What are the care gaps for immigrants in NYC’s healthcare system?
We spoke with Hewett Chiu, Founder & CEO of RaisingHealth and former Executive Director of the NYC Department of Health & Mental Hygiene, overseeing the Mental Health Service Corps under his portfolio. Below is a summary of our interview:
- How do you serve the mental healthcare needs of NYC’s immigrant communities?
- Cultural competency and language skills are essential for mental healthcare because of the stigma around treatment + high amount of trust needed to keep patients’ trust in the system.
- What are the biggest policy challenges affecting immigrant community’s healthcare outcomes?
- Stable housing is a huge challenge. So is coordinating all of the different pieces of the healthcare puzzle that want to serve communities but are poorly coordinated.
Views and opinions expressed do not necessarily reflect the official position of Commonweal Ventures or its investment team.
What's the state of New York City's mental healthcare workforce?
Not only is there a workforce shortage of mental health clinicians, but on top of that there's an issue with language capacity: we need bilingual clinicians and cultural tailoring. It's been very difficult to find and build up the mental health workforce. There's a disparity in capacity for more under-resourced communities.
So it sounds like there are two problems: 1) not enough mental health practitioners, 2) those practitioners don't speak enough languages to meet the community's needs. How do you tackle that?
They're definitely interlinked. It's a supply issue—there are just not enough individuals who are being trained to be mental health clinicians and even if they're trained, they may not want to practice anymore because the retention rate is not great. Mental health is a clinical service with very high burnout. You're holding on to a lot of vicarious trauma that you may be processing yourself.
If we hone in on the language issue, part of the solution is having individuals who speak the languages natively so they're comfortable delivering mental health therapy. Most of the time they grew up in those communities (Spanish, Chinese, Arabic, etc.) I have been in this world and worked on this problem for a long time; within each of those communities, mental health as a concept is stigmatized. It's not an open conversation or discussion that you're having growing up. Therefore, that impacts the allure of people going into mental health and choosing the profession, which exacerbates the problem.
Let's talk about cultural competency around mental health in these communities. Is that something that can be taught or do you have to rely on the supply side naturally providing? To provide mental healthcare in, let's say the Chinese community, it seems like you'd need a detailed understanding of the unspoken and implicit sides of the culture.
There's a component that can be taught and learned. I don't think it works for all communities, though. There is a difference between being able to be culturally appropriate and sensitive versus culturally competent in how you render the services. People can learn about being culturally sensitive without having lived experience. However, you have clients who are open to seeking out a mental health professional who might not identify from the same ethnic/racial/cultural background as them, and one uncomfortable interaction can totally turn them off to mental health because the situation is so vulnerable.
You were Executive Director of the Mental Health Service Corps, the largest program of its kind in the country. Tell us about how it worked.
For context: The MHSC was designed to improve NYC’s mental health system by helping high-risk, vulnerable populations get greater access to culturally competent care and address industry workforce shortages by developing a new generation of public mental health clinicians.
The individual who's providing the direct care is the behavioral care manager (a social worker, a licensed mental health counselor, etc.) They're in their training period, gaining their clinical hours toward their licensure. They're supported by a clinical supervisor and the consulting psychiatrists that work with the practices trainees were placed in.
How did the Mental Health Service Corps measure its outcomes?
Firstly, being that it's a city program we covered all of NYC. We had to make sure that all 51 council districts (at that point in time) were covered. Secondly, we focused on the need. What were the mental health profession shortages? Where were the medically underserved areas? Where are the deserts, the areas lacking FQHCs, even if it's not designated as a health professional shortage area?
You were juggling a lot of stakeholders between the city, FQHCs, etc. Lots of cooks in the kitchen. Any lessons as a leader on partnerships?
It's very important to be clear in articulating the value proposition for why we're working together. We probably do this a lot better in the startup world than in the public sector. Sometimes leaders think the value is implicit. It's clear in our minds! But we haven't really articulated that to the partner organization and that can lead to misunderstandings. A small solo primary care practice will have a very different approach than a large hospital system. It's important to scope out what is possible.
How do you think about the social drivers of health? Your organization bundles in a lot of components like language, education, and safety.
I view health from a very proactive lens. We've made great strides, but for the longest time, we've defined health as the absence of a disease or illness. That's helpful in some respects, but not really health, you know? It's much more all-encompassing, it's someone's ability to thrive at their fullest potential which goes along with the idea of wellness. That's why we bring safety and belonging into health. There are physical and mental dimensions to health, but the industry needs to recognize spiritual, emotional, occupational, and financial health too.
You're a rare example of someone with a lot of experience in the public sector and startup world. What were some of the differences and shocks to each?
In the startup world, there's a level of speed, scale, and fluidity. In the public sector, you're working on something that is a large machine. A monster! It can be highly political and visible and a lot of resources come behind it, so it's not always possible to articulate what you learned or what you need to pivot to. Pivots would take a lot of thought, conversations, and stakeholder meetings. It's joint decision-making. By the time we reach a decision, you're wondering, "Do we even need to consider this anymore? The world is kind of different now and we need to start over."
Take me back to day one of Raising Health and how it came together.
It stems from a personal tragedy. I lost my mom to cancer in a very short amount of time, in six months or so. It was over Thanksgiving; one year we found out she had cancer and by the following spring, we'd lost her. While it was shocking to see how quickly the cancer progressed, what was more shocking was the lack of support that my family and I had going through that process. The oncologists were there, but we had no social workers and no other types of support that the health system has now recognized, thankfully, as important and necessary. But that wasn't a thing back then.
The thought always was that there has to be a better way to bring more education, literacy, and awareness to healthcare. There's more nuance to it too—the way that her oncologists were adjusting her medications and chemotherapy was not tailored to her body weight or race and ethnicity. We really need to bring more light to the importance of culturally tailored healthcare for our immigrant communities.
What do you feel are some of the biggest policy questions or risks facing the NYC immigrant community right now?
Housing is a big thing for our immigrant communities. Having a permanent, stable place to go is such a large determinant of overall health. That continues to be an ongoing problem we hear of every single day, with all the temporary housing and shelters. Also, there are so many sorts of political positions that different segments of the community have that it's hard for us to unify and push a policy forward in city and state legislature.
Access to care continues to be a problem too. We've been talking about this for too many decades. Someone's level of access depends on their legal immigration status, which drives a lot of disparities we're seeing in healthcare.
Another component is how different players in healthcare work together. The community health centers, health systems, care providers, hospitals, pharmaceutical companies, and payers; we all recognize that we have to work together and everybody has a genuine interest in coming to the table. Payers recognize they are no longer just reviewing and approving providers' clinical decisions, they're taking an active role in population health management and community-based settings. Many of them are more at the forefront and willing to invest (both equities and social impact) in population health initiatives partly due to regulation but also because they think it's important to their core business. Hospitals and health systems are now more community and population-health-oriented too.
Now we're thinking about how to best leverage each of those perspectives to enable our immigrant communities to seek the social/clinical care that they need. It's always been up to the patients and their families to figure out questions like "Where do I go next? How do I make the next appointment? What pharmacy do I go to to pick up these medications?" All of that disjointedness has been a very big challenge. That's why we're trying to figure out these clinical linkages, so we can have a cohesive patient care journey.
How can readers help or get involved?
· If you are a startup addressing language, literacy, food security, mental health, or patient engagement, we could be a point of initial validation because we touch a lot of immigrant communities and we're always looking for better solutions.
· If you're in healthcare, we would love to talk about how you're tackling social healthcare for immigrant communities. It doesn't have to be a formal partnership—I just find there's often a duplication of efforts, so getting to know what we're collectively thinking and figuring out where there are synergies.
· If you want to get involved directly, you can volunteer with things like food pantry distribution or if you have a clinical background, we have opportunities to provide screenings, health education workshops, etc.
To learn more about RaisingHealth, click here. If you’d like to work with RaisingHealth as a startup, volunteer, administrator, or clinician, email me (zac@commonwealventures.com).
