CMHS Project Contract # OM5742
Jean Lau Chin, Ed.D.; CEO Services
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Executive Summary

Assessing Mental Health Needs of AAPIs

     According to the Surgeon General's Report on Mental Health (1999)ⁱ , the U.S. mental health system is not well equipped to meet the needs of racial and ethnic minority populations. In 1998, President Clinton committed the nation to the health objectives for the 21^st century of Eliminating Racial and Ethnic Disparities in Health by the year 2010 under the US Department of Health and Human Services.

     Center for Mental Health Services committed to assess the unmet needs of AAPIs, and contracted with CEO Services to conduct a needs assessment to understand the mental health needs of Asian Americans and Pacific Islanders, and if their needs are being met through federal block grant dollars within the 59 US states and territories. If states subscribe to CMHS federal block grant principles in their mission statement, state plan, and implementation plan, it is expected that access, availability, and appropriateness of care will occur for all its citizens. We need to know if the public state and federal mental health systems are adequately serving the mental health needs of AAPIs.

     A second focus of this needs assessment is on the cultural competency of state mental health systems to enable them to be responsive to the unique needs of AAPI communities. Cultural Competence is defined as:

Culture includes thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group. Competence implies having the skills and capacity to work effectively with culturally diverse clients. A culturally competent system of care acknowledges and incorporates--at all levels--the importance of culture and its influence on the delivery of care to meet the needs of culturally diverse groups.ⁱⁱ

Methodology

     A review of public documents included national and state data with the core question: Are the state mental health systems adequately serving the mental health needs of AAPIs. with regard to access, availability, and appropriateness of care? State plans, and implementation reports submitted to CMHS for the block grant application from the 59 states and territories were reviewed.

     CMHS Cultural Competence Standards were used to develop as criteria to assess the adequacy, appropriateness, and availability of services for the AAPI population as reflected in the state plans. 132 Cultural Competence Prompts were developed to identify the presence or absence of elements in the state plan related to systems and clinical standards, provider competencies, and consumer involvement.

     Based on US census data, 8 states were selected for in-depth study regarding the availability, quality and accessibility of services. These states rank among the 12 highest density states for AAPIs in the US. The cities in which focus groups were conducted include: Houston, Texas; Jersey City, New Jersey; New York City, New York; Los Angeles and San Francisco, California; Seattle, Washington; Honolulu, Hawaii; McLean, Virginia, all of which are located in the counties with the highest concentrations of AAPIs.

     Focus group participants included: AAPI mental health providers, consumers, community advocates and leaders from the AAPI community, and AAPI state mental health personnel. A total of 136 individuals participated in 9 focus groups. Participants included AAPI providers, consumers, and community leaders of diverse cultural backgrounds including: Chinese, Japanese, Korean, Vietnamese, Hawaiian, Cambodian, Laotian, Hmong, and Filipino. No focus group was conducted in the Pacific Islands.

Recommendations: Addressing Unmet Needs of AAPIs

     Despite phenomenal growth of the AAPI population between 1990-2000, states have not responded to changing demographics in their use of block grant dollars or development of block grant objectives. There is no population focus by race/ethnicity in the block grant despite frequent reference to changing demographics. There are only 2 states with targeted initiatives for AAPIs, 1 state with a performance indicator targeting AAPIs, and no outcome data. Disparities in utilization and penetration ratio for AAPIs demonstrate unmet mental health needs among AAPIs.

     While 43 states embrace the concept of cultural competence in their state plans, most of the state mental plans did not have the information to answer many of the Cultural Competence Prompts developed to audit these plans. The focus groups and key informant interviews reflect a community and AAPI perspective about the block grant and whether or not it has been adequate in meeting the diverse needs of AAPI populations. In general, focus group participants show little knowledge about the block grant. Those who were more knowledgeable felt that AAPI needs historically have not been met through block grant dollars.

     AAPIs typically face barriers access the public mental health system supported by block grant dollars because of language, eligibility restrictions, insurance, and cultural barriers. They tend to underutilize services. They do not have access to the full continuum of care; services are often limited to outpatient and support services when provided by ethnic specific agencies, serving only specific Asian ethnic groups, or inadequate when provided by mainstream agencies. State mental health systems have typically marginalized these services and have not done a sufficient job of reaching out to AAPI communities for community education or involvement in state planning of the block grant. An emerging crisis is the shrinking AAPI bilingual/bicultural workforce coupled with the growingAAPI population.

Establish a population focus in State Mental Health Plans

     Currently, state plans do not have a population focus by race/ethnicity to target underserved populations despite reports of disparities although rural and homeless populations are targeted priority populations. Failure to report on race/ethnicity data, and inconsistencies in reporting across states make the state plans less amenable to planning and accountability of block grant dollars. As such, they are also not useful in identifying or planning for AAPI needs.

Cultural Competence as an explicit criterion for the Block Grant

     A quality mental health system must be responsive to diverse segments of the population. The influence of language and culture must be considered to ensure that the services are accessible, available, appropriate, and adequate when serving diverse population groups. There must be flexibility to allow for different approaches that are culturally relevant while remaining consistent with system values and principles of quality of the block grant.

     Cultural competence as a criterion for state plans should be explicit based on CMHS standards. Cultural Competence Prompts should be expanded to assess the impact of the State Block Grant Program in meeting the needs racial/ethnic populations including the AAPI population.

Collecting Data on Race/Ethnicity and AAPIs

     Despite the presence of the OMB mandate on race/ethnicity data, most states still do not report race/ethnicity data; even fewer disaggregate data by ethnic groups. Consequently, data on AAPIs is inadequate. This problem is compounded by a lack of a uniform data set across federal agencies, and the inability of states with county systems to have access to county utilization data and client characteristics.

Performance Indicators for State Plans

     The use of performance indicators is a reflection of the move for quality assurance via a data driven, outcome focused approach. The increased emphasis on performance indicators should include cultural competence indicators and indicators targeting the AAPI population. Performance indicators currently recommended in the state plans include: employment, living independently, and average length of stay. Using a disparities approach, data reported on these performance indicators should be cross-tab by race/ethnicity to evaluate whether or not disparities in utilization or outcomes exist among racial/ethnic populations.

Promoting Workforce Development

     While states stress the need for a culturally competent workforce, the pool of bilingual/bicultural AAPI providers has, in fact, eroded while the AAPI population has doubled over the past decade. Secondly, mainstream providers working with AAPIs often do not have the competency experience to address their cultural and linguistic needs. Few states have standards or requirements to ensure a culturally competent workforce.

Recognize Ethnic Specific Services

     Ethnic specific services provided by community based, AAPI organization is a best practice that addresses AAPI needs. These services are different from mainstream services and are often preferred by AAPI consumers, especially when they are non-English speaking. The block grant is biased against ethnic specific services; AAPI vendors have difficulty obtaining resources; they need to comply with regulations and criteria that are less relevant, overly burdensome, and often contrary in purpose. Diversity initiatives and cultural competence assessment tools, for example, generally use the same criteria for mainstream and ethnic specific services. For example, achieving a diverse workforce to mirror the population within ethnic specific agencies is not a goal. Nor is serving the population in geographic vicinity since ethnic specific agencies often draw from wide geographic areas which cut across areas defined by block grant criteria.

Develop CMHS Initiatives to address unmet AAPI needs

     These initiatives might include:
 

Develop objectives for cultural competence or targeting AAPIs as part of CMHS's GPRA plans and objectives, incras
Allow flexibility in eligibility criteria currently excluded from the SMI definition such as PTSD and acculturation stress
Establish goals to increase resources to AAPI programs and services based on population changes
Support subcontracts to AAPI vendors
Establish an AAPI advisory body or workgroup within CMHS
Increase interagency coordination to address AAPI needs.
Allocate resources from the 5% set-aside to fund an AAPI data initiative to establish a baseline for state planning and evaluation, or a feasibility study to identify cultural competence indicators for populations meeting a threshold level of 5% within a county.

References

Mental Health: A Report of the Surgeon General. (1999), http://www.nimh.nih.gov/mhsgrpt/chapter2/sec2_1.html

Cross, T.L., Bazron, B.J., Dennis, K.W., & Isaacs, M.R. (1989) Toward a Culturally Competent System of Care. Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center.

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