“Treated me … like I was family”: Qualitative Evaluation of a Culturally-Adapted Health Care Manager Intervention for Latinos with Serious Mental Illness and at Risk for Cardiovascular Disease

Abstract

Latinos with serious mental illness (SMI) experience health and health care disparities and may benefit from interventions that improve access to, coordination of, and receipt of primary care services. The aim of this qualitative study was to examine the experiences of Latinos with SMI and at risk for cardiovascular disease participating in Bridges to Better Health and Wellness (B2BHW), a culturally-adapted health care manager intervention delivered in a public outpatient mental health clinic. A total of 29 Latino participants completed a post-intervention survey that included an open-ended question about the three things they liked most about B2BHW; a subset of 16 participants participated in one of three post-intervention focus groups. Results indicate that what mattered most to participants was the health education they received, the positive relationships they formed with their health care managers, the care coordination assistance they obtained, and the motivation and activation they gained from this intervention. Study findings suggest that key elements of the health care manager intervention (e.g., care coordination, and patient activation) shaped participants' experiences with B2BHW and were perceived as beneficial.

Keywords

Latinos serious mental illness health care disparities health care management patient-centered care

Introduction

Latinos with serious mental illness (SMI; e.g., schizophrenia, bipolar disorders) may benefit from health care interventions that improve access to, coordination of, and receipt of primary care services, given that this population experiences marked health disparities. Compared to non-Latino whites with SMI, Latinos with SMI tend to be at higher risk for cardiovascular-related mortality, diabetes mellitus, metabolic syndrome, and cardiometabolic abnormalities (e.g., weight gain) associated with antipsychotic medication (Carliner, Collins, Cabassa, McNallen, Joestl, & Lewis-Fernandez, 2014). Compounding these health inequities, few Latinos with SMI receive care for common medical conditions (e.g., diabetes, hypertension) and many report that the care they receive in general medicine is of poor quality and not patient-centered (Cabassa, Gomes, Meyreles, Capitelli, Younge, Dragatsi, Alvarez, Nicasio, & Lewis-Fernandez, 2014; Nasrallah et al., 2006). Several obstacles reduce access to quality health care among Latinos with SMI, including poor coordination of care between mental health and primary care providers, language barriers, low health literacy, mistrust of the health care system, discrimination, and stigmatization from medical providers (Cabassa, Siantz, Nicasio, Guarnaccia, & Lewis-Fernandez, 2014; Corrigan, Torres, Lara, Sheehan, & Larson, 2016; Ezell, Cabassa, & Siantz, 2013).

Health care manager interventions address many of these barriers by improving access to medical care for people with SMI (Bartels et al., 2004; Druss, von Esenwein, Compton, Rask, Zhao, & Parker, 2010; Kilbourne, Post, Nossek, Drill, Cooley, & Bauer, 2008). For example, the Primary Care Access, Referral, and Evaluation program (PCARE) is an intervention in which registered nurses (RNs) act as health care managers in outpatient mental health clinics. They seek to improve coordination of care between mental health and primary care providers (Druss et al., 2010) and increase patient activation around physical health issues. A randomized controlled trial found that, compared to usual care, PCARE significantly increased receipt of preventive medical care and improved the quality of cardiometabolic care and mental health-related quality of life among adults with SMI, predominantly African Americans (Druss et al., 2010).

The relevance, acceptability, and impact of interventions like PCARE among Latinos with SMI is currently unknown since these interventions have not been designed for and tested in this population. In the PCARE trial, for instance, very few Latino participants were enrolled (6 of 407 participants) (Druss et al., 2010) and cultural factors known to influence the health care of Latinos with SMI, like language and cultural norms related to patient–provider interactions, were not taken into consideration. Attention to these cultural factors is important because they can influence access to and quality of care and shape patients' health care experiences (Cabassa, Gomes, Meyreles, Capitelli, Younge, Dragatsi, Alvarez, Nicasio, & Lewis-Fernandez, 2014). For example, cultural norms such as personalismo (providing warm, personal care that goes beyond professional requirements) and respeto (Latino rules of respectful interaction) are valued by Latinos in interpersonal relationships, particularly with providers, and are critical ingredients for engaging Latino patients in care (Cabassa, Hansen, Palinkas, & Ell, 2008; Fisher, Burnet, Huang, Chin, & Cagney, 2007). These cultural norms also shape the delivery of patient-centered care, a critical standard of quality of care that ensures patients' values, preferences, and needs guide clinical decisions (Institute of Medicine, 2001).

To address these important health care gaps among Latinos with SMI, our team conducted a multi-phase project that adapted PCARE to Latino patients and expanded its use with social workers using the collaborative intervention planning framework, an approach that combines principles of community-based participatory research and intervention mapping procedures (See Cabassa, Gomes, Meyreles, Capitelli, Younge, Dragatsi, Manrique & Lewis-Fernandez, 2014 for a detailed description of this adaptation process). The evaluation of this intervention used a single-group, pre-post, 12-month open-trial design with assessments of intervention outcomes (e.g., patient activation, receipt of preventive primary care) at baseline, 6 months, and 12 months and three post-intervention focus groups conducted at 12 months. The quantitative results of our open trial of B2BHW are reported in detail elsewhere (Cabassa, Manrique, Meyreles, Camacho, Capitelli, Younge, Dragatsi, Alvarez, & Lewis-Fernández, 2018). In short, we found that it was feasible for masters-level social workers to deliver B2BHW and that the intervention was associated with statistically significant moderate-effect-size improvements in several patient-centered indicators (e.g., patient activation) and in receipt of preventive primary care over the course of 12 months (Cabassa et al., 2018).

The present study uses qualitative methods (e.g., focus groups) to describe the experience of Latino patients participating in B2BHW. We examined three research questions: 1) What did participants like best about B2BHW? 2) What benefits did they perceive from this intervention? 3) How did they perceive their relationships with their health care managers? Qualitative methods are uniquely positioned to answer these research questions because they capture participants' lived experience in their own words and help uncover participant-generated themes of “what really matters most” to them (Kleinman, 2006) participating in this intervention. This inquiry can also yield important insights into intervention elements that participants perceive as contributing to the delivery of patient-centered care.

Methods

Study overview

The data are drawn from a larger multiphase project that aims to modify PCARE for a new patient population (Latinos) and provider group (social workers) and to assess the feasibility, acceptability, and initial impact of this modified intervention (Cabassa, Gomes, Meyreles, Capitelli, Younge, Dragatsi, Alvarez, Manrique, & Lewis-Fernandez, 2014). The project was conducted at a public outpatient mental health clinic in New York City that serves predominantly low-income, Spanish-monolingual Latino adults, mostly of Dominican descent. This clinic specializes in delivering outpatient mental health services (e.g., case management, medication management) to adults diagnosed with SMI. Most clients are also overweight or obese, and the most common medical conditions include diabetes mellitus, high cholesterol, and hypertension (Hellerstein et al., 2007). In this article, we present only the findings from the qualitative evaluation of B2BHW, based on answers to a single open-ended question during the 12-month interview, and three focus groups conducted at the end of the intervention. The rationale for combining these two qualitative methods is that it provides an opportunity to explore participants' views of B2BHW from both individual and group perspectives. The institutional review boards at the New York State Psychiatric Institute (Protocol #: 6747) and Columbia University (Protocol #: AAAL9268) approved all study procedures.

Recruitment

Eligible participants were recruited through clinician referrals; they were age 18 or older, self-identified as English or Spanish-speaking Latinos, and had a chart diagnoses of SMI (e.g., schizophrenia, bipolar disorder) associated with substantial functional impairment interfering with major life activities. They also had at least one cardiovascular risk factor, including body mass index (BMI) ≥25, diabetes mellitus, hypertension, hyperlipidemia, or were current smokers. Participants were excluded if they required detoxification, were acutely suicidal or homicidal, failed a capacity-to-consent questionnaire (Zayas, Cabassa, & Pérez, 2005) or, for those age 65 or older, screened positive for cognitive impairment using the Mini-Cog Examination (Palmer & Meldon, 2003). All eligible participants provided written informed consent. Participants were compensated $15 and a subway card for each structured interview and $25 and a subway card for participating in the focus group. No compensation was provided for attending sessions with their health care managers.

Between October 2013 and October 2014, 54 Latino patients were referred to the study. Eight refused to participate because they were too busy or were uninterested in research; two could not be located and 10 were excluded – 3 did not meet eligibility criteria and 7 failed the capacity-to-consent test or had cognitive impairment. Thirty-four were enrolled in the study and participated in the B2BHW intervention. Four participants discontinued the study (three lost interest, one moved out of the area) and one was lost to follow-up. Twenty-nine (85%) completed the B2BHW intervention, participated in the 12-month interview, and were invited to participate in one of three focus groups to discuss their experiences with the intervention. Sixteen participants (55%) attended a focus group. Lack of attendance was due to being too busy, scheduling conflicts, or lack of interest.

Bridges to Better Health and Wellness (B2BHW)

A full description of B2BHW is presented elsewhere (Cabassa, Gomes, Meyreles, Capitelli, Younge, Dragatsi, Manrique & Lewis-Fernandez, 2014) and is briefly summarized here. B2BHW is a manualized health care manager intervention adapted from PCARE that consists of monthly individual 60-minute sessions delivered by masters-level social workers over the course of 12 months. Like PCARE, B2BHW focuses only on physical health issues and its core elements included care coordination and patient activation. For patients, B2BHW health care managers serve as advocates and coaches connecting them to primary care services, and helping them develop the knowledge and skills to actively participate in their own health care. For primary care and mental health providers, B2BHW health care managers serve as bridges to reduce fragmentation of care between the mental health and primary care sectors by ensuring patients' medical information (e.g., changes in medication) is shared across systems of care, monitoring patients' health (e.g., weight, blood pressure), and alerting providers when preventive primary care services are needed, following treatment guidelines for preventive primary care (United States Preventive Services Task Force, 2010) and cardiovascular health for people with SMI (American Diabetes Association, 2004).

Several surface and deep-level cultural adaptations for Latinos with SMI and provider-level adaptations for social workers were embedded in the development of B2BHW (see Cabassa, Gomes, Meyreles, Capitelli, Younge, Dragatsi, Manrique & Lewis-Fernandez, 2014 for a detailed description). Surface-level adaptations customized intervention content and messages to the observable cultural characteristics (e.g., language) of the target population; examples include using bilingual health care managers and adding health education materials in Spanish (Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999). Deep-level adaptations embed cultural values, norms, and preferences into the intervention (Resnicow et al., 1999). An example of a deep-level adaptation was the incorporation of cultural norms valued by Latinos (e.g., personalismo, respeto) into health care manager interactions. This was done by adding sections to the intervention manual defining these norms and providing concrete behavioral examples of how health care managers could express these norms in their interaction with patients, such as using a patients' last name when addressing them during their first visit or starting each session with polite conversation or platica before initiating session activities. Another deep-level adaptation was the addition of a patient activation checklist that included questions patients could ask their doctors during their visits. This list sought to reduce the impact of cultural norms among Latinos dictating that people should show deference (e.g., by not asking questions) to authority figures, like primary care doctors, in order to avoid disagreement, and adding the Cultural Formulation Interview (Lewis-Fernandez et al., 2014) to help health care managers assess participants' cultural understandings and experiences of their health conditions. Provider-level adaptations consisted of developing tools and training materials to increase social workers' knowledge and skills regarding the health care needs of people with SMI; this was necessary, since PCARE was originally developed to be administered by nurses.

Open-ended question at the 12-month interview

As part of the 12-month structured quantitative interviews with a trained bilingual research assistant (RA), each participant was asked to name three things they liked most about the B2BHW interventions. The RA wrote down participants' responses verbatim.

Post-intervention focus groups

Three 90-minute post-intervention focus groups were conducted at the study clinic in Spanish, each with 4–6 participants. Focus group were conducted once participants had completed the 12-month intervention and had their final visit with their health care manager. All groups were audiotaped and professionally transcribed. We used a focus group guide composed of open-ended questions and probes to elicit participants' views and experiences with B2BHW (focus group guide available upon request). Examples of questions and probes included: What did you think of B2BHW? What did you like most about your health care manager? What would you change about the program to make it better? How has this program helped you with your physical health problems? Focus groups were chosen over individual in-depth interviews because the group format can help stimulate discussion among group members and facilitate the identification of shared lived experiences as well as different points of views in a short amount of time.

Data Analysis

Frequencies and measures of central tendency were used to describe sample characteristics. To describe what participants liked best about B2BHW, the responses to the open-ended question in the 12-month interview were coded by the first author using a content analysis approach (Bernard, 2002). This resulted in six distinct and mutually exclusive categories that corresponded to key elements of B2BHW: health education, relationship with health care manager, care coordination, activation, health monitoring, and health benefits.

We used open-coding procedures and the constant comparative method derived from grounded theory (Strauss & Corbin, 1998) to analyze focus group transcripts. Three coders independently read all of the data and drafted analytical memos to develop an initial code list. Codes were developed from a priori (e.g., questions from the focus group guide, core intervention elements) or emergent themes. We then met on a weekly basis for one month to present and discuss our respective codes, interpretations of the data, and analytical questions. Decisions during these analytical meetings and meeting notes were used to reach consensus on emerging codes and exploration of the data. These codes were then included in the final code book. Examples of codes included: benefits of the program, what participants liked about the intervention, and relationship with health care managers.

All qualitative data was then entered and coded in Atlas.ti (Muhr, 2004). One person involved in the generation of the code book coded all qualitative data under the supervision of the primary author. We used the constant comparative method to cluster codes into categories, and derive themes (Strauss & Corbin, 1998). This process involved generating queries and reports in Atlas.ti on major codes. Through our review and discussions of these reports, we identified discernible patterns in our data, and developed analytical memos describing the emergence of categories and subcategories. We grouped our major categories into overarching themes, taking into consideration how salient these themes were across focus groups. To ensure the rigor and trustworthiness of our analysis, we used the following established strategies: 1) generation of an audit trail consisting of analytical memos and meeting minutes to document analytical decisions, 2) prolonged engagement with participants consisting of continuous contact and engagement with participants throughout the 12-month study period, and 3) member-checking activities consisting of discussions and presentations with clinic staff, the project's community advisory board, and at professional meetings to guard against researcher bias by receiving feedback on our study results and interpretation of findings from different stakeholders involved in this study and area of research (Padgett, 1998).

Results

Sample characteristics

Characteristics of the total sample and the post-intervention focus group sub-sample are presented in Table 1. Twenty-nine participants completed the 12-month interviews and 16 participated in a focus group. There were no statistically significant differences on key demographic, health and mental health characteristics (results available upon request) between participants who only participated in the structured interviews and those who participated in the structured interviews and focus groups. Participants were mostly female, Dominican, monolingual Spanish-speakers with an average age of 54. The most common psychiatric condition was schizoaffective disorder. On average, participants reported 2.8 medical conditions, most frequently high cholesterol, hypertension, and diabetes mellitus. All participants in this qualitative study completed the B2BHW intervention and on average attended 10 out of 12 health care manager sessions over the course of 12 months.

Table 1.

Sample Characteristics.

Sample Characteristics	Total Sample (N = 29)		Focus Group Sub-Sample (n = 16)
Sample Characteristics	Mean (SD)	%	Mean (S)	%
Demographics
Age	53.7 (15.32)		54.81 (14.4)
Years of Education	10.1 (3.8)		10.4 (3.8)
Female		72.4		62.5
Marital Status
Married		3.4		0
Single		51.7		62.5
Widowed/Divorced/Separated		44.8		37.5
Annual Income
$0–$9,999		89.7		81.3
$10,000–$19,999		10.3		18.8
Latino Group
Dominican		75.9		68.8
Puerto Rican		10.3		18.8
Other (e.g., Cuban, Costa Rican)		13.8		12.5
Years living in the U.S.	31.0 (14.6)		35.0 (14.4)
Language Preference
Spanish Only		72.4		62.5
Bilingual		27.6		37.5
Physical Health
Chart-Reported Medical Conditions*
Asthma		17.2		7.7
Arthritis		24.1		30.8
Diabetes Mellitus		48.3		53.8
Hypertension		48.3		53.8
Hypercholesterolemia		72.4		84.6
Average Number of Medical Conditions	2.8 (1.6)		2.8 (1.39)
Current Smoking**		28.6		38.5
Mental Health
Chart Diagnosis*
Schizophrenia		6.9		15.4
Schizoaffective disorder		37.9		46.2
Major depressive disorder		27.6		23.1
Bipolar disorder		24.1		15.4
Major depressive disorder with psychotic features		20.7		30.8
Average # of B2BHW sessions attended	10.5 (1.8)		10.8 (1.5)

Health and mental health conditions were not mutually exclusive, as participants could have more than one condition; therefore percentages add up to greater than 100.

N = 28, one missing value reported for this variable.

What did participants like best about B2BHW?

Figure 1 presents the frequencies of participants' coded responses to the open-ended question in the 12-month interview inquiring about what they liked best about B2BHW. Health education was the most valued aspect of B2BHW, reported by 89.7% of participants, as captured by responses such as “enjoyed the education … received,” “learned a lot about physical illnesses,” and “liked the advice received about nutrition.” Relationships with health care managers were highly valued by about two-thirds of participants (75.9%), as exemplified by responses describing health care managers as “compassionate”, “attentive”, “professional”, and “caring”. Participants also liked the care coordination (44.8%; e.g., scheduling appointments, receiving appointment reminders, sharing medical information between providers) and activation (41.4%; e.g., creating an action plan to reduce smoking, help developing health goals) they received from B2BHW. Health monitoring (27.6%; e.g., taking vitals) and health benefits (20.7% e.g. improvements in overall health) were less frequently mentioned by participants. Overall, participants' positive reaction to B2BHW was confirmed by their frequent mention that they would not change anything about the intervention and that they would like B2BHW to be a permanent service at their clinic.

Figure 1

What participants liked best about B2BHW.

What benefits did participants perceive from B2BHW?

Post-intervention focus groups revealed three themes that captured the benefits participants perceived from B2BHW, including gaining better awareness of their physical health issues, being more active and involved in their health care by using B2BHW tools, and achieving concrete health improvements. Many participants talked about how this intervention helped them gain awareness of their health conditions, as exemplified by Carla's comment (all names are pseudonyms, and all quotes have been translated from Spanish):

“The best part was knowing, having the wisdom that one is sick because many people die and are dying not knowing they are sick and if they [doctors] don't know you have an illness, they cannot help you” (Focus Group [FG] 1).

Others described how they gained better appreciation of their physical health conditions by working with their health care managers, which led to being more proactive in seeking medical care during times of need and in making incremental changes to improve their health, as reported by Vanesa and Marco, respectively: “I learned that when I have a problem I need to go and see my doctor” (FG3).

“I gained awareness that this really worked… My health care manager would talk to me about the importance of changing my diet as a diabetic and because of my high cholesterol… I had heard all of this before, but I had not gained awareness that this really worked. But now… when I go to the doctor and they tell me [to eat healthier] I try. I don't do it a 100 percent but I have come to realize that eating healthy is a priority” (FG1).

Moving beyond awareness, participants mentioned that B2BHW enabled them to be more active and involved in their own health care in terms of taking their medications, monitoring their own health, and going to their medical appointments, as described by Cristina: “This program has helped me because it taught me how to follow my treatments, how to take my medicines, how to weigh myself, how to eat things that are good for me” (FG3). Participants also talked about how specific B2BHW tools were instrumental in helping them get more involved in their health care. In particular, they mentioned how elements of B2BHW that focus on patient activation, like setting personal health goals and developing action plans to achieve them, helped provide them with concrete steps (e.g., eating more vegetables, drinking more water, walking every day) they could take to improve their health. The use of the personal health record was another intervention tool that participants found useful, as it provided easy access to their medical information (e.g., weight, latest laboratory results, medication list). They liked that their health care managers kept the information in these records up-to-date throughout the intervention and that the tool facilitated better communication with their primary care doctors and in some instances helped them avoid medication errors, as exemplified by Maria's comment:

“For example, one time I went to my doctor because I was having physical discomfort… it was some sort of infection and the doctor was able to prescribe me a medication and since I had my record [referring to her personal health record], the doctor was able to prescribe me a medication that did not conflict with the medicines that I was already taking” (FG1).

Lastly, participants mentioned a series of health improvements they derived from B2BHW. These included quitting smoking, losing weight, starting a healthy diet, developing a plan to increase their physical activity, and being able to gain control of chronic medical conditions like diabetes and high cholesterol by improving their adherence to medications. Participants felt that B2BHW provided them with the support, motivation, encouragement, and time to focus on their physical health issues and that having a dedicated health care manager for their physical health was essential for working towards these health benefits.

How participants described their relationships with health care managers?

Participants in all three focus groups consistently reported having very positive relationships with their health care managers suggesting that this was a highly valued aspect of B2BHW. They described how health care managers treated them with respeto (respect), cariño (affection), and confianza (trust). Participants talked about how these characteristics enabled them to talk freely with their health care managers about their health issues without fear, as captured by Cristina's comments: “I could talk to him (referring to her health care manager) about any health issues and he would answer me well… he would help me with any question I had and explain things to me” (FG3).

Participants mentioned valuing several other aspects of their relationship with their health care managers. First, they appreciated that health care managers were well-prepared and knowledgeable, as exemplified by Maria's comments describing B2BHW health care managers: “the thing that most impressed me was how well prepared they were and how they knew their materials” (FG1). Second, participants talked about how health care managers had more time than doctors to work individually with them and give them invaluable support and encouragement, as related by Marta:

“They [health care managers] are insistent and persistent, they are interested in us. The doctor almost has no time… with them [health care managers] we have more time to discuss things… they help you a lot, they give you that push” (FG1).

Third, participants appreciated that health care managers took the time to provide important care coordination support that facilitated their engagement in primary care services, like calling participants to remind them of their appointments, accompanying participants to their visits, helping participants schedule appointments, and making sure their doctors received participants' latest laboratory results or had the most up-to-date information about participants' medications. In all, participants' views portrayed the deep connections they were able to form with their health care managers, as best captured by Marcela's reflections on her relationship with her health care manager:

“She treated me very well, like I was family… She talked to me with such humility, she was very open, and I thank God that I had her for a year… She was always so open with me, always with a smile on her face, always very professional” (FG2).

Discussion

The results of this qualitative study indicate that B2BHW, an adapted version of PCARE, was a relevant health care manager intervention for this sample of Latinos with SMI and at risk for CVD. Participants' views and experiences with this intervention suggest that what mattered most to them included the health education they received, the positive relationships they were able to form with their health care managers, the care coordination assistance they obtained over the course of the intervention, and the motivation and activation they gained from B2BHW tools (e.g., action planning, personal health records). These findings show that key mechanisms of change of health care manager interventions (e.g., health education, care coordination, and patient activation) are central in shaping participants' experiences with B2BHW and are perceived as beneficial for addressing their health care needs. For Latinos with SMI, these intervention elements are critically important because they target specific barriers to care (e.g., poor care coordination, low patient activation, limited awareness of illness) that contribute to health care disparities (Cabassa, Gomes, Meyreles, Capitelli, Younge, Dragatsi, Alvarez, Nicasio, & Lewis-Fernandez, 2014; Corrigan et al., 2016; Ezell et al., 2013).

Study results also produced important insights into the aspects of the care received through B2BHW that can be considered patient-centered because they were perceived by participants as being beneficial and responsive to their needs and values. Patient-centered care is a critical dimension of health care quality that can reduce health care inequities among populations facing an intersection of vulnerabilities (e.g., ethnic minority status, SMI, comorbid health conditions) (Institute of Medicine, 2003, 2006). Key processes of patient-centered care include respect for patients' value and norms, health education, care coordination, emotional support, patient activation, and satisfaction with care, among others (Rathert, Wyrwich, & Boren, 2013). Participants' views of what they liked most about B2BHW (e.g., health education, care coordination) and the perceived benefits they derived from this intervention (e.g., gaining awareness, being more involved in their health care) reflect many of these processes. These findings are encouraging for improving the health care of Latinos with SMI because receiving patient-centered care has been linked to improvements in patient satisfaction, treatment adherence, quality of care, effective disease management, and in some instances, disease control and health outcomes (McMillan, Kendall, Sav, King, Whitty, Kelly, & Wheeler, 2013; Rathert et al., 2013).

The positive relationships participants reported forming with their health care managers was another salient characteristic of their experiences with B2BHW. These descriptions illustrated how health care managers' interpersonal styles, characterized as respectful, affectionate, warm, personable, compassionate, and professional, reflected core cultural norms (e.g., respeto, personalismo) valued by Latinos (Organista, 2007) and were perceived by participants as culturally compatible. These findings suggest that the deep-level cultural adaptations embedded in B2BHW, particularly those that incorporated cultural values and norms to foster participants' engagement and culturally-appropriate interactions with health care managers, seem to have contributed, in part, to participants' positive views of B2BHW. The presence of these cultural norms in patient–provider interactions can also help set the stage for important outcomes, such as therapeutic alliance, treatment engagement, patient activation, and self-efficacy (Organista, 2007). All are necessary to facilitate health behavior change and promote the health of Latinos with SMI. However, our design prevented us from isolating which element of B2BHW (e.g., patient-centered care, cultural adaptations, health education) specifically contributed to participants' positive views.

Interpersonal aspects of care, particularly patient–provider relationships and communication, are important factors for addressing health care disparities, as they impact quality of care and treatment engagement and retention (Kilbourne, Switzer, Hyman, Crowley-Matoka, & Fine, 2006). Among people with SMI, personal attention and individualized support from care providers have been shown to increase the frequency and duration of engagement in health interventions and to address the motivational and cognitive issues associated with SMI (McGinty, Baller, Azrin, Juliano-Bult, & Daumit, 2015). Our findings suggest that, from participants' perspectives, culturally-appropriate interpersonal aspects of care were an important ingredient of B2BHW, as they set the stage for the development of individualized, trusting, and supportive relationships with their health care managers and may have opened the door for engaging in different aspects of the intervention (e.g., using the personal health record, developing action plans for their health). These results are consistent with previous qualitative evaluations of health interventions for people with SMI that highlight how the formation of supportive, respectful, and non-stigmatizing relationships with providers can facilitate participants' commitment and engagement in health interventions (Shiner, Whitley, Van Citters, Pratt, & Bartels, 2008).

Several study limitations should be noted. First, our small sample of mostly Latinas drawn from one public outpatient mental health clinic that serves predominantly Dominican patients in New York City limits the generalizability of our findings. Future work should test the impact of B2BHW and examine patients' experiences with this intervention in a larger sample of mental health clinics with more diverse Latino samples that includes more men and people with schizophrenia. Second, this qualitative study only examined the views of the 29 participants who completed B2BHW and collected more in-depth qualitative information on only 16 participants who attended the post-intervention focus groups. Participants enrolled in the evaluation of B2BHW who did not complete the intervention (n = 5) and those who did not attend the focus groups may have had different views regarding B2BHW. Nevertheless, our sample is adequate for this type of exploratory qualitative evaluation and our study addresses an important gap in the existing literature given the scarcity of research examining the experiences of Latinos with SMI with health care interventions (Cabassa, Ezell, & Lewis-Fernandez, 2010; Siantz & Aranda, 2014). Third, qualitative data analysis is susceptible to multiple biases. We used a series of established strategies (e.g., audit trail, member-checking activities) to reduce biases and ensure the rigor of our analysis and interpretation (Padgett, 1998). Lastly, we only asked participants in the open-ended question during the 12-month interviews what they liked most about B2BHW and did not asked about what they did not like about the intervention. This could have potentially biased participants' responses to only focus on the positive aspects of their experience with B2BHW. However, we did explore in the focus groups participants' suggestions for improving B2BHW, which furthered confirmed their positive reactions to B2BHW as participants indicated that they would not change anything from the intervention and that they would like B2BHW to be a permanent service at their clinic.

This qualitative study highlights how examining participants' experiences with a culturally-adapted health care manager intervention can help identify key aspects of the intervention content, approaches, and interpersonal elements that mattered most to our participants. Our findings reveal the centrality of interpersonal care practices, particularly those that mirror culturally-compatible norms and expectations, for Latinos with SMI and how these practices may facilitate the delivery and acceptance of other core intervention elements, such as health education, patient activation, and care coordination. These qualitative findings can inform future studies using more rigorous intervention designs (e.g., randomized control trial) to test whether the impact of B2BHW on health care outcomes (e.g., patient activation, receipt of preventive primary care) is mediated by these interpersonal aspects of care. Identifying intervention mediators is a critical step for maximizing the impact of health interventions as it helps service providers prioritize the most salient therapeutic ingredients of an intervention to improve health and health care outcomes. In conclusion, reducing health care disparities faced by Latinos with SMI requires the use of empirically supported, patient-centered health interventions that can reach this underserved population and respond to their health needs, preferences, and values in a culturally-appropriate manner.

Footnotes

Acknowledgments

The authors would like to acknowledge Arminda P. Gomes, Lorena Maldonado, Seth Thompson, Analis Lopez, Marina Soto, and David Camacho for their work on this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the National Institute of Mental Health (NIMH) K01 MH091108.

Leopoldo J. Cabassa, MSW, PhD is an Associate Professor at the George Warren Brown School of Social Work at Washington University in St. Louis. His research blends quantitative and qualitative methods, implementation science, intervention research and community engagement to examine health disparities among racial/ethnic minorities with serious mental illness (SMI; e.g., schizophrenia, bipolar disorder) and inform the development and implementation of interventions to reduce these health inequities. His work has been supported by the National Institute of Mental Health, the Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation, and the New York State Office of Mental Health.

Yamira Manrique, MS is an Intensive Care Coordinator for the Cross Systems Unit – Safe Harbor Program at the Westchester County Department of Social Services (DSS). Mrs. Manrique works with youth who are at risk of sexual exploitation or trafficking or are being exploited. She utilizes a trauma-informed approach to assists youth by linking and referring them to the most appropriate services. Prior to this position, she worked at the Columbia University School of Social Work as a Research Assistant.

Quisqueya Meyreles, MSW, LCSW, is a clinical social worker and Assistant Clinical Professor of Psychiatric Social Work (in Psychiatry) at the Department of Psychiatry in the College of Physicians and Surgeons at Columbia University. She has more than 20 years of clinical experience as license clinical social worker. She specializes in working with individuals with depression, anxiety and serious mental illness.

Lucia Capitelli, RN, MSN, PMHCNS-BC is a psychiatric clinical nurse specialist at the New York State Psychiatric Institute. She currently works as a Community Mental Health Nurse working with the SMI population in Washington Heights. She is the Managed Care Coordinator for the community service, conducts quality improvement chart reviews, provides in-service education, liaises with the sustained engagement team, and coordinates the HCBS program, New York State Psychiatric Institute.

Richard Younge, MD, MPH is the Director of the Columbia University Center for Family and Community Medicine and the Chair of the New York Presbyterian, Department of Family Medicine. He is an Associate Professor of Medicine (in Family Medicine) at Columbia University Medical Center. He graduated from the University of California, San Francisco School of Medicine and the UC Berkeley School of Public Health. He did his family medicine residency training in the Residency Program in Social Medicine at Montefiore Hospital in the Bronx. He is board certified in Family Medicine and in General Preventive Medicine. He practices at the Farrell Health Center of the NYP Ambulatory Care Network. Before joining the faculty at Columbia, he was the medical director, a clinician, and a board member at the Community Health Center of Richmond – a Federally Qualified Health Center in Staten Island. He teaches medical students and residents clinical primary care, community and population health with an emphasis on integrating medical and behavioral health care.

Dianna Dragatsi, MD is an Assistant Professor of Psychiatry at the Columbia University Medical Center, Columbia University College of Physicians and Surgeons. Dr. Dragatsi is currently the Medical Director of the Comprehensive Psychiatric Emergency Program (CPEP) at New York Presbyterian Hospital. She was Director of the Inwood Clinic from 2004 to 2015, and then of the Washington Heights Community Service from 2012 to 2015. She is primarily a clinician and administrator, and in each of her roles, Dr. Dragatsi implemented new programs and interventions. Dr. Dragatsi’s focus remains on positive patient outcomes, while maintaining high quality care. She has written and presented on various topics, including the physical health of Latinos with mental illness, implementation of staff training programs, and creating Joint Crisis plans.

Juana Alvarez is a Certified Peer Specialist and Mental Health Therapist aid at the Washington Heights Community Services at the New York State Psychiatric Institute. She has more than eight years of clinical experience working with adults with serious mental illness.

Roberto Lewis-Fernandez, M.D. is a Professor of Clinical Psychiatry at Columbia University. He is Director of the New York State Center of Excellence for Cultural Competence and the Hispanic Treatment Program, and Co-Director of the Anxiety Disorders Clinic, at the New York State Psychiatric Institute. His research focuses on developing culturally valid interventions and instruments to enhance patient engagement, reduce misdiagnosis, and help overcome disparities in the care of underserved cultural groups, especially Latinos. He is Chair of the Cultural Committee of the Group for the Advancement of Psychiatry, President of the Society for the Study of Psychiatry and Culture, and President-Elect of the World Association of Cultural Psychiatry. Dr. Lewis-Fernandez is Co-Chair of the ICD-11 Working Group on Culture-Related Features and Chair of the DSM Review Committee on Internalizing Disorders. He was a member of the NIMH National Advisory Mental Health Council and Chair of the Cross-Cultural Issues Subgroup of DSM-5.

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