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CLAS Presentation May 16 017.pptx
- 1. EFFECTIVE AND EFFICIENT SERVICES FOR EVERYONE USING THE CLAS STANDARDS TO SUPPORT HEALTH EQUITY May 16, 2917 Cecily Rodriguez Refugee Health Services
- 3. SOCIAL DETERMINANTS OF HEALTH IMPORTANT DEFINITIONS 3
- 4. refugees.org refugees.org IMPORTANT DEFINITIONS 4 Social Determinants of Health Those factors that impact upon health and well-being: the circumstances into which we are born, grow up, live, work, and age, including the health system. World Health Organization: Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health: Commission on the Social Determinants of Health, 2008.
- 5. refugees.org refugees.org SOCIAL DETERMINANTS OF HEALTH 5 These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices.
- 6. 6 refugees.org 6 refugees.org 6 Health begins were we live, learn, work, and play. Your zip code may be more important to your overall health than your genetic code. SOCIAL DETERMINANTS OF HEALTH
- 8. refugees.org refugees.org HEALTH DISPARITIES ARE differences in health status among distinct segments of the population including differences that occur by gender, race or ethnicity, education or income, disability, or living in various geographic localities Ruth S. Shim, MD, MPH, Lenox Hill Hospital Department of Psychiatry, Northwell Health
- 10. refugees.org refugees.org disparities in health that are a result of systemic, avoidable, and unjust social and economic policies and practices that create barriers to opportunity HEALTH INEQUITIES ARE Ruth S. Shim, MD, MPH, Lenox Hill Hospital Department of Psychiatry, Northwell Health
- 14. refugees.org refugees.org DIMENSIONS OF CULTURE 14 Image: National Diversity, Kaiser Permanente
- 15. refugees.org refugees.org 15 CULTURAL ICEBERG Race, Age, Physical Abilities, Gender, etc. Marital Status, Religion/Spirituality, etc. Military Experience, Ethnic Background, Nationality, Educational Status, Socioeconomic Status, Language, Sexual Orientation, Political Affiliation, Hobbies, Family Roles, Health Status, etc.
- 16. refugees.org refugees.org FIVE THINGS TO UNDERSTAND ABOUT CULTURE 16 Everyone has a culture. It is core to their identity, behavior and perspectives on the way the world works and should be. There is diversity within cultures. While two people may be from the same place the are likely to have different cultural norms based on a number of variables. Cultures are not static. They grow and evolve in response to new circumstances, challenges and opportunities. Culture is not determinative. Different people take on and respond to the same cultural expectations in different ways. Assumptions therefore cannot be made about individuals based on a specific aspect of their cultural experience and identity. Cultural “differences” are complicated by differences in status and power between cultures. When one cultural group has more power and status, the norms of that culture permeate the institutions of society as the “right” way. Ify Ezeobele, MSHEd, MSN, RN CNS University of Texas
- 18. refugees.org refugees.org AND incorporate the above in all aspects of policy making, administration, practice, service delivery and involve systematically consumers, key stakeholders and communities. National Center for Cultural Competence at Georgetown University
- 20. refugees.org refugees.org WHAT IS THE CURE FOR A COMMON COLD? 20
- 21. refugees.org refugees.org 21 “To be culturally competent doesn’t mean you are an authority in the values and beliefs of every culture. What it means is that you hold a deep respect for cultural differences and are eager to learn, and willing to accept that there are many ways of viewing the world.” Dr. Okokon O. Udo
- 23. refugees.org refugees.org LINGUISTIC COMPETENCE The capacity of an organization and its personnel to communicate effectively, and convey information in a manner that is easily understood by diverse audiences including persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities. National Center for Cultural Competence
- 25. refugees.org refugees.org WHY CULTURAL AND LINGUISTIC COMPETENCE 25 • Growing Population diversity • Disparities in access and outcomes • Limited staff with CLC expertise • Lack of organizational and systemic focus on CLC Efforts • Legal requirements related to language access • Title VI- Civil Rights Law • CLAS Standards 4-7 • Federal and state expectations and accreditation criteria
- 26. refugees.org refugees.org WHAT DOES CLC REALLY LOOK LIKE? 26
- 27. refugees.org refugees.org CLC AND HEALTH SERVICE OUTCOMES 27 • More successful wellness and prevention education • An increase in individuals seeking both preliminary health care and follow-up • More appropriate testing and screening • Fewer diagnostic errors • Avoidance of drug complications • Better likelihood for adherence to medical advice and treatment plans • Expanded choices and access to a variety of providers
- 28. refugees.org refugees.org COMMON CRITIQUES OF CULTURAL & LINGUISTIC COMPETENCE 28 “It is a soft-construct because: - It is not skill based - It is not data driven - It is not linked to specific outcomes - It is hard to operationalize
- 29. A FRAMEWORK FOR PLANNING AND MEASURING CLC THE CLAS STANDARDS 29
- 32. refugees.org refugees.org THEME 1: GOVERNANCE, LEADERSHIP, AND WORKFORCE 32
- 33. refugees.org refugees.org Identify and develop champions throughout the organization. Ensure that the necessary fiscal and human resources, tools, skills, and knowledge to support and improve culturally competent policies and practices are available. National Quality Forum THEME 1: BRIGHT IDEAS Provide space for internal multidisciplinary dialogues about language and culture issues. Create financial incentives to promote, develop, and maintain accessibility to qualified health care interpreters. The Joint Commission (Wilson-Stronks & Galvez DHHS-OMH 2013
- 34. refugees.org refugees.org • Offer language assistance and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. • Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. • Ensure the competence of individuals providing language assistance. • Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. THEME 2: COMMUNICATION AND LANGUAGE ASSISTANCE 34
- 35. refugees.org refugees.org THEME 2: THINK IT IS JUST A NICE THING TO OFFER? THINK AGAIN. 35 Youdelman, Mara and Jane Perkins. 2002. Providing Language Interpretation Services in Health Care Settings: Examples from the Field https://cccdpcr.thinkc ulturalhealth.hhs.gov/ AudioPlayer/AudioPlay er.asp?AudioFileName =17_3-4-2.mp3
- 36. refugees.org refugees.org 36 Offer TTY and other assistive technology devices Offer materials in alternative formats (e.g., audiotape, Braille, enlarged print ) Use qualified translation services especially for legally binding documents Print materials in easy to read, low literacy, picture and symbol formats Utilize ethnic media in languages for outreach to diverse communities THEME 2: EXAMPLES OF LINGUISTICALLY APPROPRIATE SERVICES
- 37. refugees.org refugees.org THEME 3: ENGAGEMENT, CONTINUOUS IMPROVEMENT, AND ACCOUNTABILITY To understand how to best provide high quality services, you gotta do the hard stuff.
- 38. refugees.org refugees.org THEME 3: ENGAGEMENT, CI, & ACCOUNTABILITY 38 What do you want from an Organizational Assessment What kind of demographic information do you need? Understand the Community Health Assets & Needs
- 39. refugees.org refugees.org THEME 3: IT’S ALL ABOUT THE PLANNING 39 Effectiveness & Efficiency? Employee Development & Learning? Quality Assurance? Regulatory Compliance? Client Satisfaction? Contribution to Community Wellbeing? Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.
- 42. refugees.org refugees.org YOU TRY IT! Think of the CLAS Issues that came to your mind during this discussion. Decide which activities you will now STOP as they are no longer useful or add little value for meeting your organization’s CLAS goals Determine which activities you should CONTINUE as they are effective in developing those CLAS goals for your team or the organization as a whole. Add those activities that have been on the To Do list for much too long that you plan to START.
- 43. CLAS LINKS THINK CULTURAL HEALTH WWW.THINKCULTURALHEALTH.HHS.GOV/CLAS/STANDARDS DHSS OFFICE OF MINORITY HEALTH HTTPS://MINORITYHEALTH.HHS.GOV/OMH/BROWSE.ASPX?LVL =2&LVLID=53 AETC-NMC HTTPS://WWW.AETCNMC.ORG/CURRICULA/CLAS/ NATIONAL PARTNERSHIP FOR ACTION HTTPS://DRIVE.GOOGLE.COM/FILE/D/0BXNLB__OGMSZBLNXD 2TPTGRIYWM/VIEW
Editor's Notes
- Health Disparity - Male babies are generally born at a heavier birth weight than female babies. This is a health disparity. We expect to see this difference in birth weight because it is rooted in genetics. Because this difference is unavoidable, it is considered a health disparity.
- Health Inequity - Babies born to Black women are more likely to die in their first year of life than babies born to White women. Some of this difference can be attributed to poverty – a higher percentage of Black mothers are poor and face hardships associated with poverty that can affect their health; however, we find differences in the health of Black and White mothers and babies even if we compare Blacks and Whites with the same income. Many scientists have shown links between the stress from racism experienced by Black women and negative health outcomes. This is a health inequity because the difference between the populations is unfair, avoidable and rooted in social injustice.
- There are many, many definitions for culture and the differences between them can be dramatic. In our system, it is important to know that we define culture in a very broad sense…………….. We are very deliberate in making sure that people don’t assume we are talking about culture as a race or ethnicity or place of origin as the only thing that defines someone but rather that is just a part of the many layers of culture that people have.
- Directions The facilitator should explain the diagram on the presentation slide. Culture is comprised of behavior, knowledge, and attitudes. Share Talking Points The facilitator should recap what was discussed about culture by saying, “we see here that culture encompasses behavior, knowledge, and attitudes”. Culture is LEARNED not INHERITED! We each have the choice to adopt or disregard what we have learned or continue to learn about our cultural identities, and how we choose to demonstrate who we are. Cultural values are “rooted” in ethnic, religious, and generational beliefs, traditions, and practices that influence individual and social values (Lum, 1999)
- Share Talking Points There are primary and secondary characteristics of a person’s identity. The primary characteristics of a person can not be changed. These include, but are not limited to: age, race, physical abilities, and gender. While secondary characteristics of a person can change. These include, but are not limited to: marital status, religion, and educational status. We often meet people and only focus on the characteristics that we can see, but we need to get beneath the tip of the iceberg to truly get to know a person’s individuality. Remember, get to know a person beneath the tip of the iceberg!
- Everyone has a culture. It is core to their identity, behavior and perspectives on the way the world works and should be. In fact, everyone lives as part of multiple cultural spheres: ethnic, religious, class, gender, race, language, and others. Culture is not just the group a person is born into. It is possible to acquire a new culture by moving to a new country or region, for example, or by a change in economic status, or by becoming disabled. There is diversity within cultures. While two people may both be Latinos with parents from Mexico, for instance, a religious Catholic daughter of professionals who lived in Mexico City will have very different cultural norms and perspectives from the son of an indigenous farmer who spent early years in a very poor rural area. Cultures are not static. They grow and evolve in response to new circumstances, challenges and opportunities. The ways of being female learned by young girls in South Asian culture, for example, have changed from one generation to another, and as people have moved from place to place. Culture is not determinative. Different people take on and respond to the same cultural expectations in different ways. Assumptions therefore cannot be made about individuals based on a specific aspect of their cultural experience and identity. Cultural “differences” are complicated by differences in status and power between cultures. When one cultural group has more power and status, the norms of that culture permeate the institutions of society as the “right” way. Cultures of less status and power become seen as “other,” or even deviant and deficient. In addition to understanding cultural norms and experiences, service providers and professionals in agencies that work with diverse populations need to be aware of these kinds of cultural biases, both as they play out in the lives of communities, and as they affect the practices and policies of organizations.
- Just like with the definition of culture- there is often a lot of confusion around defining cultural competence-- There are different definitions depending on whether you are talking about individual cultural competence or organizational cultural competence. Our system has adapted the definition of the national center for cultural competence and it says that There are five abilities that are considered necessary to achieve individual cultural competence.
- Individual level. … This level really deals with an employees individual desire to work effectively with consumers from across all cultures and perspectives. Learning about different cultures and cross cultural communication strategies are an example Organizational level- deals with evaluating and modifying policies and procedures to ensure equal access to and effective treatment of illness, disabilities and disorders. Making sure that language services are in place to provide access to LEP consumers is an example. Systems level … deals with how to develop infrastructure that addresses equity in health care. Laws prohibiting discrimination based on race and ethnicity is an example.
- A GOOD METAPHOR FOR HOW IMPORTANT IT IS TO PROVIDE CULTURALLY COMPETENCE SERVICES IS LOOKING AT THE REMEDIES FOR A COMMON COLD WHAT ARE SOME OF THE REMEDIES RECOMMENDED BY MEMBERS OF YOUR FAMILY? It is clear that not everyone likes or believes in the same thing. One of the most damaging myths for cultural competency is the old adage that “we should do unto others as we would have them do unto you” I hear this all the time in programs- WE SERVE EVERYONE EQUALLY- EVERYONE RECEIVES THE SAME SERVICES— When you are working with different cultures- nothing could be further from the truth- If we would like to have Vicks- does that mean that we should give Vicks to every person we know that has a cold? What if they are chicken soup people? IF OUR PROGRAMS AND SERVICES ARE SET UP WITH THE IDEA THAT VICKS WORKS FOR EVERYONE- HOW DOES THAT RESONATE WITH PERSONS WHO HAVE DIFFERENT PREFERENCES? The question is do you want to help some people or do you want to help everyone.
- Say “Linguistic competence is not just the ability for our organizations to have interpreters and translators, but also understand how to address the needs of individuals with communication barriers or who may have literacy issues.”
- POPULATION 10% of the population in Virginia is foreign born. Between 2000 and 2006, the number of foreign born Limited English Proficient (LEP) population increase by 44.5% in Virginia Virginia is in the top 15 states for refugee resettlement. Disparities- Minority populations have a disproportionate burden of death and disability. Research has proven that communities of color don’t access services in proportion to the white community and their outcomes are less successful than that of the white community. Mental Health: Culture, Race, Ethnicity Supplement to Mental Health: Report of the Surgeon General Documented disparities for people of color include: Less availability and access to services Lower likelihood of receiving services Greater likelihood of receiving poorer quality of care and disproportionate treatment outcomes Over represented in hospitalizations (more restrictive settings) Under represented in research 2001 New York Times, March 22, “Subtle Racism in Medicine” Institute of 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.” 2002 New Freedom Commission Report- The system has neglected to incorporate respect or understanding of the histories, traditions, beliefs, languages and value systems of culturally diverse groups.” 2003 Limited Expertise- Graduate programs provide some introduction to cross cultural services and delivery but it is usually limited and not woven throughout one’s education. Degrees outside of healthcare rarely address these issues in their curricula. Lack of Historical Focus- Organizations have not historically prioritized CLC practices therefore infrastructure- ie- ability to have evidence based practices adapted to specific communities or creating policies and practices to ensure quality interpreter services. Legal Requirements-Among some of the laws around language are: The Civil Rights Act of 1964 says that no person shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination based on race, gender, ethnicity or national origin under any program or activity receiving Federal financial assistance." The Social Security Act prohibits discrimination in the Maternal and Child Health Services Block Grant. The Public Health Service Act prohibits discrimination in the Community Mental Health Services Block Grant and Substance Abuse Prevention and Treatment Block Grants. The Public Health Service Act prohibits discrimination in the Preventative Health and Health Services Block Grants Federal and state expectations and accreditation criteria Joint Commission Accreditation at Hospitals and CARF Accreditation at community mental health centers require that services be culturally and linguistically appropriate as a condition of accreditation. New language in the upcoming Licensing regulations will require that providers develop a cultural and linguistic competence plan as a condition of licensing.
- Say- what does it look like? It can be as simple as what is stated above. But it takes planning and intentionality to achieve this.
- Improve Health Communication and Health Outcomes Providing culturally competent health care can also result in improving health communication and health outcomes, including: More successful patient education, because culturally competent providers can target, tailor, and communicate health-related messages more effectively An increase in patients seeking both preliminary health care and follow-up, because trust and understanding have been improved between providers and patient More appropriate testing and screening, because providers will have more knowledge about the genetic background, risk exposure, and common health-related behavior of various cultural groups Fewer diagnostic errors, because providers compile more comprehensive and more accurate medical histories Avoidance of drug complications, because providers become aware of home or folk remedies used by patients Patients follow medical advice more closely, because providers establish a treatment plan that is most consistent with the patient's cultural beliefs and lifestyle; patients understand better how to follow the treatment plan Expanded choices and access to a variety of providers, because patients are no longer restricted to a small pool of providers who share their language and culture
- Share Talking Points Many organizations, leadership, and even some of you may feel that cultural competence is a Soft Construct because: It’s not skill-based It’s not data-driven It’s not linked to specific outcomes It’s hard to operationalize In fact, all of these critiques can be disputed if a concrete plan and evaluation process is put in place. It is just that Well, we are going to explore some of the benefits of cultural competence to make this term more concrete.
- Say: you can use the standards to achieve three important organizational goals Advance health equity – Looking to achieve the highest level of health for all people (HHS OMH, 2011) Improve quality – Growing research is demonstrating a positive impact of CLAS on health outcomes (Lie, Lee-Ray, Gomez, Bereknvel, & Braddock, 2010) Help eliminate health care disparities – Quality remains suboptimal for minority and low-income groups; despite improvements in quality (AHRQ, 2012a, 2012b) “The standards are intended to address three critical areas in health care” by advancing health equity. This is defined as the attainment of the highest level of health for all people (HHS OMH, 2011). to improve quality as preliminary research has shown a positive impact of CLAS on patient outcomes to help eliminate health care disparities. Recent reports highlight that access to quality care remains suboptimal, particularly for minority and low-income groups. You may choose to show the CLAS Video from the Think Cultural Health Website - https://www.thinkculturalhealth.hhs.gov/Content/clasvid.asp Background Information- Health equity- Lack of health equity has a significant economic and societal impact. Recent research on the economic burden of health inequality and health disparities show approximately 30.6% of direct medical care expenditures for African Americans, Asians, and Hispanics were excess costs due to health inequalities (LaVeist et al., 2009). o Eliminating health inequalities for minorities would have reduced indirect costs associated with illness and premature death by more than $1 trillion (LaVeist et al., 2009). Improve quality- A growing body of evidence illustrates the effectiveness of culturally and linguistically appropriate services in improving the quality of care and services received by individuals can help eliminate health care disparities (Beach et al., 2004; Goode et al., 2006) . o Despite improvements in quality, access and disparities have not improved. o Certain services, geographic areas and populations were found to be in serious need of improvements in quality and progress in disparities reduction.
- Say: Theme 1 has been refined to underscore that CLAS must permeate every aspect of the organization, from the top down and from the bottom up. Cultural and linguistic competency cannot just be a grass-roots strategy but rather it must the organization’s leadership that establishes the culture of the organization through its priorities, expectations, and the behavior that it models (Schyve & The Governance Institute, 2009) and through designing service delivery processes and expectations (Rice, 2007).
- Play Title VI video clip embedded under graphic Say: Theme 2 asks that organizations look at how they provide communication and language assistance to those they serve. It is important to know that as organizations who receive federal dollars in the form of Medicaid reimbursements, we are legally required to provide language assistance to individuals who are limited English proficient or who are deaf, hard of hearing, late deafened, or deaf-blind or who have other communication barriers.
- Say: “We don’t just ensure effective communication because it is the law, we do it because there can be grave consequences when the right language services are not in place for individuals. The cases listed on this slide illustrate the kinds of things that happen when language is a barrier. They are common and have a real impact on individuals, families, and communities.” (FYI - Willie Ramirez – Said he was intoxicado – ER thought he was drunk – let him stay in the waiting room – he was actually poisoned and become a paraplegic.) CLICK to PLAY AUDIO then ask…How did lack of language access services contribute to this individual's misdiagnosis? Would any of our organizations want to be responsible for something like this? CLICK to PLAY AUDIO then ask…How did lack of language access services contribute to this individual's misdiagnosis? Would any of our organizations want to be responsible for something like this? Rita Quintero http://www2.ljworld.com/news/2000/aug/13/language_barrier_turned/ You may also choose to play the CLAS part II video You may also choose to play the CLAS part II video.
- Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.
- Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. You could start out by showing the website - http://www.pewresearch.org/next-america/ - a great place to show demographic changes in the US Then you could ask people about their own organizational needs by asking the questions above and CHART ANSWERS– Org Assessment- WHAT ARE SOME CONSIDERATIONS FOR ORG ASSESSMENT? Is your organization ready? Make your own? Use a validated tool? Entire organization or certain divisions? Communicate in advance the purpose of the assessment It is a SWOT through the CLC lens. Remind participants that it is not to point out failures! Opportunity to grow! Make sure staff know this through constant communication about the purpose. Think about the orgs. readiness to do a full assessment or whether there is a division or office that is ready to undertake such a thing as a pilot. Demographic Collection - Descriptions of geographic, demographic, and socioeconomic status, Languages spoken in the community, Population densities, Ecological factors, Analysis of the cultural needs and health practices and behaviors of ethnic groups, Requests for culture-specific services, such as preferred languages, Other characteristics that some organizations may want to learn about may include: Literacy and educational levels. Remind them it is not just race, ethnicity, gender, SES, and age, Languages, subpopulations, Geography, Density, Ecological factors, Health practices, literacy, Epidemiological data, Evidence of health disparities, Health beliefs, including attitudes toward health and illness, Use of alternative medicine and, practitioners. Community Health Needs – Say a Community mapping of resources for culturally and linguistically appropriate services. This technique offers an approach to understanding and describing a community and its resources. we want to know what illness and disease and prevalence there is in the communities we serve. And we want it granulated in a way that we can understand it in a culturally and linguistically appropriate way. We also want to know what assets there are in the community. This process would be similar to any epidemiological health profile we would pursue. Collect relevant epidemiological profiles for disease in communities services Don’t forget to use this information to shape our community partnerships and programs and services.
- Theme 3 talks about establishing culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations. Say: “You will want to make sure that any plan you put in place is not just about training. That is looks globally at culturally and linguistically appropriate services. Work with executive leadership and board members to identify areas of focus and then make sure that you are communicating the plan effectively both internally and externally. Many times, we make the mistake of not sharing plan with our own staff and the rationale behind such a plan. Without support up and down the chain, you won’t find much success. If you aren’t communicating regularly with staff about the purpose, plans, and changes in operations, you won’t get that support.”
- Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.