A Novel Collaborative Mental A Novel Collaborative Mental Health Practice Model for the Health Practice Model for the Treatment of Mental Illness of Treatment of Mental Illness of the Spanish Speaking Indigent the Spanish Speaking Indigent

and Uninsuredand Uninsured

Davor Zink, Margie Hernandez, Hannah Lindsey, Vala Burton, Tara Jackman and Antonio E. Puente

University of North Carolina WilmingtonJennifer Buxton and Allison Altendorf

New Hanover Regional Medical Center

Presented at the annual meeting of the Southeastern Council of Latin American Studies

March 17, 2011 Wilmington, NC

U.S. Population: HispanicU.S. Population: Hispanic

US: 301,621,159 (100.0%)

US Hispanics: 46,943,613 (15.4%)

Largest & Fastest Ethnic Minority Group in the United States (and undercounted). Will be the Largest Group in the United States by Approximately 2050.

Source: U.S. Census Bureau, 2007 American Community Survey, Pew 2009

3

4

5

6

7

Percent Latino of the Total Percent Latino of the Total Population in the United Population in the United

States: 1970 to 2050States: 1970 to 2050

*Projected Population as of July 1

ProjectionsCensus

Source: U.S. Census Bureau, 1970, 1980, 1990, and 2000 Decennial Censuses; Population Projections, July 1, 2010 to July 1, 2050

Expected Growth Hispanics Expected Growth Hispanics in the U.S.in the U.S.

Projections of Hispanic Population 2009-2050Source: U.S. Census Bureau figures

11/12/2009 8

0

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

2009

2050

Top Five States by Latino Top Five States by Latino Growth Rate: 2000 to 2006 Growth Rate: 2000 to 2006

9

Rank State

Growth Rate

(percent)

1 Arkansas 60.9

2 Georgia 59.4

3 South Carolina 57.4

4 Tennessee 55.5

5 North Carolina 54.9

Source: U.S. Census Bureau, Population Estimates July 1, 2000 to July 1, 2006

(For states with 100,000 or more Latinos in 2006)

NC Population: HispanicNC Population: Hispanic NC: 9,061,032 (100%)

Hispanics (or Latino any race): 639,623 (7.1%)

Mexican : 408,782 (4.5%)Puerto Rican : 51,867 (0.6%)

Cuban : 14,876 (0.2%)

Other Hispanic or Latino: 164,098 (1.8%)

Current/Expected Growth: 400-500% annually

Second fastest growing after Alabama(due to increasing US and foreign born migration & birth rates)

Source: U.S. Census Bureau, 2007 American Community Survey

Latest Latest FiguresFigures

North Carolina Growth = 111% (2000-2010)

Main Problems in the Main Problems in the Hispanic PopulationHispanic Population

Low educationPovertyLanguage barriersMental Health/Health Problems

U.S. Hispanic Educational U.S. Hispanic Educational Attainment Attainment Graduate or Professional Degree: 10.1%Bachelor’s Degree: 17.4%Associate Degree: 7.4%Some College (no degree): 19.5%High School Graduate: 30.1%9th-12th grade (no diploma): 9.1%Less than 9th grade: 6.4%Note: Nationwide, 47% of undocumented

Hispanics have less than a high school degree

Source: U.S. Census Bureau, 2007 American Community Survey

Language & Poverty Co-Language & Poverty Co-variatesvariates

People who speak only English at home (219,092,969) are:

o below (11.2%) poverty lineo above (88.8%) poverty line

People who only speak Spanish or any other language at home (33,833,322) are:

o below (20.0%)o above (80.0%)

Source: U.S. Census Bureau, 2007 American Community Survey

Language ConcernsLanguage Concerns

Variation of SpanishSpanish as a Second or Even

Third LanguageLimits and Perils of TranslationsImportance of Non-Verbal

CommunicationDifficulties With Learning English

““Typical” Mental Health Typical” Mental Health ProblemsProblems

DepressionAnxietySubstance AbuseDomestic Violence

(from literature and 5 years of clinical service at Tileston Mental Health Clinic)

Origins Of Mental Health Origins Of Mental Health ProblemsProblems

Acculturation & IsolationLanguage LimitationsHealth DisparitiesDecreased Social SupportFinancial LimitationsPoor EducationLack of Religious Affiliation

The Tileston Health ClinicThe Tileston Health ClinicA non-profit clinic that has been

serving low-income and uninsured patients in southeastern North Carolina for 20 years.

Mission:◦Provide quality health services at no

cost◦No form of health insurance◦Income falls within the federal poverty

guidelines◦English and Spanish

The Tileston Health ClinicThe Tileston Health Clinic• Medical services• Dental services• On-site pharmacy• Staff

– Healthcare professionals (MAs, CPPs, PhDs and MDs)

– Support staff (undergraduate, graduate)– All volunteers

• Budget– Grants, donations, and money collected from

fundraisers• All services and medications provided by the

clinic and its affiliates are free of charge to all of the clinic’s patients.

• Daily (8-5)

The Mental Health ClinicThe Mental Health Clinic• Founded by A. E. Puente, a clinical

neuropsychologist and UNCW professor, 10 years ago.

• Psychotherapy and Counseling– Clinical Psychologists, counselors

• Medication Management– PharmD./CPP, Clinical Psychologist, MD

• Psychological and neuropsychological testing– Graduate students

• Administration– Undergraduate and graduate students

By the NumbersBy the Numbers• Number of patients = 56 (2009)

– Total served =– Total per night = 20 approx.

• Number of hours per month clinic is open = on average = 10 hrs

• Number of volunteers = 12• Number of psychotherapy encounters =

200– Average encounter = 30 mins– Average # of sessions per pt =

• Number of testing encounters = 100 (including treatment outcome)– Average testing protocol = 6 hrs/patient

The Collaborative Pharmacy The Collaborative Pharmacy Practice Model (CPPM) Practice Model (CPPM)

Clinical Pharmacist Practitioner (CPP) license.

Allowed the pharmacist to prescribe medications based on the psychologist’s working diagnosis.

Overseeing physician ◦Review all clinic notes ◦Endorse the pharmacist’s medication

recommendations

The Collaborative Pharmacy The Collaborative Pharmacy Practice Model (CPPM) Practice Model (CPPM)

Clinical psychologist and the clinical pharmacist see patients together

Pharmacist prescribes psychotropic medications based on psychologist diagnoses

Initial evaluationPsychotherapyMedication managementTesting

Typical presenting Typical presenting problemsproblems

DepressionAnxietySubstance Abuse

Disorder/AlcoholismChildren- Learning Disability,

ADHD

The Collaborative Pharmacy The Collaborative Pharmacy Practice Model (CPPM) Practice Model (CPPM)

Most patients receive psychotherapy in conjunction with pharmacotherapy

Patients with substance abuse disorders and actively suicidal and/or psychotic are ineligible for mental health clinic services

TestingTesting• Diagnostic purposes

– Psychological and neuropsychological testing – Facilitate diagnosing the patients and to – Acquire standardized data for the patient’s

records– Research purposes

• Treatment outcome – Pre-test data is

• Gathered upon the initial clinic appointment • Provide an overall picture of the patient’s current

physical and mental health status – Post-test data is

• Gathered approximately six months after the start of therapy

• Evaluate the patient’s response to therapy

Treatment Outcome Treatment Outcome • Alcohol Use Disorders Identification

Test (AUDIT)– quantity and frequency of alcohol or

substance use – detect dependence as well has harmful

or hazardous drinking • Patient Health Questionnaire for

depression (PHQ-9)– assesses and monitors depression

severity • Short Form-12 (SF-12)

– assesses quality of life

Pre and Post TestingPre and Post Testing• No significant results were found

– Measures were not sensitive enough– Small sample size– amount of time between pre and post

tests• Lack of staff• Limited hours

– Patients did not follow-up with their treatment plan• Became employed or insured• Moved• No exit interview• Attrition

Pre and Post TestingPre and Post Testing

Anecdotal evidence suggest patients are improving with treatment

The biopsychosocial well being of the patients was the primary reason for termination of treatment

The effectiveness of treatment was evident to the staff

Case Study T.P.Case Study T.P.• Depression and Anxiety

– Patient has no energy, cannot get out of bed, very anxious, helpless, physical pain, unemployed, marital problems = cannot function in society

• Medication + Psychotherapy– Paroxetine– Individual and couples psychotherapy

sessions– CPPM sessions – All treatment was provided in Spanish

• After a year: no depression, anxiety under control, no physical pain, patient familial situation is stable, patient has a stable job.

Economic Impact In 2009 Economic Impact In 2009

56 patients for a total of 316 visits. A total of 165 hours of free care,

total estimated value of $15,580.88.

A total of 775 prescriptions were issued by the CPP, total patient cost savings of $123,699.29.

Clinic patients received over $139,000 in free mental health care and prescription medications.

LimitationsLimitations

More patients than available volunteers

Large waiting listVolunteers availabilityFunding

The Tileston Mental Health The Tileston Mental Health ClinicClinic• Is one of the few institutions in the state of

NC that is able to provide free medical and mental care for uninsured Hispanics; and only one that provides bilingual services.

• The CPPM used in the clinic is a novel approach worth of replication and further improvements. – Only psychiatrists prescribe medications,

limiting the availability of this kind of treatment, especially for the clinic’s patient population (low income, uninsured, Hispanics).

• Volunteering and learning opportunity for students and professionals in the community.

Problems for North Problems for North CarolinaCarolina• Number of Hispanics in North Carolina

(111% growth)

• Some SE NC counties have over 50% of the population that are Hispanics

• Number of Doctoral Level Psychologists that are Hispanic in North Carolina = 1

• Major mental health crisis looming in the horizon

• One possible solution = Proposed UNCW PhD program (requires knowledge of Spanish)

ConclusionConclusion

Wilmington, we have a problem…

Gracias!

Preguntas?