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Service Delivery Innovation Profile

Community Health Workers Known as Promotores Enhance Access to Culturally Tailored Services for Elderly, Low-Income Racial/Ethnic Minorities, Leading to Improvements in Mental Health


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Snapshot

Summary

The Union of Pan Asian Communities manages and oversees the Elder Multicultural Access and Support Services (more commonly known as EMASS) Program, which uses community health workers known as promotores to provide culturally competent mental health education and services to elderly racial and ethnic minorities in San Diego County. Working with clients of similar racial and ethnic backgrounds and often of the same age, promotores offer group classes covering recreation, healthy living, and mental health education; one-on-one counseling and support; referrals to language-concordant mental health providers; and transportation to, and translation services at, appointments with medical and mental health providers. The program has enhanced access to mental health screening, referral, education, and peer support, leading to improved mental health status and health literacy.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of clients served, along with surveys and focus groups in which clients reported on the program's impact on their mental health symptoms and literacy.
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Developing Organizations

Union of Pan Asian Communities
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Date First Implemented

2009
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Patient Population

Vulnerable Populations > Frail elderly; Immigrants; Impoverished; Racial minoritiesend pp

Problem Addressed

San Diego County seniors who are racial and ethnic minorities are more likely suffer from mental health issues than their Caucasian peers but generally face significant barriers to accessing community-based behavioral health services and support, including lack of health literacy, language barriers with providers, and financial issues.
  • More likely to have mental health issues: Just more than one-third of San Diego County's seniors (those age 60 and older) are racial and ethnic minorities, including Hispanics (representing 15 percent of all seniors), Asians (10 percent), and African Americans (4 percent).1 Across California, African Americans, Latinos, and Asians over the age of 50 are more likely to suffer from mental distress than their Caucasian peers.2
  • Less likely to have access to care, due to multiple barriers: Among Californians age 50 and older suffering from mental health issues, African Americans, Asian/Pacific Islanders, and Latinos are about 30 percent less likely to receive mental health services than whites; those who do not speak English are 80 percent less likely to receive care than their English-speaking peers.3 Various barriers account for this discrepancy, including lack of health literacy (particularly related to mental health issues), language barriers with providers, financial issues (e.g., lack of insurance, low incomes), the stigma associated with accessing mental health services (which can be significant in many cultures), and lack of health literacy.

What They Did

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Description of the Innovative Activity

The Union of Pan Asian Communities (UPAC) manages Elder Multiculural Access and Support Services (EMASS), which uses community health workers known as promotores to provide culturally competent mental health education and services to elderly racial and ethnic minorities in San Diego County. Working with clients of similar racial and ethnic backgrounds and often of a similar age,  promotores offer group classes covering recreation, healthy living, and mental health education; one-on-one counseling and support; referral to language-concordant mental health providers; and transportation to, and translation services at, appointments with medical and mental health providers. Key program elements are detailed below:
  • Culturally tailored marketing and outreach: The program serves African Americans, Filipinos, Somalis, Chaldeans, and Latinos. Promotores from these groups use different strategies to identify individuals who might benefit from the program. For example, the Latino promotores often go to apartment complexes, swap meets, and churches frequented by their peers. The Filipino promotora attends functions for seniors held by a local Filipino-American cultural group and regularly visits Filipino restaurants, shops, and apartment complexes. The African-American promotora recruits clients primarily from functions held by churches in the African-American community (e.g., women's group meetings), and the Somali promotora visits apartment complexes and mosques frequented by elderly Somalis.
  • Culturally competent promotores: Promotores are from the same ethnic and racial background as their clients, and most promotores are 55 or older and hence can relate to the issues facing older individuals. Most promotores also have personal experience helping a close relative with mental health issues.
  • Initial enrollment: Promotores develop a rapport with older adults they meet through various outreach activities. To build trusting relationships, promotores help clients with pressing issues or concerns they may have (such as the lack of health insurance or safe housing or a path to citizenship) before introducing mental health awareness and education services. Promotores also encourage clients to attend EMASS activities or allow home visits.
  • Culturally tailored education and counseling: Promotores deliver culturally tailored education and peer counseling designed to improve physical and mental health and mental health literacy to reduce the stigma associated with accessing mental health services. As detailed below, key services include group classes and one-on-one peer counseling and support targeted at each group served.
    • Latino community: Twice each week, the promotores host lunches and recreational classes at an EMASS community center in Escondido, CA, which has a large Latino population. These classes are designed to reduce clients’ social isolation and improve their emotional well-being by engaging them in activities such as music, dance, and "laughter yoga" (which combines voluntary laughter and deep-breathing exercises). Trained as peer facilitators, the Latino promotores also teach Stanford University’s Chronic Disease Self-Management Program and a 1-hour class (known as Good Mental Health Is Ageless) on the signs of depression and coping skills. Both programs are taught in conjunction with Aging and Independence Services, a San Diego County agency. The promotores also meet one-on-one with clients to offer peer counseling and support. They generally split their time evenly between group activities and one-on-one meetings.
    • Filipino community: The Filipino promotora provides one-on-one mental-health education,  peer support, and counseling to seniors. She and her clients also join the recreational activities and educational classes held at the EMASS community center in Escondido. She also teaches the Chronic Disease Self-Management Program and Good Mental Health Is Ageless.
    • African-American and Somali communities: The promotores serving African Americans and Somalis generally provide peer support and education on a one-to-one basis in clients’ homes. In the case of Somali clients, the promotores help family members; they also teach the Chronic Disease Self-Management and Good Mental Health Is Ageless classes at community rooms located at either apartment complexes or Somali Family Service of San Diego.
    • Chaldean community: Promotores provide one-on-one peer support at the EMASS community center in El Cajon, a city in San Diego County where many Chaldeans live. They also host regular social activities, including craft classes for women and table games (e.g., Arabic board games, dominos, and cards) for men. Representatives from Laubach Literary Council of San Diego, an all-volunteer group, and Project SHINE at Cuyamaca College in El Cajon also teach weekly English classes at the center. These activities draw many elderly Chaldeans and hence also function as a way to identify potential new enrollees to the program. Consequently, Chaldean promotores generally do not engage in much outreach work in the community. The promotores teach a workshop on adjusting to life in the United States in addition to Good Mental Health Is Ageless.
  • Screening for depression: Promotores screen EMASS participants for depression in the following ways:
    • They observe how clients interact with others during group activities as well as clients' behavior during one-on-one conversations and peer counseling sessions.
    • They also use the 15-item Geriatric Depression Scale (GDS), which uses a yes-or-no, question-and-answer format to screen clients for symptoms of depression.
  • Referral to language-concordant mental health providers: As necessary, based on screening results and promotores' observation of clients' behavior, EMASS provides referral to mental health care professionals, pairing clients with someone who speaks their native language whenever possible. Examples of provider organizations that commonly care for EMASS-referred clients include the following:
    • Positive Solutions: A separate program run by UPAC, Positive Solutions employs two geriatric specialists (including one who speaks Spanish) and a Spanish-speaking therapist. Geriatric specialists provide 30-day crisis management and brief counseling sessions.
    • South Bay Guidance Center: Based in Chula Vista, South Bay Guidance has Spanish-speaking therapists.
    • San Diego Geriatric Specialty Program: A county-funded program in which geriatric specialists from several nonprofit organizations provide mental health case management to homebound seniors.
    • Chaldean Middle Eastern Social Services: A social service organization in El Cajon, Chaldean Middle Eastern Social Services employs an Arabic-speaking psychiatrist and therapist.
  • Transportation and translation services for appointments: EMASS pays for transportation to bring clients to the community centers and to medical and behavioral health appointments, either by providing tokens for public transit or arranging for van service. EMASS also refers clients to the North County Transit District's Mobility Management Program, which teaches seniors how to use the mass transit system by providing trainers who ride on the system with them. EMASS promotores are also available to accompany clients to medical and behavioral health appointments, providing translation services in those cases where a language-concordant provider is not available.

Context of the Innovation

The impetus for EMASS came from San Diego County officials, who wanted to offer preventive and early-intervention mental health services to the many elderly, low-income racial and ethnic minorities living in the county. In 2009, the county selected UPAC in San Diego to develop and manage EMASS for 5 years. UPAC provides education, nutrition, mental health, and community development services to Asian, Pacific Islanders, and other ethnic groups in San Diego.

Did It Work?

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Results

EMASS has enhanced access to mental health screening, referral, education, and peer support, leading to improved mental health status and health literacy.
  • Enhanced access to mental health services: Between July 2010 and June 2011, EMASS served 906 seniors, including 202 African Americans, 315 Filipinos, 302 Latinos, and 87 Somalis. In the absence of this program, many of these individuals would not have had access to the services available through the program, including referral to providers able to treat them.
  • Improved mental health status: In a survey of 213 EMASS participants from 5 ethnic groups (Filipinos, Latinos, African Americans, Chaldeans, and Somalis), 88.2 percent reported feeling “less sad” since enrolling in EMASS. In 4 1-hour focus groups, 33 participants reported improvements in their physical and mental health symptoms since joining the program, including feeling less isolated and confined to their homes.4
  • Improved mental health literacy: In the survey referenced above, 87 percent of respondents reported that the program helped them "know better" where to seek help. In addition, varying proportions of participants could recognize the symptoms of depression, including nearly two thirds of African Americans (65.7 percent), nearly a quarter of Hispanics (24.2 percent), and a small portion of Chaldeans (12.5 percent). No Filipinos could recognize the symptoms of depression. (This result was likely influenced by the lack of a clear translation of the word "depression" into Tagalog. Filipinos used descriptions such as "sadness," "loneliness," or "not themselves" to describe the symptoms of depression.)

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of clients served, along with surveys and focus groups in which clients reported on the program's impact on their mental health symptoms and literacy.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Hiring program manager: UPAC hired a manager to oversee and develop EMASS.
  • Opening community center: UPAC rented space to serve as a community center in a local professional office building located on a main thoroughfare in Escondido.
  • Forging community partnerships: UPAC developed partnerships with local advocacy and service groups to assist in developing the program, including creating educational content and recruiting promotores and language-concordant mental health professionals who could treat program participants as needed.
  • Developing training materials: The program manager collaborated with several local academic experts to develop a training curriculum for promotores. The curriculum expanded on existing materials to incorporate content on the aging process and mental health, including signs of poor mental health. The program manager created a handbook that includes information on how to meet and establish a rapport with potential clients and conduct educational and recreational sessions. It also covers theories of adult learning and explains the Promotores de Salud model of community outreach.
  • Hiring promotores: Community partners recruited many of the promotores, including promotores from the African-American community (selected by the Urban League), the Somali community (Somali Family Service), and the Latino community (San Diego County branch of the National Alliance on Mental Illness). UPAC recruited a promotora from the Filipino community.
  • Initial and ongoing promotores training: Newly hired promotores attended extensive training sessions consisting of three classes that each lasted 6 hours. These classes covered various topics, including an overview of the Promotores de Salud model, outreach and network-building techniques, motivational interviewing skills, strategies for handling difficult people and situations, home visits, and provider referrals. They also attended 10 2-hour sessions on peer counseling, taught by staff from Wise and Healthy Aging, a nonprofit social services organization for seniors in Santa Monica, and 40 hours of training on Stanford University’s Chronic Disease Self-Management Program. On an ongoing basis, EMASS provides numerous training opportunities for promotores, including monthly meetings, one-on-one sessions with the program manager (a clinical social worker) to assist in dealing with the emotional toll of the work, and periodic skill-development workshops. EMASS also sends promotores to an annual conference hosted by Vision y Compromiso, a Los Angeles-based organization that provides training and advocacy for promotores.
  • Expanding through additional center: In August 2012, EMASS opened a second community center in El Cajon to serve Chaldean refugees. Leaders of Chaldean-Middle Eastern Social Services provided input throughout this process.

Resources Used and Skills Needed

  • Staffing: Program staff includes a full-time manager, a part-time activities coordinator, a full-time staff (who spends half her time as an administrative assistant and the other half as a Latino promotora), two additional part-time Latino promotores, two Chaldean promotores (one full- and one part-time), and three other full-time promotores (one each for the Filipino, African-American, and Somali communities).
  • Costs: The annual budget for EMASS totals roughly $500,000, which covers staff compensation, rent at community centers in El Cajon and Escondido and Somali Family Service of San Diego, utilities, office supplies, transportation costs for clients, and travel expenses for promotores.
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Funding Sources

County of San Diego Health and Human Services Agency
San Diego County Behavioral Health Services Division funds EMASS, including the salaries and benefits paid to promotores by UPAC. This funding comes from California’s Mental Health Services Act—Prevention and Early Intervention Fund.end fs

Tools and Other Resources

More information on EMASS can be found on the program's Web site, available at: http://www.upacsd.com/services-2/adult-older-adult-mental-health/emass-elder-multicultural-access-and-support-services
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Manuals and other information on the Stanford School of Medicine’s Chronic Disease Self-Management Program are available at: http://patienteducation.stanford.edu/programs/cdsmp.html.

For more information on the Promotores de Salud model of community outreach, see Vision Y Compromiso's Web site at: http://www.visionycompromiso.org/.

Adoption Considerations

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Getting Started with This Innovation

  • Collaborate with organizations that have similar goals and objectives: Local advocacy and service organizations that cater to specific racial and ethnic groups can serve as good sources for recruiting promotores and prospective clients as well as funding. By partnering with Aging and Independence Services, Cuyamaca College, and North County Transit District, EMASS tapped into grant-funded resources it would not have had access to otherwise.
  • Hire promotores of similar age: Promotores who share a similar age as clients (in addition to a similar racial and ethnic background) can offer a shared perspective based on common life experiences, such as the joy of interacting with grandchildren and the frustration of managing an aging body. These similarities can help to forge strong personal bonds between promotores and their clients.
  • Develop relationships with language-concordant providers: Elderly clients are more likely to feel comfortable being referred to a therapist or psychiatrist who speaks the same language.

Sustaining This Innovation

  • Provide promotores with counseling as needed: Because community outreach work can be emotionally draining, promotores may benefit from periodic one-on-one sessions with a therapist.
  • Provide ongoing training: To maximize their effectiveness, promotores need periodic training focused on maintaining and improving skills in areas such as peer counseling, facilitating group classes, cultural awareness, written communication, and listening skills.

More Information

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Contact the Innovator

Agnes Hajek, ACSW
UPAC-EMASS Program Manager
200 North Ash Street, Suite 100
Escondido, CA 92027
Tel: (760) 233-1984, Ext. 202
Fax:(760) 233-1987
E-mail: ahajek@upacsd.com


Dixie Galapon, PhD
Mental Health Services Director
Union of Pan Asian Communities
5348 University Avenue, Suite 101
San Diego, CA 92123
Tel: (619) 229-2999
Fax: (619) 229-2998
E-mail: dgalapon@upacsd.com

Innovator Disclosures

Dr. Galapon and Ms. Hajek reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.

Recognition

The Union of Pan Asian Communities' Elder Multicultural Access and Support Services (EMASS) Program received a Public Health Champion Award from San Diego County's Health and Human Services Agency in 2012. The awards are components of the Live Well, San Diego! Initiative, the county's 10-year plan to improve the health and safety of local residents and communities. EMASS was recognized for its contributions to Aging and Independence Services.

Footnotes

1 Survey of older Americans living in San Diego County 2012. San Diego: San Diego Association of Governments Service Bureau. Available at: http://www.sdcounty.ca.gov/hhsa/programs/ais/documents/surveyofolderamericans2003report.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
2 Sorkin DH, Pham E, Ngo-Metzger Q. Racial and ethnic differences in the mental health needs and access to care of older adults in California. J Am Geriatr Soc. 2009;57(12):2311-7.[PubMed]
3 Sentell T, Shumway M. Language, cultural, and systemic barriers to mental health care among racial and ethnic groups in California: scope of the problem and implications for State policy. San Francisco: University of California, 2004. Available at: http://healthpolicy.ucla.edu/chis/research/pages/detail.aspx?projectID=3587
4 Elder multicultural access and support services. San Diego: County of San Diego Health and Human Services Agency, 2011. Available at: http://hsrc.ucsd.edu/public/OA01_EMASS_FY10-11_Report_011712.pdf.
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Original publication: February 26, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 07, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Agnes Hajek, ACSW
Dixie Galapon, PhD