Transcript Behavioural health disparities among diverse US youth: can

University of Bath
Institute for Policy Research International Partners Symposium:
Lost youth in the 21st Century
17-18 September 2014
 50% of Americans (including youth) experience a
diagnosable mental health disorder over lifetime
 Initial onset in childhood or adolescence
 1 in 4-5 children experiences serious behavioral
health disorder
 Suicide is 3rd leading cause of death in youth ages 10-14;
2nd leading cause of death in youth 15-24
 Only 1/3 receive specialized mental health services
(Sources: AACAP, 2009; CDC, 2011; Kessler et al., 2005; Merikangas et al., 2010, 2011)
Greater disparities in care for people of color
 Less access to care and fewer services available
 Less likely to receive needed mental health
services
 More likely to receive poorer quality of care
 More often misdiagnosed
 Underrepresented in mental health research
(e.g., intervention studies)
 Less likely to have health insurance
(Sources: Fox et al., 2007; Merikangas et al., 2011; President’s New Freedom Commission Report, 2003;
USDHHS, 1999)
Among adolescents, greatest disparities for
youth of color and youth living in poverty
 Over 42 million adolescents (ages 10-19) in the
U.S. (14% of American population)
 9.8% lack health insurance
 Racial & ethnic minorities = 39% of U.S.
adolescent population
 Hispanic and Black children and youth have
least access to and use of mental health care
 Health outcomes disparities for racially and
ethnically diverse youth and youth living in
poverty (obesity, teen pregnancy, tooth decay,
educational achievement)
(Sources: Behrens et al., 2013; Fox et al., 2007; U.S. Public Health Service, 2000)
 In 2011, suicide attempts for Hispanic girls,
grades 9-12, were 70% higher than for
White girls
(http://minorityhealth.hhs.gov/templates/content.aspx
?lvl=3&lvlID=9&ID=6477)
 In 2012, Major Depressive Episode rate was
highest among Latino youth, who were also
less likely to received treatment than White
youth
(http://www.samhsa.gov/data/StatesInBrief/2K14/Nati
onal_BHBarometer.pdf)
 Children & youth in poverty have highest
rates of unmet need and highest prevalence
rates
(Sources: Behrens et al., 2013; Fox et al., 2007; U.S. Public Health Service, 2000)
Disparities in the use of
mental health services,
including outpatient care
and psychotropic drug
prescriptions, persist for
black and Latino children,
reports a new study in
Health Services Research.
“Children’s mental illness is very
predictive of poor outcomes later in life—
socially, educationally, income-wise and
employment-wise.” said lead author
Benjamin Lê Cook, Ph.D., senior scientist
at the Center for Multicultural mental
Health Research at the Cambridge Health
Alliance and assistant professor at
Harvard Medical School…”
(Source: http://www.cfah.org/hbns/2012/mental-health-care-disparities-persist-for-black-and-latino-children)
 Stigma
 Negative cultural views on mental illness
 Self-care decision-making (medications,
managing symptoms, appointment
follow through)
 Insurance coverage
 Workforce shortage
 Lack of culturally relevant care
 Inaccuracies in identifying and
diagnosing mental health
disorders
 Issues with provider-patient
communication
 Culturally inappropriate patient
care plans
 Ill-prepared clinicians
(Sources: President’s New Freedom Commission Report, 2003; Conner et al., 2010; Vega et al., 2009)
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Challenges
Inadequate funding
Sustained focus on services for
children and youth with serious
emotional disturbance
Complexity of child mental health
service delivery systems and
funding
Locally-controlled school policies
and priorities complicate statefunded school-based efforts
Insufficient availability of mental
health services, esp. for lowincome children and youth
Supports
 Expanding insurance coverage
increases access to services
 Increasing advocacy across
multiple levels effects policy
change
 Promising practices to improve
access: Telemedicine/Telepsychiatry, Teacher accreditation
and mental health training,
Classroom-based socialemotional learning and positive
behavioral instructional
supports
Support and Challenge
 Varying impact of court actions on access to services
 Comprehensive school-based care approach increases access to
prevention, early intervention and treatment services
 Multiple child serving systems
 Fragmented public service systems
 Silo financing structures, service
regulations, electronic records
systems
 Inadequate funding of mental health
services
 Funding and services depend on
state of residence and sources of
funding available to child and family
 Funding targets high need children
with payment tied to specific
diagnoses
“When it comes to
providing preventive care,
early intervention, or
multidisciplinary
approaches, there are few
structural incentives, and
many disincentives, to
addressing mental
wellness.”
(Murphey et al., 2014, p. 8.)
 Insurance funding lags in covering
evidence-based practices
(Sources: Garland, et al., 2001; Stagman & Cooper, 2010; Stagman & Cooper, 2010; Cooper, 2008)
Reduced educational
achievement
Increased
involvement in or
relinquishment to
child serving systems
Substance abuse
System cycling
Poor employment
Adulthood poverty
Self-destructive
behaviors
Exacerbation of
mental illness
Premature death
(Sources: AACAP, 2009; Bullock, 2005; Kapphahn et al., 2006; Stagman & Cooper, 2010; United States General Accounting
Office, 2003; Colton & Manderscheid, 2006)
Systems of Care for Children’s
Mental Health
Mental Health Parity and
Addiction Equity Act of 2008
and the Children’s Health
Insurance Program
Reauthorization Act of 2009
 Finances collaboration among
 Increased levels of mental health
agencies, families and youth to
provide culturally relevant, youth
guided and family-driven services
using a wraparound service delivery
approach
 Several years of funding to create
integrated system structures across
child serving systems
 Overall positive outcomes
 Concern: Sustainability
(Sources: Bailey & Davis, 2012; Murphey et al., 2014)
care covered
 Removed limitations and
restrictions on mental health
coverage
 Concern: Managed mental
healthcare limitations for chronic
illness
Patient Protection and Affordable Care Act (ACA) of 2010
 Anticipated health care for over 90% of Americans
 Embeds provisions of Parity Law
 Emphasizes prevention (with no patient cost sharing), quality of care,
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efficiencies in healthcare delivery esp. for high-cost chronic diseases
(including mental illness)
Guaranteed renewal of insurance policy
Non-discriminatory premiums (poor health ≠ higher premiums)
Supports new healthcare service delivery approaches to increase access
and care coordination (esp. integrated health and behavioral healthcare)
Recognizes importance of social determinants of health
Significant role of primary care providers
Emerging evidence base is favorable for patient and fiscal outcomes
Concerns: Focus on adult healthcare models and ability to meet demand
for providers
(Sources: Bazelon Center for Mental Health Law, 2010; Department of Health and Human Services Office of the Assistant
Secretary for Planning and Evaluation (ASPE), 2013)
Young adults (up to age 26) may remain on parents’ health
insurance
Current and former children in foster care Medicaid eligible until
age 26
Special catastrophic health plan for young adults under age 30
ACA expected to make 4.2 million more adolescent U.S. citizens
and legal immigrants eligible for healthcare
- 35% Latino, 16% non-Latino African American; 19% rural)
Youth healthcare needs differ from adults
- Fewer chronic conditions (17-20%)
- Need access to healthcare, preventive and wellness care, health
education
(Sources: Bazelon Center for Mental Health Law, 2010; Department of Health and Human Services Office of the Assistant
Secretary for Planning and Evaluation (ASPE), 2013)
Covered child and adolescent preventive services and
screenings:
• Behavioral assessments for adolescents
• counseling, sexually transmitted infection prevention counseling,
contraception and patient education screening for sexually active
adolescents, immunizations, obesity screening, drugs
Essential benefits relevant to adolescents:
• Pediatric dental and vision services for children up to age 19
• Habilitative services for developmental disorders
• Mental health and substance use disorder services, including
behavioral health treatment
(Sources: Bazelon Center for Mental Health Law, 2010; Department of Health and Human Services Office of the Assistant
Secretary for Planning and Evaluation (ASPE), 2013)
Other relevant ACA provisions
• School-based health centers (capital funds)
• Teen pregnancy prevention programs
• Home visiting programs – support for families to improve
health and development outcomes for at-risk children
• Childhood obesity demonstration project (ages 2-12)
• Expansion of community health centers – access to a “usual
source of care”
Concern: Needs of youth will get inadequate attention if
innovations in integrating care do not keep pace with adultfocused initiatives
(Sources: Bazelon Center for Mental Health Law, 2010; Department of Health and Human Services Office of the Assistant
Secretary for Planning and Evaluation (ASPE), 2013)
Health
conditions
Developmental
conditions
Asthma
Learning
disabilities
Allergies
Speech problems
Obesity
Autism spectrum
disorders
Behavioral
health
conditions
Attention
deficit/attention
deficit
hyperactivity
disorder
(ADD/ADHD)
Oppositional
defiant or
conduct disorder
Anxiety
Depression
Substance use
(Sources: Bloom, et al., 2011; CDC, http://www.cdc.gov/chronicdisease/overview/; Kolko & Perrin, 2014; U.S. Department
of Health & Human Services, 2011)
 Families generally seek help most often from family doctor
 In rural communities, families seek help from:
 Physician (62.5%), teachers (55.1%), family/friends (54.7%),
counselor/therapist (24.7%), pastor (10.7%), other (2.8%) Only 21% were in
clinically significant range
 Over 90% of children in U.S. visit a primary care provider annually
 Behavior problems are among top pediatric primary care physician
concerns
 Primary care clinicians (PCC) prescribe most psychotropic medications in the
U.S.
 Low rates of problem identification remain among PCCs
 PCCs receive little training in recognizing and treating mental health issues
 PCCs report payment barriers and problems accessing mental health specialists
(Sources: Arndofer et al., 1999; Polaha et al., 2010, Campo et al., 2005)
Residential and
inpatient care
with
communitybased care
Children’s
mental
health into
K-12 schools
(Source: Behrens et al., 2013)
Trends over past
20 years:
Integrate…
Primary
medical and
mental
health care
Family
priorities
(family voice)
into plans of
care
Integrated care
• Improves health outcomes
for adults
• Is cost effective for adults
(Sources: Collins et al., 2010; Milliman, Inc. et al., 2014)
Emerging child and
adolescent adapted
integrated models showing
promise
• Standardized screening and
assessment tools
• Evidence informed
practices
• Medication and
management
• Team approach
• Care management
• Quality control
• Behavioral health
consultant
 Little evidence exists to support integrated care efforts for adolescents
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in the U.S.
Consensus recommendations to improve adolescent healthcare:
 Increase adolescent and parent engagement and self-care
management
 Improve clinical preventive services to reduce risk
 Integrate physical, behavioral and reproductive health services
Use combination of Four Quadrant Clinical Integration Model along
with Chronic Care and Systems of Care Models to design integrated care
practice
Focus on multiple levels of study: (1) child/youth; (2) caregiver/family;
(3) organizational relationships, (4) cost-effectiveness
Programs of practice: Bright Futures; school-based integrated care
(Sources: SAMHSA-HRSA Center for Integrated Health Solutions, 2013; Campo, 2005; Foy et al., 2010)
 Access to care with shifts created by the ACA
 Use of digital technology for psychosocial screening and
assessment
 Decision support technologies for team planning and
management
 Access to medication protocols for primary care providers
 Health systems transformation
 Process evaluation of provider practices relevant to
integrated care
 Comparative effectiveness research
(Source: Kolko et al., 2012)