1. Health Care with CLAS (Culturally and Linguistically Appropriate Services) Zori Rodríguez, MA AAFP Health Disparities Manager November 10, 2007

2. Goal Identify all standards and how they can positively impact the health care you provide Learn reasons for and how to comply with the mandated standards regarding language assistance Develop strategies and resources to assist your practice in providing culturally and linguistically appropriate services

3. Definition of Cultural Proficiency While there is no agreed upon definition of cultural proficiency, for our purposes it is defined as the knowledge, skills, and attitudes/beliefs that enable people to work well with, respond effectively to, and be supportive of people in cross-cultural settings. The three core elements of Cultural Proficiency are:

4. Definition Knowledge: An academic knowledge of the complex history of race, class, culture, and gender relations in the U S and our educational systems is needed.

5. Definition Skills: It is essential to demonstrate skills to respond effectively to those who are different from us.

6. Definition Attitudes and beliefs: An awareness of personal bias, its roots in one’s own background, and the importance of examining and working to transcend it are necessary to enhance cultural proficiency.

7. The CLAS standards are proposed as one means to correct inequities that currently exist in the provision of health services and to make these services more responsive to the individual needs of all patients/consumers. The standards are intended to be inclusive of all cultures and not limited to any particular population group or sets of groups. However, they are especially designed to address the needs of racial, ethnic, and linguistic population groups that experience unequal access to health services. Ultimately, the aim of the standards is to contribute to the elimination of racial and ethnic health disparities and to improve the health of all Americans.

8. Why CLAS? It’s the right thing to do! State medical re-licensure requirements in NJ, WA & CA require continuing medical education courses STFM Guidelines-- Recommended Core Curriculum Guidelines on Culturally Sensitive and Competent Health Care

9. Why CLAS? Changing demographics of US—2000 US Census, about (33%) of United States residents self-identified as African American, American Indian /Alaska Native, Asian/Pacific American, or Latino, and the US Census Bureau predicts that in 2020, these racial and ethnic groups will comprise nearly (40%) of the US population.

10. Why CLAS? AAMC’s Tool for Assessing Cultural Competence Training (TACCT) I. Rationale, Context, & Definition II. Key Aspects of Cultural Competence III. Understanding the Impact of Stereotyping on Medical Decision- Making IV. Health Disparities & Factors Influencing Health V. Cross-Cultural Clinical Settings

11. Why CLAS? Seminal 2002 Institute of Medicine’s (IOM) “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” report highlights the fact that racial and ethnic disparities in healthcare are associated with worse health outcomes in many cases, and are unacceptable.

12. Why CLAS? Reports indicate that racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when patients’ insurance status and income are controlled. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health care, Board on Health Sciences Policy, Institute of Medicine. Washington, DC: National Academies Press; 2002. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1993;340:618-626

13. Why CLAS? According to a number of other reports, “good patient-healthcare professional communication is associated with better patient satisfaction, better adherence to treatment recommendations, and improved health outcomes.” Betancourt J. Cross-cultural medical education: conceptual approaches and frameworks for evaluation. Acad Med. 2003;78(6):560-569. Brach C, Fraserirector I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57(4 suppl 1):181-217

14. Nelson Mandela If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.

15. Federal CLAS Standards National Standards on Culturally and Linguistically Appropriate Services (CLAS) under the direction of the US Dept. Of Health & Human Services’ Office of Minority Health mandates attention to cultural proficiency to all recipients of Federal funds.

16. CLAS Mandates CLAS mandates are current Federal requirements for all recipients of Federal funds (4, 5, 6, and 7) out of 14 standards. 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.

17. CLAS Mandates 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.

18. Language A 45-year-old Latino immigrant, Mr. G, was given a prescription to control his blood pressure. The doctor prescribing the medication knew that adherence was simple because the pill was to be taken once a day. Mr. G went to the emergency room one week later with dizziness and very low blood pressure. He had been taking the medicine as prescribed on the bottle--once each day. “Once” means “11” in Spanish.

19. CLAS Mandates Standard 6 Health care organizations must assure the 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).

20. Medication Error A two-year-old is diagnosed with an inner ear infection and prescribed an antibiotic. Her mother understands that her daughter should take the prescribed medication twice a day. After carefully studying the label on the bottle and deciding that it doesn’t tell how to take the medicine, she fills a teaspoon and pours the antibiotic into her daughter’s painful ear (Parker et al, 2003).

21. CLAS Mandates Standard 7 Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

22. Patient Education Sample

24. CLAS Guidelines CLAS guidelines are activities recommended by OMH for adoption as mandates by Federal, State, and national accrediting agencies Standard 1 Health care organizations should ensure that patients/consumers receive from all staff member's effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.

25. CLAS Guidelines 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. 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.

26. CLAS Guidelines 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.

27. CLAS Guidelines 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.

28. CLAS Guidelines 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.

29. CLAS Guidelines 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 service area.

30. CLAS Guidelines 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.

31. CLAS Guidelines 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.

32. CLAS Recommendation CLAS recommendations are suggested by OMH for voluntary adoption by health care organizations 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.

33. The standards are also intended for use by: Policymakers, to draft consistent and comprehensive laws, regulations, and contract language. This audience would include Federal, State and local legislators, administrative and oversight staff, and program managers.

34. The standards are also intended for use by: Accreditation and credentialing agencies, to assess and compare providers who say they offer culturally competent services and to assure quality for diverse populations. This audience would include the Joint Commission on Accreditation of Healthcare Organizations, the National Committee for Quality Assurance, professional organizations such as the American Medical Association and American Nurses Association, and quality review organizations such as peer review organizations.

35. The standards are also intended for use by: Purchasers, to advocate for the needs of ethnic consumers of health benefits, and leverage responses from insurers and health plans. This audience would include government and employer purchasers of health benefits, including labor unions. Patients, to understand their right to receive accessible and appropriate health careservices, and to evaluate whether providers can offer them.

36. The standards are also intended for use by: Advocates, to promote quality health care for diverse populations and to assess and monitor care being delivered by providers. The potential audience is wide, including legal services and consumer education/protection agencies; local and national ethnic, immigrant, and other community- focused organizations; and local and national nonprofit organizations that address health care issues.

37. The standards are also intended for use by: Educators, to incorporate cultural and linguistic competence into their curricula and to raise awareness about the impact of culture and language on health care delivery. This audience would include educators from health care professions and training institutions, as well as educators from legal and social services professions.

38. The standards are also intended for use by:  The health care community in general, to debate and assess the applicability and adoption of culturally and linguistically appropriate health services into standard health care practice.

39. Errors made due to cultural or linguistic misunderstandings in health care encounters can lead to repeat appointments, extra time spent rectifying misdiagnoses, unnecessary emergency room visits, longer hospital stays, and canceled diagnostic or surgical procedures. While cultural competence training and language assistance services require financial and staff resources, avoiding one costly lawsuit can finance a considerable number of activities related to the CLAS standards.

40. CLAS Exercise Standard 4; a large practice setting in urban area, where open scheduling/unscheduled patients are common, and the presenting patient speaks a language you do not recognize How would you insure that Standard 4 is met? What factors are important in meeting this standard?

41. CLAS Exercise Standard 5; a clinic setting, where you are starting an intake of new patient with LEP, and of unknown primary language, which was an unknown factor when the appointment was made How would you insure that Standard 5 is met? What factors are important in meeting this standard?

42. CLAS Exercise Standard 6; a large hospital setting, where interpreters are commonly used, but a patient on an inpatient unit continues to seem confused about discharge instructions even though an interpreter is being utilized How would you insure that Standard 6 is met? What factors are important in meeting this standard?

43. CLAS Exercise Standard 7; a large practice setting in urban area, where you provide patient education course in diabetes and asthma How would you insure that Standard 7 is met? What factors are important in meeting this standard?

44. It takes 2! While we need to know the reasons to address cultural competency in our medical practices, we must also be aware that all interactions are cross-cultural interactions. You too, bring cultural factors to the table!

45. Questions in Assessing One's Level of Cultural Competence Am I knowledgeable about the world views of different cultural and ethnic groups? Am I aware of my biases and prejudices towards other cultural groups, as well as racism in healthcare?

46. Questions Do I seek out face-to-face, and other types of encounters with individuals who are different from myself? How do I react when a person I encounter does not speak English? What are my beliefs toward folk remedies?

47. Questions Do I really want to become culturally competent? Would I hire, befriend, or avoid any of the individuals portrayed on the following slide?

49. Things to keep in mind… Generalization = a starting point When generalizing, one begins with an assumption about a group but then seeks further information about whether the assumption fits that individual. Stereotype = an ending point When stereotyping, one makes an assumption about a person based on group membership without learning whether or not that individual fits the assumption.

50. Common Health Beliefs Some Chinese individuals believe in hot and cold food items to treat disease. Some Japanese patients may see doctors as authority figures and individuals/their families may hesitate to ask questions.

51. Common Health Beliefs With some Mexican patients, some spiritual amulets, religious medallions, or rosary beads may be present near the person. Russian individuals may prefer alternative methods or treatment such as massage or mud-therapy, a popular treatment in Russia.

52. Resources Diversity Rx’s culturally and linguistically appropriate services (CLAS) talk listserv http://www.diversityrx.org/HTML/N ESIGN.htm US’ Health and Human Services Office of Minority Health's "Think Cultural Health“ http://thinkculturalhealth.org/

53. Resources Provider's Guide to Quality & Culture's Quality & Culture-- http://erc.msh.org/mainpage.cfm?fil e=3.0.htm&module=provider&language =English

54. Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly, affects all indirectly.” --Martin Luther King, Jr.; letter from Birmingham Jail, April 16, 1963 Final Thought