Partnered Development of a Community Health Worker Model for Mental Health Outreach

Partnered Development of a Community
Health Worker Model for
Mental Health Outreach
29 JUNE 2009
Post-disaster New Orleans, high unmet
mental health needs persist
 Communities face high burden of mental illness
 1 in 3 person estimated to experience symptoms of depression
and or PTSD since Katrina/Rita (Kessler et al 2006),
 Thousands of providers displaced, many clinical agencies
closed after hurricanes; access to specialty mental health
remains limited (Springgate et al 2009; LPHI 2009)
 Quality care does not reach the post-disaster
population despite a publicized mental health crisis
Few people get appropriate or high quality mental health care
(Wang et al 2007), despite significant health and societal
benefits that such care would offer (Schoenbaum et al 2009)
Community members in post-disaster setting
are unlikely to seek mental health care
 Stigma of illness may prevent care-seeking behavior
in post-disaster setting
 Primary care clinics, social service agencies,
neighborhood associations may be more accessible
to persons with mental health needs in post-disaster
environment (Springgate et al 2007)
 As trusted entities, these organizations may facilitate
entry into care, yet may have limited experience or
training in dealing with mental health issues
(Dossett et al 2005)
REACH NOLA sought a partnered, public health
response to the mental health crisis
 REACH NOLA’s partners identified need for:
 Increased access to mental health services for underserved
community members, and particularly mental health outreach
to improve access and utilization
 Broader implementation of models of evidence-based care to
improve outcomes
 We hypothesized that partnered development of a community
health worker (CHW) model for mental health outreach for
depression might serve to meet community goals of improving
access, but would face challenges in implementation and
REACH NOLA’s goals in developing a new
public health/mental health program
 Be responsive to community needs
 Acknowledge community strengths while being
sensitive to post-disaster limitations in
 Be consistent with key components of the
collaborative care model of chronic disease
management (Wagner, Austin, & Von Korff, 1996)
such as promoting evidence-based treatments, care
coordination, and patient participation
Our goals in developing a public
health/mental health program
 Build on existing CHW models that address mental
health issues or health disparities
 Follow community-based participatory research
(CBPR) principles, such as promoting equal power
for community and academic partners and building
community capacity while advancing knowledge
(Jones & Wells 2007)
REACH NOLA Mental Health Infrastructure
and Training Project Components
Training over 300 participants from partner agencies and
other health and social services agencies
Social workers
Primary care providers
Community health workers
Support integrated evidence-based therapies and
practices for treating depression and PTSD
Collaborative care model of chronic disease management
 Problem solving treatment & cognitive behavioral therapy
 Medication management by primary care, with specialty
provider consultation
 Care management and outcome tracking
Development of CHW model for
mental health outreach
 23 training participants from original training in
July 2008 volunteered to participate in CHW
training development
 Emails, conference calls, in-person meetings, and
partnered document review served as basis of
training communication and collaboration by a
community-academic working group
 We conducted a partnered qualitative evaluation of
development, feasibility and impact using a teambased approach to qualitative research as applied to
a partnered working group
Results of Partnered CHW Model Development
 CHWs from social service, clinical, and nonprofit agencies
worked with academic partners to adapt and develop training
program and materials, with emphasis on
Problem-solving treatment for CHWs
Behavioral activation
Cultural competency
Role playing
 Materials
 Outreach manual
 Consent and confidentiality forms
 Co-authoring of article on model development, feasibility and
 CHW and case manger support group
Community academic team also evaluated
model development, feasibility, and impact
 The team identified six questions to frame analysis
 1) What are the needs of residents?
 2) How is outreach currently conducted and what do CHWs
and community-based organizations need to address stress
and depression?
 3) How was the training developed and how did community
input affect the training?
 4) What role did partnership play and how did it develop?
 5) In what ways did CHWs incorporate skills learned in the
trainings and how did the model fit with their organizations?
 6) What are the barriers, challenges, and successes CHWs face
in implementing their role and what is the early impact and
future potential?
The team reviewed several data sources to
evaluate development, feasibility, impact
 31 email strings from work group members
 Field notes for 12 conference calls and for follow-up
support calls
 Meeting minutes and action plans
 Semi-structured telephone interviews on experiences
with the model from five CHWs who participated in
the trainings and follow-up calls
 Training-participant survey regarding usefulness,
clarity, cultural appropriateness, and comfort level in
providing new services
Highlights of Evaluation Results
 Most CHWs had tried or were routinely using the
PHQ-2 or PHQ-9
While most found that this task was applicable to their job and
that screening had high community acceptability, some
reported awkwardness of screening in public locations or client
resistance to addressing mental health issues.
 Participants acknowledged the helpfulness of guided
role playing in training and the follow-up support
calls that allowed them to discuss their application of
training concepts in actual practice.
Highlights of Evaluation Results
 Some CHWs commented on the usefulness of
confidentiality/HIPAA training
 Training in problem solving and behavioral
activation was novel for most CHWs.
 CHWs still felt awkward interfacing with clinical
agencies and providers such as physicians
 Emphasis on cultural competency in trainings was
well regarded
CHWs noted several types of impact of
training program on their work
 Increased hope that clients would receive needed
 Opportunities for networking and certification were
perceived as valuable by CHWs
 Potential of providing higher quality care and
increased competitiveness for organizational funding
were beneficial to CHWs’ employers and
 Increased respect for CHWs improved their morale
Potential Next Steps
 Prospective evaluation of the role of CHWs on access
and quality of care for mental illness
 Development of additional resources to support
longer term implementation of the model and
additional training, including a CHW Training
Thanks to our partners
 Kenneth Wells, Elizabeth O’toole, Judy Ho, Loretta Jones, Bowen Chung,
Jeanne Miranda and the entire UCLA RAND NIMH Partnered Research Center
Jurgen Unutzer, Steven Vannoy, Wayne Bentham, Doug Zatzick, Rita
Haverkamp, and University of Washington IMPACT Center
Karen Desalvo, Ashley Wennerstrom, Donisha Dunn, Eboni Price, Shawna
Herbst and Tulane Section of General Internal Medicine
Diana Meyers and St. Anna Medical Mission
Vicki Ngo, Brittany Butler, Eunice Wong, David Kennedy, Gery Ryan of the
RAND Corporation
REACH NOLA Board of Directors
Holy Cross Neighborhood Association
Common Ground Health Clinic
Lower Ninth Ward Center for Sustainable Engagement and Development
St. Anna Medical Mission
St. Thomas Health Clinic
Trinity Counseling and Training Center
Contact information
Ben Springgate
[email protected]
Charles Allen
[email protected]
Special thanks to the American Red Cross and NIMH
for their generous support of this project