Effective Strategies for Promoting Systemic Cultural Competence Cathy Cave & Miriam E. Delphin, Ph.D. Washington Hilton Hotel June 29, 2006 June 29, 2006

Overview Cultural Competence: Why Now? Cultural Competence: Why Now? Defining Cultural Competence Defining Cultural Competence Systems Strategies for Promoting Cultural Competence Systems Strategies for Promoting Cultural Competence Future Directions Future Directions

The President’s New Freedom Report Commission on Mental Health (2003) The President’s New Freedom Report Commission on Mental Health (2003) “ The system has neglected to incorporate respect or understanding of the histories, traditions, beliefs, languages and value systems of culturally diverse groups.” “ The system has neglected to incorporate respect or understanding of the histories, traditions, beliefs, languages and value systems of culturally diverse groups.” “ The system is not oriented to the single most important goal of the people it serves – the hope of recovery” “ The system is not oriented to the single most important goal of the people it serves – the hope of recovery”

Institute of Medicine: Unequal Treatment (2002) New York Times, March 22, “Subtle Racism in Medicine” “... a disturbing new study by the Institute of Medicine has concluded that even when members of minority groups have the same incomes, insurance coverage and medical conditions as whites, they receive notably poorer care. Biases, prejudices and negative racial stereotypes, the panel concludes, may be misleading doctors and other health professionals.”

Institute of Medicine: Unequal Treatment (2002) The Washington Post, March 23, “The Health Care Gap” “Race-based inequities are a sad fact in more than one facet of American life. History has shown how hard they are to overcome. But this week's report paints a picture that cannot be ignored.”

Mental Health: Culture, Race and Ethnicity, Supplement to the Surgeon General’s Report (2001) Ethnic & Racial Minorities: Less access to, & availability of, behavioral health services Less access to, & availability of, behavioral health services Less likely to receive needed behavioral health services Less likely to receive needed behavioral health services Less likely to receive high quality behavioral health care Less likely to receive high quality behavioral health care Underrepresented in behavioral health research Underrepresented in behavioral health research Experience a greater burden of disability Experience a greater burden of disability

Schizophrenia Depression Bail Amounts Heart Disease Homelessness Low income Sickle Cell Insurance Rates Graduation Rates Asset Accumulation Sentencing Voting Literacy HIV Capital Punishment Nutrition Diabetes Unemployment Obesity Maternal/infant Deaths Political Office Criminal Justice Substance Abuse Personality Disorders

What is Cultural Competence? Knowledge Information and Data From and About Individuals and Groups Integrated & Transformed INTO Clinical Standards Skills Service Approaches Techniques Marketing Programs that match the individual’s culture and increase both the quality and appropriateness of health care and health outcomes. (King Davis, 2003)

Cultural Considerations: Primary and Secondary Dimensions of Diversity Employment Community Networks Geographic Location Family/Extended Family Immigration Status Marital Status Military Experience English Language Proficiency Spiritual Beliefs Education Literacy Parental Status Class Income Economics Political Context Country of Origin Sexual Orientation Race Ethnicity Language Cultural + Historical Knowledge/Experience Perceptions of Physical Qualities Physical Abilities Gender Age Primary dimensions influence “who” an individual is. Secondary dimensions influence an individual’s participation. (adapted from Rasmussen, 1996)

Developing a Culturally Competent System of Care Multi-dimensional/multi-leveled process System Level System Level Organization Level Organization Level Program Level Program Level Individual Level Individual Level

Cultural Competence at the Systems level Commissioner’s Leadership Commissioner’s Leadership Articulate the Policy Vision Articulate the Policy Vision Strategic Planning and Fiscal Alignment Strategic Planning and Fiscal Alignment Ignite Interest Ignite Interest Statewide Multicultural Advisory Statewide Multicultural Advisory Create Accessible Framework Create Accessible Framework Accountability: Standards, Contracting and New Initiatives Accountability: Standards, Contracting and New Initiatives Assuring Provider Plan Development Assuring Provider Plan Development

Challenges to Systemic Change Systemic Organizational Assessment Systemic Organizational Assessment Data Collection and Management Decisions Data Collection and Management Decisions Engaging All Lines of Business Engaging All Lines of Business Meaningful Grassroots Consumer, Family and Provider Involvement and Education Meaningful Grassroots Consumer, Family and Provider Involvement and Education Linkage: Cultural Competency and Recovery Linkage: Cultural Competency and Recovery Recognition and engagement of Natural Networks Recognition and engagement of Natural Networks Workforce Development Workforce Development Legislative Action Legislative Action

Cultural Competence at the Organizational Level Executive level support Executive level support Cultural Competence committee Cultural Competence committee Organizational cultural competence assessments Organizational cultural competence assessments Cultural competence plans Cultural competence plans Monitor utilization & outcomes by race/ethnicity Monitor utilization & outcomes by race/ethnicity Culturally & linguistic competence Culturally & linguistic competence Staff training & supervision Staff training & supervision Connections to community & natural supports Connections to community & natural supports Client satisfaction surveys Client satisfaction surveys

Challenges to Organizational Cultural Competence Cultural competence plan implementation Cultural competence plan implementation Service utilization and outcome monitoring Service utilization and outcome monitoring Expectations of committee members Expectations of committee members Certification or monitoring staff need clear standards and benchmarks in order to assure accountability Certification or monitoring staff need clear standards and benchmarks in order to assure accountability Ongoing staff development needs Ongoing staff development needs

Cultural Competence at the Program Level Access – flexible hours, natural supports, peer staff Access – flexible hours, natural supports, peer staff Holistic Programming Holistic Programming Beyond symptom reduction Beyond symptom reduction Employment, housing, health, spirituality Employment, housing, health, spirituality Strength Based Approach Strength Based Approach Consumer, Family and/or Community Driven Consumer, Family and/or Community Driven Culturally Specific Approaches Culturally Specific Approaches Outcome Assessments Outcome Assessments

Cultural Competence at the Individual Level Multidimensional, culturally relevant assessment Multidimensional, culturally relevant assessment Flexible roles and boundaries Flexible roles and boundaries Questioning Stance Questioning Stance Awareness of differences in cultural norms Awareness of differences in cultural norms individualism vs. collectivism individualism vs. collectivism Willingness to relinquish control and foster consumer direction Willingness to relinquish control and foster consumer direction Consumer assessment of provider cultural competence Consumer assessment of provider cultural competence

Cultural Competence: Future Directions Measure Development and Refinement Measure Development and Refinement Outcome Research Outcome Research Feedback Loops Feedback Loops Evidence-based for Whom? Evidence-based for Whom?