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

A Novel Collaborative Mental Health Practice Model for the Treatment of Mental Illness of the Spanish Speaking Indigent and Uninsured. Davor Zink, Margie Hernandez, Hannah Lindsey, Vala Burton, Tara Jackman and Antonio E. Puente University of North Carolina Wilmington

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

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  1. A Novel Collaborative Mental Health Practice Model for the Treatment of Mental Illness of the Spanish Speaking Indigent and Uninsured Davor Zink, Margie Hernandez, Hannah Lindsey, Vala Burton, Tara Jackman and Antonio E. Puente University of North Carolina Wilmington Jennifer 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

  2. U.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. Percent Latino of the Total Population in the United States: 1970 to 2050 Census Projections *Projected Population as of July 1 Source: U.S. Census Bureau, 1970, 1980, 1990, and 2000 Decennial Censuses; PopulationProjections, July 1, 2010 to July 1, 2050

  4. Expected Growth Hispanics in the U.S. Projections of Hispanic Population 2009-2050 Source: U.S. Census Bureau figures

  5. Top Five States by Latino Growth Rate: 2000 to 2006 (For states with 100,000 or more Latinos in 2006) Source: U.S. Census Bureau, Population Estimates July 1, 2000 to July 1, 2006

  6. NC 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

  7. Latest Figures • North Carolina Growth = 111% (2000-2010)

  8. Main Problems in the Hispanic Population • Low education • Poverty • Language barriers • Mental Health/Health Problems

  9. U.S. Hispanic Educational 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

  10. Language & Poverty Co-variates • People who speak only English at home (219,092,969) are: • below (11.2%) poverty line • above (88.8%) poverty line • People who only speak Spanish or any other language at home (33,833,322) are: • below (20.0%) • above (80.0%) Source: U.S. Census Bureau, 2007 American Community Survey

  11. Language Concerns • Variation of Spanish • Spanish as a Second or Even Third Language • Limits and Perils of Translations • Importance of Non-Verbal Communication • Difficulties With Learning English

  12. “Typical” Mental Health Problems • Depression • Anxiety • Substance Abuse • Domestic Violence • (from literature and 5 years of clinical service at Tileston Mental Health Clinic)

  13. Origins Of Mental Health Problems • Acculturation & Isolation • Language Limitations • Health Disparities • Decreased Social Support • Financial Limitations • Poor Education • Lack of Religious Affiliation

  14. The Tileston Health Clinic • A 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

  15. The 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)

  16. The 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

  17. By 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

  18. The Collaborative Pharmacy 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

  19. The Collaborative Pharmacy Practice Model (CPPM) • Clinical psychologist and the clinical pharmacist see patients together • Pharmacist prescribes psychotropic medications based on psychologist diagnoses • Initial evaluation • Psychotherapy • Medication management • Testing

  20. Typical presenting problems • Depression • Anxiety • Substance Abuse Disorder/Alcoholism • Children- Learning Disability, ADHD

  21. The Collaborative Pharmacy 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

  22. Testing • 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

  23. 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

  24. Pre 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

  25. Pre 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

  26. 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.

  27. 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.

  28. Limitations • More patients than available volunteers • Large waiting list • Volunteers availability • Funding

  29. The Tileston Mental Health Clinic • 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.

  30. Problems for North Carolina • 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)

  31. Conclusion • Wilmington, we have a problem… • Gracias! • Preguntas?

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