Implementing the Enhanced Culturally and Linguistically Appropriate Services in Health and Healthcare (CLAS )Standards to Reduce HIV Disparity June 29, 2011 Updated August 2013 An Overview: Strategies for HIV/AIDS Providers Co-Presented by: : Ms. Tawara Goode, MA, Director, National Center for Cultural Competence and Ms. Wendy Jones, Director, Children & Youth with Special Health Care Needs project of the National Center for Cultural Competence National Center for Cultural Competence, Georgetown University Medical Center

Learning Objectives At the completion of this webinar each participant will: state the importance of the 15 CLAS Standards and their relevance to HIV/AIDS care and treatment. identify at least one implementation strategy relative to HIV/AIDS care and treatment for each of the 15 Standards.

The New CLAS Standards In 2013, U.S. Department of Health and Human Services , Office of Minority Health, reissued a new set of CLAS standards. The new 15 CLAS Standards promote the advancement of health equity, improving the deliver of quality care, and the elimination of health care disparities. All of the CLAS Standards are of equal importance Reissued in 2013; new version of Standards—promote health equity, improving the delivering of quality care/elimination of health care disparities OMH’s U.S. DHHS, National Standards for Culturally and Linguistically Appropriate Services in Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice, April 2013 In the enhanced National CLAS Standards, each Standard is viewed as equally important for implementation.

The New CLAS Standards The Introductory Statement: The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations to: Principle Standard 1) Provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs. -OMH’s U.S. DHHS, National Standards for Culturally and Linguistically Appropriate Services in Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice, April 2013

The New CLAS Themes Theme 1) 2-4: Governance, Leadership, and Workforce Theme 2) 5-8: Communication and Language Assistance Theme 3) 9-15: Engagement, Continuous Improvement, and Accountability -Three major themes; again with equal importance. -OMH’s U.S. DHHS, National Standards for Culturally and Linguistically Appropriate Services in Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice, April 2013

(adapted from Cross, Bazron, Dennis and Isaacs, 1989) Cultural Competence behaviors attitudes policies structures practices requires that organizations have a clearly defined, congruent set of values and principles, and demonstrate behaviors, attitudes, policies, structures, and practices that enable them to work effectively cross-culturally -There are many definitions and conceptual frameworks for cultural and linguistic competence. We are presenting a conceptual framework based on the work of Cross et.al, which is the most widely adapted definition in the literature. (adapted from Cross, Bazron, Dennis and Isaacs, 1989) Slide Source:© 2011 - National Center for Cultural Competence

Five Elements of Cultural Competence Organizational Level value diversity conduct cultural self-assessment manage the dynamics of difference institutionalize cultural knowledge adapt to diversity - policies - structures - values - services -Framework for cultural competence at an organizational level has 5 components. -Cultural competence must be manifested at all levels of the organization including, but not limited to policy makers, administration, clinical staff, front line staff, greeters, transporters, etc. (Cross, Bazron, Dennis and Isaacs, 1989) Slide Source:© 2011 - National Center for Cultural Competence

Five Elements of Cultural Competence Individual Level acknowledge cultural differences understand your own culture engage in self-assessment acquire cultural knowledge & skills view behavior within a cultural context -The framework for cultural competence at an individual level also has 5 components (Cross, Bazron, Dennis and Isaacs, 1989) Slide Source:© 2011 - National Center for Cultural Competence

LINGUISTIC COMPETENCE FRAMEWORK POLICY PRACTICES STRUCTURES PROCEDURES RESOURCES PERSONNEL DEDICATED FISCAL -Linguistic competence is 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, individuals with disabilities, and those who are deaf or hard of hearing. Linguistic competency requires organizational and provider capacity to respond effectively to the health and mental health literacy needs of populations served. -The organization must have policy, structures, practices, procedures, and dedicated resources to support this capacity. Goode & Jones (modified 2009). National Center for Cultural Competence, Georgetown University Center for Child & Human Development. Goode & Jones, Revised 2009, National Center for Cultural Competence Slide Source:© 2011 - National Center for Cultural Competence

Key Values for Cultural Competence Values and Guiding Principles for Cultural Competence Cultural competence: embraces the principles of equal access and non- discriminatory practices in service delivery. is achieved by identifying and understanding the needs and help-seeking behaviors of individuals and families. involves working in conjunction with natural, informal support and helping networks within culturally diverse communities. Source: National Center for Cultural Competence, Foundations/Guiding Values and Principles http://nccc.georgetown.edu/foundations/frameworks.html -The definitions and frameworks for cultural competence are based on specific values. Consider the values that your health organization has in place for people living with HIV/AIDS. There is great diversity among the population of people living with HIV/AIDS. Culture greatly influences help seeking behaviors; as such you will see differences based upon age, gender identification, sexual orientation, geographic local, language spoken, race and ethnicity. 10

Key Values for Linguistic Competence Values and Guiding Principles for Linguistic Competence Services and supports are delivered in the preferred language and/or mode of delivery of the population served. Written materials are translated, adapted, and/or provided in alternative formats based on the needs and preferences of the populations served. Interpretation and translation services comply with all relevant Federal, state, and local mandates governing language access. Consumers are engaged in evaluation of language access and other communication services to ensure for quality and satisfaction. National Center for Cultural Competence, Foundations/Guiding Values and Principles -Census data indicates that the numbers of individuals that speak languages other than English at home continues to grow. -There are 311 languages spoken in the US (162 are indigenous to the U.S. and 149 are immigrant languages). -English is not the primary language spoken in 14 million households in the U.S. -Many individuals living with HIV/AIDS may be less than proficient in English. -Rendering them a part of the growing population of individuals living in linguistic isolation where no one in a household over the age of 14 speaks English at least very well. Source: National Center for Cultural Competence, Foundations/Guiding Values and Principles http://nccc.georgetown.edu/foundations/frameworks.html 11

Culture Shapes Health Beliefs and Practices Culture influences the way people interact with health and mental health care systems including: Participation in health prevention and promotion programs Access to health information and services Choices and decisions related to health and mental health services Understanding of and priorities related to health and illness Help-seeking behavior and adherence to recommended treatment -Culture is the learned and shared knowledge that specific groups use to generate their behavior and use to interpret the world. -Culture structures perceptions, shapes behaviors including those associated with health, illness and well-being. -This is particularly relevant for cultural beliefs associated with HIV/AIDS. 12

Barriers to Culturally and Linguistically Competent Care Systems of care poorly designed for diverse populations Poor cross-cultural communication between providers and patients Patient/client fears and distrust Cultural stigma Lack of diversity in health care leadership and workforce -Bullet 1- In most healthcare settings when PLWHA, particularly members of a high risk group, walk in it’s not a given that they will encounter providers or staff who look anything like them or even understand their lifestyle, their experiences, what has brought them to the point they are at in their life. -Think about how that might make someone who may already feel marginalized by the larger society feel.

Why should your organization implement the CLAS Standards? evidence indicates improvement Access Effectiveness Care Services Supports Outcomes Acceptability Satisfaction -There is clear and compelling evidence that cultural and linguistic competence has significant impact on improving multiple dimensions of health and health care. Slide Source:© 2011 - National Center for Cultural Competence

Implementing CLAS will enable your staff to: gain knowledge about cultural values and beliefs of the patient and apply that knowledge in a health care context. interact effectively with people whose cultures and belief systems are different than your own. provide quality care that is respectful and nonjudgmental. deliver health care, services, and supports in the primary languages spoken be patients/clients and their families identify and respond effectively to the preferences and needs of populations served. -Providing equitable care is one of the goal’s of CLAS.

CLAS Webinar Series The remainder of this Webinar series will discuss each Standard and strategies organizations might pursue to implement CLAS. We will use the case studies that we asked you to download when you registered to illustrate various points. This Webinar series is designed to increase your awareness and knowledge of how you deliver care. Remember, how patients/clients see you may not be how you see yourself. Bullet 2- You are encouraged to offer your experiences in implementing the Standards and also raise questions regarding barriers to implementation.

How do others see you? -While you may view yourself or your organization as providing optimal, accessible care, others may view you and your organization as being fiercely differently. -Implementing the CLAS standards offer a number of opportunities for managing and enhancing perspectives about the care provided by your organization. 17

CLAS Principle Standard Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Creates a safe/welcoming environment appreciation of diversity/focuses on patient-centered care Individuals receive services in a culturally and linguistically appropriate manner to enable them to meet their communication needs/understand their care & participate in their care To eliminate discrimination and disparities -Providing respectful care that addresses the patients cultural and linguistic needs; cultural health beliefs and practices; preferred languages, and health literacy.

CLAS Standard 1: Implementation Strategies Provide processes to ensure staff are trained on the civil rights laws that affect equitable healthcare service delivery Develop policies and procedures to ensure patients are provide information on their rights to receive health care services that address that cultural and linguistic needs Institute cross-cultural training for front-line and clinical staff on the health care needs of cultural/linguistically diverse populations

CLAS Standard 2 Advance and sustain organizational goverance and leadership that promote CLAS and health equity through policy, practices, and allocated resources.

CLAS Standard 2 Implementation Strategies: Develop a mission statement/core values/vision statement-that promotes health equity Seek commitment from top board, management leadership Management/board should set policy/program goals, development of strategic plan of promoting organizational diversity, providing CC care, eliminating health disparities; written policies, practices, procedures, programs, etc. Provide fiscal, human resources, tools, skills, and knowledge to support a culturally competent organization. -All these components are critical in developing a culturally competent organization

CLAS Standard 3 Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.

CLAS Standard 3: Implementation Strategies Obtain patient feedback on their preference for patient-provider concordance (e.g. race, ethnicity, language, sexual orientation, gender, gender identity). Assess the degree to which staff demographics match patient preferences. Bullet 1- For example members of some groups do not want others in their group to be aware of their HIV status and hence do not want to be served by staff from that group. Case Study 1- Diversity in the Workforce Bullet 2- Create a profile of staff demographics – age, gender, languages, other diversity indicators and compare with the same indicators for the patient population.

CLAS Standard 3: Implementation Strategies Establish staff diversity as recruitment, hiring, and retention goals for your organization. Post notices of job announcements and vacancies in forums, venues, and in varied languages to increase the likelihood of attracting diverse applicants. Where possible, recruit and hire qualified individuals (including past and current patients/clients) of the populations and communities impacted by the HIV epidemic. Assist individuals from culturally and linguistically diverse groups to complete required training needed to qualify for varied positions within the health and/or mental health care setting. Bullet 2 - Find out where these groups access information and use these sources particularly for lay staff e.g. peer counselors, outreach workers. Examples of sources include magazines, websites of minority professional and service organizations; minority health organizations; newsletters of ethnic and HIV service associations and organizations; substance abuse treatment bulletins, newsletters, and professional organizations; and gay, lesbian, bisexual, and transgender associations and agencies.

CLAS Standard 3: Implementation Strategies Provide ongoing training and mentoring to all staff, including new hires, to enhance their cultural competency and their capacity to communicate effectively cross-culturally (including but not limited to patients/clients and their families who speak languages other than English, those who have disabilities, and individuals who are deaf or hard of hearing). Include criteria for cultural and linguistic competence in staff performance evaluations. Provide staff with an open and safe forum and a process to raise and address issues related to individual and the organizational capacity to deliver culturally and linguistically competent services. Bullet 1- For mentoring pair high skill staff with low skill staff. Case Study 2 Systems of Care Bullet 2- The physician’s performance in Case Study 5 – Cultural Stigma Bullet 3- Stress that these arrangements can and should be used by staff without fear of reprisal. Case Study 2

CLAS Standard 4 Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

CLAS Standard 4: Implementation Strategies Periodically query staff about their perceived learning needs in the area of cultural and linguistic competence. Designate interested and knowledgeable staff the responsibility of coordinating in-service training/professional development. Provide cross- and discipline-specific training in cultural and linguistic competency that is responsive to staff’s expressed interests, needs, and learning styles. Keep abreast of current trends and emerging evidence about culturally and linguistically competent care to include in all in-service training and professional development efforts. Bullet 3- The AETC NMC, the rest of the AETC network and other sources of training including local, non profit advocacy organizations and educational institutions that might be able to offer training at reduced cost. Bullet 4 – For example, monitor changes in the patient population – arrival of new ethnic groups, increased infection rates in certain risk groups and adjusting training curricula accordingly. Case Study 4-Patients’ Fears and Distrust

CLAS Standard 4: Implementation Strategies Staff performance evaluations should include criteria that addresses active participation in and completion of training/professional development activities. Support professional development by offering varied modalities for learning (e.g. Web-based, self-directed and self-paced curricula, coaching and mentoring, continuing education, journal/book clubs, discussion groups) . Address cultural and linguistic competency as a routine component of staff meetings and retreats. Bullet 4 -Staff participation in training should be documented at the individual and departmental level. Establish meaningful incentives and special recognition awards for cultural and linguistic competency within the organization. 28

CLAS Standard 5 Offer language assistance to individuals who limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.

CLAS Standard 5: Implementation Strategies Conduct an annual assessment of languages (other than English) spoken within the geographic locale served by the organization to ensure language access. Include data on the population of people who are deaf or hard of hearing. Update the organization’s language access plan on an annual basis. Ensure that there are adequate resources (fiscal and personnel) for the provision of language access services. Ensure that all staff are knowledgeable of organizational policy, procedures, and practices for language access, including individual responsibility according to job function. Bullet 4- Do not reinvent the wheel. Contact these resources for materials and only develop materials from scratch if none already exist. When developing new materials, consider involving select patients and patient advocates in the design and development of new materials. Also conduct pre-tests with a sample (10 to 20) of the prospective users of the materials to assess readability, ease of comprehension, and other features that will determine if and how they are accepted.

CLAS Standard 5: Implementation Strategies Ensure that language access services include sign language interpretation. Ensure that all legally binding documents are professionally translated into the languages spoken by the patient/client population. Such documents may include, but is not limited to, consent forms, confidentiality and patient rights statements, release of information, eligibility and applications for services. Ensure that medical orders, patient education, and health/mental health promotion resources are translated into the languages spoken by the patient/client population. Such documents should also be offered in Braille. Bullet 1- Insist on professional translators to ensure accuracy. Pay particular attention to ensure the accurate translations of HIV-specific terms such as viral load, anti-retrovirals, as well as other terms referring to behaviors and practices. Also see the NCCC’s Guide to Choosing and Adapting Cultural and Linguistic Competence in Health Promotion Materials http://www11.georgetown.edu/research/gucchd/nccc/documents/Materials_Guide.pdf In addition, contact local Developmental Disabilities organizations for assistance with making materials available in Braille and/or large print. Case Study 2- Systems of Care and Case Study 4- Patients’ Fears and Distrust

CLAS Standard 6 Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.

CLAS Standard 6: Implementation Strategies Post signage in prominent locations stating patients’/clients’ rights to receive language access services (at no cost) in the health/mental health facility. Ensure that staff provide both verbal and written notification of patients’/clients’ rights to receive language access services at no cost. Bullet 1- Insist on professional translators to ensure accuracy. Pay particular attention to ensure the accurate translations of HIV-specific terms such as viral load, anti-retrovirals, as well as other terms referring to behaviors and practices. Case Study 2- Systems of Care and Case Study 4- Patients’ Fears and Distrust

Case Presentation: More than Language An elderly African American woman newly diagnosed with HIV presents for the first time at Clinic A. She approaches the receptionist’s desk and hands her the appointment slip. The twenty year old receptionist takes it, and while looking at her computer screen says rather loudly “You’re Mary Smith. Well Mary I need you to complete this intake form and bring it back to me. Here you go Mary, here’s a pen and here’s the form.” The African American woman does not take the forms instead she turns on her heels and walks out. Anybody want to guess what communication glitch might have occurred here.

Thank You National Center for Cultural Competence, Georgetown University Medical Center

Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTN-A, FAAN Goulda Downer, Ph.D., RD, LN, CNS - Principal Investigator/Project Director (AETC-NMC) Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTN-A, FAAN I. Jean Davis, PhD, DC,PA Denise Bailey, MEd. National Center for Cultural Competence, Georgetown University Medical Center

1840 7th Street NW, 2nd Floor Washington, DC 20001 202-865-8146 (Office) 202-667-1382 (Fax) Goulda Downer, Ph.D., RD, LN, CNS Principle Investigator/Project Director (AETC-NMC) www.AETCNMC.org HRSA Grant Number: U2THA19645 National Center for Cultural Competence, Georgetown University Medical Center