Cultural Competence and EvidenceBased Practices: Implications for Action

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Cultural Competence and Evidence-Based
PracticesImplications for Action
Vijay Ganju, Ph.D. Director, Center for Mental
Health Quality and Accountability NASMHPD
Research Institute, Inc. Phone [phone],
ext. 132 Email vijay.ganju_at_nri-inc.org

• Presentation at the conference on
• Balancing Evidence Cultural Competency and
  Evidence-Based Practices
• Seattle, Washington ? December 6, 2005

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• Even more than other areas of health and
  medicine, the mental health field is plagued by
  disparities in the availability of and access to
  its services. These disparities are viewed
  readily through the lenses of racial and cultural
  diversity, age, and gender.

Surgeon General David Satcher, M.D., Ph.D. in
Mental Health A Report of the Surgeon General
(DHHS, 1999, p.vi.).
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What Are Mental Health Disparities?

• Access
• Availability
• Utilization
• Quality of Care
• Research and Data

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Selected Performance Measures by
Ethnicity(Five-State Feasibility Study, 1997)
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Patterns in Cause of Death by Minority Group, 1992
? Indicates higher death rate than for whites
Source National Center for Health Statistics,
1994. From Nickens, HW The Role of
Race/Ethnicity and Social Class in Minority
Health Status, Health Services Research, 30 (1)
156, 1995
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Benefits of Cultural Competence in Healthcare
Improved Health Outcomes
Maximal Use of Limited Resources
Increased Customer Retention and Access to Care
Increased Customer Recruitment Increased
Customer Satisfaction
Provide Products and Services Consistent with
Client Needs
Culturally Competent Management, Staff and
Practitioners
(Adapted from American Association of Health
Plans, Minority Management Program, 1997)
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Rationale for Cultural Competence

• Cultural Competence Quality of Care
• Cultural Competence Disparity Reduction
• Cultural Competence Risk Management
• Cultural Competence Parity (within MH system)
• Cultural Competence Linguistic Competence
• Cultural Competence A Fundamental Social
• Responsibility
  

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What are Evidence-Based Practices?

• Evidence-based practices refer to services and
  programs that have been shown to be effective
  using the highest standards of scientific proof.
• NOTE Only a few mental health services and
  programs meet this high standard

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Evidence-Based PracticesSelect Definitions

• An evidence-based practice is considered to be
  any practice that has been established as
  effective through scientific research according
  to a set of explicit criteria (Drake, et al,
  2001)
• Evidence-based treatment is the use of treatments
  for which there is sufficiently persuasive
  evidence to support their effectiveness in
  attaining desired outcomes (Rosen and Proctor,
  2002)
• Evidence-based practice is an approach to make
  clinical decisions for individual patients
  (McKibbon, 1998)
• Evidence-based practice is the integration of
  best research evidence with clinical expertise
  and patient values (Institute of Medicine, 2001)

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Levels of Evidence

• Level I Randomized control trials
• Level II
• Well designed trials without randomization
• Cohort or case control, preferably multi-site
• Multiple time series with or without
  intervention
• Level III Opinions of respected authorities
  based on clinical experience, descriptive
  studies, case reports

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The Quality Pyramid

• System Outcomes

Quality Improvement
Evidence-based Practices
Performance Measurement
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Evidence-Based PracticesExamples
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Evidence-Based PracticesExamples, Contd
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SAMHSAs New Implementation Resource Kits for
EBPs and Promising Practices

• Supported Housing
• Consumer-Operated Services
• Older Adults
• Children and Adolescents

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Promising Other Practices that are Effective but
Lack Strong Evidentiary Base

• Consumer-operated services
• Jail diversion and community re-entry programs
• School mental health services
• Trauma-specific interventions
• Wraparound services for children

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Example of Benefits of EBPs Related to Crime
Reduction
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Public Mental Health Authority

• Leadership
• Policies
• Regulation
• Resources

Provider Organization

• Leadership
• Organizational Culture
• Administrative Support
• Information Technology

• EBP
• Cost
• Compatibility
• Payoffs
• Complexity

• Practitioner
• Knowledge
• Perceived advantage
• Feedback

• Consumer/Family Member
• Choice
• Commitment
• Perceived Advantage

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Factors Affecting State-Wide EBP Implementation

• System leadership
• Organizational culture/consensus
• IT capacity/outcomes measurement
• Policies/procedures
• Integration with performance/quality improvement
• Human resource capacity/training
• Funding methods

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EBP Implementation The Need for an
Outcomes-Based QI and Recovery Framework

• EBP implementation must occur within a
  person-based, recovery/resilience, and culturally
  competent framework
• Implementation of evidence-based practices
  requires outcomes data at the clinical level
• EBP implementation has to occur within a quality
  improvement framework

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Consensus Statement of Evidence-Based Programs
and Cultural Competence

• Evidence exists that shows that specific programs
  are effective for specific populations in
  specific settings
• Helpful practices exist for which evidence has
  not been fully established
• Little research on EBPs has been conducted on
  diverse populations
• Within this limitation, existing data suggest
  that there are no significant differences in
  outcomes across different racial, ethnic, or
  cultural groups
• Implementation of EBPs depends on adequate
  infrastructure
• Emergent research suggests that adaptations can
  be made for specific populations

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Consensus Statement (contd)Recommendations

• Investigate differences in outcomes
• Investigate factors that contribute to consumer
  and practitioner access
• Investigate the critical system, infrastructure,
  and knowledge transfer components related to
  successful EBP implementation
• Develop new models of research
• Understand relationships of community
  infrastructure to resilience and recovery
• Develop curricula of training and professional
  programs that include cultural aspects and
  differences
• Provide resources to develop and increase
  workforce capacity to effectively implement
  appropriate interventions

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Cultural Competence and EBPsCommon Features

• Similar goals - improved quality, improved
  outcomes
• Require individual development
• Require organizational development (leadership,
  data collection, infrastructure, resources)
• Fuzzy concepts (different definitions,
  concepts, etc.)

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Cultural Concerns Regarding EBPs
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Approaches to Reflecting Cultural Competence

• Measure outcomes for each race/ethnicity/
  cultural group (e.g. California)
• Adapt evidence-based practices for specific
  ethnicity/cultural group (e.g. Hawaii, Los
  Angeles)
• Expand definition of evidence to include
  culture-specific interventions (e.g. Oregon)