what they delivered, but how they delivered services. As one said,
“We involve clients in their treatment planning and development; we try to adjust it to what
the client sees as his or her immediate needs, instead of prescribing them treatment as we
see best.” So although many of these agencies had fairly
focused missions to look at one or another factor in clients’ lives, they were attentive
to the need to think through the array of needs that clients bring.
Finally, a third strategy in order to address these needs providers and administrators so
that they would rely on a network of other providers and other agencies in their community.
They would either deliver care for a variety of needs or they would try to refer clients
for care in the community to address other needs they couldn’t address directly. As one
said, “We have a lot of staff members who do a variety of things in terms of being multi-disciplinary
and multi-faceted and very resourceful in finding an array of services for clients.”
So just to summarize, clients with depression in under-resourced communities identify mental
and physical health needs as most important, followed closely by needs for help with housing
and caregiving or interpersonal concerns. And clients do bring an array of needs with
them into any treatment encounter they have with service providers.
Providers and administrators that serve these clients recognize this array of needs and
agencies use some form of needs assessments. They use client-centered approaches and they
understand themselves to be reliant on a network of providers in their community to address
the diverse needs of their clients. This was a very exploratory study, with a number of
limitations, of course. First, we use our (inaudible) sampling strategy. We didn’t try
to capture representative samples. So we can’t say that these findings are representative
either of the larger CPIC population as a whole, or necessarily generalizable to clients
in other under-resourced communities with depression. In addition to other limitations,
we don’t actually match clients and providers. So we’re not certain that providers’ understandings
of their clients’ needs are directly in response to these same clients that we interviewed,
though these were the same agencies where our CPIC clients were recruited from.
Finally, we sampled providers and administrators that had participated in the CPIC intervention,
albeit from both of the study arms – the resources for services and the community engagement
arms. So it may be that the CPIC experience directly or indirectly has impacted providers’
understanding of the array of needs our clients have or the importance of a network of providers
to addressing those needs. However, not all of the providers that we interviewed had participated
in CPIC because of high rates of turnover in these communities. Agencies often — those
that we interviewed were new to the agency and may not have been exposed in the CPIC
intervention itself. So in conclusion, our findings suggest that
whole-person approaches, population-level approaches require robust partnerships and
collaborations between the healthcare and social community sector agencies and those
providers that work in those agencies. And it does seem that the reach and the strength
of local networks of service providers are going to shape the impact of initiatives such
as the Campbell Care Communities, Health Neighborhood Initiative, and other initiatives that aim
to transform how we think about sectors’ collaboration in public healthcare. Thank you for your attention.
CASTILLO: Hi, everyone. Thank you so much. Thank you so much for coming. I really appreciate
it. I’m Enrico Castillo. I’m a community psychiatrist, public psychiatrist and also a second-year
research fellow in the Robert Wood Johnson Clinical Scholars Program, and also a staff
psychiatrist at the Department of Mental Health. So in my presentation, I’ll be focusing on
how community engagement and planning models from CPIC is being adopted in L.A. County
specifically to address these health and social needs that were just described; and also the
perspectives of agency leaders on community partnerships in general.
So I wanted to start with this quote because I think it exemplifies the translation into
policy of CPIC science and community partners’ research Experience. So a DMH agency leader
said, “We’ve tried to use what you’ve learned in CPIC to help us design community engagement
activities that will work better because we’ve learned from your experience.” So starting
with health neighborhoods – what is a health neighborhoods? HNI is a public sector mental
health initiative with two parts. The first part is multi-sector service delivery coordination.
The second part is place-based strategies to address community level social determinants
of mental health; in particular, a broad definition of trauma that includes adverse childhood
and adult experiences. The HNI also includes predefined initiatives that are outlined by
the agency and then adapted by the communities, by the health neighborhoods in which they
are implemented. So some examples are universal approaches such as transitional age youth,
peer support networks to target social isolation, to more selective approaches like coordinated
employment within health neighborhoods, building partnerships with private businesses to focus
on people with serious mental illness, as well as homelessness, and then also, for example,
use of community-based resources and support groups for caregivers of those with mental
illness. This figure speaks to the first tenet of Health
Neighborhoods Initiative, which, and I quote, “assumes there’s a reciprocal interconnectedness
between the community’s health and well-being and that of individuals — of individual community
members.” So the Department of Mental Health is seeking to address the structural and contextual
contributors of individual illness and poor well-being through partnerships. And I’ll
speak to that a little bit more. This first timeline on the bottom shows the research
— the research timeline that led to the Health Neighborhood Initiative. So this begins in
1995 with the collaborative depression care study, Partners in Care. And it — in 2003, that Partners in Care trial
inspired another partnership with Healthy African American Communities, Charles Drew
University, UCLA Center for Health Services and Society, and also the RAND Corporation
to do Windows for Wellness, which was to engage minority communities in discussions around
depression and also mental health treatment. And then as you can see the planning for CPIC
— the CPIC partnership was extensive, engaging 93 programs within 50 agencies as you just
heard from Dr. Chung (ph). And then in 2010 to ’13, the study was conducted, but the work
continues in the form of active engagement with community, policy healthcare, and other
stakeholders around the results of the study and how it can inform what we can do about
mental health services. The second timeline shows the — shows the
health policy context that informs the Health Neighborhoods Initiative. For example, you
can see in 2005 there was the passage of California’s Proposition 63, also known as the Mental Health
Services Act, which is a one percent tax on personal incomes above $1 million to fund
public sector mental health, to the tune of about $8 billion a year. And specifically,
the MHSA, the Mental Health Services Act, supports county efforts in prevention and
innovative service delivery models. And you can also see in 2015, the Health Neighborhoods
Initiative was passed and approved by the L.A. County Board of Supervisors, and in that
same year California’s two waivers were approved by CMS, which in brief reemphasized the importance
of the Specialty Mental Healthcare System, but also introduced the Whole Person Care
Initiative which focuses on holistic services addressing both health and social needs.
So in this policy context, you can see a drive toward innovation to address the social determinants
of health for a growing population that’s engaged in the public mental health system.
So this figure, this model was created by Dr. Loretta Jones, which is one — who is
one of CPIC’s leaders and the CEO of Healthy African American Families. And it describes
the bi-directional exchange between Partners in Community partnered participatory research
and the community. But the same process also occurred among the partners, of course, specifically
the Department of Mental Health. Through CPIC, DMH leaders were exposed to community-based
organizations. They had experience with the community engagement and planning model of
partnered care. And there was continual intellectual exchange and sharing of CPIC results, with
the focus on practically implementing the science into policy. So the questions are:
How can community engagement of planning from CPIC be implemented at a county mental health
agency? Then how do agency leaders understand and implement those partnerships with community
members and community-based organizations? You know, how does the rubber hit the road?
So the methods are qualitative interviews. We focused on the development of the Health
Neighborhoods Initiative. And there were 49 interviewees and 25 interviews focusing on
Department of Mental Health leaders, but also leaders in other agencies in the city, for
example, the Departments of Public Health and Health Services, L.A. Homeless Services
Authority and First Five, which focuses on child health. Then there were also leaders
from the National Alliance on Mental Illness in L.A. County.
So here you can see L.A. County is a big place. It’s much bigger than the city of L.A., which
is represented roughly by service area four, which is Metro L.A. There are other parts
of L.A. But then there is service area six, which is South L.A., and then the more rural
service area one. So L.A. is a very diverse place, a very large place geographically,
as well as with its population. The analyses of the — of this work was coding by two analysts
with either the review of results by academic, as well as community team members continuing
the partnered approach. And then thematic analyses conducted through cost and comparative
coding to identify themes that are relevant to our research questions. So the results.
So I’m going to talk about some themes in three topic areas, and I’m
going to have some illustrative quotes. The three topic areas are the promise to partnerships,
the hurdles to partnerships, and then a stronger focus on the — on transforming bureaucracy.
So, partners spoke a great deal about the partner — about the promise of partnerships.
The agency leaders that were interviewed, they expressed the increase of awareness of
agency leaders of the community assets and how partnerships helped them to understand
how to access a wide array of community services, from employment to housing to peer programs.
So in doing so, community partners, it raised to them the importance of coordination and
management of scarce resources. For example, time and personnel. You know, they recognized
services that community partners provided that overlapped or duplicated with the work
of the agency, specifically in housing. So next I’m going to share a quote that speaks
to the last two points here, which are the sharing of narratives and the building of
capacity for the community. So this first quote was by a Department of Public Health
agency leader talking about sharing narratives, building capacity. Since we’re talking about
social determinants of health and their community partners, like there’s a name for that? So
I think it almost reenergizes the work they’re doing because they’ve known it in their hearts
and they’ve lived it. I think that’s been a huge benefit by showing legitimacy
— helping them construct the story so they can talk to other people, especially funders.
The agency leaders also spoke about hurdles to partnerships, particularly the length of
time it takes to develop partnerships and to do work in a partnered way, and the issue
of building trust and sustaining it, particularly in light of initiatives that may be pilot
in nature that may change over time, but also initiatives that build community capacity
that may be even designed to disappear over time as the community’s capacity evolves.
And then there’s the challenge of becoming part of existing strong community coalitions,
you know, how to gain entrance. You know, this next quote will focus on the
varied limitations in service capacity. So a Department of Mental Health service planning
area district chief said, “To the degree that we can be supportive by bringing in our existing
programs, by saying here’s a program, have some people, come and take this, that’s good.
To the degree that community groups say here’s a need that we have that you have no program
for, that’s a challenge.” So I want to focus on this theme a little bit in more depth and
we’re going to hear quotes from all four bullet points. And by bureaucracy, so transforming
bureaucracy, what we mean is the role of agency processes,
from training opportunities, to formal job descriptions, to incentives and systems that
promote or discourage partnerships. So this first quote is a by a Department of
Public Health agency leader focusing on promoting communication and crossing silos. That person
says, “There’s public health; There’s mental health; There’s health service; There’s community-based
organizations. And then there are community members. For different reasons, we operate
in our silos. It’s often easier for governments to interact with other governments, to interact
with other types of partners; or to really communicate with community is a lot more complicated.”
An L.A. Homeland Service Authority agency leader talked about sharing power, following
the community’s lead. So this person said, “I think the number one barrier is the willingness
to share the space with others so that we’re all working together, and then trusting that
the community has the answers.” A Department of Public Health agency leader talked about
establishing tools and accountability within the organization. He said, “Most people have
an understanding that we need to partner with the community, but how to actually do that?
I don’t think that is either in our training or in our organizational structure. So until
there are really tools or accountability built in the bureaucracy, partnering is not going
to be effective.” And then lastly, a Department of Mental Health
Service planning area district chief talked about the expanding scope of public mental
health services in response to community priorities. So this person said, “DMH is an entity whose
primary focus is working on the severe – working with the severe and persistently mentally
ill through our community members. Their issues may not rise to that level of severity. So
the issue is how can we provide what I’m going to call mental health supportive services
that can be done by peers or maybe faith-based leaders? It’s still linked with the Department
of Mental Health.” So in summary, Community Partners in Care
has had a substantial impact on L.A. County public mental health services. CPIC provided
an evidence-based model for community engagement and partnerships and also brought in agency
leaders from public mental health services to experience that partner-building process
first hand. Now in the county, we’re seeing agency leaders
inserting CPIC’s community engagement models into the programs that they direct.
You know, in this section of presentation, we show how agency leaders perceive partnerships,
mostly in very positive ways, as a means toward equity in our healthcare system. But also
with barriers that suggest how the agency needs to evolve over time. And I think the
key takeaway from this presentation are some the key of — some of the critical ingredients
that enable a mental health system to take on robust community partnerships to address
issues of equity in mental health. You know, the first is trust and relationships, which
we heard about; also a robust planning partnership — robust planning processes that include
community stakeholders at the table. The third is resources to provide time and sustainability
for change. And then the fourth are new organizational processes, bureaucracy — transforming bureaucracy
to allow for dynamic changes in mission strategy in resource allocation that reflects community
priorities and perspectives. So how can an organization — a public mental health system
be agile to community needs? So I want to acknowledge the whole team did this research
that I’m presenting and I’m representing. Thank you for listening. So I want to introduce
Dr. Southard. SOUTHARD: It’s — it’s a great pleasure for
me to be here and I could probably talk for two hours on the health neighborhoods and
the potential impact that this initiative might be able to produce in our communities
and how it’s built on what Community Partners in Care was able to help us accomplish. But
let me frame this by speaking about the gap that Dr. Evans spoke about in his keynote
speech, about the gap that is bidirectional between community practice and research, and
the piece of the gap that is — that I have experienced started on the community practice
side. In the late ’90s, I was the mental health
director in Kern County, which is just north of Los Angeles County. Bakersfield, if you’ve
heard of that, is the largest city there. And we started something there called our
neighborhood partnerships. And the neighborhood partnerships were organized in different communities
around school resource centers, but they were developed in partnership with the county superintendent
of schools, the CAO (ph), the mental health director, the public health director, and
everybody came together in a way that focused on community engagement as the key to improving
communities. And it was actually a wonderful initiative. It worked out really well. I’ll
give you one example of the sorts of things they were able to do. In one neighborhood
partnership, the apartment managers from a group of low-income apartment complexes banded
together and decided that what they needed for their neighborhood was childcare. And
so they developed childcare that the superintendent of schools funded.
The Mental Health Department provided counselors to go work with the kids while they were in
there, and it turned out to be a great success. As a matter of fact, that engagement was so
powerful they were able to get the city to build a park so that the kids who lived in
that neighborhood have — would have a place to play. So it was a real strong example of
what community engagement could do. But then what happened was the leadership changed and
the superintendent of schools retired. I got the job as mental health director in L.A.
The county administrative officer got a huge job in the private sector. And so even though
the funding didn’t change initially, the leadership changed. And secondly, we had not brought
in any academic or science to what we were doing. So what we had were stories from community
members about this great thing that happened. But we didn’t have any proof. We didn’t have
any data to show that this wonderful thing was effective. So then I got the job in L.A.
County and I was determined that if I was going to do this
again and try to engage the social determinants of health outcomes at a community level, then
we needed to do it in a way that would be sustainable over time, even if the leadership
should change, and to have data and outcomes that could show that what we were doing is
really worthwhile so that others might be able to replicate it. And that’s why we were
really happy in Los Angeles County to engage with UCLA and RAND
for Community Partners in Care and all of the research associated with it so that we
could have a model for what we — what we ended up calling our health neighborhoods.
So Dr. Castillo already spoke a little bit about what a health neighborhood is, but I
like to describe it as existing at two levels. At one level, it’s merely a consortium of
all of those who provide help in a particular community, mainly the mental health, the substance
abuse, and the healthcare providers, but also churches and schools or whatever other community
resource that is available, with agreements for data sharing so that there could be consents
for treatments so people can share information, form a common plan, and move forward in working
with the family in an integrated way. But maybe more powerful is the second part of
the health neighborhood was meant to be a community consortium for empowerment, where
the community got to decide what it wanted to work on to improve the social determinants
in their neighborhood. So in one community, for example the idea was, well, maybe we should
work on what happens when there is a street shooting. Is there an ability for us as a
community to respond to the trauma that happens to neighbors and neighborhoods when there’s
a body been lying on the street for several hours with tape around them and everybody
can see it? How does the community respond to that kind of trauma? So the idea was to
put together teams — that community’s idea — that could respond and
those teams might be based in a church or school or something. Anyway, those are the
kind of ideas that came up. And luckily in Los Angeles, as Dr. Castillo was mentioning,
we have the Mental Health Services Act funding that allows for us to invest money in innovations.
So as I was leaving L.A., the plan was to invest $91 million in communities for what
those communities believed was the approach to changing the social determinant that they
would decide would be useful for their own particular community. So I think one of the
outcomes of Community Partners in Care and their thinking on what we wanted to do in
the development of health neighborhoods focused on some particular things that I would like
to highlight. One of them was a community engagement strategy, a technology for us to
approach engaging communities. Because as I think was observed earlier, we don’t necessarily
know how to do it from a broad perspective. In other words, as a mental health director,
I knew how to involve the National Alliance for Mentally Ill and all the usual resources
that we were engaged. I did not even know some of the public health initiatives that
were taking place in the very communities that I was trying to serve in mental health.
So what I didn’t have a way of doing is finding a unifying force for all of those entities,
but it turns out the community can be that. If we listen and pay attention to communities
and what they need, that provides the unifying glue that can give us the technology for integrating.
The second thing is in the Department of Mental Health, we have had — long had an initiative
for faith-based services because our clients told us a long time ago that they believe
that their faith was one of their strengths for recovery that ought to be engaged as a
process of helping them recover. But our engagement with faith communities was episodic. You know,
we might outreach to this congregation or that church or that synagogue, but we didn’t
have an overall approach. Health Neighborhoods gave us a template for engaging in communities
where we would engage not just with one particular congregation, but with all of the congregations
that served a particular community. And we really had some amazing outcomes from tying
our community-based health neighborhood approach with faith outreach. So for example, in one
community – Hawthorne in Los Angeles — we ended up training 150 individuals at a Catholic
church to become health — mental health promotors for their own community, and also engaging
the local hospital and the substance abuse provider, and the social service agency.
So it was a way of tying together something the Department of Mental Health wanted to
do anyway, which is the faith outreach, but giving us a way of systematizing that through
the Health Neighborhoods. Two other things that I’ll close with in terms
of why this is so important. One of the things that is happening right now, as all of us
know, is an integration of health, mental health, substance abuse, into a combined entity.
And so kind of the division between mental health and physical health and substance abuse
is being overcome. And that’s — at least in theory, that’s a really good thing. In
practice, it may not be a good thing. And to my mind, in practice, what can help
it be a good thing is if we listen to communities and what communities actually need and to
find out how communities are actually experiencing the integration projects that we’re undertaking.
So if we have an integration that is putting three boxes into one box, does that really
change the patient experience in the way that we want? Does it really change the experience
of care? And if it changes, does it change it in the right direction? And I think the
only way that the integration will end up happening in the way that all of us would
want it to happen is if that integration takes place in a way that listens to the community
on an ongoing basis through that process. Community Partners in Care and Health Neighborhoods
gives us a technology for getting that information to make sure that the policy moves in the
proper way. Then one last thing I wanted to highlight
was from Dr. Bowen’s presentation. The key idea, or I guess the most important thing
that leapt out to me was that one little fact about the significant decrease in in-patient
days, not only initially but over time after the — the use of the CPIC technology. From
a mental health director’s perspective, that’s a really important piece of data to follow
because as this integration takes place, at least in California, the biggest cost and
the shortest resource is acute in-patient psychiatric care. And if we can show that
what we’re doing in communities — based in communities lessens the pressure on this precious
resource, I think it will give us even more impetus to what we’re trying to create in
changing and supporting the policies that we want to have developed. And so from my
perspective, as an ex-mental health director, is that these things that Community Partners
in Care, and that research showing that community practice is not just a nice thing, but really
an important way of improving care, doing preventive work and saving money, what could
be better? Thank you. So just thanks for your patience.
This is a long presentation. Of course, it always feels longer than you expect. But you
know, I think the take-home message is that, you know, that this kind of community partner
work is feasible; takes a long time; that you can do rigorous science; and that if one
engages partners, including communities and patients and other types of stakeholders,
including a director of mental health, that you can develop strategies; that you can translate
something like NIH-funded science into policy. How that looks from a fidelity point of view,
in the traditional model may not necessarily be what one thinks about. But in a lot of
ways, what the story is that the community engagement itself as an approach is kind of
the thing that really sort of the system has tried to take up as they try to sort of figure
out how to respond to patients’ and communities’ needs.