CHAPTER 7

A Vision for the Future

Improve Access to Treatment

Race, ethnicity, culture, language, geographic region, and other social factors affect the perception, availability, utilization, and, potentially, the outcomes of mental health services. Therfore the provision of high-quality, culturally responsive, and language-appropriate mental health services in locations accessible to racial and ethnic minorities is essential to creating a more equitable system.

Improve Geographic Access

Racial and ethnic minorities have less access than white Americans to mental health services. Minorities are more likely to be poor and uninsured. Many live in areas where general health care and specialty mental health services are in short supply. An increasingly distressed safety net of community health centers, rural and migrant health centers, and community mental health agencies provides physical and mental health care services to racial and ethnic minorities in medically underserved areas (IOM, 2000). Innovative strategies for training providers, delivering services, creating incentives for providers to work in underserved areas, and strengthening the public health safety net promise to provide greater geographic access to mental health services for those in need.

Integrate Mental Health and Primary Care

Many racial and ethnic minority consumers and families prefer to receive mental health services through their primary care physicians. Explanations of this preference may be that members of minority groups fear, feel ill at ease with, or are unfamiliar with the specialty mental health system. Community health centers as well as other public and private primary health settings provide a vital frontline for the detection and treatment of mental illnesses and the co-occurrence of mental illnesses with physical illnesses.

The Federal Government, in collaboration with the private sector, is working to bring mental health care to the primary health care system. A variety of demonstration and research programs have been or will be created to strengthen the capacity of these providers to meet the demand for mental health services and to encourage the delivery of integrated primary health and mental health services that match the needs of the diverse communities they serve. Developing strong links between primary care providers and community mental health centers will also assure continuity of care when more complex or intensive mental health services are warranted.

For example, the Chinatown Health Center in New York City, a Health Resource Services Administration (HRSA)-funded community health center, participates in two important Federal projects. The first is a study of whether it is more effective to treat older Chinese American health center patients with mental illnesses in an integrated primary and behavioral health program or to have the primary care physician refer them to specialty mental health services. The second project is part of a “Break-through Collabrative” series co-sponsored by the Institute for Healthcare Improvement, the Robert Wood Johnson Foundation, and several Federal agencies. This intensive quality improvement program is aimed at trans-forming the way the health center treats patients with depression. These Breakthrough Collaboratives are changing the way safety net health providers engage and treat their patients who may have chronic physical health conditions as well as mental health problems.

Ensure Language Access

A major barrier to effective mental health treatment arises when provider and patient do not speak the same language. The DHHS Office of Civil Rights has published guidance on this subject for health and social services providers (DHHS, 2000). All organizations or individuals receiving Federal financial assistance from DHHS, including hospitals, nursing homes, home health agencies, managed health care organizations, health and mental health service providers, and human services organizations have an obligation under the 1964 Civil Rights Act to ensure that persons with limited English proficiency (LEP) have meaningful and equal access to benefits and services. As outlined in the guidance, satisfactory service to LEP clients includes identifying and documenting the language needs of the individual provider and the client population, providing a range of translation options, monitoring the quality of language services, and providing written materials in languages other than English wherever a significant percentage of the target population has LEP. Efforts such as these will help ensure that limited English skills do not restrict access to the fullest use of services for a significant proportion of racial and ethnic minority Americans.

Coordinate and Integrate Mental Health Services for High-Need Populations

The Nation is struggling to meet the needs of its most vulnerable individuals, such as those in foster care, jails, prisons, homeless shelters, and refugee resettlement pro-grams. Accordingly, the attention being given to the development and provision of effective, culturally responsive mental health services for these populations is increasing. Because racial and ethnic minorities are over-represented among these vulnerable, high-need populations, the introduction, expansion, and improvement of mental health services in settings where these groups are is critical to reducing mental health disparities. Another promising line of research is the role of mental health treatment in preventing individuals from falling into these vulnerable populations.

One innovative Center for Mental Health Services (CMHS) demonstration program to reduce homelessness integrates housing supports with medical and mental health services. This program has successfully brought adults with serious mental illness off the streets and helped them stay in housing, reduced their illicit drug use, decreased minor crime, and increased their use of outpatient mental health services. It has also shown that it is possible for organizations with very different missions and funding streams to work together to deliver effective, integrated services when they are focused on a common goal: to meet the real and complex needs of vulnerable people. These grants have helped several thousand homeless adults with severe mental illness (over 50 percent of whom were racial or ethnic minorities) to move off the streets and into stable housing (CMHS, Rosenheck et al., 1998). Because of the over-representation of ethnic minorities among persons who are homeless, such programs may play an important role in reducing racial and ethnic disparities in access to the mental health system.