A local nonprofit that provides mental health services to Latino communities will receive nearly a million dollars in funding over the next two years from Alliance Health, the managed care organization (MCO) that serves uninsured residents and Medicaid recipients in the Triangle.
The funding will go toward expanding El Futuro’s Mentes Fuertes, or “Strong Minds,” program, which launched last year. Mentes Fuertes draws inspiration from the promotoras movement in Latin America that sees people who are already trusted and ingrained within a community trained to serve as mental health workers for their friends and neighbors. Mentes Fuertes currently employs four bilingual community health workers and has enrolled 78 participants to date.
The $464,000 per year commitment that Alliance Health announced last week for the next two years comes about a year after the MCO furnished $218,000 to get Mentes Fuertes off the ground. The funding reflects a feat of community organizing that came in response to the refusal of Cardinal Innovations, Alliance’s predecessor, to fund mental health services for undocumented immigrants. Groups including Orange County Justice United and the North Carolina Congress of Latino Organizations began organizing around the issue early in the pandemic and spent two years building people power before organizing an accountability assembly that attracted more than 300 residents and pushed Alliance to make its first contribution.
The INDY spoke with El Futuro founder and executive director Luke Smith, a psychiatrist, to learn more about the community-driven approach to mental health care that the money from Alliance is helping to support.
INDY: Can you talk about the evolution of El Futuro’s relationship with managed care organizations?
Smith: El Futuro was founded in Carrboro 2004. Our mission is to nurture stronger familias to live out their dreams. We look for individuals and families who are suffering mental health or substance use problems in the Latino community and try to deliver a service that will help them. A bunch of people came together to bring this work about: social workers, psychologists, psychiatrists.
In 2012, the state—which contracted with what then were called LMEs, local management entities known now as MCOs—put a local management entity in place in Orange and Chatham Counties called Cardinal Innovations Healthcare Solutions. When Cardinal came in, it immediately said that it would no longer provide any type of funding for services for people who are undocumented. That impacted a significant number of people that we served.
Around 2015, we found that offering services in Orange County was going to cause us to not be solvent. We were going to go bankrupt because of the lack of funding from Cardinal Innovations, which was a proxy for the state and the county. (County commissioners select this organization which contracts with HHS, brings down funding from the state, and distributes grant funding from the federal government.) We weren’t getting that money and we found our work in Orange and Chatham Counties to really suffer because of that. We were able to keep our clinics in Durham and Siler City open, but we had to shut down our Carrboro clinic.
I appreciate you walking me through the context.
Why this story becomes so incredible is, in the fall of 2022, a grassroots group—made up primarily of churches, including a lot of people from St. Thomas More, the Latino parish—came together in Orange County and said, ‘This is not right. We’re not getting services. It doesn’t matter if we’re undocumented or what our status is. This is a basic human right.’ (And actually, the federal government agrees with that. There’s precedent that mental health is kind of like tuberculosis, or HIV AIDS, or the COVID-19 pandemic: It’s communicable.)
There was a big community meeting at Binkley Baptist Church. Everybody from state senators, to county commissioners, to school board members were there. And the community made demands. This was very different from when we exited in 2016 in a little cloud of dust. The very community we’re serving found its voice powerfully, went to decision makers in the front of the room, and said, ‘These are my demands: will you agree to them, or not?’ And one by one, those decision makers said, ‘Yes, yes, yes.’ There were tears of joy. And the community says, ‘Well, we just got you on tape, and we’re going to check in with you in six months to see how things are going.’
So now we come back to the drawing board. As it turns out, we found ourselves very closely partnered with Alliance Health, which is the MCO over Orange County, Durham County, and other counties including Mecklenburg and Johnston. We came to the table with them in a very, ‘Let’s do this’ kind of manner. We said to them, ‘We could start another clinic in Orange County, but we found that there’s another intervention that’s really powerful—and it’s Spanish-speaking community mental health workers.’
Tell me about the bilingual community mental health worker approach.
When El Futuro was founded, we envisioned that we would be working within churches and schools and primary care clinics and community organizations. We have an appreciation that mental health isn’t just getting people into an office for therapy and psychiatry and substance use counseling, it’s being out in the community. We tried to do that, but the system doesn’t really pay for that type of service very well. You need grant funding to do that kind of work.
But then, during the pandemic, the Department of Health and Human Services began to employ what in Latin America are called promotores de salud, or community health workers. With the urgency of things, all of a sudden there was a full scale implementation. It’s a very time tested model throughout Latin America.
One of El Futuro’s board members, Gaby Livas Stein, along with a partner at Harvard, had begun to to test an approach back in 2017. This was a new frontier. They tested an intervention that found that after three months of training, somebody who has trust, or confianza, somebody who has street cred in the community, they can go out and provide ten sessions of very foundational mental health support for individuals who are struggling.
So we told Alliance, if you would give us the money, we think we can make it go further and be more effective by finding individuals who can do this work in Orange County and employing them.
Earlier this year, in January, we began that work. It has been lights-out amazing. We advertised it once on a Facebook Live post, and automatically 48 people signed up. The community health workers went to churches and rape crisis centers. They offered these sessions right there in the community and in trusted places. And it’s been tremendous. People are getting better. They felt valued and supported. So about a month ago, we went back to Alliance and said, ‘This is really working.’ And they said, ‘We’re excited about it.’ We had employed four community health workers part-time. They said, ‘We want to help you make them full time.’
So the new funding from Alliance Health will be going toward salaries for those workers?
Yes, initially. These are individuals who are on the frontlines. When they first started, we were hearing them say things like, ‘This person is expressing feelings of suicidality, and I don’t really know how to handle that’ or, ‘This is really hard for me, I don’t know how to get up and go do this work again tomorrow.’ It’s really hard getting their feet wet. I was nine years into training before I got to the point of taking care of patients. They’re doing it after three months of training. So we have to provide really good supervision support for them, in order for them to stay for the long term and provide quality work.
What you see in these individuals is that they’re thinking holistically. Oftentimes, in the academic worlds that we’ve created, we don’t think holistically. Watching their intuition to really be community-driven and anchor themselves in community feedback is something that we’re all learning from them.
Can you speak to what the need for mental health services looks like for Latino communities in Orange County right now?
A lot of our work begins with people who are struggling with mood disorders like depression or anxiety. They’ve suffered from some kind of traumatic experience in their home country or during the migration journey, or when they get here: discrimination is one of the big things people report. We call them acculturation stresses: the disruption of family networks, being estranged from family, going into new environments and feeling isolated or othered. We’re trying to increase their ability to buffer those acculturative stresses. The data shows that the longer they live in a community, the less ability they have to buffer against those stresses and they actually have worse health outcomes, the longer they live in the host nation. So an immigrant comes here and they’re actually healthier, but as they live here, they succumb more and more to those stresses.
What does the community health workers model look like in practice?
There’s 10 sessions. We want to be able to work with them for some length of time. We really stop, listen to their story, meet them where they’re at, and also bring these tools—behavioral activation, motivational interviewing, supportive care, self, self care, mindfulness activities, a lot of things—in a way that, the next time a crisis comes up, they’re able to deal with it. What we’ve seen is that after the 10 sessions, people are really able to go on their merry way and get back into life.
Traditional treatments like psychiatry or therapy are good, but we need to look upstream, to think about building resilience and building engagements. Here are some things that can help: strengthening family, connecting them to community resources, helping them with their ‘hopeful orientation’—that they don’t lose hope. Another one that I love to talk about is cultural pride. One of our board members, Rosa Gonzalez-Guarda—she’s a dean in the School of Nursing at Duke—she did a really foundational research project that found that when a person who is Latino feels more pride in their culture, they will experience less depression and less anxiety. If a young girl who is 15 years old has a quinceanera, for instance, she’s going to be less vulnerable to the stresses that cause depression, anxiety, and so on.
So [since launching Mentes Fuertes], our community health workers have been organizing events. We had celebrations for Dia de los Muertos; for the Posadas; for Dia de Los Madres, or Mother’s Day. Hundreds of people came. So these community health workers are not just doing these sessions, but they’re also helping us to cultivate that cultural pride. And that becomes a treatment intervention.
What kind of specific benefits does this approach have?
Something that we’re seeing is a better uptake from men. Oftentimes, women are the primary users of mental health services, proportionally. But we’re seeing that more men are actually seeking this kind of help. Why it’s working, I think, is the cornerstone of trust. Our values here at El Futuro are confianza; calor humano, which is human warmth and authenticity; and then respeto, respect. That means meeting them where they are: maybe in how they want to be called, or what their type of Spanish or indigenous language is, or going to the place where they feel most at home, which is at a site like a church. The key foundational element of this that’s making it work is that they are moving along lines of trust.
This interview has been edited for length and clarity.
Correction: El Futuro will receive $464,000 per year from Alliance Health for its Mentes Fuertes program. Also, Alliance originally provided $218,000 to get Mentes Fuertes off the ground, and the program began last year. The story has been corrected.
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