Serving a Diverse Jackson County

Transcription

1 Serving a Diverse Jackson County Mental Health Response to Spanish-Speaking Telephone Callers THE JACKSON COUNTY COMMUNITY MENTAL HEALTH FUND 301 EAST ARMOUR BOULEVARD, SUITE 640 KANSAS CITY, MISSOURI Telephone: R

2 Mental Health Response to Spanish-Speaking Telephone Callers September 2009 Background THE JACKSON COUNTY COMMUNITY MENTAL HEALTH FUND 301 EAST ARMOUR BOULEVARD, SUITE 640 KANSAS CITY, MISSOURI Telephone: R In March of 2009, the Jackson County Community Mental Health Fund (Levy) undertook a brief survey of clinical directors of local mental health organizations to better understand community 1 capacity to deliver mental health to consumers who do not speak English. The on-line survey focused on Levy-funded mental healthcare for people with mental illness and their families. In that survey, 38% of the clinical directors surveyed reported that non-english mental health services were provided directly by clinical staff, and more than four-fifths (85%) reported that mental health services were provided using spoken language interpreters. Spanish was the most commonly reported non-english language in which services were offered. 2 Purpose of this Project The purpose of this pilot study was to gather information about the quality of responses provided to Spanish-speaking consumers by Levy-funded agencies who reported being able to provide services in Spanish. Although we have been able to document linguistic diversity in mental health services, conclusions about the cultural and linguistic competence of non-english mental health services in Jackson County could not be made from the March 2009 survey. More information on agency response from a consumer perspective was needed, including information on: Linguistic competence of agency personnel; Appropriateness of basic information and referral; Cultural competence regarding beliefs about mental illness by consumers with Spanish as their primary language; and Accessibility of mental health information and services. Important factors of cost, accessibility, clinical acumen, linguistic competence and cultural competence are complex and can be difficult to measure. However the lack of any one of them can pose a major barrier to accessing needed services. Through the Education and Planning Committee we planned a pilot study to examine the experiences of persons who speak Spanish with mental health agencies who indicated the capacity to serve them. The project was announced in an Education and Planning committee report in a public meeting of the Board of Trustees on January 22, 2009.

3 Method Interviewers. This project used a secret shopper approach to information gathering, a widely accepted method that uses trained consumers to provide feedback about actual agency performance. 3 Three community members were recruited by a member of the Education and Planning Committee to serve as callers. Two were female, one was male. Each caller was a native Spanish speaker, also English-speaking. None had professional training in mental health, although each had personal experiences involving a family member or friend with a diagnosed or suspected psychiatric disorder. Selection of Agencies. In our March 2009 Survey of levy-funded agencies, ten indicated having an 1, 4 internal capacity to provide mental health services in Spanish. All ten agencies were included in this project. We attempted to exclude agencies indicating Spanish language services through the use of telephone translation. Two additional agencies are known to offer Spanish language services, but these either did not participate in the March 2009 survey, or they did not indicate Spanish services were available in that survey. Instrument. A brief interview form in Spanish (Appendix A) was used to record callers experiences of: Agencies immediate response to a caller requesting Spanish-language assistance; Length of time required for agencies to return messages left in Spanish; Information provided about mental illness and access to Spanish-language services; and Fluency, courtesy and information provided. The instrument also provided a way to rate overall impressions of courtesy/respectful treatment, information provided, linguistic competence, and to record other observations on the interviewers experiences. Callers also participated in a follow-up meeting in which they discussed their experiences overall. Procedure. Callers were trained as to the purpose of the study and in the use of the brief format interview summary. Practice interviews provided the opportunity to rehearse various scenarios and completion of the forms. Each of the 10 agencies was contacted by two callers. Each caller contacted 6-7 selected Levy-funded agencies by telephone, to request staff who spoke Spanish, information on a suspected mental illness, and an explanation of the process of obtaining no-cost services. The calls were conducted between June 15 and June 29, Results Because of the small number of agencies and the specificity of services, results do not identify specific agencies. Results are not intended to provide a report card on specific agencies. Instead, results are intended to broadly capture the experiences of persons speaking Spanish who seek mental health care. The results are considered preliminary in nature and will have no impact upon funding decisions or matters of contract performance. Directors of each agency contacted in this project will be provided with results specific to their own agency only. 2

4 Responses to Request for Spanish. Callers initially asked in English if the person answering the telephone spoke Spanish. If the agency respondent spoke English, callers then asked to speak with someone in Spanish. If an automated system answered, callers attempted to use voice mail options using either English or Spanish instructions; and then left recorded messages in Spanish. Each agency in this project reported in a previous survey that they had the availability to provide mental health services in Spanish. But in our current study, only two-thirds of calls to those agencies reached Spanish-speaking staff, and only half resulted in Spanish language response on the same day of the call. The results are shown in the adjacent graph and the table on the following page. Half of the calls received an excellent response. The caller was able to speak with Spanish-speaking staff either at the time of the call, or the call was returned by a Spanish-speaker on the same day. Excellent responses also included the provision of relevant, appropriate information. Three calls received a good response. Information was provided as requested, in Spanish, within three days of the initial call. Two calls resulted in information being provided only in English. Agency staff attempted to provide helpful information, however the responses were inadequate, since English information may not have been understood by a consumer who prefers Spanish. One-fourth of calls to agencies who reported the capacity to provide services in Spanish yielded poor results. Callers left messages which were not returned, or callers were left on hold for more than 10 minutes without the ability to leave a message. One caller was provided with referrals to churches for treatment of depression, which we consider to be incompatible with expectations of public funding. Return Calls. In our March 2009 grantee survey on non-english mental health services, more than two-thirds of clinical directors reported that when non-english interpreter services are available, consumers wait less than two days. Callers experiences in the current study were slightly less favorable. One call took three days to be returned, and none of the calls placed to one agency were ever returned. Cost of Interpreters. Our recent study of non-english mental health services found two agencies that charge consumers an additional fee for spoken language interpretation. None of the agencies contacted in this project mentioned additional costs for Spanish language services. 3

5 Agency Responses Children and Families, Education and Vocational Agency First Caller Second Caller Agency A Agency B Agency C No Spanish at initial call. Call was returned within 1 hour by competent Spanish speaker. Information provided as requested. No Spanish at initial call. Arranged interpreter for call-back on the following day. Left voice mail at initial call. Spanish speaking staff returned call within 3 hours. No Spanish at initial call. Caller on hold 10 minutes without a response or being directed to voice mail. No Spanish at initial call. Provided information in English. Spanish available at initial call. Provided information in Spanish Domestic and Sexual Violence Agency D Agency E Agency F Agency G No Spanish at initial call, offered to arrange, but provided info. in English. Spanish interpreter provided at initial call. Provided information in Spanish. Spanish available at initial call. Provided information in Spanish. Safety Net Left voice mail in Spanish. Call returned in Spanish 3 days following initial call. Spanish available at initial call. Provided information in Spanish. Spanish interpreter provided at initial call. Provided information in Spanish Spanish available at initial call. Provided information in Spanish. Left voice mail in Spanish. Call returned in Spanish 2 days following initial call. Agency H Agency I Agency J No Spanish at initial call. Call was returned promptly by competent Spanish speaker. Information provided as requested. Spanish available at initial call. Recommended caller seek help for depression from other agencies or churches. Left voice mail messages. Calls not returned. No Spanish at initial call. Caller was told no Spanish-speaking staff available. No number requested for return call. Spanish available at initial call. Provided information in Spanish. Left voice mail message. Call not returned. Dark Green = Excellent; Light Green = Good; Yellow = Inadequate; Pink = Poor Comparison of Response by Funding Category. The agencies contacted in this project were 5 broadly representative of several Mental Health Levy funding programs. Notable in the performance of responses is the variation when funding categories are compared. Safety Net agencies are the largest and most diverse group of Levy grantees, and the Safety Net funding program is the Levy s largest financial allocation. This subgroup performed least 4

6 well, with poor responses to half the calls. Agencies funded in the Children & Families and Educational & Vocational funding programs are grouped together in the table above. These results are rather mixed, with half the initial response yielding excellent responses and only one poor response. Five of six responses by Domestic and Sexual Violence agencies were excellent. Requests for Information and Service. Fourteen of the 20 calls (over two-thirds) reached staff able to speak Spanish. As noted above, 13 of those responses were rated good or excellent. Having established communication, callers proceeded to describe their concerns regarding a person they believed to be in emotional distress. Callers then asked for information on the possible disorder and how to obtain appropriate services without cost. Each of these 13 requests received information generally responsive to the request and appropriate for the agency contacted. Callers comments from all 20 requests for information and services, translated from Spanish to English, are presented in Appendix B. When the two calls to each agency are compared, callers observations indicate that agencies occasionally provided inconsistent information about topics including: Whether there were Spanish-speaking staff, How to obtain services, What services were provided, and What was needed to obtain services at no cost. Additional information and a more tightly controlled methodology would be needed in order to determine how this pattern compares with inconsistencies that may be experienced by Englishspeaking callers, or by callers requesting services in some other language. Callers Overall Satisfaction. Callers provided brief ratings of their experiences after each call. Ratings, summarized in the adjacent graph and table below, included the perceived pleasantness/ respectfulness of responding agency staff, satisfaction with the information provided, and ratings of the linguistic competence of responding staff. Considering the three satisfaction questions together, callers gave good ratings, on average. Agency staff were rated most highly on being pleasant and respectful. Callers ratings of staff were nearly always excellent. In a de-briefing with the callers at the close of data collection, callers emphasized that, with the exception of calls that yielded poor results, they found agency staff to be pleasant and professional. Callers were generally satisfied with the information they received about the reported signs and symptoms of mental distress, and about accessing services at no cost. The information that callers received was rated as good, on average. One caller noted that the explanations from agency staff were clear. 5

7 Caller Satisfaction Ratings A, B Agency Staff Pleasant/Respectful 3.82 Satisfaction with Information 3.41 Competence in Spanish 2.75 Overall Mean 3.22 A Average caller satisfaction ratings on a 4-point scale (1 = low; 4 = high). B 17 calls. Ratings exclude calls that were not returned. Ratings of agency staff linguistic competence in Spanish were lowest among the three satisfaction measures. On average, the ratings were somewhat lower than a good rating. In discussing their experiences, callers agreed that although agency staff could often speak Spanish, they were less culturally competent in discussing psychological symptoms with callers. Conclusions Quality of Responses. Spanish-speaking callers contacted agencies who reported being able to provide services in Spanish. About two-thirds of the 20 calls resulted in responses that were of excellent or good quality, and one-fourth of the calls got a poor quality response. Performance by Grant Category. Agencies funded in the Domestic and Sexual Violence grant program were the most consistent in providing excellent quality responses. Agencies funded in the Children & Families and Education & Vocational grant programs performed well, but less consistently. Half of the responses of Safety Net agencies were of poor quality. Callers Impressions. On average, callers gave high ratings to agency staff for their pleasant, respectful manner on the telephone. The information provided was also generally satisfactory. However, the linguistic competence of agency staff was rated somewhat less favorably. This finding 6 is consistent with our recent analysis of grantee agency cultural competence plans, which found that few Levy grantee agencies had included assessment of linguistic competence within their internal cultural competence plans. Encouraging Results. The general overall satisfaction of callers is a good indication of a maturing capacity within Jackson County mental health agencies for response to Spanish-speaking consumers of mental health services. As we continue to highlight expanding availability of services we must also look for ways to provide various supports and assistance to encourage further development of agencies capacity for non-english mental health services. Internal Training Suggestions. This project found a few areas where the quality of response could be improved through internal training or supervision. First, we found indications that agency staff appear to have provided inconsistent information to callers regarding services and service access. This suggests there is a need for improving staff support and/or their access to information on agency capacity. Messages that went unreturned may be a function of voice mail system management, 6

8 confusing options for Spanish language callers, or needs for improved procedures for handling non- English-language messages. External Technical Assistance. As the Mental Health Levy considers future technical assistance, we should encourage cultural competence plans that include procedures for handling non-english speaking callers and empowering front-line staff to seek or develop appropriate information about their agencies and services, in order that they can provide the most consistent, complete information to the predominant cultural groups in their areas. Follow-Up with Agencies. As noted above, agencies contacted in this project will be contacted individually. Each will be offered the opportunity to meet with staff, discuss findings in more depth, and explore opportunities for future collaboration and/or technical assistance. Future Secret Shopper Projects. This project is the first time that we have worked in partnership with community members to examine consumers perceptions of agencies that receive Levy funding. Although this project is only a preliminary study carried out with the assistance of community participants, the results are unique and useful. We recommend that secret shopper methodology be considered in future examinations of service quality and consumer responsiveness. Notes 1. Jackson County Community Mental Health Fund (2009). Linguistic diversity of public mental health care in Jackson County, Missouri. Kansas City, MO: Author. 2. This is an appropriate response to local demographics. Spanish is the most common non- English language spoken in Jackson County. The US Census Bureau s 2006 American Communities Survey found that 2.7% of Jackson County households are linguistically isolated. Of those, 39% use Spanish only. 3. Secret shopper methodology is widely used and accepted. For example, in June 2008, The American Medical Association's Council on Ethical and Judicial Affairs released a recommendation on the use of "secret shopper patients" in the healthcare arena: "Physicians have an ethical responsibility to engage in activities that contribute to continual improvements in patient care. One method for promoting such quality improvement is through the use of secret shopper patients who have been appropriately trained to provide feedback about physician performance in the clinical setting." TM 4. Agencies who indicated Spanish available through the Language Line were not included in the survey because this is a contractual service and response to our study would have entailed additional cost beyond grantees planned staffing. One agency selected for this study did not TM indicate use of the Language Line in the prior study, but used it in the present study. 5. Noted elsewhere, sampling was based on agencies self-reported ability to provide Spanish language services in our March 2009 survey (Note 1). We did not attempt to carry out statistically representative sampling of funding programs. 6. Jackson County Community Mental Health Fund (2009 in draft). Cultural competence plans of public mental healthcare providers. Kansas City, MO: Author. 7

9 - Appendix A- FORMA PARA ENTREVISTAS interview form Agéncia Agency Teléfono Telephone Fecha Date Hora Time PREGUNTAS Questions 1) Hello. Do You speak Spanish? (Y contestan...) and they answer Sí yes No Mensaje / Voic Fecha/hora que contestan Observaciónes como me ayudaron: Observations how they helped me date / time they ansered 2) Estoy preocupado en mi. I am worried about my Cuales son las síntomas de (la depresión)? What are the symptoms of (depression) 3) Como puede recibir consejería gratis? How can (s)he receive free counseling? Observaciónes: observations SOBRE LA LLAMADA about the call Amable - Respeto amiable respect Información information Competencia en mi idioma competence in my language Observaciónes:observations 8

10 - Appendix B - A Caller Observations Children and Families, Education and Vocational Agency First Caller Second Caller Agency A Agency B Agency C They answered in a friendly way and told me to call back later. They told me the person who speaks Spanish will return Monday. I called again and a man answered in Spanish, giving information and also coached me. They seemed friendly but didn t have anyone to speak Spanish. They told me they will get an interpreter and call me the next day (caller did not indicate whether this took place) They gave me information on all that they do. The mother has to come in, in order to receive free or low-cost therapy. Waiting for 10 minutes and they never answered me in Spanish. Friendly attention. They don t have free help; they need Medicaid. Friendly with very good explanations. They require a form to confirm what type of abuse or neglect is present (I don t really understand this). They offer free help and attention in Spanish if it is required. Domestic and Sexual Violence Agency D Agency E They took care of me well and explained what I have to do to obtain help. (S)he told me the the telephone number of my sister and that someone would call her in Spanish and explain and if she would like counseling in Spanish if it s available. They don t have anyone to answer (the telephone) in Spanish, but I think they give good help in Spanish. They took good care of me and got an interpreter and they explained what to do. They get a hold of the interpreters and the police bring people to the shelters for help and they say that there are personnel or volunteers that speak Spanish. They showed themselves to be kind and gave me all the information I needed. The person that helped me was named She said everything was free if I needed shelter or a counselor. In English by means of an interpreter in Spanish. The two were very friendly, offering various options for the person referred. Once a person goes there (to the shelter), it will be explained how they will help and that it can be free. 9

11 Agency F Agency G Agency H They have some services----, don t work with ---- and have two employees who speak Spanish. They can t give me counseling since they don t have therapy in Spanish. They told me about other agencies. She told me she doesn t know how to express her emotions in Spanish. Safety Net They had a system with an option in Spanish, but you have to know the extension of the person you want to speak with, or leave a message. I left a message, having called two times, they called me the following day. A person called me three days after (the initial call) in Spanish. They treated me well and told that (s)he was with a patient, that we will talk in an hour. The only counselor who speaks Spanish is named I think she is white and doesn t speak Spanish perfectly but understands it well. Very friendly with clear explanations. They offer free counseling without regard to legal status or economic circumstances. The person that helped me offered her personal telephone number for Spanish. They have messages for Spanish, I left message, they only take messages (I left a message). They apologized for having answered my call two days late. Her name is They said the therapy is free if I qualify. The person that answered said they don t have anybody that speaks Spanish. They were going to try to get someone in Spanish that would communicate (with me) but they didn t speak with me now. Agency I They asked me If I have insurance before taking 45 minuted to fill out the paperwork. They told me it s free but they recommended other agencies because the (mental health) program is psychiatric. Clear and cordial attention. Help is not free, if your income is very low, they charge a minimum. First appointment bring supporting information, notarized letter with income if any and photo ID. Agency J Only the answering system answered and I left a message for a person that speaks Spanish. I called two times and left message(s). They didn t return the call. They need an address and check stub. They had messaging in Spanish but didn t have a mailbox to leave a message in Spanish. They didn t answer, I tried to leave a message but they didn t return the call. They only had a message in Spanish. They had another phone number for making appointments A Observations were originally written in Spanish. 10