Access to quality mental and physical health services can be a complex challenge, but for individuals of color and people with severe or chronic mental illnesses, finding treatment can be exceptionally hard. In this conversation, Tracey Lavallias, executive director of behavioral health at Penn Medicine Lancaster General Health, discusses potential solutions to make access easier for patients, including cultural competency training, medical interpreter services, and most importantly, integration of mental and physical health services.

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Tom Haederle

Access to quality mental and physical health services can be a challenge for many people, even those with good health insurance and plenty of care providers nearby. However, for individuals of color, various ethnicities, and people dealing with severe or chronic mental illness, finding the treatment they need is even a steeper hill to climb.

00;00;30;00 - 00;01;00;27

Tom Haederle

Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Studies have shown that among individuals diagnosed with a severe or chronic mental illness, black people are less likely to seek out treatment than whites, often facing barriers such as cost, transportation and even provider bias. In this podcast hosted by the AH's Rebecca Chickey, senior director of Behavioral Health; Tracey Lavallias, executive director of behavioral health with Penn Medicine,

00;01;00;27 - 00;01;23;19

Tom Haederle

Lancaster General Health, talks about the steps Penn Medicine has taken to increase access to care among underserved patient populations. They include cultural competency training, help with language barriers and most importantly, integration of mental and physical health services that are more likely to flag a problem and direct a patient to the care they need. Let's join Rebecca and Tracey.

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Rebecca Chickey

Thank you Tom. Indeed, it is an honor and a privilege to be here today with Tracey. Tracey and I are going to be talking about the value of integration. And when I say integration, I mean integrating physical and behavioral health, in particular the value of integration as it relates to improving access to care for historically underserved patient populations: individuals of color, various ethnicities, as well as individuals with severe and persistent or chronic mental illnesses.

00;01;56;14 - 00;02;27;29

Rebecca Chickey

Often you may think of disorders or conditions such as schizophrenia or bipolar disorder when you think of someone with a severe or chronic mental illness. All of those patient populations that I've just mentioned often struggle even more than others to improve access to care. And Tracey has experience and expertise in having seen the value of integration and how it can reduce stigma and increase access to care.

00;02;28;01 - 00;02;53;12

Rebecca Chickey

So enough about me. I'm going to turn now to Tracey and say, Tracey, can you share with the listeners a couple of things. One: What are the realities of the challenges of accessing mental health services and treatment for addiction for individuals of color as well as, what are some of the reasons for those challenges?

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Tracey Lavallias

Well, first of all, Rebecca, thank you for having me. I appreciate the opportunity to discuss this very important topic. We have been on this journey at Penn Medicine for a long period of time. And one of the things that you mentioned was the disparity amongst individuals of color versus individuals who are white. So I'll give you a little bit of information that we found. That even when diagnosed individuals are diagnosed with a mental health disorder, Hispanics and blacks are traditionally less likely to seek mental health treatment than whites.

00;03;28;11 - 00;03;53;02

Tracey Lavallias

This has been highlighted in many studies and it certainly has manifested in our particular environment here. There are a variety of barriers to receiving mental health care for individuals of color, some reports. We did a recent study here in our community about the stigma associated with mental health. Recently there was a campaign called Five Signs that helped to reduce that.

00;03;53;02 - 00;04;16;24

Tracey Lavallias

But we're still not at the level of where individuals can speak about mental health in the same way that we speak about physical health. And that has been exacerbated in the, communities of color. Also, biases of providers. Interestingly enough, we spent a great deal of time just having a campaign to reduce the biases of our provider community.

00;04;16;27 - 00;04;39;26

Tracey Lavallias

we focused on our emergency department here. We've also focused on our treatment providers. We've instituted things such as cultural competency to try to reduce those barriers. In many cases some of our communities of colors have poor health literacy. We do have a large immigrant population. And so, as you know, mental health means different things to different individuals.

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Tracey Lavallias

And the interpretation of mental health is perceived differently in certain cultures. So that's an issue. Sometimes its poor insight into navigation. And our mental health system, particularly in state of Pennsylvania, is not easy to navigate. So in some cases, being able to navigate the health system and the insight into navigating a health system calls for some concern for those populations.

00;05;05;20 - 00;05;32;22

Tracey Lavallias

There's geographic inaccessibility. And what I mean by that is poor transportation. In many cases, these individuals don't have an opportunity to access it because of not having transportation and the right means. And then there's other things like linguistic, or as I stated earlier, just cultural barriers. And so in many cases, the language is not being spoken in a way that can be communicated in order for these individuals to receive care.

00;05;32;23 - 00;05;47;04

Tracey Lavallias

So, you know, those are the realities that we deal with on a regular basis. And some of the things that we work to try to reduce, to make sure that those individuals have the same level of access that our white patients do.

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Rebecca Chickey

Well, it's particularly timely that we're having this discussion now, Tracy. For the listeners, we are releasing this podcast in the month of July, and July is Minority Mental Health Awareness Month. And the challenges that Tracy just described, I will share, just briefly, a personal journey. I am white, and I had a family member who was suffering from major depression and had what I would call the the "golden egg" of health plans and many connections.

00;06;21;16 - 00;06;54;11

Rebecca Chickey

I've been in this field for over 30 years, and so I know the chiefs of psychiatry at stellar organizations across the country. And even so, trying to get treatment for my family member, it took over two months to get in to see a psychiatrist. And even then, they did not take my health insurance. As an individual who is connected, reasonably educated in trying to navigate the mental health system as well as having, you know, stellar health insurance

00;06;54;13 - 00;07;23;04

Rebecca Chickey

thanks to the American Hospital Association, it was still a struggle. We want to talk about the value of integration. But first I want to ask you about another patient population. As I mentioned earlier, those with severe and persistent mental illness, chronic mental illness. I don't know if the listeners know this, but, individuals with chronic mental illness usually die somewhere between 15 and 25 years earlier than individuals without schizophrenia or bipolar.

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Rebecca Chickey

And you may jump to the conclusion that that might be due to higher suicide rates. Indeed it is not. They die most often from their physical illnesses, which they are not taking care of because of lack of access to both physical health and mental health services. So can you speak a little bit to that? Because that's also a health disparity.

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Rebecca Chickey

And, I wonder how you have been addressing that and what you know about their challenges and the realities.

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Tracey Lavallias

Yeah. Rebecca, you bring up a really important point, and I appreciate the conversation around this. And in fact, we, try to stress this issue locally and any opportunity we get to kind of speak about this. But these are preventable diseases. In many cases, the individuals with serious mental illness, interact with and die from earlier than the same population

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Tracey Lavallias

that does not have a serious mental illness. Things such as, you know, cardiovascular disease, diabetes and, you know, complying with insulin. These are different types of things that are preventable. The largest percentage of care in our particular - in any network - is through primary care. And we have found that individuals with serious mental illness do not seek this level of care out, as much as they should. In particularly those, as you spoke about earlier, those that are in minority communities, they have not access the primary care services as much as we would like.

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Tracey Lavallias

In many cases, those individuals seek care in traditional mental health or inpatient environments. In many cases, we found them in our emergency department. So the fact of the matter is that individuals with significant severe mental illness do not access their primary care as often. And then you add on top of that those individuals that are communities of color access - those primary care resources and less.

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Tracey Lavallias

And subsequently it leads to those factors that cause premature death. Cigarette smoking, things of that nature or diet and those types of issues that can be addressed if they went to a primary care physician.

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Rebecca Chickey

So now that we painted a unfortunately fairly bleak picture for the listeners here, let's give them a bit of light, a bit of hope. How can and does integration help to reduce these disparities? Give me some examples.

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Tracey Lavallias

What we found here, in fact, what my doctoral dissertation was done on our primary care offices here ... we did a study on - this is going back, maybe seven years ago now. And we utilized four primary care sites here. And we went to look about three different factors, actually, we were really focusing on. First factor was, was there a reduction in the issues that we just spoke about, some of those issues that were preventable.

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Tracey Lavallias

Did they actually comply with the primary care physicians, recommendations for those individuals that were receiving integrated care within a primary care practice? And the other components that we spoke about, we wanted to see if there was a reduction in the emergency room utilization of those individuals that received primary care and mental health services within the primary care practice.

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Tracey Lavallias

And the last factor that we focused on was, whether or not those individuals sought care in our emergency department. Remember I spoke about traditionally those individuals sort of surfaced in our emergency department due to the lack of primary care resources. The study found that we have 50% reduction in those individuals receiving care, under primary care integration.

00;11;29;06 - 00;11;55;25

Tracey Lavallias

So they're less likely to come to the word see department. There was a significant reduction of stigma in the primary care office, based on the fact that these individuals did not seek services or receive services under the umbrella or title of a mental health facility. There was more compliance with the recommendations of their medication management or the recommendation of their primary care physician.

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Tracey Lavallias

And this was primarily based on the fact that they may have been depressed. There may have been other factors that, were focused on their mental health issues that caused them not to take their physical health medication. So the fact that we were integrating care within a primary care office and allowing these services to be seen as seamless, really improve the quality of care for those individuals.

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Tracey Lavallias

And as a by-factor of that, there was a significant increase in provider satisfaction. So not only did the patients get better and services delivered in a more quantitative fashion, but the provider satisfaction just increased. So I think that's the positive side of integrating mental health into your primary care offices.

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Rebecca Chickey

So I'm going to emphasize again, some of the key points you just said. One, with all the workforce challenges that are out there right now, if you can improve provider satisfaction, that is a positive impact. Equally, perhaps even more importantly, what you said is that you improved patient outcomes. That's what we got into healthcare for in the first place, right, is to improve individual's quality of health and ability to live their best lives.

00;13;15;23 - 00;13;31;23

Rebecca Chickey

You reduced stigma through integration and then, I'm going to connect the dots here. So please keep me honest if this is not the case. But you said you reduced visits to the emergency department by around 50%, and so that's correct?

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Tracey Lavallias

That's correct. Yeah.

00;13;33;03 - 00;13;57;07

Rebecca Chickey

And every emergency department visit, it's not the least costly level of care, I will say. And so you have you're reducing the total cost of care for that individual as a whole. And you're also improving access to other emergency services because the emergency room is not treating someone who could have been treated in a lower level of care.

00;13;57;09 - 00;14;10;25

Rebecca Chickey

Well, is there a story that you might want to share for the listeners? Of course, not identifying a name, but is there a story that you might want to share to, illustrate this on a on a personal level?

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Tracey Lavallias

We had an individual and I spent a lot of time with this individual, and he was a parent of a individual that was a chronic behavioral health patient. And what I mean by chronic symptomology had become so severe that she would cycle through our emergency department on a regular basis. This situation all escalated up to our CEO and CEO sent the information to me.

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Tracey Lavallias

So I had several conversations with the parent of this individual who was really reaching out for help and really didn't have the ability or capacity because he had been dealing with this particular issue for such a long period of time. It manifested in complaints. But really, when you drill down and you had a more conversation, it was about access and the fact that this individual had not accessed our services within our PCP.

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Tracey Lavallias

One thing led to another, and I'm shortening the story because of the time frame. But imagine this situation went on for about six months. We began to build a bridge with the parent who in fact begin to build a bridge with the daughter. We connected this daughter with our integrated care within our primary care offices, they're currently in all our primary care offices now.

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Tracey Lavallias

So we integrated them based upon the location that was closest. She immediately connected with the therapist there. There was less of a stigma associated with the services that she received. And, she just got better, significantly better, throughout the course of time. Her parent was a conduit because she was limited linguistically and really reached out to us to talk to us about the care that they received in this environment.

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Tracey Lavallias

The therapist, the integration of the primary care doctor, addressing the physical health needs. She became much more compliant with her physical health medication which was a conduit to her being in the emergency department as well. So I point that story out just to say that that is probably one that came to my attention, but that's the norm for what we've what we have seen in our primary care offices when we integrate our mental health clinicians there.

00;16;37;19 - 00;16;50;22

Tracey Lavallias

And has been certainly a positive outcome for the system because these individuals are receiving timely care and just getting better, Rebecca. And so I'm really, really proud of the work that they've done there.

00;16;50;25 - 00;17;09;23

Rebecca Chickey

I think what you just described was truly patient centered care. So thank you for doing that and for sharing that story. As we close out the podcast today, is there a call to action that you'd like to perhaps challenge or encourage the listeners to consider doing?

00;17;09;26 - 00;17;29;07

Tracey Lavallias

A couple things? One thing that I would say is that you had, alluded to this earlier. There are significant challenges from a workforce perspective to be able to keep up with the amount of patients that need health care. So in the medical field, you can see it nationally that there's just not enough providers, not enough individuals going into the field.

00;17;29;09 - 00;17;53;14

Tracey Lavallias

So I encourage those who have an empathy for this population to go into this field, contribute in any way that you can to this population so that these individuals will have the same quality of life that we've grown accustomed to. The second thing that I would say is we talked about the disparity between the physical health and the mental health, and really trying to close that gap as relates to stigma.

00;17;53;17 - 00;18;32;18

Tracey Lavallias

We talked a little bit about it earlier. I would like to prioritize things such as mental health first aid. You know, we get first aid in many of our jobs that we go into, particularly in the health care field, and it's a way to sort of prevent the physical issues if you're so encountered and trying to stabilize the patient. The same things are taught as it relates to mental health first aid, the ability for individuals, loved ones, family members, friends to engage with individuals because in most cases, they're the ones that see them first to be able to do some of their first aid, mental health, first aid, things that can stabilize the

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Tracey Lavallias

patient prior to them engaging with the system. It would broaden our ability to have access, and it creates the opportunity to reduce stigma. So in those cases, I think that would be my two calls to actions.

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Rebecca Chickey

Thank you so much. I think I'm about to quote Maya Angelou, but as you were saying that, this quote came to mind: "Once you know better, do better."

And that would be my call to action. So as we close this out, there are a number of resources, around the value of integration, the value of integrating physical and behavioral health that can be found at

00;19;12;26 - 00;19;28;14

Rebecca Chickey

www.aha.org/behavioral health. This podcast will be available there and of course on AHA's Advancing Health podcast. Tracy, thank you so much for the work that you do and your willingness to share your insights and expertise with us today.

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Tracey Lavallias

Thank you so much, Rebecca. I appreciate you the opportunity to discuss this important topic. And I'll see you soon.

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Tom Haederle

Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.