Adherence with the National Standards on Culturally and Linguistically Appropriate Services (CLAS) is a common expectation for healthcare organizations of all types. Many providers assume that their efforts are sufficient as long as they hire staff who reflect the racial, ethnic, cultural, and linguistic background of their client population. Yet, full CLAS adherence, and responsive population health planning, require more thorough consideration, system-wide analysis and on-going review than most providers realize. Recent attention to the needs of immigrant and refugee communities offers a lens through which the CLAS standards might be more closely considered.
CLAS for Refugees
Considering refugees as an example of just one underserved population’s needs opens the door to many questions worth considering for other populations. Many providers are not aware that NYS ranks among the top three state for refugee resettlement in the United States, behind Texas and California (Office of the New York State Comptroller, a Portrait of Immigrants in New York, 2016). Refugees are highly likely to have experienced stress and trauma, and, after they resettle, they frequently face additional, compounding issues related to poverty and limited education, discrimination, low paying jobs, and social isolation (American Psychological Association, Working with Immigrant-Origin Clients, 2013). Yet, refugees are also some of the least likely to utilize behavioral health services due to cultural and systematic barriers (CDC, Guidelines for Mental Health Screening during the Domestic Medical Examination for Newly Arrived Refugees, 2014). Although they are eligible for Medicaid under the Affordable Care Act, refugees still face obstacles to receiving proper care, including lack of access to appropriate and culturally sensitive mental health services in necessary languages, shortage of mental health workers trained to work with their presenting needs, and a lack of knowledge regarding available resources to facilitate access to services (i.e. transportation and child care). Within many refugee communities, there is an inherent mistrust associated with seeking services outside of the community. Most of the community outreach is done through word of mouth, via cultural organizations and groups, or through religious and/or spiritual forums, and many groups who are fundamentally connected to faith will take their cues from pastors and faith leaders. Addressing language barriers, the impact of new systems, and the burden of poverty, as well as secondary adversities such as the loss of and separation from loved ones, displacement, and trauma and loss reminders, is essential to providing effective interdisciplinary care (Pottie, K., Greenaway, C., Feightner, J., Welch, V., Swinkels, H., Rashid, M., & Narasiah, L., et.al., Evidence-based Clinical Guidelines for Immigrants and Refugees, 2011).
The U.S. Department of Health and Human Services Office of Minority Health developed 15 national standards for Culturally and Linguistically Appropriate Services (CLAS) in health care. While the Principal CLAS Standard is the “provision of 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,” the additional standards, detailed in the sidebar to the right, go deeper into three broad focus areas: 1) Governance, Leadership and Workforce; 2) Communication and Language Assistance; and (3) Engagement, Continuous Improvement, and Accountability (HHS, CLAS and the CLAS Standards, 2015).
CLAS standards are endorsed by the NYS Office of Mental Health and the Department of Health. Indeed, the state required Performing Provider Systems (PPS) working within the Delivery System Reform Incentive Payment (DSRIP) Program to develop and submit cultural competency and health literacy strategies for serving their communities. These strategies directly relate to specific needs and regional demographics identified in each PPS’ initial Community Health Needs Assessment, and they outline specific approaches that will be taken by the PPS to ensure success in addressing health disparities. As well, NYS Certified Community Behavioral Health Center (CCBHC) sites are required to adhere to a number of requirements related to cultural competency, including the requirement that the CCBHC staff must be culturally and linguistically trained to serve the needs of the clinic’s patient population. Staff training must address the diversity within the organization’s service population and must include information related to military culture if veterans are served (SAMHSA, Criteria for the Demonstration Program to Improve Community Mental Health Centers and to Establish Certified Community Behavioral Health Clinics, 2015). Finally, notable for behavioral health providers integrating primary care, the standards for a Patient Centered Medical Home (PCMH) also incorporate CLAS into requirements. For instance, certification demands that providers assess population diversity and language needs and provide interpretation services and printed materials in relevant languages, collect thorough demographic information, and obtain feedback from patients and families on their experiences with the practice and their care at least on an annual basis.
Despite the wealth of standards and requirements related to cultural competency, CLAS adherence in practice is only possible when care is truly person-centered and relationship-based to meet the individual patient/consumer and family’s needs, preferences, and priorities. Robust stakeholder and community input is vital. Person-centered care, the key to achieving cultural competency, is defined by the Agency for Healthcare Research and Quality (AHRQ) as “relationship-based…care that meets the individual patient and family’s needs, preferences, and priorities.” The provision of culturally responsive health care has evolved from specific training about groups to a more universal focus on rapport-building, clear empathic communication, and respect and negotiated treatment planning that embrace patient world views and health decisions. Indeed, reviews of traditional provider educational interventions focused on the specific needs of racial/ethnic minority populations found evidence that this type of cultural competence training can have mixed effects, with two studies reporting increased negative attitudes and/or stigma among staff resulting from intervention (AHRQ, Improving Cultural Competence To Reduce Health Disparities, 2016).
Person-centered care demands that providers find ways to engage with individuals based on their specific needs, informed by an understanding of—or an openness to learning about—each clients’ unique values, attitudes, and beliefs, which are intricately influenced by a variety of variables such as culture, race, ethnicity, disability, religion, sexual orientation, neighborhood, when a person immigrated to the country and immigration status, as well as incarceration history, etc. The use of professional interpreters or trained culture brokers (not children or other family members) can help providers identify patients’ concerns, explain illness beliefs, monitor progress, ensure adherence, and address the social causes and the consequences of behavioral health issues (Kirmayer, L.J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A.G., Guzder, J., Hassan, G., Rousseau, C., & Pottie, K., Common Mental Health Problems in Immigrants and Refugees, 2011). The list is numerous and every “group” that can be named is comprised of individuals whose affiliations and influences cross and overlap with other groups. So, while learning population norms and trends for those of specific immigrant communities, religious groups, or racial/ethnic populations can provide a useful starting place for understanding an individual, it is by no means sufficient, and the risk of unintended stereotyping and bias is inherent.
Organizations reaching and serving culturally-based groups are often small not-for-profits with minimal resources. Although they see improvements in consumers’ connection to care as a result of their services, their present size does not enable them to meet the need that exists within the community. Increasingly, these agencies are partnering with other stakeholders within the delivery system to engage in integrated care coordination, which brings together caregivers, psychiatrists, primary care providers, case managers, teachers, refugee resettlement agencies, and refugee community and religious leaders, are finding success addressing the characteristics, culture, and preferences of refugees (Isakson, B.L., Legerski, J.P., & Layne, C.M., Adapting and Implementing Evidence-Based Interventions for Trauma-Exposed Refugee Youth and Families, 2015). These approaches can be financed under emerging models for value based, accountable care.
CLAS Focus Areas
Governance, Leadership and Workforce
- Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.
- Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.
- Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.
Communication and Language Assistance
- Offer language assistance to individuals who have limited English proficiency 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, recognizing that the use of untrained individuals (i.e., family members) and/or minors as interpreters should be avoided.
- Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.
Engagement, Continuous Improvement, and Accountability
- Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.
- 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.
- Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.
- Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.
- Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.
What You Can Do
Many tools and resources exist to help organizations comply with CLAS guidance, including organizational self-assessments and toolkits, a few of which are listed below under Resources. Providers preparing for value-based payment are analyzing their continuous quality improvement data to assess which populations and groups they are serving AND what populations are being lost to care, based on local health needs data and population demographics. Proactive providers are not waiting for new funding opportunities to support specialized programs. Rather, capitated rates and new quality incentives, plus attention to CLAS standards that has included increased planning input from community groups, are leading accountable entities to identify new partners, such as community-based organizations addressing the social determinants of health or faith based organizations serving unique cultural and/or religious communities.
- Race Matters: Organizational Self-Assessment: http://www.aecf.org/resources/race-matters-organizational-self-assessment/
- Self-Assessment for Cultural Competence: http://www.asha.org/practice/multicultural/self.htm
- The Cultural Competence Self-Assessment Protocol for Health Care Organizations and Systems: http://erc.msh.org/mainpage.cfm?file=9.1g.htm&module=provider&language=English
- Health Research and Educational Trust Disparities Toolkit: http://www.hretdisparities.org
- “Improving communication—improving care”: the AMA Ethical Force program toolkit: http://www.ethicalforce.org/