Meeting the Challenge: Incorporating Culturally and Linguistically Appropriate Services (CLAS) Standards into Our Continuum of Care Tamu Nolfo, PhD ONTRACK Program Resources This presentation can be made available in Braille, large print, computer disk, or tape cassette as a disability-related reasonable accommodation for an individual with a disability.

Acknowledgements Thank you to Rachel Guerrero, LCSW, for her contribution to these training materials. Several exercises are borrowed from the JUMP “Respecting Differences” Curriculum. This training has been adapted from an earlier version developed by Tamu Nolfo (formerly Mitchell) for the EMT Group, also with funding from the California Department of Alcohol and Drug Programs. 2

Background Until 2010, ADP provided technical assistance (TA) and training through nine separate contracts, each dedicated to a specific, traditionally underserved population, including:  African American  Latino/Hispanic  Asian/Pacific Islander  Native American/American Indian  Persons with Disabilities  LGBTQ  Women  Aging  Youth 3

Community Alliance for CLAS Replaces the nine independent contracts with a comprehensive strategy intended to:  Improve systems and policies that support cultural competence for all underserved populations.  Stay in the forefront of the historic changes and opportunities in emerging healthcare reforms.  Better serve California’s increasingly diverse cultural, linguistic, and other underserved minority groups. 4

Module 1 My World, Your World: Who Am I? Who Are You?

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Objectives Participants will: Gain a working definition of culture. Explore the role and purpose of culture. Assess cultural impacts in everyday interaction and in specific work. Explore cultural homogeneity and other destructive myths. Understand personal values in relation to client or program participant values. 7

CONOCIMIENTO 8

What is Culture? Where does culture come from? What purpose does culture serve? How does culture impact everyday interaction? How does it specifically impact your work? How are cultural differences bridged in our everyday lives? 9

Disparities in Health Care National Report 10

Unequal Treatment Confronting Racial and Ethnic Disparities in Healthcare  Disparities in healthcare exist and are unacceptable.  Bias, stereotyping, prejudice, and clinical uncertainty on part of healthcare providers may contribute to racial and ethnic disparities in healthcare.  Disparities occur in the context of broader historic and contemporary social and economic inequality.  More research is needed. Source: Unequal Treatment Confronting Racial &Ethnic Disparities in Healthcare, Institute of Medicine of the National Academies,

Mental Health: Culture, Race, Ethnicity (A Supplement to Mental Health: A Report of the Surgeon General) Racial and ethnic minorities:  Bear a greater burden for unmet mental health needs and thus suffer a greater loss to their overall health and productivity  Are less likely than whites to use services and receive poorer quality mental health care  Have disproportionately high unmet mental health needs  Are significantly under-represented in mental health research. Source: U.S.DHHS, Public Health, Office of the Surgeon,

GUIDING PRINCIPLES OF CULTURAL PROFICIENCY 13

Culture is ever present. 14

People are served in varying degrees by the dominant culture. 15

People have group identities and personal identities. 16

Diversity within cultures is important. 17

Each group has unique cultural needs. 18

JUMP: RESPECTING DIFFERENCES 19

Activity #1: What I Value Look in your purse/wallet/briefcase/pocket or on yourself and find something that represents or symbolizes some aspect of your values or lifestyle. Cluster with three other people sitting near you and take turns explaining this item’s significance. 20

Activity #2: Understanding Values What are values? What are the personal values that influence how you lead your daily life? How do these values manifest themselves in your daily life? From where do people get their values? 21

Activity #3: Put Yourself in Your Participants’ Shoes What are some of the values that are important to the participants/clients you are serving? How do you know these are their values? How have they presented themselves? 22

Agency-Client Values Similarities? Discrepancies? How do the differences arise? Are they a function of age, class, ethnic or religious background, or neighborhood norms? While the relationship is building, focus on the values held in common. 23

Module 2 Worlds Collide: Working It Out

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Module 2 Objectives Participants will: Explore the cultural competence continuum. Recognize five essential elements of the cultural competence model. Identify the Lewin Group’s seven cultural competency indicators that should be included in an organizational self-assessment Learn how to improve cultural outcomes in each step of the planning process. 26

27 Cultural Cultural Cultural Cultural Cultural Cultural Destructive Incapacity Denial* Pre-Competent Competence Proficiency/ The Cultural Competence Continuum Advanced Source: Cross, T.L., Bazron, B.J. Dennis, K.W., Issacs, M.R. & Benjamin, M.P. Towards A Culturally Competent System of Care, (Vol. 1). (1989) Washington, DC. * The original term “cultural blindness” has been replaced with “cultural denial”.

Definition of Cultural Competence The ability of individuals and systems to interact responsively, respectfully and effectively with people of all cultures. 28

Organizational Cultural Competence  A set of congruent behaviors, attitudes and policies that come together in a system, agency, or amongst professionals and consumer providers that enables that system, agency or those professionals and consumers to work effectively in cross-cultural situations.  Cultural competence is a developmental process, one that occurs over time. Source: Adapted from Cross, T.L., Bazron, B.J. Dennis, K.W., Issacs, M.R. & Benjamin, M.P. Towards A Culturally Competent System of Care, (Vol.1). Washington, DC. (1989). 29

Quality of Care Cultural and linguistic competency is all about t he capacity to deliver services that are:  Safe  Appropriate  Timely  Efficient  Effective  Equitable 30

The Five Essential Elements of Culturally Competent Organizations: What They Do 1. Value Diversity 2. Cultural Self Assessment 3. Manage the Dynamics of Difference 4. Adapt to Diversity 5. Institutionalize Cultural Knowledge Source: Cross, T.L., Bazron, B.J. Dennis, K.W., Issacs, M.R. & Benjamin, M.P. Towards A Culturally Competent System of Care, (Vol. 1). (1989).Washington, DC. 31

Seven Indicators of Cultural Competence in Health & Behavioral Health Delivery Organizations: How They Do It 1. Organizational Values 2. Governance 3. Planning and Monitoring/Evaluation 4. Communication 5. Staff Development 6. Organizational Infrastructure 7. Services and Interventions Source: Lewin Group,

Strategic Planning Framework (more commonly known as the Strategic Prevention Framework) In your small group, discuss how your agency is addressing the questions on your handout for one of the SPF steps (assigned by the facilitator) Needs Assessment Capacity Building Planning Implementation Evaluation 33

Module 3 Building a Better World

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Module 3 Objectives Participants will: Become familiar with the 14 CLAS standards and their function as an organizational framework for moving organizations towards becoming culturally and linguistically competent. Compare how approaches to cultural competence have changed over time. Revisit commitment to this work and cultural competency. 36

Culturally and Linguistically Appropriate Services (CLAS) The14 CLAS Standards 37

CLAS as Format to Support Organizational Change 38  U.S. Dept. Health & Human Services (HHS), Office of Minority Health (OMH), CLAS standards  Federal financial assistance recipients regarding Title VI, of Civil Rights Act prohibition against National origin discrimination affecting limited English proficient persons  Revised HHS, LEP guidance issued pursuant to Executive Order

Title VI - Civil Rights Act 1964 Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons “No person shall on the ground of race, color, or national origin, be excluded from participating in, be denied the benefits of, or be subject to discrimination under any program or activity receiving Federal financial assistance.” 39

National CLAS Standards - Intentions  Correct inequities in health services  Make services more responsive to diverse clients and families  Contribute to the elimination of racial and ethnic health disparities 40

National CLAS Standards - Development  Issued by U.S. Department of Health & Human Services (DHHS), Office of Minority Health (OMH), March 2001  CLAS standards were primarily directed at health care organizations (other agencies encouraged to use them)  Final report contains 14 CLAS standards  CLAS standards include: mandates, guidelines and recommendations  Updated CLAS Standards expected to be released in early

42 Culturally Competent Care (1-3) Culturally Competent Care (1-3) Language Access Services (4-7) Language Access Services (4-7) Organizational Support for Cultural Competence (8-14) Organizational Support for Cultural Competence (8-14) 14 CLAS Standards National CLAS Standards - Themes

43 “Health care organizations should ensure that patient/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.” (Guideline) CLAS Standard 1

44 CLAS Standard 2 “Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.” (Guideline)

45 CLAS Standard 3 “Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.” (Guideline)

46 CLAS Standard 4 “Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter service, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.” (Mandate*)

47 CLAS Standard 5 “Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.” (Mandate*)

48 CLAS Standard 6 “Health care organization must assure the competence of language assistance provided to limited English proficient patient/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).” (Mandate*)

49 CLAS Standard 7 “Health care organization must make available easily understood patient- related materials and post signage in the language of the commonly encountered groups and/or group represented in the service area.” (Mandate*)

50 CLAS Standard 8 “Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.” (Guideline)

51 CLAS Standard 9 “Health care organizations should conduct initial and ongoing organizational self- assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes- based evaluations.” (Guideline)

52 CLAS Standard 10 “Health care organizations should ensure that data on the individual patient’s/consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated.” (Guideline)

53 CLAS Standard 11 “Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the services area.” (Guideline)

54 CLAS Standard 12 “Health care organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities” (Guideline)

55 CLAS Standard 13 “Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross- cultural conflicts or complaints by patients/consumers.” (Guideline)

56 CLAS Standard 14 “Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information.” (Recommendation)

57 NEW  Support for CLAS Standards  Culturally appropriate models  System has capacity to engage dialogue of race/culture/disparities  Agencies have road map for progress  Use of disparities data to target strategies to include underserved & inappropriately served  Development performance outcomes to evaluate & monitor disparities & outcomes  System support for cultural competence planning integration Eliminating Disparities - Some Comparisons OLD  One approach fits all communities  Cultural denial is seen as way to prevent disparities  Data & outcomes are not tracked across racial /ethnic cultural groups  Disparities are not monitored or tracked  No support for engaging discussion of race/ethnicity and disparities in care  Failure to access services is client’s problem  Requirements are void of language to monitor and include strategies to address disparities  Language access not monitored

58 Are You Ready to Provide CLAS Services to All of Your Clientele? Culturally diverse leadership & staff? Ability to identify cultural diversity in client lives? Possess skill involving the translation of cultural awareness into decisions that result in effective prevention, intervention & treatment? Consistent integration of diverse approaches in client services? Are the knowledge, resources and flexibility to meet the needs of diverse populations present within your organization?

Seven Indicators of Cultural Competence in Health & Behavioral Health Delivery Organizations: Similarity to CLAS Standards Added 1. Organizational Values: CLAS # 1, 8 2. Governance: CLAS # 8 3. Planning and Monitoring/Evaluation: CLAS # 8, 9, 10, Communication: CLAS # 5, 7, 6, 12, Staff Development: CLAS # 2, 3 6. Organizational Infrastructure: CLAS # 1, 3, 8, 9 7. Services/Interventions: CLAS # 4, 5, 6, 7, 13 Source: Lewin Group,

Why Work in This Profession?

It’s In the Heart Share with the person next to you why you do this work. Listen carefully as they tell you why they do. 61

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Help is Available: Accessing CLAS TA & Training (916) Project Manager – Tamu Nolfo, PhD Free Continuing Education Hours All services provided without cost to you 64