Spanish-Language Community-Based Mental Health Treatment Programs,Policy-Required Language-Assistance Programming,and Mental Health Treatment Access Among Spanish-Speaking Clients

Objectives. We investigated the extent to which implementing language assistance programming through contracting with community-based organizations improved the accessibility of mental health care under Medi-Cal (California’s Medicaid program) for Spanish-speaking persons with limited English proficiency, and whether it reduced language-based treatment access disparities.Methods. Using a time series nonequivalent control group design, we studied county-level penetration of language assistance programming over 10 years (1997–2006) for Spanish-speaking persons with limited English proficiency covered under Medi-Cal. We used linear regression with county fixed effects to control for ongoing trends and other influences.Results. When county mental health plans contracted with community-based organizations, those implementing language assistance programming increased penetration rates of Spanish-language mental health services under Medi-Cal more than other plans (0.28 percentage points, a 25% increase on average; P < .05). However, the increase was insufficient to significantly reduce language-related disparities.Conclusions. Mental health treatment programs operated by community-based organizations may have moderately improved access after implementing required language assistance programming, but the programming did not reduce entrenched disparities in the accessibility of mental health services.Among the roughly 55.5 million persons in the United States speaking a non-English language at home in 2007, about 34.5 million spoke Spanish; of those Spanish speakers, more than 10 million spoke English “not well” or “not at all”1 and were thus considered persons with limited English proficiency (LEP). Persons with LEP “are unable to communicate effectively in English because their primary language is not English and they have not developed fluency in the English language.”2 In California, the state with the largest Spanish-speaking population in the United States, about 40% of persons aged 5 years or older among the state’s 14 million Latino/Hispanic population are considered persons with LEP.3LEP intersects with sociocultural and immigration-related barriers, thus preventing mentally ill persons with LEP from receiving needed care. Being uninformed about mental illness and interpreting and expressing symptoms of mental illness as something other than mental illness by using a culturally preferred idiom of distress, as well as turning to family and community network members when seeking help who reinforce nonpsychiatric perspectives, can divert persons with LEP from the path to mental health specialty care.4 The stigma associated with mental illness,5 distrust of treatment bureaucracies (S. Leask and L. R. Snowden, unpublished data, 2012), and, for immigrants, fear of being challenged by authorities and asked to account for their immigration status6 create additional barriers.Nonetheless, LEP introduces a significant barrier of its own. Persons with LEP find it difficult to communicate in English language–oriented health care settings,7–9 and they often either do not receive needed health care or receive ineffective care.10–20 Language proficiency may be especially challenging in mental health treatment because psychiatric evaluation hinges on obtaining a thorough history, and because key symptoms are not reflected in directly observable behaviors or signs of morbidity and can be elicited only via self-report.21 Language barriers can prevent recognizing and labeling mental health problems and can interfere with successful communication about treatment needs and care options.22–26According to legal interpretations, executive-branch directives, and US Office of Civil Rights enforcement actions, Title VI of the 1964 Civil Rights Act27 requires recipients of federal funds to provide language assistance services to persons with LEP.28,29 By 2008, every state had passed laws supplementing federal law, further requiring language assistance for persons with LEP seen in health care settings.30To assist in compliance, the US Office of Civil Rights issued guidelines for implementing Title VI requirements. These guidelines call for assessment of the language needs of service-eligible populations and development of written policies to meet needs; training of staff in language assistance policies and procedures; monitoring of the implementation of policy and procedures; provision of trained interpreters; translation of written materials; and notification of beneficiaries that they are entitled to translation assistance free of charge.31Like other mental health agencies, in 1997 the California Department of Mental Health (DMH) adopted a “threshold language access policy” to meet its Title VI obligation for treating persons insured through the state’s Medicaid program, called Medi-Cal.32 Under the policy, threshold status is reached when either 3000 Medi-Cal enrollees in a county or 5% of the county’s Medi-Cal residents, whichever is greater, speak a non-English language. For threshold languages, the policy directs county mental health plans toward a 4-part response: (1) a 24-hour, toll-free phone line with linguistic capability; (2) translated written materials to assist beneficiaries in accessing medically necessary specialty mental health services, including personal correspondence; (3) bilingual clinicians or other bilingual nonstaff, or interpreters or telephonic translation capacity at intake appointments, assessment interviews, treatment sessions, and at other key points of contact; and (4) information to consumers and communities about the availability of these linguistic services, free of charge.One previous study of the threshold policy’s impact in California found that the policy’s mandated language assistance programming increased access to mental health treatment for Vietnamese-speaking and Russian-speaking Medi-Cal beneficiaries, but it found no evidence that access increased for Spanish-speaking beneficiaries.33 However, the study did not examine how counties implemented threshold language programming and could not detect differences associated with the mode of implementation.Contracting with community-based organizations (CBOs) operating specialized treatment programs for non-English-language speakers34,35 is an attractive option for implementing the required language assistance programming. CBOs are

not-for-profit organizations such as non-governmental, civil society organizations, or other grassroots organizations, overseen by an elected board of directors and guided by a strategic plan developed in consultation with community stakeholders.36^(p33)

They operate health and social programs, as well as LEP-focused mental health programs, to fulfill a wider community service mission.36 CBOs seek strong community ties and pursue community oversight and governance; they also practice social, economic, and political advocacy, thereby promoting credibility and community trust.36 Seeking the advantages enjoyed by CBO-operated programs, mental health officials sometimes establish specialized LEP-serving programs operating directly under their authority.A handful of past reports indicated that specialized mental health programs for persons with LEP may be especially effective at bringing them into treatment. In 1 study, Latino and Asian persons with LEP received more outpatient care in such programs than their counterparts seen elsewhere, and their initial contact with a treatment program was significantly less likely to come about via emergency service encounters.37 A second study found that mental health programs specializing in clients speaking Asian languages provided an alternative to threshold language policy requirements for bringing Asian-language speakers into treatment.38We investigated whether access rates for Spanish-language mental health treatment rose for persons with LEP when CBOs’ mental health treatment programs implemented the language assistance programming required by threshold language policy. We hypothesized that, because their goals are closely aligned with addressing the cultural and linguistic orientation and interests of Spanish-speaking communities, and because this enables them to reach out effectively to LEP community members, CBOs’ language assistance programs will promote greater treatment entry than programs that are directly county operated.We also explored whether CBOs’ implementation of language assistance programming was effective and widespread enough to bring about a statewide reduction in the disparity in access between English and Spanish speakers.39 We evaluated any potential increased access experienced by Spanish speakers within a larger framework of disparities in access to mental health treatment. To our knowledge, this study was the first covering a large and diverse region, including a substantial Spanish-speaking population, to assess the effect of CBOs’ implementation of language assistance programming on the accessibility of mental health services for Spanish speakers with LEP. We also assessed reductions in disparities in access to mental health treatment for Spanish versus English speakers.