COMMUNITY-BASED PARTICIPATORY DEVELOPMENT OF A COMMUNITY HEALTH WORKER OUTREACH ROLE TO EXTEND COLLABORATIVE CARE IN POST-KATRINA NEW ORLEANS

Objectives: The REACH NOLA Mental Health Ashley Wennerstrom, MPH; Steven D. Vannoy, PhD, MPH; Infrastructure and Training Project (MHIT) Charles E. Allen, III, MSPH; Diana Meyers, RN, BSN; aimed to reduce disparities in access to and quality of services for depression and post- Elizabeth O’Toole, MSPH; Kenneth B. Wells, MD, MPH; traumatic stress disorder (PTSD) in post-Katrina Benjamin F. Springgate, MD, MPH New Orleans by developing a mental health outreach role for community health workers (CHWs) and case managers as a complement that could support quality improve- to the collaborative care model for depression INTRODUCTION treatment. ment, but staff and administrators may Underserved communities are at lack adequate training to address 10 Intervention: Community agency leaders, high risk for poor access to quality mental health issues, facilitate appro- academics, healthcare organizations, and care for common mental disorders priate referrals for care, and help CHWs engaged in a community participatory affected persons overcome mental process to develop a CHW training program. such as depression and posttraumatic stress disorder (PTSD),1,2 particularly health related stigma. Design: A review of qualitative data including following exposure to disasters such as Health and social service agencies semi-structured interviews, project team con- the 2005 Gulf storms.3,4 Evidence- often utilize community health workers ference calls, email strings, and meeting based quality improvement programs (CHWs) – personnel who provide minutes was conducted to document CHW fellow community members with health input into training and responses to imple- such as collaborative care approaches mentation. that integrate providers, services including education and health- patient care managers, and mental care referrals – to fill unmet public Results: CHW contributions resulted in a health specialists into patient-focused health needs in underserved communi- 11 training program focused on community en- teams increase access to services and ties. CHW engagement is a promising gagement, depression screening, education, strategy to overcome disaster-resultant referral assistance, collaboration with clinical improve health and employment out- teams, and self-care. CHWs reported use of comes for depressed and anxious healthcare infrastructure limitations in screening tools, early client successes in spite primary care patients, including un- contexts such as post-Katrina New 12 of challenges with client engagement, increase derserved groups.5–8 However, such Orleans, where the shuttering of in networking and collaboration with other programs may be difficult to imple- healthcare facilities and exodus of community agencies and providers, and on- going community hurricane recovery issues. ment in public sector agencies and providers diminished local capacity to those damaged by disaster, owing to address well-documented unmet, ongo- 3,4,13 Conclusions: This intervention development resource and infrastructure limita- ing mental health needs. CHW approach and model may be used to address tions.9 Secular and faith-based social facilitation of early entry into appropri- post-disaster mental health disparities and as a ate care for community members with complement to traditional implementation of service organizations often have infra- collaborative care. (Ethn Dis. 2011;21[Suppl structure for post-disaster outreach, mild to moderate symptoms of anxiety, 1]:S1-45–S1-51) case management, and medical care depression, and trauma may prevent serious mental health sequelae and Key Words: Community Health Workers, subsequent use of emergency health Community-Based Participatory Research, services. CHW provision of peer-to- Collaborative Care, Disaster, Mental Health Services and Society, University of Califor- nia, Los Angeles (EO, KW); Semel Institute peer support for fellow community for Neuroscience and Human Behavior, members may fill gaps in availability University of California Los Angeles (KW); of traditional counseling services, and Department of Health Services, University their participation as members of col- From Tulane University School of Med- of California, Los Angeles School of Public laborative mental health treatment icine, Office of Community Affairs and Health (KW); RAND Corporation (KW, BS); Health Policy (AW); Tulane University Tulane University School of Medicine, teams could increase patient engage- School of Public Health and Tropical Department of Medicine (BS); RAND ment, leading to increased efficacy of Medicine, Department of Community Health (BS); and REACH NOLA (BS). care delivery. Previous CHW participa- Health Sciences (AW); University of Wash- tion in addressing community mental ington, Department of and Be- Address correspondence to Ashley havioral Sciences (SDV); Holy Cross Neigh- Wennerstrom; 1430 Tulane Ave. SL-16; health needs has included application to borhood Association (CEA); St. Anna’s New Orleans, LA 70112; 504.988.4007; homeless or severely mentally ill popu- Episcopal Church (DM); Center for Health 504.988.8252 (fax); [email protected] lations,14,15 international settings,16 and

Ethnicity & Disease, Volume 21, Summer 2011 S1-45 POST-KATRINA MENTAL HEALTH OUTREACH - Wennerstrom et al in one study, following a disaster,17 but address these feasibility and potential evidenced-based therapy; and care man- CHWs have not previously been docu- effectiveness issues. ager sessions on coordination of depres- mented in the scientific literature as sion treatment. serving as members of a mental health The addition of CHWs as members treatment team in a post-disaster envi- METHODS of the collaborative care team required ronment. the development of a CHW-specific In this article, we explore: 1) the Community-based participatory re- training curriculum and resources. A process and viability of using a commu- search (CBPR) approaches have been work group of community and academ- nity-based participatory approach to recommended to address health dispar- ic MHIT project co-leads, and New develop a framework and model for ities,18 particularly in groups with Orleans-based CHWs engaged in a CHW and case manager mental health historical distrust in research and ser- participatory, iterative process with the outreach as a complement to quality vices.19 This approach has been applied goal of developing a sustainable, cultur- improvement training in collaborative to mental health services research,20,21 ally competent CHW training program care for depression in post-Katrina New and was the basis for development of the for mental health outreach. Work group Orleans; and 2) the feasibility of the participatory REACH NOLA partner- collaborators sought to: 1) be responsive model itself, as well as early responses to ship22,23 that led the Mental Health to community needs and acknowledge a training curriculum that was devel- Infrastructure and Training Project community strengths; 2) be consistent oped to operationalize the model. While (MHIT). with key components of the collabora- the need for developing a mental health tive care model of chronic disease outreach model was jointly recognized Training Development management24 such as promoting evi- by academic and community partici- Initiated in May 2008, MHIT dence-based treatments, care coordina- pants in early stages of the project we aimed to address limitations in access tion, and patient participation; 3) build describe, we were uncertain of whether and quality of mental for on existing CHW models that address 25 the community-based participatory ap- New Orleans area hurricane survivors health disparities; and 4) support proach would lead to an implementable by providing staff and administrators at CHW-patient engagement in nonclini- model within the short time period social service and safety-net agencies cal settings to contribute to patient required by the urgency of the post- with multi-day training seminars and education that results in an increase in disaster situation. We were also uncer- follow-up technical support in evidence- the utilization of evidence-based screen- tain whether CHWs receiving relatively based practices for treatment of depres- ing tools, and to contribute to the little training in mental health issues sion and psychological trauma. Approx- referral of patients into treatment, would find the outreach model and imately 400 therapists, psychiatrists, which may be critical to bringing training applicable to their work. We primary care providers, care managers, underserved populations into appropri- report on the process of model devel- administrators, CHWs, and case man- ate care.22 opment and early experiences with agers employed by 70 participating Sixty-two CHWs and case managers implementing a training program to institutions attended team-focused ses- attended the first three MHIT training sions on implementation of collabora- seminars held between July 2008 and tive care for depression that included: February 2009. Trainers used didactic overview of the collaborative care mod- instruction, role-playing and discussion We report on the process of our el; implementing system change at Training 1 to demonstrate the use of through structured quality improve- depression screening tools and teach mental health outreach model ment methods; improving care coordi- principles of community engagement; at development and early nation and communication between this time participants and trainers clinical providers; strategies for assem- identified a need for additional instruc- experiences with bling a collaborative care team; net- tion to address more adequately com- working with other community provid- munity concerns. All participants in implementing a training ers; and quality improvement metho- Trainings 1 through 3 were invited to program to address these dology. contribute to a revised CHW mental Profession-specific collaborative care health outreach curriculum by provid- feasibility and potential competencies were developed through: ing insights on community context and effectiveness issues. instruction of medication management feedback on training materials and principles for primary care providers; resources. The project team altered therapist training in administration of training topics, techniques, and materi-

S1-46 Ethnicity & Disease, Volume 21, Summer 2011 POST-KATRINA MENTAL HEALTH OUTREACH - Wennerstrom et al als in response to CHWs’ goals and by IRBs at RAND, Tulane University, follow-up support calls. CHWs offered concerns. and the University of Washington. specific suggestions for improvement of All information presented at train- training and materials such as inclusion ings was documented in a written of additional role-playing sessions, em- manual and distributed with a CD of RESULTS phasizing cultural competence and net- resources and a client education DVD. working, simplifying the case registry CHWs received a book on depression Community input into training form, and integrating training for education and treatment options, in- development is summarized in Table 1. CHWs and therapists. CHWs identified cluding collaborative care26 and com- CHWs revealed the following primary a number of challenges to conducting munity resource guides describing low- concerns: complex post-hurricane chal- outreach and client follow-up, including or no-cost social services resources to lenges; need for services for vulnerable difficulty of reaching clients, stigma, address client needs. populations; continuing stressors such lack of community infrastructure, job as concern about future hurricanes; conditions, and barriers to collabora- Partnered Working Group frustration with inability to satisfy tion. Training participants acknowl- Qualitative Assessment clients’ financial needs; difficulty re- edged five types of positive training We conducted a qualitative review sponding to suicidal clients; and con- impact: increased delivery of high- of CHW input into training develop- cern about existing community and quality care, improved networking op- ment and responses to training and agency capacity, resources, and infra- portunities, increased respect for pro- implementation using a partnered structure to support mental health viders, assistance with continuing edu- working group approach.27 Data sets services and referrals. CHWs and case cation requirements, and increased hope were reviewed by two-member work managers reported strengths in the areas for community mental health recovery. group teams, with each member inde- of trust-building with clients, knowl- The final CHW training curriculum pendently reviewing the source material. edge of the community, and flexibility. contained modules that covered: over- We analyzed blinded data from all Many CHWs described difficulty ac- view of depression and PTSD; tech- sources of CHW feedback that includ- commodating the stresses of being on niques for building trust with clients; ed: minutes taken during 20 CHW- the front line, facing personal recovery instruction in use of PHQ-2 and PHQ- specific breakout sessions during Train- needs, and lacking time or resources to 9 depression screening tools; communi- ings 1, 2, and 3; 12 MHIT project team get help for personal recovery. CHWs ty resources for referring depressed weekly conference calls among academic requested instruction in self-care tech- patients; skills for problem-solving and and community partners including niques to cope with personal and work- behavioral activation, which were adapt- CHWs; three CHW support calls, in related stress. ed from psychotherapy trainings in which academic partners provided Table 2 summarizes findings con- other collaborative care initiatives; self- CHWs with post-seminar technical cerning CHW responses to the training. care for community health workers; assistance for implementation of out- The CHWs generally offered positive community education techniques; and reach techniques and use of screening feedback on the training content and tools for tracking client services and tools; 31 email strings from project valued both guided role playing and outcomes. team members, including CHWs; and follow-up support calls. They reported five semi-structured telephone inter- using PHQ-229 and PHQ-930 screening views of CHWs who participated in questionnaires. To increase community DISCUSSION the training seminars and support calls. acceptability, some rephrased screening A structured form was developed to questions to include colloquial lan- This project aimed to expand the record themes and text examples based guage, or they incorporated screening implementation of collaborative care for on the analysis questions. Then team questions into informal conversations. depression through a community-part- members together reviewed all docu- Although most CHWs were familiar nered, participatory approach to devel- ments to identify common and uncom- with employers’ existing privacy poli- oping and evaluating a culturally ap- mon themes and associated citations. cies, some CHWs identified confiden- propriate mental health training Authors integrated these summaries to tiality/HIPAA training as useful – program for CHWs and case managers reduce redundancies and clarify distinct particularly role playing the application in post-Katrina New Orleans. The themes.28 of policy and tools. Training in prob- effort integrated principles of collabora- No financial incentives were offered lem-solving skills and behavioral activa- tive care, CHW models for other health to participants. Research procedures tion support was novel for most CHWs, conditions, and participatory planning. were found to be exempt from review and use of these techniques was noted in The result, a program presented in a

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Table 1. Community input into development of community health worker training program

Themes Quotations What are the needs of New Orleans residents? Multiple problems ‘‘Most people before the storm could handle their issues, but afterwards, it was difficult to deal with because all the problems were adding up.’’ Difficulty of housing ‘‘It’s always housing issues.’’ Vulnerable populations and mental health issues ‘‘There are a lot of scary things being noticed in the community in terms of children without parents in homes by themselves, people not able to find jobs and not having any hope for dealing with rebuilding issues, elderly folks living alone on dark streets with no relatives checking on them, children in desperate need of mental health interventions.’’ Suicidal clients ‘‘Just talking to them straight out. Are you having thoughts of killing yourself? They want someone to listen to them, and are relieved that I brought it out.’’ ‘‘I met a woman in the doctor’s office who wanted to die.’’ Fit with agency scope ‘‘They say ‘I need this fixed’ rather than accepting assistance.’’ ‘‘75% of clients are hard to get a follow-through because what you are offering is not direct enough.’’ Continuing stressors ‘‘We are back from (evacuation due to hurricane) Gustav and seeing people in the community centers and counseling offices whose needs have only increased.’’ How is mental health outreach currently conducted? Lack of mental health outreach programs ‘‘There is nothing out there in the community that addresses the needs of mental health outreach workers.’’ Knowledge of local needs ‘‘History of serving low-income and/or African-American populations of post-disaster Greater New Orleans area.’’ Engage in client’s story ‘‘I want to hear your story, tell me what you’re experiencing.’’ Support without enabling ‘‘There is a thin line between empowering and enabling.’’ Faith-based support ‘‘I had to go to the Bible.’’ ‘‘I pray with them.’’ Build trust ‘‘We deal with building the trust of community folks to work with them.’’ Flexible style ‘‘Let people know that we are here for them and won’t abandon them.’’ ‘‘Need to be flexible in terms of meeting people on their own terms.’’ What do CHWs and community-based organizations need to address stress and depression in New Orleans? Resources/staff ‘‘Get so many (clients) that you become overwhelmed.’’ ‘‘Clients are responding, but would respond better if we weren’t standing on someone’s porch going door to door.’’ ‘‘A place we can refer our clients—that’s our big need as case management.’’ Funds for medication ‘‘One of the major problems we have is funds for medication.’’ Self-care/personal treatment ‘‘You need to treat yourself as a patient.’’ ‘‘Discussion of having recently trained counselor run support group for outreach workers for mutual benefit.’’ Integrate into existing programs ‘‘Work with other programs—nutrition for high school students, encourage exercise and healthy habits.’’ Agency capacity and accountability ‘‘The vast majority of those agencies are not doing what they say they are doing; lack of direction; no enforcement mechanisms.’’

training manual31 is itself an important knowledge exchange between commu- ble to develop awareness of the many addition to the public mental health nity and academic partners enabled the challenges for the population and envi- field, building on prior documented development of a community-relevant ronment post-disaster, while maintain- approaches.32 Early feedback suggests program informed by experts in local ing an asset-based approach that sup- that CHW participation in post-disaster context. We were encouraged that a ported hope in participants.21 mental health outreach may bolster participatory model was effective in The data suggested a positive overall community resilience by increasing supporting program development in a response to training and desire for interagency collaboration, building short time period, and for a stigmatized additional information in problem-solv- trust, and alleviating mental health- issue in the context of a historically ing therapy and PTSD. Participants associated stigma. underserved community following a valued confidentiality training. Depres- Data from the partnered evaluation major disaster. Consistent with partici- sion screening was implemented by of the program suggest that the two-way patory research principles, it was possi- many participants and was often report-

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Table 2. Community health worker responses to training program

Themes Quotations What did CHWs think of the training and materials? Informative ‘‘Training was well done, well put together, very informative and educational for those who wouldn’t have as much knowledge on a particular subject.’’ ‘‘The role-playing on how to deal with difficult clients was very interesting.’’ What components are CHWs using? PHQ-2 and PHQ-9: Strategies for use of ‘‘Several of our workers have used the PHQ-2.’’ screening and referral resources ‘‘Paraphrasing (screening items), so we could understand each other.’’ ‘‘I suggest they go to a clinic because I don’t want them to say I said they have ‘such and such.’ When they come back I ask about the visit and then ask the questions and present the options.’’ Confidentiality tools ‘‘Confidentiality materials were helpful, especially HIPAA laws’’ Behavioral activation ‘‘Elderly man who develops a plan to get off bus one block early to return to exercise, feels better; then gets off 2 blocks early and runs into a friend.’’ How can CHW training and support materials be improved? Case registry ‘‘The form is too long, break it down. Some questions need to be eliminated.’’ Cultural competence ‘‘Spanish version or simplified version for folks with low education.’’ ‘‘Would like a more community-oriented approach and language.’’ More role playing ‘‘People need more practice and a practice session is very helpful.’’ More relationship building ‘‘Needs to be a greater effort to get them all to talk. Have everybody exchange phone numbers and have some conversations.’’ Therapy for CHWs ‘‘Having recently trained counselor run support group for outreach workers.’’ Integrate with counseling skills ‘‘You created an artificial distinction between counseling and outreach piece, that didn’t work (for our needs in mental health agency).’’ What are the challenges associated with implementing the CHW role? Community infrastructure ‘‘Reluctance to call police because of the way they handle it sometimes.’’ ‘‘Limited services.’’ ‘‘Long wait for buses.’’ Client resistance and denial ‘‘We get the ‘I’m not crazy.’’’ ‘‘Denial issues.’’ ‘‘People don’t want to go to care.’’ ‘‘When we try to get people to accept some responsibility, people get upset with us and report us to the front office.’’ Hard-to-reach clients and clients with complex issues ‘‘‘Catch me if you can’ clients.’’ ‘‘When I called her the following week, have not been able to get through.’’ ‘‘Try to reach family to follow-up with elderly.’’ ‘‘Clients dealing with multiple issues—health is last.’’ ‘‘Problems on top of problems.’’ Job conditions ‘‘Work force too small, pay too little.’’ ‘‘Management is not on the same page.’’ Agency relationships and provider collaboration ‘‘Don’t have the interrelationships within and between agencies.’’ ‘‘Still trying to collaborate (to find a) place we can refer our clients.’’ ‘‘Outreach workers could work more closely with providers, churches.’’ What is the early impact? Hope ‘‘It gives us all hope…It’s good that you started that process.’’ Networking ‘‘The most important thing is that we stay in touch to make sure we are working on the same basis so we can all help each other.’’ ‘‘We increased ease of getting help for clients, working with other agencies.’’ ‘‘Do a resource network of mental health and rehabilitation providers. That would be a great service you could do.’’ Certification ‘‘Our agency pre-Katrina, failed Joint Commission because we did not do this. They will look to see if you have things like this in your program.’’ Improved quality and funding ‘‘Helps set our own standards, better opportunity to shine, clarify ourselves, and get more money.’’ Perception of providers ‘‘First time realized these providers want to do well.’’

Ethnicity & Disease, Volume 21, Summer 2011 S1-49 POST-KATRINA MENTAL HEALTH OUTREACH - Wennerstrom et al ed as acceptable in the community. Health Care. Washington, DC: The National Some adapted screening tool questions Academies Press; 2002. This intervention may offer 2. US Department of Health and Human to increase cultural appropriateness, but Services, Office of the Surgeon General. these informal adaptations were not an important resource for Mental Health: Culture, Race and Ethnicity. validated for reliability. Some CHWs underserved communities to A Supplement to Mental Health: A Report of the noted resistance and difficulties with Surgeon General. Rockville, MD: USDHHS; follow-up for referrals among those address mental health 2001. 3. Kessler RC, Galea S, Jones RT, Parker HA. clients who screened positive for depres- disparities following major Mental illness and suicidality after Hurricane sion. CHWs requested enhanced focus Katrina. B World Health Organ. 2006;84: on cultural competence, which was disasters, as a complement to 930–939. implemented in a training session after 4. Wang PS, Gruber MJ, Powers RE, et al. the data collection period. Additional implementation of Mental health service use among hurricane CHW suggestions included adding Katrina survivors in the eight months after the collaborative care programs in disaster. Psychiat Serv. 2007;58:1403. information on managing severely men- 5. Miranda J, Chung JY, Green BL, et al. tally ill clients and addressing workplace healthcare settings. Treating depression in predominantly low- safety concerns, both addressed in income young minority women: JAMA. subsequent seminars. We found that 2003;290:57–65. the program instilled hope, offered 6. Roy-Byrne PP, Craske MG, Stein MB, et al. A In summary, we found that it was randomized effectiveness trial of cognitive- networking opportunities, helped with possible to use a community-partnered, behavioral therapy and medication for primary continuing education requirements, and participatory research approach to de- care panic disorder. Arch Gen Psychiat. supported CHWs’ commitments to 2005;62:290–298. sign, implement, and evaluate feasibility improving the quality of their services 7. Unutzer J, Katon W, Callahan CM, et al. of a CHW mental health outreach We found many challenges to imple- Collaborative care management of late-life training program built on evidence-based depression in the primary care setting: A mentation of mental health outreach practices in post-disaster New Orleans. randomized controlled trial. JAMA. 2002;288: practices, especially limited community Preliminary data support the acceptabil- 2836–2845. capacity for service delivery, inadequate 8. Wells K, Sherbourne C, Schoenbaum M, et al. ity and feasibility of implementation of funding for CHWs, and social stigma of Five-year impact of quality improvement most components, including novel fea- mental illness. We failed to generate for depression: Results of a group-level tures such as behavioral activation. We randomized. Arch Gen Psychiat. 2004;61:378– consistent use of both web- and paper- recommend ongoing program develop- 386. based case registry tools designed to track ment supported by community input, as 9. Hogan MF. Public sector mental health care: client interactions and depression scores, well as a formal evaluation to determine new challenges. Health Affairs. 1999;18:106– as these tools were perceived as burden- 111. effectiveness of the model. This interven- 10. Dossett D, Fuentes S, Klap R, Wells K. some. CHWs expressed a strong need for tion may offer an important resource for personal assistance with recovery stressors Obstacles and opportunities for providing underserved communities to address mental health services through a faith-based and anxiety about future hurricanes. The mental health disparities following major network in Los Angeles. Psychiat Serv. participatory nature of the project al- disasters, as a complement to implemen- 2005;56:206–208. lowed us to implement modifications in tation of collaborative care programs in 11. U S Department of Health and Human Services, Health Resources and Services Ad- response to many of these concerns. healthcare settings. Some challenges, such as environmental ministration. Community Health Workers Na- tional Workforce Study. 2007;Available at: factors, could not be directly addressed by ftp://ftp.hrsa.gov/bhpr/workforce/chw307. the CHW intervention, but generating ACKNOWLEDGMENTS pdf. Last accessed February 1, 2010. awareness of them improved the ability of This project was supported by NIMH 12. Yun K, Lurie N, Hyde PS. Moving mental CHWs to anticipate client needs. Partnered Research Center for Quality Care, health into the disaster preparedness spotlight. We were somewhat surprised that Award # P30MH082760 and NIH, N Engl J Med. 2010;363(13):1193–1195. Award # KL2 RR025015; Investigator: 13. Barrow B. Area’s mental health much worse the most innovative feature of the than before Katrina, experts say. The Times- Vannoy; and by NIH Research Grant program, orientation to problem solving Picayune. 2009;Available at: http://www.nola. # P30MH068639 and P30MH082760 and behavioral activation, reportedly led com/health/index.ssf/2009/09/mt-preview- funded by the National Institute of 6b8ef7bb1a2a2a15481772d97881be860d3e1dc7. to early client successes, with one CHW Mental Health. using behavioral activation to assist a html. Last accessed February 1, 2010. 14. 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