CLAS Standards Applied to a Community Health Center Setting Our Mission Lowell Community Health Center: Our Mission To provide caring, quality, and culturally appropriate health services to the people of Greater Lowell, regardless of their financial status. To enhance the health of our community and to empower each individual to maximize overall well being. Our Motto Our Motto LCHC: L inking C ommunity to H ealth C are - CLAS Std. 8 -

Why Focus on Cultural & Linguistic Competence? Lowell: Population - 105,000, 2 nd largest Cambodian population in U.S. at 25,000; 17% Latino; 7% African immigrant; 7% Portuguese speaking Lowell Community Health Center: serves 24,000 people annually with medical care, complementary medicine, behavioral health care, and public health promotion. 60% are persons best served in a language other than English.

How Could We NOT Focus on Cultural Competence??

3 Major Themes 1.Culturally Competent Care: Standards 1-3 (Recommended) 2.Language Access Services: Standards 4-7 (Required) 3. Organizational Supports: Standards 8-14

What is Cultural Competence? “…a set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals that enable effective interactions in a cross-cultural framework.” Georgetown University Child Development Center

In a nut shell Cultural Competence Cultural Competence is the ability to function effectively in the context of cultural differences

Standards 2 & 3 2 2: Implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff & leadership representative of the demographics of the service area. 3 3: Ensure that staff at all levels and disciplines receive ongoing education and training in culturally & linguistically appropriate service delivery

STD. 2 – Staffing LCHC Response Decision to hire bilingual, bicultural staff in open positions, over 50% of staff – complicated by the large number of countries, languages, and cultures represented in the patient population Targeted staff recruitment through associations, CBOs, community leaders & mailings On the job training where needed when there may not be many candidates who have a certain type of experience - CLAS Std. 2 -

STD. 3 – Cultural Competence Training LCHC Response A staff person received training, along with AAC staff and MAPS staff, to be a trainer in cultural competence Cultural competence training for all staff through new staff orientation and annual orientation required for all staff PLUS specific education about specific cultures and beliefs in individual departments and helping staff to understand the fears of undocumented immigrants, for example - CLAS Std. 3 -

Standard 4 Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, 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.

LASIT Language Access Systems Improvement Team Offer medical interpreter training and financial incentives; Set up contract arrangement with CBOs - AAC, MAPS - to provide interpreting, AT&T language line availability Increased the number of staff trained for medical interpreting Over 50% of our staff is bilingual and bicultural Language classes on site - CLAS Std

LASIT On-going registration staff training on “Asking the Question” regarding race, ethnicity and interpreter need Secured funding through Blue Cross Blue Shield Foundation of Massachusetts to develop interpreter training & assessment program Developing “Promotoras de Salud” Training on cross-cultural communication skills between patient, provider and interpreter - CLAS Std

LASIT To improve access to interpreter services within the health center in order to improve patients’ health To improve our patient registration process To improve the scheduling of interpreters To ensure that sites are complying with the interpreter policy To use formally trained interpreters

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.

Std. 5 – Written materials LCHC Response Developed new signage in many languages for five entrances to two buildings Developed new materials about accessing health care in Portuguese, French and Swahili

Standard 6 Health Care organizations must assure that competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).

Std. 6 – Interpreter Competence LCHC Response Language Proficiency Testing is required to be a participant in Interpreter Training programs Develop LCHC verbal language proficiency testing for all health care providers and support staff who self-declare as bilingual Developed Medical Interpreter Policy Formed a Language Access Improvement Team Created interpreter lists to be placed at clinical areas for easier accessibility for providers

Standard 7 Patient-related materials and signage in languages of commonly encountered groups in the service area

The Environment of Services Signage at all sites including English, Spanish, Portuguese, Khmer, Laotian, Swahili, and French Art work, world maps & pictures from various cultures in clinical areas,

Standards 10, 11, & 12 10: 10: Ensure that data on patient’s race, ethnicity, and spoken and written language are in health records, integrated into MIS, & periodically updated 11: 11: Maintain current demographic, cultural, epidemiological community profile as well as a needs assessment to accurately plan for & implement services that respond to cultural, linguistic characteristics of service area 12: 12: Develop participatory, collaborative community partnerships; facilitate community & consumer involvement in designing & implementing CLAS activities

Community Input Patient Advisory or focus groups with African, SEA, and Spanish/ Portuguese speaking patients to learn about their barriers to care, needs, expectations and, through CBOs - focus groups with other community members Input from African, SEA, and Spanish and Portuguese speaking staff Partnering with ethnic-specific CBOs, sharing funding »- CLAS Std. 11 & 12 -

Board and Senior Staff Support Governing Board members represent communities served, consumer majority Senior staff expect cultural competence development throughout the center & hiring of bilingual, bicultural staff - CLAS Std. 11 & 12 -

Internal & External Data Issues Asking the Questions Practice management system Brazilians Language vs Race/Ethnicity “Lumping” data issue

Our First Major Effort: Metta Health Center LCHC Metta Health Center: Integrates mental, spiritual, and physical health services through Southeast Asian and western treatment 1999 – 2000 Planning

Reasons for Starting a New Center to Focus on Southeast Asians 30,000 Southeast Asians in Lowell (25,000 Khmer, 5000 Lao, 1,500 Vietnamese) – over 2000% increase Only 1,600 used LCHC Many barriers to care for SEAs in Lowell Tremendous health & mental health needs

Metta Model and Services Integration of mental, physical, and spiritual health services Integration of SEA and western approaches Many gateways to service Focus on decreasing stigma of mental health care Staffed & directed by SEAs (Std. 2) Tri-lingual signage, materials, interpreting (Stds. 4, 5, 6, 7) Cross-cultural & cross-disciplinary staff training (Std. 3) Based on focus groups, interviews, needs assessment, data; SEA Advisory Board (Stds. 8, 11, 12)

Spread to Other Sites & Communities Attending to changing demographics - Applying lessons learned from Metta Health Center to Latino, Brazilian, and African immigrant communities Partnering (sharing funding) with ethnic-specific CBOs New patient and community advisory groups Faith leader partnerships

Community Outreach Health Promotion Director Outreach includes –LCHC staff and AAC/MAPS/ CMAA staff going to temples, churches, community events -Outreach Works! –Visiting pastors, informing people about how to access health services, resources available, and issues such as payment for health services –Sponsoring African, Brazilian, Cambodian, Latino community events and putting ads in programs –Connecting with newly arriving African, Cambodian, other refugees through provision of Refugee Health Assessments

Funding Obviously critical. As we have learned more about what the key issues are, we have worked with staff, patients, and organizations such as AAC to write grants to fund the joint ideas. For example, federal CHC grant funds outreach, state and federal grants fund HIV work, and federal and United Nations grant funds community education about results of torture and trauma as well as mental health services.

Thank you.