“ The Enhanced Culturally and

Linguistically Appropriate Services

in Health and Health Care (CLAS)

Standards”: Another Tool To

Facilitate Health Outcomes

Guadalupe Pacheco, MSW

President/CEO, Pacheco Consulting Group, LLC

October 9, 2014

1

Presentation Themes

Changing Demographics

Health Disparities/Social Determinants of Health

What is CLAS?

CLAS Awareness

CLAS Standards Enhancement Initiative

Describe the CLAS Standards 2.0

Summary/Questions

2

Changing Demographics

*Sources: U.S. Census Bureau,

Population Reference Bureau, 2008

3

4

America's estimated 2.5 million gay seniors are

twice as likely to live alone, four times less likely to

have adult children to help them, and far more

fearful of discrimination from health care workers.

Older adults may not be aware of the

services recommended for their age group or

may not know that the services are covered

by Medicare.

Young people from racial and ethnic

minority groups in the United States suffer

disproportionately from a number of

preventable diseases and health problems.

American Indians and Alaska

Natives have a lower life expectancy

than other Americans perhaps due to

economic adversity and poor social

conditions.

Disparities in America (Source: DHHS, OMH,2012)

Social Determinants of Health:

Why Are Culturally and Linguistically

Appropriate Services Important?5

• Services that are respectful of and responsive to

individual cultural health beliefs and practices,

preferred languages, health literacy levels, and

communication needs and employed by all

members of an organization (regardless of size)

at every point of contact.

• Use CLAS as a tool to eliminate/reduce racial & ethnic health disparities

What Are Culturally and Linguistically

Appropriate Services?

*Source: National CLAS Standards, HHS OMH, 2013

6

CLAS Awareness

Office of the Inspector General Report on Guidance and Standards on Language Access Services (Medicare Providers/Medicaid) – 2010

National Committee on Quality Assurance-Standards & Guidelines in Multicultural Health Care Settings – 2010

Affordable Care Act (19 references to cultural competency) –2010

The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals - 2010

National Quality Forum Healthcare Disparities and Cultural Competency Consensus Standards project – 2011

7

CLAS Awareness: State Level

Cultural Competency Legislation

*Source: Think Cultural Health, 2011

8

CLAS Awareness: 2000-2012:

Publications/Citations

0

500

1000

1500

2000

2500

3000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Numbers of Publications and Citations

Number of Publications Number of Citations*

* Reported citations are approximated based on Web of Science® analysis

reporting.

9

National Standards for Culturally and

Linguistically Appropriate Services in

Health and Health Care (CLAS)

10

Launched: 2013Enhanced National CLAS Standards

Development: 2011Analysis Consultations Drafting

Research: 2010

Literature Review Public Comment Advisory Committee

11National CLAS Standards

Enhancement Initiative: Timeline

Institutions and Associations• American Medical Association

• American Nurses Association

• American Public Health Association

• Asian and Pacific Islander American Health

Forum

• Association of Asian Pacific Community Health

Organizations

• Blue Cross Blue Shield

• Institute for Diversity in Health Management

• Johns Hopkins University

• Joint Commission

• Kaiser Permanente

• Massachusetts Executive Office of Health and

Human Services Medicaid Program

• National Business Group on Health

• National Center for Cultural Competence

• National Council of Asian Pacific Islander

Physicians

• National Committee for Quality Assurance

• National Health Law Program (NHeLP)

• National Hispanic Medical Association

• National Medical Association

Institutions and Associations (con’t)• National Public Health and Hospital Institute

• Southcentral Foundation

• Texas Health Institute

• University of Albany, SUNY

• University of California, Davis

• University of Medicine and Dentistry of New

Jersey

Federal• Administration for Children and Families

• Administration on Aging

• Agency for Healthcare Research and Quality

• Centers for Disease Control and Prevention

• Centers for Medicare and Medicaid Services

• Health Resources and Services Administration

• Indian Health Service

• National Institutes of Health

• Office for Civil Rights

• Office of the Assistant Secretary for Legislation

• Office of Minority Health*

• Office on Women's Health

• Substance Abuse and Mental Health Services

Administration

12

National CLAS Standards Enhancement

Initiative: Advisory Committee

*Convener

All National CLAS Standards are of equal importance:

The enhanced National CLAS Standards promote collective

adoption of all Standards to most effectively affect the health and

well-being of all Americans.

Each of the 15 Standards is equally important to an organization’s

ability to advance health equity, improve quality, and help eliminate

health care disparities.

CLAS Enhancements 13

CLAS Video

14

Enhanced CLAS Standards

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.

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

15

National CLAS Standards

Principal Standard

Governance, Leadership and Workforce

Communication and Language Assistance

Engagement, Continuous Improvement, and Accountability

1

2-4

5-8

9-15

16

All National CLAS Standards are of equal

importance:

The enhanced National CLAS Standards promote collective

adoption of all Standards to most effectively affect the health and

well-being of all Americans.

Each of the 15 Standards is equally important to an organization’s

ability to advance health equity, improve quality, and help eliminate

health care disparities.

Original 2000 CLAS Standards, each Standard was designated as

a recommendation, mandate, or guideline.

CLAS Enhancements 17

Comparison – 2000 and 2012

CLAS Standards

18

2000 Standards 2012 Standards

Goal: to decrease health care disparities

and make practices more culturally and

linguistically appropriate

Goal: to advance health equity, improve

quality and help eliminate health and health

care disparities.

“Culture”: racial, ethnic and linguistic groups “Culture”: racial, ethnic and linguistic

groups, as well as geographical, religious

and spiritual, biological and sociological

characteristics

Audience: health care organizations Audience: health and health care

organizations

Implicit definition of health Explicit definition of health to include

physical, mental, social and spiritual well-

being

Recipients: patients and consumers Recipients: individuals and groups

1-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

19

Scale of Justice-Equal Representation-

Equal access to health care

20

2: Advance and sustain governance and

leadership that promotes CLAS and health

equity through policy, practices and allocated

resources (2-4: Governance, Leadership & Workforce)

Mission statement/core values/vision statement-promoting health equity

Commitment from top board, management leadership,

Management/board 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.

21

CLAS Management 22

3: Recruit, Promote, and Support a Diverse

Governance, Leadership, and Workforce

Top Management should promote diversity throughout the organization, including board membership

Support not only recruitment but retention, and promotion as well

Use traditional and untraditional job advertisement approaches; use ethnic media, partner with minority health organizations, religious groups, chamber of commerce chapters, business groups

Work with minority serving institutions

Use social media methods (Facebook, Link-in, Twitter, etc.)

23

Inclusion 24

4: Educate and Train Governance,

Leadership, and Workforce in CLAS

CLAS education and training for professionals working in health/human services must be ongoing;

Training should be based on sound educational principles (adult learning, pre-test, post-test, knowledge based, skill-based, attitude-based)

Training in the areas of effective communication, health literacy, socio-economic status, race, ethnicity, effects of cultural differences in access heath and other human services;

Applicable civil rights laws, Affordable Care Act of 2010, Title VI of the Civil Rights Act of 1964, HHS Title VI Guidance for LEP Individuals.

Integration of CLAS in agency training to ensure it becomes part of the organizational culture

25

5: Offer Communication and Language

Assistance (5-8: Communication and Language

Assistance)

Establish a process to inform LEP individuals of their right to receive

language assistance at no cost to them

All notifications should be conducted the right literacy level of the LEP person

Organizations should notify LEP individuals in their preferred language of

language assistance, “I speak” cards or other new forms of technologies

(Ipad, Iphone, Apps)

Point-of entry (intake) should be used to language assistance notifications

26

Inform Availability of Language

Interpreter Services27

6: Inform Individuals of Availability of

Language Assistance

Provide Organizations that receive federal funds must comply with Title VI of the 1964 Civil Rights Act, nondiscrimination provisions as it applies to LEP individuals

Oral (verbal) and Translation services (written): Interpreters/Translators

Should develop systems to provide quality interpretation services, including translation of pertinent health promotion/disease prevention and medical consent/treatment forms

Strategically should use the HHS OCR Four-factor analysis to map-out the language needs of the community

Should develop a language assistance plan to execute and monitor progress in meeting the language needs of LEP individuals

28

Language Interpretation Options 29

Translations of Medical Forms 30

7: Ensure the Competence of Individuals

Providing Language Assistance

Entities should develop strategies for providing language assistance (use of trained vs untrained interpreters, bilingual staff)

Discourage the use of family or children as interpreters

Develop policies/procedures for the provision of competent language assistance services

Testing of competencies of language providers

Use nationally recognized entities for testing interpretations/translation skills (The American Translation Association, the National Council on Interpreting in Health Care, the Certification Commission for Healthcare Interpreters, and the National Board for Certification of Medical Interpreters)

31

Medical Interpretation Bodies 32

8: Provide Easy-to-Understand Materials

and Signage

Purpose: To enable individuals to make informed decisions regarding their health and their care/service options: Examples of materials to translate as appropriate:

Administrative/legal documents (informed consent, living wills, emergency room/discharge releases);

Clinical information-prevention/treatment instructions, how to take medicine, how to perform self-care or self-monitoring);

Developing materials that address the literacy levels of service population

Use of multilingual signage of languages of the population

33

Health Literacy34

9: Infuse CLAS Goals, Policies, and

Management Accountability Throughout the

Organization’s Planning and Operations (9-15:

Engagement, Continuous Improvement, and Accountability)

Establish CL appropriate goals and policies for the delivery of cultural competent care based on health equity concepts/ideas

CLAS should be embedded throughout various levels of the organization’s workforce (upper and lower management)

CLAS should be core elements of the organization’s identity, mission, operating principles, service focus, budget/quality improvement activities

Establish accountability mechanisms throughout the organization, staff evaluations, individuals’ satisfaction measures, and quality improvement measures

35

10: Conduct Organizational Assessments

Conduct ongoing assessment (self-assessment) of the organization’s CLAS-related activities;

Conduct a cultural audit using cultural and linguistic assessment tools (structural policies, procedures, and practices—barriers to care; positive/negatives)

Use audit data to Integrate CLAS-related measures into continuous quality improvement activities

Establish feedback “loops,” internally and externally, to continuing monitor and improve on your CLAS activities (service delivery)

36

11: Collect and Maintain Demographic Data

Collect demographic data such as race, ethnicity, sex, language, and disability status;

Use data to identify population groups within service area;

Ensure equal allocation of organization resources;

Use data to monitor/evaluate the impact of CLAS on health equity/outcomes/to inform service delivery.

37

12: Conduct Assessments of Community

Health Assets and Needs

Conduct regular assessments of community health assets and

needs (needs assessment, resource inventory, gap analysis);

Identify potential disparities in care or services; and

Identify language and other needs of the community

Plan/implement services that respond to the cultural & linguistic

diversity of the populations in the service area

38

13: Partner with the Community

Health care entities should partner w/ the community to design,

implement, and evaluate policies, practices, & services to

ensure cultural/linguistic appropriateness ( vehicle to build trust)

Health care entities should use town hall meetings, hold

community forums, and/or conduct focus groups, talking

sessions, webinars, etc. to acquire stakeholder input

Sponsor or participate in health fairs with community-based

organizations, cultural festivals, and celebrations

39

CLAS Public Engagement 40

14: Create Conflict and Grievance Resolution

Processes

Create a system to address discriminatory or inequitable

practice ( unfair treatment due to race, ethnicity, sex, age,

economic status, sexual orientation, gender identity);

Create a system to meet federal/state level regulations that

address grievance procedures/appeal processes, or use of

ombudspersons.

Create conflict/grievance resolution processes that are

culturally/linguistically appropriate to identify, prevent, and

resolve conflicts or complaints;

41

15: Communicating the Organization’s

Progress in Implementing and Sustaining

CLAS

Communicate to stakeholders, constituents, and general public of CLAS accomplishments;

Helps build and sustains communication on CLAS priorities/fosters trust between community and service setting

Helps meet community benefit requirements

Serves as an accountability mechanism to the community but also part of continuous improvement process

42

Principle Standard:

1) Provide effective, equitable, understandable, respectful, and quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

2) 15 CLAS Standards, Three Themes:

Governance, Leadership, and Workforce

Communication and Language Assistance, and

Engagement, Continuous Improvement, andAccountability

All the standards have equal standing.

Summary of CLAS43

“I will now take questions from the floor”

Resources

www.thinkculturalhealth.hhs.gov

www.minorityhealth.hhs.gov

www.hrsa.gov/publichealth/healthliteracy

www.cms.gov/writtenmaterialstoolkit/

www.healthcareinterpreterscertification.org

www.aamc.org/initiatives/tacct/

www.transculturalcare.net/iapcc-r.htm

45

Contact Information:

Guadalupe Pacheco, President/CEO

Pacheco Consulting, LLC

1516 U Street, NW

Washington, DC 20009

(202) 352-5303

(202) 387-1732 (fax)

guadalupepacheco2@gmail.com

www.pachecoconsultinggroup.com

Power-point:©copyright 2014 All Rights Reserved,

Guadalupe Pacheco

46