Effects of Hospital-Community-Public Health Integration on Racial and Ethnic Disparities in Mental Health

摘要 在美国，精神疾病是一个主要的公共卫生问题，也是发病率和死亡率的重要来源。 种族和少数民族患者经历了共同的身体健康状况的不成比例的负担 与精神疾病有关，这主要是由于缺乏保健机会和社会污名。有效地 治疗精神疾病和相关疾病将取决于一种全面的方法 保健系统和政策，如《社区惠益州法律》，以“人口健康”和 强调健康的社会决定因素的价值。然而，目前的精神卫生保健系统在 这是一个孤岛，缺乏医疗保健协调解决健康差距的证据。这项研究的目标是检查 医院、社区和公共卫生机构之间的系统级护理协调，并估计其 对非洲裔美国人和拉美裔精神病患者未得到满足的卫生保健需求的影响。其基本原理是 对于拟议的研究来说，一旦知道具体的协调做法(例如，医疗服务， 交通、公共住房)和政策对于不同的患者群体是最成功的，整合 可以以更具成本效益的方式设计精神和身体保健提供系统，以克服 来自污名和有限的医疗保健机会的障碍。在这个项目中，我们将首先确定 社区受益于国家关于种族和民族在医疗保健机会、质量和成本方面的差异的法律 精神病患者(目标1)。在此背景下，我们将进一步确定以医院为基础的变异 护理协调做法的采用及其与患者和社区层面社会责任的相关性 人口结构、当地公共卫生资源以及社区福利法律的实施程度 (目标2)；并确定医院、社区和公共部门之间护理协调做法的影响 卫生机构关于种族和族裔健康差距的报告(目标3)。我们将使用混合方法：(1)我们将 通过链接多个具有全国代表性的数据集来构建多层次数据集，并使用差异在- 采用差异法估计系统一级护理协调对不同种族/族裔群体的影响； 以及(2)我们将调查使用种族焦点小组实施系统级协调的挑战 和少数民族患者代表，医院管理人员和提供者，以及来自 公共卫生机构。拟议的研究具有重要意义，因为(1)已确定的实践有望 为如何为少数民族患者提供个性化的心理健康护理协调提供证据 解决精神卫生治疗中的不同偏好；(2)确定系统层面的护理协调 预期实践将具有成本效益，这反过来又可以使协调可持续地 服务不足的人群。预计我们的结果将打破长期存在的孤岛，弥合差距 在卫生保健提供者、社区组织、社会服务机构和公共卫生之间 除了提供证据以通过护理协调来减少卫生差距外，还提供了部门提供的服务系统。

Summary Mental illness is a major public health concern in the U.S. and a significant source of morbidity and mortality. Racial and ethnic minority patients experience disproportionate burdens of common physical health conditions associated with mental illness, largely due to the lack of health care access and social stigma. Effectively treating mental illness and the associated conditions will depend on a comprehensive approach that crosses health systems and policies, such as the Community Benefit State Laws, to target “Population Health” and emphasize the value of social determinants of health. However, the current mental health care system works in a silo, and evidence of care coordination on health disparities is lacking. The goal of this study is to examine system-level care coordination among hospitals, communities, and public health agencies, and to estimate its impacts on unmet health care needs in African American and Latino patients with mental illness. The rationale for the proposed research is that once it is known what specific coordination practices (e.g. medical services, transportation, public housing) and policies are most successful for different patient populations, integration of mental and physical health care delivery systems can be designed in a more cost-effective way to overcome the barriers from stigma and limited health care access. In this project, we will first determine the effects of Community Benefit State Laws on racial and ethnic disparities in health care access, quality, and costs among people with mental illness (Aim 1). Within this context, we will further identify the variation of hospital-based adoption of care coordination practices and its correlation with patient and community level socio- demographics, local public health resources, and the extent of the implementation of community benefit laws (Aim 2); and determine the impact of care coordination practices between hospitals, communities, and public health agencies on racial and ethnic health disparities (Aim 3). We will use mixed methods: (1) we will construct a multi-level data set by linking multiple nationally representative data sets and use difference-in- differences approach to estimate the impact of system-level care coordination on different racial/ethnic groups; and (2) we will investigate challenges to implementing system-level coordination using focus groups of racial and ethnic minority patient representatives, hospital administrators and providers, and representatives from public health agencies. The proposed research is significant because (1) identified practices are expected to provide evidence on how to personalize mental health care coordination for racial and ethnic minority patients to address heterogeneous preferences in mental health treatment; (2) identified system-level care coordination practices are expected to be cost-effective, which in turn can make the coordination sustainable for underserved populations. Our results are expected to break down longstanding silos and bridge the gap between health care providers, community based organizations, social service agencies, and the public health sector delivery system, in addition to providing evidence to reduce health disparities through care coordination.