(Getty Images)

Kaiser Permanente is failing to provide timely access to mental health treatment for some of its members according to a recent report by the Department of Managed Health Care.

The report says Kaiser’s mental health services are deficient in key areas.

State regulators found insufficient staffing at some clinics across the state — with patients waiting longer than the legal limit of 10 days for appointments. The report also says some patients were being misled due to inaccurate information about Kaiser’s mental health services. Regulators also found that at Northern California facilities staff members were not accurately tracking and reporting how long patients had to wait to get initial appointments or follow ups.

Shelly Rouillard, chief deputy director at the department, says the agency will be taking the unusual step of conducting a follow-up survey in six months rather than the normal 18 months.

“These are significant deficiencies, and we’re concerned that consumers aren’t getting the care that they need when they need it,” she said “and particularly when they are in distress.”

Kaiser employees affiliated with the National Union of Healthcare Workers are calling the report a vindication of concerns they laid out in 2011. Clement Papazian is a social worker with Kaiser Oakland and a chapter officer for the union that represents more than 2000 clinicians and psychologists. Papazian says delays have been hard on patients.

“Some of them will drop out of care,” he described. “Some of them will seek medication only — or the services that are available to them: group services.”

But Kaiser Permanente officials say the problems occurred at a limited number of sites and did not effect the quality of mental health care. Mason Turner is assistant director of regional mental health for Kaiser Permanente Northern California. He says the agency has been working hard to correct problems since it received a draft of the report last August.

“We have hired more staff,” he said. “We have provided more appointments for our patients, and we’re very committed to correcting these issues and providing the highest quality of care that we possibly can.”

Kaiser also issued a complete response to all its members.

The Department of Managed Health Care’s enforcement office is now evaluating options for penalties, including fines.

Chef Lars Kronmark teaches veterans how to remove the skin of a fish; part of a four-day “boot camp” at Napa’s Culinary Institute of America where injured veterans and their spouses learn healthy cooking tips. (Mina Kim/KQED)

In a stainless-steel teaching kitchen deep within the old stone walls of the elite Culinary Institute of America in Napa Valley, acclaimed chef Lars Kronmark pulls a piece of fat from the cavity of a raw, whole chicken.

“A big chunk of fat like that, it doesn’t really hurt to leave it in there,” Kronmark said. “But in the end of the day, that’s still going to be too much fat.”

It looks like a standard cooking class. But this is an unusual class for an unusual group of students. It’s a healthy cooking “boot camp” designed for wounded veterans of the Iraq and Afghanistan wars with a goal of helping veterans connect with each other and learn to eat healthier.

Six military veterans and their spouses dressed in white chef’s coats and hats watch Kronmark closely. His healthy cooking techniques are welcome tips to the group of 12, including veteran James McQuoid, who lives with post-traumatic stress disorder.

“I’m of the larger variety,” McQuoid said. “A couple years ago, I didn’t care about my health. I was very reclusive and what not, but through therapy and stuff I’ve come to realize — I’ve got a younger child — I want to be around a bit longer, and I’m really not helping myself at all.”

A healthy dinner is served at Napa’s Culinary Institute of America healthy-cooking boot camp for injured veterans. (Mina Kim/KQED)

Federal officials estimate more than 70 percent of the veterans receiving care in the VA are overweight or obese. McQuoid’s doctor recommended he get more omega-3 fatty acids by eating fish instead of fatty meats.

“But I didn’t know how to cook fish,” McQuoid said. “After being here though, I can cook fish!”

The four-day boot camp is a program of the Wounded Warrior Project, a nonprofit that serves injured veterans transitioning to civilian life. The camp’s days begin with lectures on subjects like the physiology of taste and end with vets and their partners preparing dishes for dinner. Today’s menu includes roast chicken with lemon and rosemary, Baja fish tacos, and pork loin cooked in a pomegranate glaze.

Invisible Wounds

Yet, the program is playing a much bigger role than helping veterans eat better. Julia Valentour, health and wellness coordinator at the Wounded Warrior Project’s San Diego office, said there’s a waiting list for the classes that often helps veterans break through the isolation they feel when they return from war.

“I don’t think people realize what [veterans] go through and how much they sacrifice for us,” Valentour said. “You’re not hearing about the war on TV everyday, so you tend to forget that it’s still going on.”

At one cooking station a young man in a wheelchair with prosthetic legs, quietly peels sweet potatoes. Another veteran purses his lips in concentration as he chops cilantro using only one hand. But for many of the veterans, their wounds are not visible.

Tiffany Rush-Green who flew in from Phoenix for the class with her husband Yancy Green, a Marine, said this is the first time she’s seen her husband smile in a long time.

“Finally we can do something together, and take our time and just be a team so we can find that common ground,” Rush-Green said. “I am not a veteran, so a lot of times I can’t relate to him on certain issues, but cooking I think we’re going to be able to relate to each other on.”

Yancy Green said his wife is happy because she won’t have to do all the cooking anymore.

“I have no more excuses after this week,” he said.

For Renee Hampton and her husband — who asked not to give his name because he’s on active duty — being here is a dream come true. Hampton said her husband learned to cook when he was five and always wanted to be a chef, but chemicals used in the war robbed him of his ability to smell and taste. Still, it hasn’t dampened his experience in the class.

“I absolutely love this,” he said. “Besides, all my life, I’ve always wanted one of these [chef] jackets, and now I get one.”

For Culinary Institute chef Kronmark, the service members humble him in ways he hasn’t felt before.

“Makes you remember how lucky you are,” Kronmark said. “It’s really amazing.”

The next class is scheduled for May, and will be for spouses or caregivers of veterans.

Listen to Mina Kim’s story:

President Obama speaks at an interfaith vigil for the shooting victims at Sandy Hook Elementary School (Olivier Douliery-Pool/Getty Images).

On Monday White House spokesman Jay Carney pointed to the federal health law as evidence that the administration has already started to tackle the issue. Mental health issues are “clearly a factor that needs to be addressed in some of these cases of horrific violence,” Carney said. ”Obamacare, if you will, has ensured that mental health services are a part of the services” provided under the health law.

While the Affordable Care Act, along with the Mental Health Parity Act of 2008, go a long way toward assuring coverage for most Americans, some gaps remain.

Here are some answers to frequently asked questions about mental health coverage:

Didn’t the Mental Health Parity Act already guarantee coverage for Americans with insurance?

The Mental Health Parity and Addiction Equity Act, signed into law in 2008, made a big dent in the problem of mental health coverage. But it depends on how you get your insurance

• Large Employers (more than 50 workers): If large companies include mental health services in their insurance plans, they must cover those services at same or higher level as other medical conditions. That means that the plans could not provide fewer inpatient hospital days or require higher out-of-pocket costs, more cost sharing or separate deductibles for mental health conditions. But Paul N. Samuels, director and president of the Legal Action Center, says that some people still aren’t receiving equal coverage, and the law is not always enforced. “That’s a problem we’re really concerned about,” he says. Note that large employers are not required to offer mental health insurance, but most do.
• Small Business/Individual Plans: Not included in the Parity Act.

In short, whether you have mental health coverage in an employer-sponsored insurance plan depends on where you work.

What if I don’t have mental health coverage in my employer’s insurance plan? Will the ACA change that?

Small group and individual plans will be required to offer the coverage in 2014 through health exchanges created under the law. But employers with 50 or more workers can continue to not offer the benefits.

I’m planning to buy an insurance plan through one of the new exchanges. What kind of mental health coverage will I have?

Again, as noted above, all plans sold in the exchanges will be required to provide coverage for mental health and substance abuse. The exchanges will be open to individuals and small businesses.

The same rules will apply to small group and individual plans purchased outside of the exchange.

In other words, beginning in 2014, if you (or your small employer) are purchasing any new insurance plan, coverage will include mental health benefits on par with any other medical condition.

I’ll be covered under the Medicaid expansion authorized by the law. What kind of mental health coverage will I get?

If you earn less than 138 percent of the federal poverty level (about $32,809 for a family of four), you may be newly eligible for Medicaid coverage in 2014. Like people who purchase coverage through the exchange, new Medicaid beneficiaries will receive mental health benefits on par with other medical or surgical needs.

What problems might arise?

While the ACA “provides enormous potential and opportunity to make sure than many millions more Americans obtain the services they need,” says Samuels, “that will only happen if the implementation of those reforms is effective.” Samuels worries that the rules from HHS will not be clear or strong enough to make the parity laws meaningful. He also worries about getting everyone who is eligible for coverage enrolled, particularly those with severe mental health disorders who be may homeless or living on the fringes of society.

Access to treatment will likely also remain a serious stumbling block. As many as 30 million people are expected to gain insurance coverage beginning in 2014. Of those, the U.S. Substance Abuse and Mental Health Services Administration estimates that 6 to 10 million will have untreated mental illnesses or addiction, adding additional demands to a system that is already overwhelmed. Patients may experience long wait times to see a psychiatrist, for example, and may require additional investments to expand the mental health workforce.

Learn More: KQED Forum Shooting Puts Spotlight on Mental Health

Wendy Georges (second from the left) leads a planning session for the new TRUST Clinic (Photo: David Modersbach)

By Alvin Tran

Alameda County has new plans in store for its homeless population – it intends to open an integrated medical clinic in downtown Oakland.

The TRUST Clinic is one of the county’s newest projects and involves the collaboration of several agencies including Alameda County’s Health Care for the Homeless Program, Social Services Agency and Behavioral Health Services.

But unlike other clinics in Alameda County, TRUST will be one of just two which will offer integrated health services, including primary care, behavioral health, case management with housing assistance, and medical-legal partnerships.

“This clinic is a very innovative idea. It’s not something that’s being done in very many places,” said Dr. Michael Boroff, a clinical psychologist who will be working at the clinic. “It embraces the integrated health care … with medical and mental health and all of these different aspects of services combining and working together as a team.”

“I’d be hard-pressed to identify the population who needs these services more than the homeless population that we’re going to be serving,” Boroff added. And that population is large — more than 4,000 people in 2011, according to a report by EveryOne Home, an advocacy group.

Wendy Georges, the TRUST Clinic Manager, said many homeless people deal with a variety of health and behavioral problems. Homeless individuals might have mental illness and substance abuse issues, they may have difficulty keeping track of their medical appointments, and might struggle in social settings.

The TRUST Clinic is intended to be a place where people can get a variety of services for up to 24 months. The hope is that during this time, patients will achieve financial and housing stability and be prepared to transition to other permanent clinics in Oakland.

“What we’re hoping to do in the TRUST Clinic is to address all of those problems across a spectrum — stabilize their health, stabilize their mental health, offer effective substance abuse and interventions for addiction, provide legal advocacy to people so that they can successfully transition off of (General Assistance), get on to insurance which will then increase their access to medical care, mental health care,” Georges explained.

While many homeless individuals are current recipients of General Assistance, also known as welfare, Georges said that many of them are still unable to obtain adequate health services. TRUST will help enroll individuals in other areas of assistance.

“If they get on to Social Security, Supplemental Security Income — SSI — or SSDI, they’ll have access, automatic access, then to Medi-Cal and, in some instances, to Medicare,” Georges said.

But when more people become insured, there will be other challenges to face.

According to Georges, more than 56,000 people in Alameda County will become eligible for health insurance once President Obama’s Affordable Care Act takes full effect in California.

“The demand outweighs the supply,” Georges said, adding that the current community clinic system in Alameda County will continue to be overburdened with patients from the safety net population –- a population in need which lacks health insurance.

This is where the TRUST Clinic comes into play. Georges describes the clinic as the “safety net for the safety net.”

“By redirecting the homeless population to the TRUST Clinic we relieve the burden on our community health network and enhance an already inadequate safety net system in Alameda County,” Georges explained later in an email. “Our clients/patients already have difficulties gaining access to the system and fitting in even when they do. We are establishing the (clinic) with just such clients/patients in mind, so truly to function as a safety net for the safety net.”

While the bricks and mortar clinic opens in 2013, Alameda’s homeless population does not have to wait until then to begin receiving the TRUST Clinic’s integrated health services. Starting Tuesday staff members of the clinic, including a nurse practitioner and a clinical psychologist, began offering part-time, interim mental health services at two locations in Oakland.

“We’re going to start with mental health and we’re going to begin this building up process, get our mechanisms in place,” Georges said. “It’s a little bit of a practice run for a ramp up to full scale services.”

Alameda County Mobile Health Services Unit van, set up to treat patients in downtown Berkeley. (Photo: Alvin Tran)

The walking wounded wander the streets of Alameda County.

They are people who are homeless and live day to day in public parks and shelters. They are people in need of support for mental health issues and drug and alcohol addiction. And says Addie Brown, they are also one of the most difficult groups of patients to treat.

Brown would know. She oversees the operation of the Mobile Health Services Van headed by the Alameda County Health Care for the Homeless Program (ACHCHP). The van travels throughout Alameda County serving approximately 160 homeless individuals each month. A team of healthcare providers, including nurse practitioners and social workers, provide no-cost primary care and support services, such as counseling and testing for sexually transmitted diseases.

“Over the years, we’ve saved a lot of lives. A lot of clients come with conditions that would have gone untreated had we not gone out there. We’ve been able to help them with their medical issues and getting them hooked up to the appropriate clinic, or doctor, or specialty care,” Brown explained.

Reggie Evans came to the van to get treated for his allergies. As a street vendor who sells homemade jewelry on the streets in downtown Berkeley, Reggie said he often encounters passersby who ignore and discriminate against him for being homeless. But on the van, it’s different. “They’re not snotty. They don’t judge you,” Reggie told me.

But despite the mobile team’s success in treating the homeless over the years, there has been a growth of patients with untreated mental health conditions and drug and alcohol addiction.

Not altogether surprisingly, Brown says these patients often fail to follow through with their medical referrals and go on with their lives — untreated.

“Those are the hardest clients to work with and the hardest clients to get a positive outcome with because of their struggles with mental health and substance abuse,” Brown said.

Gerald Walker, a mental health specialist from Alameda County Behavioral Health Services Agency, counsels mentally ill patients and helps them seek proper treatment. Walker began working for the van on a part-time basis in 1991 to help patients with mental illnesses. While he cannot treat them, he can refer them to the appropriate care.

“Part of our job is to teach them to become better patients,” Walker said.

He described the van’s mentally ill patients as “treatment resistant individuals,” because it is up to them to decide if they want to get treated for their conditions.

“They haven’t come to a point where they want to admit that they have a mental illness,” said Walker. “It’s almost impossible to treat someone who is telling you that the problem does not exist.

Even with the current challenges, Walker remains optimistic and points to Alameda County and the state of California’s current push to combine behavioral health care and primary care in treating patients.

“We are a few steps ahead of many others because we … realized that this has been a problem for a really long time. We’ve been putting systems together that can address that,” Walker explained.

Still, the systems do not support all patients equally.

“In Alameda County right now, we have a pretty strong system of care for people that have a serious mental illness,” said David Modersbach, Director of ACHCHP. “That could be something like schizophrenia or very severe depression or other sometimes organic mental illnesses. However, persons that have a low acuity mental illness such as depression, anxiety, personality disorders — these mental illnesses don’t qualify them for low cost care.”

Modersbach calls these patients the “walking wounded” because they don’t have access to support services and care that other community members “take for granted.”

To address these patients, Modersbach said his team is working with Alameda County Behavioral Health Care Services to explore expanding the current mental health services being offered.

Part of this potential expansion includes adding psychiatrists and licensed clinical social workers to the Health Services Vans so they can directly treat mentally ill patients.

“What we would like to do is have a system where we’re able to provide some sort of treatment for people at the places where homeless people are,” Modersbach explained.

While ACHCHP and Behavioral Health Care Services are still in the planning stage of the expansion, Modersbach said he remains optimistic and hopes to see the expansion happen in early 2013.

(Courtesy: African American Health Institute San Bernardino County)

African-Americans in California are less likely than white people to get the mental health care they need. State public health officials have lacked a good road map on how to change those disparities, until now. A statewide study released today looks at ways to reduce disparities in mental health care for black Californians.

The report, commissioned by the California Department of Mental Health, sifted through more than a decade of literature on why African-Americans in California aren’t getting adequate mental health care. A major reason is poverty and all of the barriers to getting health care that come with it.

Diane Woods is the lead author of the study and the founding president of the African American Health Institute of San Bernardino County.

“It is unpleasant to admit, but some people do not receive appropriate services,” Woods said.

The Northern California city of Richmond is nearly 27 percent African American, and has many pockets of low-income neighborhoods. Anne Cevallos is a therapist at Rubicon, a nonprofit in Richmond that offers treatment and housing for people mental illnesses. She says her clients face multiple barriers to treatment.

“From a mental health perspective there could be triggers,” Cevallos said. “Not having enough to eat, domestic violence, neighborhood violence, never learning to cope.”

Cevallos said almost all of her Richmond patients have lived through traumatic experiences. Like Dorothy Perkins. Now in her 60s, Perkins said she first started suffering from depression when she was 12 years old. That’s when her alcoholic father started sexually abusing her. Decades later, after her husband died of untreated diabetes, she says living with that depression became too painful. She started using crack to escape and eventually ended up living on the streets of North Richmond.

“And it was really hard out there. I mean, a black woman on the streets, elderly … It’s very dangerous.”

Perkins finally got the help she needed at Rubicon. But that’s often not the case. Study author Diane Woods says that while poverty plays a significant role in blacks not having access to mental health care — like in Dorothy Perkins’ case — there’s much more to the picture. Like racism.

Of the 1,195 black study participants, most reported experiencing some level of ongoing racism regardless of their education or income. ”So these constant micro-aggressions, this constant bombardment of a negative, negative, negative, negative, is something that we have to deal with continually,” said Woods. “And of course, that works on your psyche, about who you are as a person and about how you fit in society and this whole idea that anything you do is never valued and it’s looked down upon.”

Then there’s the stigma long associated with seeking mental health services. And that, Woods says, can further alienate black people from a society that already marginalizes them.

“The respondents in our particular study indicated it had to do with symbolism,” Woods said. “They do not like to be put in categories with diagnoses like bipolar, schizophrenia, that doesn’t mean anything to them. That conjures up someone who is dependent, some who is not a viable or productive individual in society. All of these mental images of someone who out of control.”

The study offered a series of recommendations on addressing stigma and bridging the mental health care gap. For starters, more black providers are urgently needed. African-Americans make up 13 percent of the U.S. population but are only two percent of all psychologists, according to the 2001 Surgeon General’s Report.

The study also suggests incorporating group therapy sessions for some black patients. Woods says many of the study participants didn’t like the standard one-on-one model of mental health care. They preferred a community model, because black culture, she said, embraces a broad idea of family.

“We congregate together as groups and we like to be in groups. We like to interact with other people of like-mind and of like-thought,” Woods said. “The concept that even though you are not biologically related to an individual, because of our culture, and you come from African heritage, you come from a larger family. So you hear the terms, ‘brother, sister.’”

Group therapy and supportive community housing helped Dorothy Perkins stop using drugs and work through her depression, she said.

“We talk about things we’re going through,” Perkins said. “And then you get the feedback in the groups. If you’re going through something and you talk about it in the group you get the feedback. And that helps too.”

Another version of this story ran on KQED Radio. Listen here:

Lali Moheno & her family worked the fields in Modesto. Three of her family members had untreated mental health problems. (Sandy Huffaker/Getty Images)

Lali Moheno went to school in Texas as a kid. But she, her parents, and her six siblings would bus to Modesto, California every summers to work the fields. Then in late August or September, her parents would put her and her siblings back in a bus to Texas. Mohseno worked the fields all the way through graduating from the University of Texas.

“Life was hard,” said Moheno said during a press conference at UC Davis. “We had three family members who had mental health issues. But of course, in our family, we didn’t recognize it. They’d say, ‘Ese? Esta un poquito loco [Him? He's a little crazy]. Don’t pay attention to him. We don’t know what to do with him. He just follows us into the migrant camps.”

Moheno said her family didn’t know that visiting a psychologist or psychiatrist was even an option. That’s why she became a health activist working with farmworkers in Visalia. And that’s why she participated in a series of community forums looking at Latino mental health care disparities.

The result of the forums is a UC Davis study released this week, Community-Defined Solutions for Mental Health Care Disparities. Researchers highlight a variety of methods to close the mental health care gaps for Latinos in California.

Latinos make up over one-third of the nation’s population, and they’re the largest racial or ethnic group in California. But they’re also one of the most under-served communities in the state when it comes to getting mental health care.

Access to health insurance, transportation and language services all play into it. As does stigma associated with getting mental health care. Access to care also fluctuates based on ethnicity: Latinos of Mexican descent are less likely to get mental health care than other Latino groups, like Puerto Ricans. The report says about eighty-five percent of Mexican immigrants who need mental health services remain untreated.

The study recommendations range from using social media sites like Twitter and Facebook, to producing fotonovelas — stories using images and audio to promote a better understanding of mental health issues.

I spoke with Sergio Aguilar-Gaxiola, the lead author and Director of the UC Davis Center for Reducing Health Disparities, about the study’s recommendations on how to reduce these mental health disparities. We focused on two methods in particular: training school personnel working with young Latinos about possible mental health issues in their students; and teaching families and religious leaders about mental health problems and stigma — so that they can educate others.

More than half of California’s elementary children are of Latino origin, according to the California Department of Education. Aguilar-Gaxiola said that many start developing mental health problems at a young age, adding that about 50 percent of severe mental illness are identified by age 15.

But instead of providing troubled children with counseling options, Aguilar-Gaxiola said they often get disciplined at school as the ‘problem kids,’ or even as bullies, instead. He said if schools used available curricula to teach educators how to identify things like depression and anxiety, they’d have a better chance of flagging it in their students.

“I think there is a unique opportunity in the school settings to have early interventions and screenings for kids that may be manifesting some behavioral problems. Depression screening, for example. It can be the teacher that is trained on how to deliver this information. Or it can be the school nurse. Some should be familiar with this information. ”

Aguilar-Gaxiola said and a clinical psychologist recently met with the principal and teachers of a school in Sacramento to give them a tutorial about mental health disorders in adolescents.

“It was a an eye opener for us in terms of the questions we got from the teachers,” he said. “They didn’t know that mental illnesses could manifest through certain kinds of behaviors.”

Another barrier to care is stigma. Aguilar-Gaxiola told me most of the Latino participants in the UC Davis study associated mental illness with being ‘crazy,’ like Lali Moheno’s family had done. He also found that prayer was the number one thing that participants said they turned to when they had problems like depression. Aguilar-Caxiola said while it’s fine to turn to family or religion for help with mental illness, sometimes therapy or other mental health support is also needed.

“Often when someone suffers from depression, unfortunately some family members — and I have seen it in churches also — they say it’s because of the weak character that they have, or they haven’t prayed hard enough. Sending the message that they would change if they would only put there will to work. Well it doesn’t work like that.”

Aguilar-Gaxiola said telling people with depression to toughen up, or to use their will, could actually make their depression worse. He said educating priests and family members that, in addition to prayer, they could also look at psychiatric and psychotherapy options, could help change the dialogue about mental health both in the church and in the home.

“We need to reach out much more to religious leaders. Not only priests, but rabbis and pastors, and work with them to learn how to identify and deal with mental illness.”