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NO. 5

ISSUE BRIEFT h e M a s s a c h u s e t t s H e a l t h P o l i c y F o r u m

CULTURALCOMPETENCE ANDHEALTH CARE INMASSACHUSETTS

WHERE ARE WE?WHERE SHOULDWE BE?

Thursday, July 15, 19998:30 to 9:00 – Breakfast9:00 to 11:00 – Presentation & DiscussionOmni Parker House HotelSchool and Tremont StreetsBoston

Registration: Please call Sue Thomson at 617-338-2726 as soon as possible

Copyright © 1999 Massachusetts Health Policy Forum . All rights reserved.

Issue brief prepared by Jean Lau Chin,Ed.D.,President of CEO Services,providing clinical, educa-tional, and organizational services with an emphasison culturally competent,integrated systems of care. Sheis a practicing psychologist in Quincy, MA, with 30years of clinical, consulting, and management experi-ence including: Regional Director, Mass BehavioralHealth Partnership; Executive Director, South CoveCommunity Health Center; and, Co-Director, DouglasA. Thom Clinic

Intr oduction

The rapid growth of the non-White population inMassachusetts during the last decade mirrors that of theU.S. population with racial/ethnic minorities in 1995making up 27% of the total population. Forty percent ofthe U.S. population will be immigrants or first genera-tion Americans by the year 2000. Estimates predict thatracial/ethnic minorities in the U.S. will make up 48% ofthe total population by 2050; 14.4% will be Black,22.5% Hispanic, 9.7% Asian American,0.9% AmericanIndian,and 52.5% White.1 This does not include newmigrations from Europe.

The growing diversity of the U.S. population isreflected also in the heterogeneity within racial/ethnicminority groups. Blacks include Afr ican Americans,Haitian Creole, and other Caribbean groups,while His-panic or Latino Americans include individuals fromSouth America, Central America, Mexicans,Cubans,Puerto Ricans,and others. Asian Americans includeover 40 groups,with the most common in Massachu-setts being Chinese, Vietnamese, Cambodian,Korean,Filipino, Japanese, and Indian. Native Americansinclude 365 tribes,with the Wampanoag and Micmactribes being most common in Massachusetts. Each ofthe racial/ethnic groups has emphasized the significantheterogeneity within groups with respect to populationdemographics and health risk factors.2

Each racial/ethnic group has sought to eliminatethe adverse effects of racism and stereotypes while sup-porting the importance of attending to unique groupdifferences. The prevalence of negative stereotypes forBlacks and Hispanics and the adverse effects of thehealthy model minority myth for Asians have resulted indiscriminatory practices in service delivery andresource allocation for all of these groups. Yet, it isclear that the sociopolitical context of poverty, racism,immigration, and culture has had a significant bearingon health status,health care utilization, and access tocare for all racial/ethnic groups.

Movement From Cultural Sensitivity toCultur al Competence

Demands for cultural competence arose out of thefailures of the service delivery system to be responsiveto all segments of the population. Initially, an emphasison cultural sensitivity was stressed when providingservices to ethnic minorities and culturally differentgroups,especially given language and cultural barriersfaced by non-English speaking immigrants/refugees,and racial and economic barriers faced by ethnicminorities. While this meant responsiveness to culturaldifferences in attitudes,behaviors,beliefs,values andlif estyles as well as language, the system continued tofail for these underserved groups. The communityhealth and mental health movements dovetailed with theCivil Rights Movement of the ‘60s,giving voice to thedilemma of agencies and communities grappling withthe availability of services to ethnic minorities and lowincome populations.

During the ‘80s, this focus on cultural sensitivityshifted to a demand for cultural competence, i.e., a skill-focused paradigm, over one of mere sensitivity. Whilethe use of bilingual/bicultural providers and the impor-tance of familiarity with the culture of one’s clientscontinued to be stressed, this transformation to a skill-focused paradigm resulted in efforts during the ‘90s tooperationalize and define those components necessaryto achieve cultural competence.

As managed care and health care reform effortsgrew during the ‘90s,advocates of cultural competenceexpressed a growing concern that the small gains madeby institutions and agencies within the health care deliv-ery system in the previous decade to become culturallycompetent could now be lost. In an environment of costcontainment,many fear that cultural competence as apriority would be subordinated to economic and marketincentives.

Defining Cultur al Competence

Cultural competence was initially defined by theChildren and Adolescent Service System Programs(CASSP) initiative in its seminal monograph,Toward aCulturally Competent System of Care3 in 1989. Devel-oped as a model for services to minority children whoare severely emotionally disturbed, it emphasized a sys-tems perspective consisting of four levels:

• Policy making

• Administrative

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• Practitioner

• Consumer

The CASSP defined cultural competence along adevelopmental continuum from cultural destructivenessto cultural proficiency as:

"A set of congruent behaviors,attitudes,and poli-cies that come together in a system,agency, oramongst professionals and enables that system,agency, or those professionals to work effectivelyin cross-cultural situations. The word culture isused because it implies the integrated pattern ofhuman behavior that includes thoughts,communi-cations, actions, customs,beliefs, values, andinstitutions of a racial, ethnic, religious,or socialgroup. The word competence is used because itimplies having the capacity to function effectively.A culturally competent system of care acknowl-edges and incorporates—at all levels—theimportance of culture, the assessment of cross-cul-tural relations, vigilance towards the dynamicsthat result from cultural differences,the expansionof cultural knowledge, and the adaptation of serv-ices to culturally unique needs."4

Many definitions of cultural competence havesince emerged, often focused on the process necessaryto achieve it, or the criteria to decide if it exists. TheCalifornia Cultural Competency Task Force, establishedin 1993 by its Department of Mental Health is one suchexample. It defined a culturally competent process asone,

"which requires individuals and systems to developand expand their ability to know about,be sensi-tive to,and have respect for cultural diversity. Theresult of this process should be an increasedawareness,acceptance, valuing and utilization ofand an openness to learn from general and healthrelated beliefs,practices,traditions, languages,religions,histories and current needs of individu-als and the cultural groups to which they belong.Cultural competency is appropriate and effectivecommunication which requires the willingness tolisten to and learn from members of diverse cul-tures, and the provision of services andinformation in appropriate languages,at appropri-ate comprehension and literacy levels,and in thecontext of an individual’s cultural health beliefsand practices."5

Other definitions have delineated overarching prin-ciples necessary for institutions and providers if they areto provide culturally competent services. The state ofWashington issued a blueprint for providing a frame-work6 while other definitions include: principles ofdiversity and difference,7 conceptualizations of organi-zational change,8 operationalization of multiculturalcounseling competencies,9 attending to culture in diag-nosis using the DSM IV,10 guidelines for counseling theculturally different,11 developmental models,12 and self-reflection models.13

Yet, there is a general sense that few providershave thought about biases they may bring to patientencounters or about their own cultural/ethnic back-ground, health beliefs,and practices. Their goal is oftento get the patient to conform to the mainstream,and notto meet them on their cultural ground. In medicine, thisquickly translates into patient attitudes about healthwhich will affect compliance, traditions,and views ofreligion and death which will influence attention to dis-cussion of disease and disease management,views ofrace and power which will inf luence the nature of thecommunication between doctor and patient.14,15

While health care providers have been urged to becognizant of cultural traits,religious beliefs,concepts ofhealth,and health practices that are uncommon in West-ern medicine, the following scenarios illustrate onlysome of the issues that may arise.16

• Prescribing practices:A physician prescribesmedication without knowing or asking about thepatient's use of an herbal medicine that hasadverse interaction effects.

• Erroneous translation: A Latino client says herchild is "se me enfermo" which was translated as"he got sick." The physician does not realize theseriousness attached to this and dismisses it asinconsequential.17

• Poorer access for non-English speaking patients:A Latino immigrant diagnosed with chronic backpain and an ulcer is referred to a hospital for aspecial test; she complains that she would ratherdie than to keep going. "First, I have to wake upearly in the morning, leave home about 7AM forthe hospital. I wait and wait to have this specialtest,and come home by 4PM. A translator is notalways available. I think the test takes only tenminutes,but I have to wait 5-6 hours."

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• Folk remedies used by Asian American groupsmisunderstood by providers: A Cambodianrefugee uses cao gio or coin rubbing to dispel the"bad wind," or to restore natural balancebetween hot and cold elements of the universe,when her daughter is feverish. The bruise left bythis remedy is reported as abuse by the provider.

• Mistrust of the health care system and providers:An Afr ican American patient does not returnafter he is told of a new experimental procedureto be used for his condition. He is afraid that hewill be used in experimentation like the subjectsin the Tuskegee syphilis experiments.

Cultur al Competence in Health Care

While many of the cultural competence initiativesoriginated in the mental health arena,these quicklymushroomed into the health arena as well. Increasingly,the need for providers and service delivery systems tobe culturally competent has become pressing, fueled byeconomic imperatives. As advocacy groups challengethe system to serve diverse segments of the population,and as ethnic minorities grow in market share, there iseconomic value in marketing to a diverse population.Diversity and cultural competence have become buzz-words for good business while also satisfyingaffirmative action objectives.

Nevertheless, cultural competence has yet toachieve a status as being integral to health professionstraining,18 or essential to standards of professional prac-tice. The relevance of individual and cultural bias,andprovider and institutional values as they influence healthcare utilization, service delivery systems,and lifestylebehaviors has yet to be recognized. Discussions of cul-tural competence in health care generally have beenlimited to language access or the ability of providers tocommunicate with their patients.

How is cultural competence different in healthcare? While cultural competence slowly made its wayinto the language and practices of the health care deliv-ery system, this varied across specialties.Technology-based specialties were less likely to seecultural competence as relevant to its practice whilecommunity health and primary care settings were morelikely to view it as important given the more direct inter-face with patients,families,and communities.

IMPACT OF TRENDS INHEALTH CARE

National trends within health care have had a sig-nificant impact on the evolution of cultural competencewithin health care. Many of the changes in reimburse-ment and in the marketplace nationally have beenmirrored within Massachusetts.

Racial Disparities

Cultural competence has been intricately inter-woven with minority health premised upon theimportance of appropriate disease management and pre-vention as it relates to the population. Consequently,the presence of racial disparities in disease incidence,prevalence, and health status suggests a system that hasnot been responsive to all segments of the population.

The 1985 Report of the Secretary’s Task Force onBlack and Minority Health19 began the discussion onracial disparities in health. While Blacks and Hispanicsdemonstrated significant disparities from Whites on thesix leading causes of death, Asian Americans andNative Americans did not even appear on the charts,"suggesting their good overall health." While thisreport on racial disparities has been positive in drawingnational and local attention to improving Black and His-panic health status,it has been challenged for ignoringsignificant and meaningful disparities among other eth-nic minority groups. Asian American and NativeAmerican groups,in particular, have criticized its inade-quacies in masking significant differences among thoseracial/ethnic groups who make up a disproportionatelysmaller share of the population. This resulted in few ofthe Healthy People 2000 objectives targeting thesegroups.20 The public health datasets upon which thisreport is based have also been challenged because oftheir failure to disaggregate racial/ethnic groups,insuf-ficient sample sizes to allow meaningful analyses,21

inadequate sampling methods,and selection bias inidentifying diseases relevant and specific to ethnicminority populations.

A major criticism of racial disparities has been theuse of a comparative paradigm in which minority healthis defined against a White standard. This comparisonignores other significant trends and differences in healthstatus not found within the White populations; it hasadversely resulted in creating and sustaining stereotypesthat result in ignoring the health needs and relevant indi-cators of health status among ethnic minority

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populations. For example, while hepatitis B and tuber-culosis carrier rates among Asian Americans were morethan ten times greater than in the White population, theydid not make the list of indicators.

The National Comparative Survey of MinorityHealth Care in 1995,22 in fact, showed that minorityadults from all four racial/ethnic groups,i.e., Black,Hispanic, Asian, and Native American, are twice aslikely as Whites to be uninsured. In addition, they aremore likely to experience difficulties in receiving appro-priate and needed medical care, they have less choice asto where they receive care and less access to regularsources of care, and, they report more negative experi-ences with the health care system.

In February 1998,President Clinton announced anEliminating Racial Disparities Initiative that set anational goal to eliminate longstanding disparities inhealth status among racial/ethnic minority groups by theYear 2010.23 Calling for collaborative public-privatepartnerships,this effort dovetails with President Clin-ton’s Race Initiative, which recommends a "blueprintfor national policy to eliminate racial disparities, tobridge the racial divide, and to value diversity inembracing common values."24 These initiatives,in turn,dovetail with the Healthy People 2010 initiative of theU.S. Department of Health and Human Services,theoverall goal of which is to improve the health of allAmericans through disease prevention.25

State and local health departments have respondedto these initiatives to eliminate disparities in health sta-tus. Governor Michael Dukakis appointed a task forceto examine low birthweight and infant mortality in1990; this resulted in a major federally funded HealthyStart Initiative in Boston to address the disproportionaterates of infant deaths within Black and Hispanic com-munities during the ‘90s. These issues were revisited in1997 through the Mayor's Infant Mortality Summit inBoston. The National Association of County HealthOfficials’ Multicultural Health Project26 paired healthdepartments with community-based organizations toincrease access to care for targeted populations,stress-ing the importance of collaboration. Most recently, theMassachusetts Department of Public Health,Office forMinority Health began a strategic planning process in1996,and has formed a Minority Health Advisory boardthat will help the department address health disparities.

Population Demographics

The measurement of health status,service utiliza-tion, quality and access to care has been critical toidentifying the health of the nation's population and itscommunities. Typically, national and state public healthdatasets have used global indicators as a basis for policyplanning, program development,and resource alloca-tion. With the growing diversity of the U.S. population,racial classification and the use of ethnic identifiers havebecome significant variables within these datasets.

The use of ethnic identifiers, i.e., who makes upthe population, enables policymakers,payers,and serv-ice providers to target interventions to specificpopulation needs,and therefore, reflects cultural com-petence. The ability of a system of care to identifypatterns of utilization, quality, and access for differentracial/ethnic groups is important because there exist dif-ferential prevalence patterns and epidemiologic rates ofdisease. It also reflects the growing belief that a uni-form standard based on the White population can nolonger be the norm for public health indicators,and thatdata needs to be disaggregated for meaningful analysisand competent health planning. The U.S. Censusrecently increased the number of racial/ethnic classifi-cations for the 2000 census,and will allow formulti-racial classifications. In Massachusetts,theDepartment of Public Health compiled Latino andAsian databooks on births in 1993 toward this effort.27

The City of Boston also began to collect data onrace/ethnicity in its Health of Bostonreport.28

In general however, public health datasets typicallydo not disaggregate ethnic groups,or are insufficient inidentifying racial group differences,therefore losing theopportunity for meaningful analysis. Racial/ethnicdata, if available, tend to be limited to White, Hispanic,and Black. Native Americans and Asian Americans aregenerally excluded, as well as significant subgroupswithin the Hispanic and Black populations,e.g., HaitianCreole. The Latino Coalition for a Healthy California,and the Asian Pacific Islander American Health Forumat the national level, and the Latino Health Data Con-sortium in Massachusetts have supported initiatives todisaggregate data.

Growing Integration of Services

The rapid growth of managed care, privatization ofservices,increased competition within the tertiary caresystem,and health care reform provided the impetus forrapid change in the health care environment. This influ-

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enced a growing integration of services between pri-mary and tertiary care, between health and mentalhealth care, between hospitals and community-basedsystems,etc. Several factors have contributed to a grow-ing integration of these systems of care.

Emphasis on cost containment resulted in a rapidgrowth of managed care with over 40% of Massachu-setts residents now enrolled in health maintenanceorganizations (HMOs),compared to its near absence inthe ‘80s. As primary care providers became the gate-keepers of services within a managed care system,hospital systems needed to restructure themselves tomaintain market share. The development of hospitalnetworks and integrated systems became a means tosurvival, and competition for covered lives grew as ameans to maintain market share. During the ‘90s,hos-pital closings and mergers involved all the major playersin Massachusetts in response to changes in the market-place and reimbursement mechanisms.

Health and mental health systems,which have his-torically been separate, are now also being integrated inresponse to these trends. A growing recognition of psy-chosocial influences on lifestyle behaviors, patientcompliance, and disease management and evidence thatthe onset and course of chronic disease conditions canbe modified by lif estyle behaviors have resulted in agrowing emphasis on prevention and patient education.The influence of sociocultural factors on lifestylebehaviors, and racial/ethnic differences in healthbeliefs,lif estyle behaviors,and health behaviors makethis an issue of cultural competence.

A growing consumer movement has also con-tributed to a growing integration of services withemphasis on consumer choice and consumer empower-ment. Consumer participation in health care decisionmaking, emphasis on patient satisfaction,and expandedbenefits to include acupuncture respond to consumerdemand. With changing population demographics,wholistic health beliefs,common among many ethnicminority communities,have resulted in a demand formind-body approaches to health care and traditionalhealth care methods such as herbal medicine.Providers,hospitals,and payers,alike, are beginning torealize the economic value of accommodating a diversepopulation in order to capture market share. Growinginterest in alternative medicine has extended to themajority population, creating greater consumer demandfor such products and services beyond that of racial/eth-nic communities.

Megaproviders and Networks

As Massachusetts began to privatize its purchaseof services,the emergence of megaproviders,coalitions,and networks also became the means by which to gain aplace at the table for negotiating contracts and rates inhuman services. With the growing integration of serv-ices, size has become increasingly important forsurvival. "Mainstream institutions" and megaprovidersincreasingly are partnering with community-basedorganizations to gain access to minority communitiesand ethnic-specific providers. The resources of largeinstitutions and access to minority communities havecreated attractive partnerships.

The ability of megaproviders and networks to mir-ror and be responsive to their designated communities isbecoming an economic imperative, representing a shiftfrom the charitable obligation of non-profit hospitalsunder community benefits. The Massachusetts AttorneyGeneral (A.G.) issued voluntary Community BenefitsGuidelines for Nonprofit Acute Care Hospitals in199429 that encouraged hospitals to provide benefitsthat enhance the health status of designated communi-ties and aim to reduce racial and ethnic disparities inhealth status. The A.G.’s Community Benefits Guide-lines for Health Maintenance Organizations,issued in1996,30 encourage a commitment to reducing cultural,linguistic, and physical barriers to accessible health careat key points of patient contact.

The development of integrated networks and merg-ers was fueled by the need to provide a comprehensivecontinuum of care. The emergence of megaprovidersenabled different entities to combine their expertise andlike entities to capture greater market share. However,we are currently seeing its failure as the different cul-tures within these merged entities could not be melded.At the same time, the growing dominance ofmegaproviders are beginning to threaten the viability ofsmall community-based organizations that have histori-cally targeted ethnic-specific communities. Providerswho disproportionately serve and maintain ties to ethnicminority communities could disappear. Asmegaproviders begin to drive the standard for healthcare delivery, the demise of ethnic-specific agencies andcommunity-based organizations could be replaced bymainstream comprehensive systems.

Cultural competence has very different meaningfor organizations whose missions are dedicated to serv-ing culturally specific populations (i.e., ethnic-specificagencies or community-based organizations (CBOs))

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vs. institutions whose missions are dedicated to servingall populations (i.e., mainstream agencies). A CBOresponsive to all populations would dilute its very mis-sion while cultural competence is core to its missionand programs. The goal of CBOs is not to be morediverse, but to fill an unmet need and advocate for thelarger system to become more responsive to its targetedpopulation. Within large mainstream institutions,cul-tural competence often means diversity initiatives toensure that the institution is responsive to racial/ethnicpopulations. While the demand for all systems tobecome culturally competent is critical, the role of andcriteria for community-based organizations must be dif-ferent from those within the mainstream.

SERVICE DELIVER Y ISSUES:COSTLY VS. COST EFFECTIVE

Most initiatives on cultural competence focus onthe service delivery systems,and the skills or attitudesof providers within that system. Essentially, Who deliv-ers the care? As the demand for institutions to beculturally competent has grown, the number of work-shops, conferences, and training to promote thediversity, awareness,and skills of providers serving adiverse population has mushroomed. Many institutionsnow have cultural competence initiatives or designatedoffices to address specific needs of ethnic minority pop-ulations. It is common for organizations to articulate acommitment to diversity, multiculturalism or culturalcompetence in their goals,objectives,or mission state-ments.

Few initiatives focus on a second, and perhapsmore important question:What is the system of care,and is it culturally competent?An examination of thegovernance, administrative and consumer levels is asimportant as examining provider competencies. Toensure that the system is culturally competent,systemicvariables to evaluate these levels for all segments of thepopulation include:Do all segments of the populationhave equal access to care? What are the utilization pat-terns for different racial/ethnic groups? Is quality ofcare provided as measured by health status of the desig-nated population groups?

Access to Care

Access to care, or the degree to which services areconvenient,quickly and readily obtainable, is a core cri-

terion. This has been a primary focus of cultural com-petence activities, typically described as cultural andlinguistic barriers to care. Can diverse segments of thepopulation access care? For non-English speakingpopulations, the paucity of bilingual providers hasnecessitated interpreters as intermediaries in theprovider-patient dyad. While few have argued theimportance of being able to communicate with thepatient in his/her primary language, controversy hasoccurred over its implementation and cost. Bilingualproviders are generally more available within ethnic-specific agencies and community-based organizations.This is complemented by interpreters, often hired asnursing assistants,case managers,or outreach workersto perform other patient-related functions. Within hos-pitals,interpreter pools for different languages are oftenused and triaged to where they are needed. AT&T inter-preters are commonly used for back-up or for moreesoteric dialects and languages; this has been criticizedbecause it is not face-to-face, and is often provided byuntrained interpreters or ones who are unfamiliar withmedical terminology. The use of interpreters, in gen-eral, has been criticized because of long waits,inappropriate translations,and inconvenience in sched-uling appointments. Its absence altogether or the use offamily members, especially young children,as inter-preters has been severely criticized.

While generally considered necessary to ensureaccess to care, the cost of interpreters is not factoredinto reimbursement mechanisms. Differential reim-bursement or incentives is also not factored in forbilingual providers. Some agencies and institutionsinclude differential pay scales for bilingual providers asa recruitment incentive. While this is a positive prac-tice, it has inadvertently resulted in their competitionwith ethnic-specific agencies who are unable to matchthese pay differentials when the majority of their staffare bilingual,and there is no differential in reimburse-ment.

Cultural barriers,while recognized as important tocultural competence, are often given little attention inthe implementation of programs and policies. Institu-tions have attempted to provide not only translatedmaterials,but also materials that are culturally relevantand appropriate in their marketing and outreach efforts.Institutions have also provided in-service training topromote cultural awareness or build cultural knowledgeof racial/ethnic groups that they serve, often describedas diversity, multicultural, or cultural competence initia-tives.

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Utilization

Utilization refers to which services are being used,their availability in a system,how frequently, andwhether their use is appropriate. What are the utiliza-tion patterns across diverse segments of the population?Enabling services supporting the medical visit have typ-ically been found to be necessary to promoteappropriate utilization when working with low incomeand ethnic minority populations. Enabling services,which include case management,outreach, transporta-tion, babysitting, and those services enabling clients touse the system,also have been omitted from most reim-bursement mechanisms; if provided, they are expectedto be covered by grants. California and Hawaii includean adjustment in their capitation rates of approximately$1.50 to cover the cost of these services.

Utilization patterns have been shown to differ bypopulation variables. Low income, immigrants/refugees from ethnic/minority groups typically delayentry into care, underutilize services,and/or overutilizeemergency room services because of language, cultural,and financial barriers. While many ethnic-specificagencies have organized their program services to pro-mote appropriate utilization, cost benefit analyses ofthese strategies have not been conducted. The use ofethnic identifiers would help to promote this process.

Quality of Care

Quality refers to the question,How good is thecare once it is received? While earlier emphasis in cul-tural competence has focused on access and utilizationissues,there is now an increasing focus on culturallycompetent principles of quality and outcomes. Someprinciples of quality include:

• Access to culturally competent services

• Linguistically appropriate and culturally relevantservices at all points of client contact

• Biculturalism and multiculturalism as a modelfor assessment and intervention

• Clinical outcomes which promote improvedhealth status of the targeted communities

Principles of diversity31 and cultural competence32

increasingly are being articulated as important to a qual-ity health care system. Community health psychologyintegrating biopsychosocial factors and emphasizing acommunity-based approach to health care delivery hasalso been proposed as a model.33 However, these prin-

ciples have not been translated into measurable out-comes,professional standards, or competencies thathave been institutionalized within the mainstreamhealth care delivery system. Often,the existence of aninstitutional diversity initiative is used as the sole crite-rion for defining its cultural competency. Moreover, theassessment of cultural competence is often limited toprovider skills without looking of systemic issueswithin an institution or macroscopic issues of healthprofessions training, professional and regulatory bodieswho set the standards,and payers who determine thereimbursement rates. The collaboration and intersec-tion of these multiple sectors are critical. Culturalcompetence is costly when instituted as an add-on ini-tiative, but cost-effective when integrated into themultiple factors critical to providing quality health care.

Dif ferent sectors characterize the service deliverysystem. One example of an effort in the hospital sectoris the Office of Community Benefits at the Beth Israel-Deaconess Medical Center, which contains a CulturalCompetence Oversight Committee to look at its organi-zational environment,workforce, and patient care toevaluate and develop its cultural competence. It haspublished newsletters, supported environmental andprotocol changes,and hosted multicultural events andconferences to develop the "business case for culturalcompetence." It also has worked with the Picker Insti-tute to incorporate the patient's perspective to improvecare through the inclusion of health beliefs,to under-stand and integrate cultural perspectives of patients intocare and to value cultural differences. Measures,how-ever, have yet to be developed.

Community health centers,on the other hand, see adisproportionate number of low income and ethnicminority clients. A handful of them are ethnic-specificagencies targeting racial/ethnic populations, and arecommitted to being responsive to the specific racial/eth-nic groups they serve. Cultural competence is integralto the programs and missions of these agencies. Manyof the community-based organizations are ethnic-spe-cific agencies targeting Black, Latino,Asian or NativeAmerican communities. Most started as grassrootsorganizations and have strong social service, commu-nity outreach, or civic service components. The LatinoHealth Institute is one such agency targeting the His-panic community, and combining prevention andcommunity outreach activities with public health,andresearch activities. It offers training and consultation oncultural competence.

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TRAINING ISSUESAn examination of health profession training is

important to assess the cultural competence of the insti-tutions training the providers who deliver the care.Currently, many are playing catch-up by providingworkshops,training, and continuing education confer-ences for providers to develop their culturalcompetence. Often, this takes the form of culturalknowledge about specific populations and communitiesunder the premise that one must know about the beliefs,values,practices,and lifestyles of a particular culture inorder to work with members from that culture. Less fre-quent, but more important, is the presentation ofmulticultural principles and culturally competentframeworks to guide practice.

The Society of Teachers of Family Medicine(STFM) published curriculum guidelines for teachingculturally sensitive and competent health care to familymedicine residents and other health professions stu-dents.34 The Health of the Public Initiative was fundedby the Pew and Rockefeller Foundations for medicalschool training, with programs locally at Tufts Univer-sity School of Medicine, Department of FamilyMedicine and Community Health and at CambridgeHospital. This initiative used a systemic approach topromote the health of communities and to reorient aca-demic health centers toward community health needs.35

Two approaches to health professions training rele-vant to cultural competence are important to mention.The Center for Community Health, Education,Research, and Service (CCHERS) and Center forMinority Training Program (CMTP) train health andmental health professionals targeting diverse popula-tions, and have developed culturally competentapproaches to address specific population needs. CCH-ERS is one example of a community-based perspectivewith a holistic vision of health professionals focused onproactive services to the communities in which they liveand work. Its goals are to provide an "out-of-hospitaleducational system for professionals to deliver commu-nity focused, real world health care decisions,and tocreate academic/community partnerships." The otherapproach has been through an overarching initiativewithin a generic training program to be more culturallycompetent and responsive in serving diverse popula-tions. Harvard Medical School and Beth IsraelDeaconess Medical Center36 are two such institutionsthat articulate a commitment to diversity and have"made the business case for cultural competence."

GUIDELINES AND STANDARDSCultural competence has increasingly captured the

imagination of those in health and human services. Thepublic sector, service delivery system,training institu-tions,regulatory authorities,and payers all have begunto include concepts of diversity and cultural competencein their mission statements and to develop diversity,multicultural, and/or cultural competence initiatives.While guidelines and standards have always guided theprofessions in the definition of quality, there is a grow-ing emphasis on quality indicators and outcomes thatare less aspirational and more measurable.

Professional Standards

What are the standards or guidelines to define cul-turally competent quality? To date, culturalcompetence has been defined as aspirational principlesor guidelines. Access to care (i.e., Can they get in?),Utilization patterns (i.e., Do they use it?), and Quality ofcare (i.e., How good is it?) for cultural competence havenot been translated into quality indicators or outcomesthat are monitored, evaluated, or mandated as profes-sional and regulatory standards.

The Office for Ethnic Minority Af fairs of theAmerican Psychological Association issued Guidelinesfor Providers of Psychological Services toLinguistic/Ethnic Minority populations in 1990 to pro-vide a sociocultural framework for psychologists toconsider diverse values, interactional styles,andcultural expectations in a systematic fashion.37 Massa-chusetts was the first,and one of few states,to mandateprogram and professional experience requirementsrelated to racial/ethnic basis of behavior for the licen-sure of psychologists in 1993,i.e., cultural competencebecame a proficiency necessary for professional licen-sure. This has yet to be expanded to other professions.Research evaluation guidelines,38 program guidelines,and ethical guidelines for providers all have been devel-oped to articulate aspirational principles to define thesecompetencies. The California Department of MentalHealth,mentioned above, established a Cultural Com-petence Task Force in 1993,and has since establishedstandards and plan requirements for Mental HealthPlans to achieve cultural and linguistic competency.39

This translated into a legislative mandate requiring allcounties to submit a cultural competency plan toinclude the population, organizational and serviceprovider assessments and services designed to addresscultural competence.40 These plans are to include:

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demographics,policies,practices,human resource com-position,quality of care criteria,and assurance to ensurecultural competence with specific measures and indica-tors. Within these standards and a series of criteria,there must be observable changes in behaviors, skillattainment and attitudes in order for a therapist to bejudged competent to work with cultural others,41 i.e.,multicultural proficiency.

The Health Care Financing Administration(HCFA) issued a draft regulation in September 1998 torequire that state agencies ensure that managed careorganizations provide services in a culturally competentmanner since more than one-half of Medicaid recipientsare members of racial or ethnic minority groups.42

These regulations require managed care organizations(MCOs) to propose a method for determining the preva-lent languages spoken by their members. Resources forCross Cultural Health Care is working on a U.S.Department of Health and Human Services (HHS)-sponsored project to develop national standards forculturally and linguistically appropriate services(CLAS) in health care, and to develop a research agendaon CLAS issues (see Appendix A). They are currentlywritten as provider requirements,but ultimately will bewritten for use by policymakers and advocates, andcould be used to evaluate documents such as therecently released Medicaid MCO regulations.43 Thisevaluation project will review existing language andcultural competence standards or measures in a nationalcontext assess the information or research needed torelate these guidelines to outcomes,and develop a draftnational standard and an agenda for future work.

Outcomes

We now see trends in health care toward anincreased emphasis on quality indicators and measura-ble outcomes. Whereas the development ofprofessional standards has implications for licensureand accreditation, the measurement of outcomes hasimplications for reimbursement and accountability. Theidentification of quality indicators provides the clinicaland program criteria against which to measure theseoutcomes. The Bureau of Primary Health Care44 identi-fied seven such indicators to assess the importantaspects of culture and develop cultural competence pro-grams,but these have not had the force of standards toregulate the delivery of health care services. Identifica-tion of indicators has largely been limited to languageaccess,or the availability of interpreters. In Massachu-setts,the statewide medical interpreter association has

developed interpreter standards and provides continuingeducation workshops to maintain and improve skills.45

On the federal level, the Disadvantaged MinorityHealth Act of 1990 (P. L. 101-527) provided a legisla-tive directive for language access. While this waslimited because it was funded by only $3 million for theentire country, it spawned the prolif eration of relatedinitiatives. The Center for Linguistic and Cultural Com-petence in Health Care was established in 1995 by theU.S. Office of Minority Health to address the healthneeds of limited English speaking populations. TheOffice for Civil Rights of the U.S. Department of Healthand Human Services defined inadequate interpretationas a form of discrimination under the Civil Rights Act of1964. Thus,cultural competence became defined as acivil r ights issue.

Cultural competence guidelines for managedbehavioral health services provided to racial/ethnic pop-ulations,completed in 1998,were developed by fournational panels commissioned through the Center forMental Health Services (CMHS) in conjunction withthe Western Interstate Commission for Higher Educa-tion (WICHE).46 These guidelines identified indicatorsand domains with an underlying principle that, in theprovision of mental health services,consumers and theirexperiences should be viewed within the context of theircultural group.

Not only are organizations and providers beingasked to be culturally competent as an ethical standardor aspirational goal,but also they are asked to identifymeasurable outcomes and specific quality indicators.How does an organization get there? How do you knowif you are there? What are the key components andobstacles to achieving cultural competence?And last,but not least,How do we measure it? This emphasis onoutcomes has bearing on influencing scope of practice,and achieving a set of professional standards that man-dates cultural competence as essential for licensure,accreditation, and risk management. None of thosedeveloped so far has been tied to population health sta-tus.

Quality Indica tors and Assessment Tools

Cultural competence initiatives in several stateshave resulted in the development of assessment tools tomeasure outcomes,e.g., WICHE in Colorado,47 Masonin Portland, Oregon,48 Latino Coalition for a HealthyCalifornia,and New Jersey.49 These assessment toolsare mostly process and survey tools,and include patient

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satisfaction surveys,provider self-assessment question-naires,and organizational self-assessment checklists ofcultural competence variables.

These differ from the use of report cards that oper-ationalize, measure and monitor quality indicators tohold health care providers and payers accountable;report cards are slowly being considered as a tool toassess cultural competence. The National Associationof State Mental Health Program Directors(NASMHPD) worked on a core set of quality indicatorsthat public purchasers (states) could use when negotiat-ing contracts with private providers particularly throughmanaged care risk contracts. Four primary domains:access,accountability, outcome, and plan managementwere identified. Indicators for each domain and meas-ures for each indicator were developed. The CMHSused these domains and indicators to develop a reportcard for cultural competence modeled after the MentalHealth Statistics Improvement Program (MHSIP),aconsumer-oriented mental health report card.50 Thereport card, for use by states to monitor standards ofcultural competence, has yet to be implemented. TheHealth Services Research Institute has compiled adirectory of existing measures,standards,and datasetsfor cultural competence in behavioral health.

Currently, both the Joint Commission on Accredi-tation of Health Care Organizations (JCAHO),whichregulates hospitals,and the National Committee onQuality Assurance (NCQA), which developed theHealth Plan Employer Data and Information Set(HEDIS) measures to evaluate health plan performance,have quality indicators related to cultural competencelimited to language access. These measure the numberof bilingual/multilingual providers and staff available;they have not addressed the complexities of languageaccess or cultural appropriateness.

The Agency for Health Care Policy and Research(AHCPR) developed the Healthcare Cost and Utiliza-tion Project Quality Indicators (HCUP QIs),a set of 33clinical performance measures that informs hospitals'self-assessments of inpatient quality of care as well asstate and community assessments of access to primarycare. Three primary dimensions include:adverse hospi-tal outcomes,inappropriate utilization of hospitalprocedure, and avoidable hospital admissions. The abil-ity of this instrument to define and track outcomes ofinterest to populations at risk can be used to includedimensions of cultural competence, and differentialrates among racial/ethnic groups.

Assessment tools to measure these indicators havealso been developed. CONQUEST, the COmputerizedNeeds-Oriented QUality Measurement Evaluation Sys-Tem, is a quality improvement software tool, alsodeveloped by the AHCPR,comprised of clinical per-formance measures measuring quality through providercharacteristics (e.g., whether appropriate action wasprovided at the right time) and procedures which resultin better outcomes for the patient. Other assessmenttools have focused on costs and medical expenditures,or utilization patterns. The Medical Expenditure PanelSurvey (MEPS) is a nationally representative subsampleof the National Health Inventory Survey (NHIS) con-ducted by the National Center for Health Statistics(NCHS). Data are collected over multiple years,using acomputer-assisted interviewing system and includesdemographics,health status,and health insurance datarelated to expenditures. While none of these tools wasdeveloped for measuring cultural competence quality,MEPS does disaggregate use and expenditure byracial/ethnic groups, and can potentially identifyracial/ethnic variations in utilization patterns.

The development of quality improvement projectsor plans by states and trade associations has beenanother way to influence professional standards andguidelines. The incorporation of outcomes associatedwith population health status can be used to monitor andensure cultural competence as an aspect of clinical andprogram quality.

The Health Care Financing Agency (HCFA) con-tracted with Abt Associates to developrecommendations of measures to support the require-ments of Quality Improvement System for ManagedCare (QISMC) relating to cultural competence. QISMCis a set of standards and guidelines designed to ensurethat managed care organizations provide health careservices to Medicare and/or Medicaid beneficiaries inways that "protect and improve the health and satisfac-tion" of their enrollees; it is an ongoing process ofperformance assessment and improvement.51 Essentialelements include:

• Availability: needs assessments to understandcommunity needs and ethnic makeup

• Outreach: strategies tailored to communitiesbased on needs assessments

• Access:reaching patients from diverse cultures,meeting language needs,breaking down geo-graphic barriers

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• Cultural Competence:in diagnosis, treatmentregimens,patient compliance and satisfaction,and clinical outcomes.

PAYER ISSUES:MAN AGED CARE

While cultural competence initiatives often fol-lowed a separate track from the cost containment effortsof managed care, we cannot evaluate cultural compe-tence without looking at the reimbursement structure,i.e., Who pays for care? As the service delivery systemhas shifted toward a managed care model,there hasbeen a growing concern that cost containment issueswill preempt the demand for cultural competence asimportant,but too expensive.

Public payers have embraced cultural competencegiven the disproportionate share of racial/ethnic groupsin Medicaid and Medicare programs. HCFA set stan-dards for culturally and linguistically appropriateservices,and the Massachusetts Department of MedicalAssistance has a cultural competence initiative to ensurethat MCOs are responsive to diverse racial/ethnicgroups. The Massachusetts Behavioral Health Partner-ship (MBHP) also has a cultural competence initiative,in which behavioral health agencies are invited to sub-mit cultural competency plans; these plans must includean agency self-assessment and community assessmentprocess.52 This initiative promotes cultural competenceof providers within the MCO network only; an exami-nation of how MCOs are culturally competent is alsoneeded. Harvard Pilgrim Health Care has a CulturalDiversity Office that chronicles its efforts on an annualbasis with its Diversity Journal. As a MCO, it offersongoing diversity workshops to Harvard Vanguard andthe rest of its provider network to promote systemsawareness and provider training, and has diversity goalslinked to its executive compensation. Some issues yetto be reviewed among MCOs include:

• What benefits are covered in the plan? Are theyspecific and relevant to diverse populations? Isalternative medicine covered given its commonusage by ethnic minorities or is it not consideredmedically necessary?

• What about access? Does the gatekeeper func-tion, a keystone of managed care, prevent accessto care for those most in need?

• Who is eligible? How does one become enrolledin the plan? Is there adverse selection against

ethnic minority populations because they are highrisk?

• What about the provider network? Does limitingthe number of providers in a panel result in limit-ing access and choice to bilingual/biculturalproviders? How are providers evaluated as totheir level of cultural competence?

• How is patient satisfaction measured? Are sur-veys conducted only in English?

• Given the tendency among ethnic minoritygroups to underutilize services,what outreachefforts are there to promote access,availabilityand utilization by these groups?

• As MCOs develop criteria and guidelines to man-age the provider network, what consumerprotectionsand criteria are there to ensure thatthey do not inadvertently pose barriers for differ-ent racial/ethnic groups?

Whereas racial/ethnic groups are more likely tohave poor outcomes,consumer protections are neededto ensure that profiling and risk adjustment ratings arenot used by MCOs to impact adversely ethnic minoritypopulations. Given racial/ethnic differences in worldviews,utilization reviewers may deny authorization forservices based on set criteria because of a failure tounderstand the cultural issues involved. While MCOsare increasingly emphasizing a consumer-orientedapproach, quality indicators and consumer satisfactionratings are often dichotomous from cultural competentmeasures,which are deemed secondary in importanceor too costly to consider. For example, member satis-faction surveys are generally conducted only in English.Quality measures are not specific to diverse popula-tions. Ethnic identifiers of the provider network are notavailable to allow consumer choice. Measures of cul-tural competence are absent, other than providerself-report of language availability, i.e., unlike theextensive credentialling process required of providers inthe network. There are no increased rates for bilingualproviders. Reimbursement for interpretation is consid-ered a cost to be borne by the provider.

The development of provider networks andmegaproviders occurred to gain a competitive edge inmanaged care contracting. While these networks weredeveloped to provide a continuum and comprehensivearray of services,ethnic-specific services and respon-siveness to a diverse population within these networksare often diluted by the few providers available to servethe entire network, i.e., while the network is representa-

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tive of the population, services are not targeted to meettheir needs. Contracting by MCOs that favor these net-works often adversely selects against smallcommunity-based providers.

POLICY ISSUES: MANDATINGCULTURAL COMPETENCE?

The health care trends,service delivery, training ofproviders, reimbursement,and the development of stan-dards already discussed all have policy implications forcultural competence. Should cultural competence bemandated? Should we define standards and outcomesfor providers and payers to ensure a quality health caresystem responsive to all segments of the population?What are the obstacles to achieving cultural compe-tence within the health care system? What are the costimplications? Policymakers,decision makers,and leg-islators should consider the following policy issues:

Mandating the Use of Ethnic Identifiers

An underlying notion of a culturally competentsystem of care is that it is responsive to the lowest com-mon denominator of the diverse groups within the totalpopulation. To achieve cultural competence within theentire health care system,we need to start from a prem-ise that all segments of the population have equal accessto quality care. To do this,we need to examine the pop-ulation demographics, i.e., who makes up thepopulation, who is or is not served? The ability to iden-tify the ethnicity of its members is critical to itsimplementation.

This is often viewed as too costly or unwieldy,although the federal 2000 Census has already begun thisprocess by expanding the number of racial categoriesand allowing individuals to check more than oneracial/ethnic category. State health agencies in Massa-chusetts could require that all public datasets besimilarly expanded and that MCOs collect and trackethnic-specific data using federal census categories.This will enable the identification of racial/ethnic differ-ences in utilization, access,and quality, and theidentification of provider expertise. Whereas there hasbeen a history of discriminatory actions associated withethnic identification, consumer protections are essentialto avoid any adverse impact of identifying ethnicity.For example, the use of ethnic identifiers could also be

used for profiling high risk and frequent users foradverse risk selection.

Population-based vs. Geographic Criter ia

The growth of megaproviders and the developmentof regional networks have consistently defined access tocare based on geographic boundaries rather than oncommunity- and population-based criteria. Their sizeand dominance in the health care marketplace, there-fore, drive the indicators and measures being used todefine health care quality. The geographic focus inparceling out covered lives in managed care systemsand in identifying vendors to purchase services defiesthe crosscutting issues of a population focus. Whendefined from a geographic focus,specific ethnic popula-tions become more costly to serve and culturalcompetence become an add-on cost. The identificationof ethnic communities often cuts across geographicboundaries.

The use of population based criteria for payers andstate agencies in defining regions, in addition to geo-graphic boundaries,would permit greater integrationwithin the health care system,and be more responsiveto the diverse needs of communities. Individuals fromracial/ethnic groups often live in one geographic area,but identify with communities with large concentrationsin another. Regional boundaries used in the public andprivate sectors,by providers and payers,often serve tomask the identification of populations and communitieswhich define themselves across geographic boundaries,or do not make a large enough impact within any partic-ular defined boundary.

Language vs. Culture

The availability and use of interpreters is a basicand necessary criterion for a culturally competent sys-tem; however, it is not sufficient despite the fact that it isoften viewed as the sole criterion for cultural compe-tence. Most initiatives on cultural competenceemphasize linguistic access and the availability of inter-preters for non-English speaking groups. Consumerswho prefer to choose ethnic-specific providers oftencannot get institutions to identify this cultural expertisewithin their provider networks,or even to view culturalcompetence as an expertise or proficiency. Definitionsof cultural competence must go beyond interpreter sup-port to the use of bilingual providers and the integrationof cultural appropriate care.

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Eliminating Disparities in Health Status

Risk factors have been a common approach used toexamine health status,resource allocation, and programdevelopment in the public and research sectors. Manyin minority communities have objected to this approachbecause it has often had adverse consequences for eth-nic minority populations with the tendency tomarginalize the very groups that are defined. Many sup-port the use of a resiliency approach or the identificationof protective factors as an alternative to validate andpromote those elements that are positive and facilitatesurvival and adaptation within a racial/ethnic group.

The longstanding disparities in health statusamong racial/ethnic groups do need to be addressed,and are consistent with President Clinton's initiative toEliminate Disparities by 2010.53 As mentioned above,the Massachusetts Department of Public Health’sMinority Health Advisory Board assists the Departmentin achieving its goals to eliminate disparities.

At the same time, the notion of racial disparitiesuses a comparative paradigm in which Whites becomethe comparative standard. This often does not identifymeaningful trends among racial/ethnic groups withsmall sizes because their differences are masked orinsignificant in representative samples. These compar-isons also tend to ignore meaningful indicators withinracial/ethnic groups that are not significant within theWhite population. Oversampling can be used to getmeaningful sample sizes for small ethnic groups. Useof intraethnic data as comparison groups, i.e., notrequiring White comparison groups,should be consid-ered a valid research paradigm. More importantly, thesestrategies presume that we support an underlying princi-ple that the health care needs of all groups within thepopulation must be met to achieve cultural competence.

Standards: Flexibility vs. Unif ormity

It is common to expect adherence to a uniform setof professional or practice standards. Emphasis ondiversity and cultural competence challenges us toimplement standards that are flexible enough to capturethe differences within diverse populations without com-promising quality. A one-size-fits-all mentality inapplying eligibility cr iteria, credentialling standards,practice standards, etc. merely overlooks and omitsvariables essential to achieving cultural competence.The credentialling and licensure of providers shouldrequire cultural competence as a proficiency.

Culture and language are still viewed as distrac-tions or incidental to health care delivery. Existingstandards tend to emphasize individuals,not individualsin the context of families and communities,i.e., to pro-mote the health of communities. Standards mustinclude system competenciessuch as:workforce diver-sity, language capacity at all points of entry into care,population based criteria of health status,enabling serv-ices to promote access to care for underserved groups,and culturally relevant outcomes to measure client suc-cess.54 Institutions should be required to meet a set ofculturally competent quality standards. Existing stan-dards can be reviewed to assess whether or not theymeet culturally competent criteria.

Outcomes as Measured by Health Status

The growing movement toward accountability andoutcomes in the health care system must dovetail with asimilar emphasis in the area of cultural competence.This should include the identification of clinical out-comes,which are population based and culturallyrelevant. It should include system audit tools,consumerreport cards,accreditation standards,and HEDIS meas-ures that measure specific components of culturalcompetence and target improved health status as anobjective.

As we move toward an outcomes-orientedapproach, we need to ask:How do we measure it? Twoapproaches are important. Cultural and systems auditsor report cards can be used to assess the degree to whichinstitutions,providers,payers,and systems are cultur-ally competent. These can include both self-assessmentsurveys as well as independent audits. On the otherhand, existing tools measuring quality, utilization ormedical expenditures can be adapted to incorporate cri-teria for cultural competence.

Voluntary guidelines modeled after the Massachu-setts Attorney General's Community Benefits Programis another mechanism to define expected outcomes asmeasured by the health of the designated community orpopulation. Modifying and implementing the standardsdeveloped by the CMHS would provide a useful set ofcriteria and indicators for cultural competence. Devel-opment of monitoring and oversight mechanisms wouldbe important to ensure compliance.

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Mandating Cultur al Competence

Should we mandate cultural competence? Such amandate could ensure oversight, compliance andresource allocation to achieve its implementation.Undoubtedly, issues are raised by such a mandate; forexample:What should be the minimum criteria? Whoshould require it? How do we set criteria for training,research, and service?

Massachusetts could follow what has been done inCalifornia using a 3% threshold criterion. Countiesmust provide linguistic and culturally appropriate serv-ices if 3%,or at least 2500 individuals,of the populationwithin the county speak a language other than English.Massachusetts could define a threshold criterion forracial/ethnic groups within a pre-defined area of meas-urement (e.g., zip code) to ensure that services targetingthat group will be available and culturally competent.Given that racial/ethnic groups tend to cluster in geo-graphic areas,a variation might be to let communitiesdefine their own target areas.

Currently, many initiatives are limited to the inclu-sion of cultural competence in mission statements,objectives,or plans. These need to be expanded suchthat self-assessment tools,55 continuous qualityimprovement plans,and continuing education traininginclude the planning, development,and implementationof cultural competence plans and transformation withinan integrated system of care.56 Federal, state, local,andprivate entities could expand and broaden their objec-tives to define how they operationalize culturalcompetence through resource allocation, programdevelopment,quality indicators, and regulatory over-sight. Allocation of resources must be woven into andintegrated in the fabric of the care delivery system.

Where Do We Go From Here?

Many institutions have articulated a commitmentto diversity, have cultural competence initiatives, orhave offices designated to address specific needs of eth-nic minority populations. Cultural competence is coreto the mission and programs of most community-basedorganizations. The concerns of multiple stakeholdersimpinge upon the system of care. To achieve culturalcompetence within a system of care, collaborationacross multiple sectors is needed. The multiple sectorswithin the health care system include:hospitals and ter-tiary care system,community health centers andcommunity-based organizations,payers, training insti-tutions, research and outcomes,state agencies and

regulatory authorities,trade associations,legislative andadvocacy groups. We can model after best practices andlearn from past initiatives.

What Can We Do?

Integration of systems across these multiple sec-tors is needed to identify objectives and defineoutcomes which includes cultural competence as adefining criterion. While awareness of culture and theimportance of a culturally competent system has grownsignificantly over the past decades,there is still much tobe done. Mission statements,goals and objectives needto be translated into action plans. Programs and serv-ices,and more importantly, the system of care includingpayers and regulatory authorities need to be evaluatedand audited for their cultural competence. Outcomesand outcome measures for cultural competence needdevelopment,implementation and oversight to ensurecompliance throughout the system and its multiple sec-tors. What can each of these sectors do?

Providers

The provider community can institute agency stafftraining, prevention,community health education activ-ities and agency and self-assessment audits whichexamine, identify, and promote cultural competence inthe delivery of care. These can include cultural compe-tence as objectives in their strategic plans,and developadministrative and clinical quality performance meas-ures to achieve them.

Trade Associations

Trade associations can support clinical practices,organizational systems,licensure, credentialling, andprofessional standards that require training and profi-ciency in cultural competence not only for theirmembers,but also within the association.

Public Sector

State and local agencies can ensure that commu-nity-based vendors will be eligible and competitive fordollars that are outsourced. They can provide regula-tory oversight which mandate culturally competentquality indicators. They, too,can do self-assessment andsystem audits to examine, identify, and promote culturalcompetence in their activities. It is important that theyidentify and bring to the table, racial/ethnic profession-als with expertise in cultural competence to review and

15

provide input into oversight,regulatory, and other activ-ities related to health of communities.

Payers

Payers can respond to health of the communityobjectives,and use a population based approach in thedefinition of benefits and protocols. Design of benefitpackages,utilization management activities, creden-tialling, and quality assurance must be relevant toethnic-specific populations,and support small ethnic-specific, or community-based providers. Risk factorrating adjustments and population based profilingshould have as its goal, the reduction of disparities,notadverse selection or the reduction of costs.

Regulators

Regulatory authorities, training and accreditinginstitutions can provide guidelines and standards toensure that training of providers and oversight ofproviders and institution are culturally competent. Thismay include the review of licensure, credentialling cri-teria, HEDIS measures,and accreditation site visitors.They can ensure that racial/ethnic professionals withexpertise in these areas are included in the process.

Legislators / Policymakers

Legislators and policymakers can create a legisla-tive or regulatory mandate to require the achievement ofcultural competent indicators. Cultural and linguisticcompetence standards using a 3% threshold criterioncan require the provision of culturally competent serv-ices if 3% of a particular racial/ethnic group resideswithin the defined geographic area. Legislators can alsoconsider the recommendations of state initiatives,asthey are developed.

Consumers

Patients and their families,or consumers,can insiston cultural competence in the measurement of patientsatisfaction. The use of report cards is a means bywhich to hold institutions and providers accountable.Consumers can define their own cultural and linguisticneeds and the ways in which the system can be respon-sive to them.

Conclusions

In conclusion, this is a New Age of economicimperatives. As we enter the 21st century, the healthcare system is evolving toward an integrated system ofcombined hospital and community systems,health andmental health,Western and traditional medicine, pri-mary and tertiary, technology and clinical practice, etc.As providers and systems strive to gain market share,competition for patients and covered lives becomesforemost. Regional systems,alliances,mergers, andnetworks have become commonplace withmegaproviders dominating the marketplace and defin-ing the health care system.

Whereas the emergence and advocacy for culturalcompetence within health grew from the ranks of com-munity-based systems targeting ethnic-specificpopulations, it is essential that these systems do notbecome defunct as the health care system evolves. Toachieve cultural competence within a system of care,collaboration across multiple sectors is needed. Whileawareness of culture and the imperative of cultural com-petence has grown significantly over the past decades,there is still much to be done. Mission statements,goalsand objectives need to be translated into action plans.Programs and services,and all aspects of the system ofcare including payers and regulatory authorities need tobe evaluated and audited as to their level of culturalcompetence. Standards of culturally competent careneed to be mandated, developed, implemented andmonitored throughout the system and across its multiplesectors. As we have shifted from cultural sensitivity tocultural competence, we now must shift to the develop-ment of standards and measurement of outcomes forcultural competence.

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Appendix A*

Draft Standards for Cultur ally and Linguistically Appropriate Services (CLAS) Version 1:July 1998,Revisedwith Advisory Committee input: September 1998

1. Health care providers have a responsibility to offer culturally and linguistically appropriate services (CLAS) toensure accessible and quality health care for diverse populations.

2. Providers should make available for all limited English proficient (LEP) individuals oral bilingual/interpretationservices.

3. Providers should provide oral and written notices,including translated signage at key points of contact,to clients intheir primary language informing them of their right to receive no-cost interpreter services.

4. Providers and other agencies that communicate with LEP about health related matters should translate and makeavailable commonly-used written materials and signage for members of the predominate language groups in theirservice areas.

5. Providers and policymakers should support the development and adoption of national standards for health careinterpreting, training, and skills assessment. In the meantime, providers should be required to ensure that interpretersand bilingual staff can demonstrate: bilingual proficiency, training that includes the skills and ethics of interpreting,and fundamental knowledge in both languages of any specialized terms and concepts peculiar to the program or activ-ity. The skills and fluency of interpreters should be evaluated on an ongoing basis.

6. Providers should have an organized management strategy to address culturally and linguistically appropriate serv-ices (CLAS),including plans,policies,procedures,and responsible individuals.

7. Providers should have formal mechanisms for community and consumer input/involvement at all levels of servicedelivery, including planning, operations,evaluation, training, and, as appropriate, treatment planning.

8. Providers should require and, as appropriate, offer ongoing education and training of administrative, clinical, andsupport staff in cultural competent service delivery.

9. Providers should recruit, retain and promote a diverse and culturally competent administrative, clinical, and sup-port staff.

10. Providers should develop (or integrate into existing mechanisms) institutional policies and procedures to addresscomplaints by patients and staff about unfair, culturally insensitive or discriminatory treatment.

11. Providers should collect information about clients' primary (at-home) language use and include this informationin any patient records used by provider departments.

12. Providers should use a variety of methods to collect and utilize demographic, cultural and epidemiological dataabout communities in the provider's service area,and on the ethnic/cultural needs of its own patients.

13. Providers should implement ongoing organizational self-assessments of cultural competence, and integrate meas-ures of access,satisfaction,quality, and outcomes for CLAS in other organizational internal audits.

*Di versity Rx is sponsored by: The National Conference of State Legislatures,Resources for Cross Cultural Health Care, The Henry J. Kaiser Family Foundation.URL: http:///www.diversityrx.org

Appendix B*

Systems Checklist of Cultur al Competence Questions

CULTURALLY COMPETENT CARE

• Is staff adequately trained to work with diverse populations of the community served?

• Do patients have the choice to see a provider from their own culture?

• Do beneficiaries from minority populations receive more critical and relevant interventions reflectingdisparities?

• Do they express satisfaction with their care? Are surveys reaching out and representing non-Englishpopulations?

• Are community outreach and education programs focused on disparities prevalent within diversepopulations?

• Are there guidelines for medical interpreting available?

• Are there financial provisions to support institutionalizing cultural competence throughout the organization?

CULTURALLY COMPETENT ACCESS TO CARE

• Does the agency welcome and outreach to racial/ethnic groups in their target area?

• Is there diversity and representation of minority professionals and managers within the system?

CULTURALLY COMPETENT QUALITY MEASURES

• What quality measures are there to measure cultural competence at all points of the system?

• What are the utilization patterns,enrollment rates,and health status indicators for diverse groups?

• Do patient satisfaction measures reflect differences within the population?

ACCESS

• Do all groups have equal access to services offered by the system?

QUALITY

• Are there quality indicators specific to population based measures of health status?

*Jean L. Chin,Ed.D.

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18

References

1 U.S. Bureau of the Census. Statistical Abstractof the U.S., 1995.

2 Chen MS, Hawks BL. A debunking of the mythof healthy Asian Americans and Pacific Islanders.American Journal of Health Promotion 1995;9(4):261-268.

3 Cross T, Bazron BJ, Dennis KW, Isaacs,MR.Towards a culturally competent system of care. Vol. 1:Monograph on effective services for minority childrenwho are severely emotionally disturbed. Washington(DC): CASSP Technical Assistance Center, George-town University Child Development Center; 1989.

4 Id.

5 The Task Force on Multicultural Competence(California):Summary of Findings,February 1993.URL: http://www.dhs.cahwnet.gov

6 White K,Community and Family Health Multi-cultural Work Group,Washington State Department ofHealth. Building cultural competence:a blueprint foraction. Austin (TX):National Maternal and ChildHealth Resource Center on Cultural Competency; 1995.

7 De La Cancela V, Chin JL,Jenkins YM. Com-munity Health Psychology: empowerment for diversecommunities. New York: Routledge; 1998.

8 Cox TH. Cultural diversity in organizations:the-ory, research & practice. San Francisco:Berrett-Koehler; 1994.

9 Arrendondo P, Toporek R,Brown S, Jones J,Locke DC,Sanchez J, Stadler H. Operationalization ofthe Multicultural Counseling Competencies. The Dawnof a New Century, Leading the way to competent multi-cultural counseling and development. Alexandria (VA):AMCD; 1996.

10 Kleinman A. How is culture important forDSM-IV? Culture and psychiatric diagnosis:a DSM-IV perspective. Washington (DC):AmericanPsychiatric Association Press; 1996.

11 Sue DW, Sue D. Counseling the culturally dif-ferent:theory and practice. New York: John Wiley &Sons; 1990.

12 Bennett JM. Intercultural communication incultural self-awareness. Minneapolis:University ofMinnesota; 1984.

13 Tervalon M,Murray-Garcia J. Cultural humil-ity versus cultural competence:a critical distinction indefining physician training outcomes in multiculturaleducation. Journal of Health Care for the Poor andUnderserved 1998;9(2):117-125.

14 Welch, M. Culturally competent care fordiverse populations. Bureau of Primary Health CareProgram. 1997. URL:http://www.bphc.hrsa.dhhs.gov

15 Beyond Language Differences:The role of cul-tural beliefs and practices in health care. OpeningDoors:Reducing sociocultural barriers to health care.Menlo Park (CA): Kaiser Family Foundation; 1997.

16 Hoang GN, Erickson RV. Cultural barriers toeffective medical care among Indochinese patients.Annual Review of Medicine 1985;36:229-39.

17 Pediatric Access Project:Investigating theimpact of language barriers on children's health care.Opening Doors:Reducing sociocultural barriers toHealth Care. Menlo Park (CA): Kaiser Family Founda-tion; 1997.

18 Welch, M. Why do we need to do diversity andcross cultural work in medicine? Culturally competentcare for diverse populations; 1998. URL:www.ucsf.edu

19 Heckler MM. Report of the Secretary’s TaskForce on Black and Minority Health. Washington,DC:U.S. Department of Health and Human Services; 1985.

20 Asian Pacific Islander American Health Forum.Comments by APIAHF regarding the Draft Objectives;1998. URL:http://www.apiahf.org

21 Kuo J, Porter K. National Center for HealthStatistics. Health Status of Asian Americans,UnitedStates,1992-94,Advance Data. 1998 Aug 7;298:1-13.

22 The Commonwealth Fund. Bettering the healthof minority Americans. New York: The Common-wealth Fund; 1995.

23 URL: http://raceandhealth.hhs.gov

24 One America in the 21st Century: Forging aNew Future – Report of the Race Advisory Board.Washington (DC):The White House; 1999.

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25 URL: http://web.health.gov/healthypeople

26 Ferebee A. Providing culturally appropriateservices:local health departments and community-based organizations working together. CooperativeAgreement between National Association of CountyHealth Officials and U.S. Public Health Service, Bureauof Primary Health Care 1994. Reference #CSU110033.

27 Massachusetts Department of Public Health,Bureau of Health Statistics,Research and Evaluation,Bureau of Family and Community Health. Chinese andSoutheast Asian births in Massachusetts. Boston:MDPH; 1993.

28 Office of Research and Health Statistics,TheHealth of Boston,1989-94. Division of Public Health,Trustees of Health and Hospitals,The City of Boston;1996.

29 Attorney General’s Community Benefits Guide-lines for Nonprofit Acute Care Hospitals.Massachusetts Office of the Attorney General; June1994.

30 Attorney General’s Community Benefits Guide-lines for Health Maintenance Organizations.Massachusetts Office of the Attorney General; Febru-rary 1996.

31 Barker JC. Cultural diversity—changing thecontext of medical practice. Western Journal of Medi-cine 1992;157(3):248-254.

32 Welch M, see note 13.

33 De La Cancela et al,see note 6.

34 Like R,Prasaad S, Rubel A. STFM core cur-riculum guidelines. Recommended core curriculumguidelines on culturally sensitive and competent healthcare. Family Medicine 1996;28(4):291-7.

35 Kaufman A, Waterman RE. Health of the pub-lic: a challenge to academic health centers. The PewCharitable Trusts and the Rockefeller Foundation;1993.

36 Beth Israel Deaconess Medical Center. Servinga diverse patient population: the business case for cul-tural competence. Boston:Beth Israel DeaconessMedical Center; 1997.

37 Board of Ethnic Minority Affairs. Guidelinesfor providers of psychological services to ethnic, lin-

guistic, and culturally diverse populations. Washington(DC): U.S. Office of Ethnic Minority Affairs; 1990.

38 Kim S, McLeod JH,Shantzis C. Cultural com-petence for evaluators working with Asian Americancommunities:some practical considerations. In:Orlandi MA,Weston R,Epstein LG, editors. Culturalcompetence for evaluators:a guide for alcohol andother drug abuse prevention practitioners working withethnic/racial communities. Rockville (MD): Office forSubstance Abuse Prevention,U.S. Department ofHealth and Human Services; 1992.

39 The Task Force on Multicultural Competence(Summary of Findings February 1993). Office of Mul-ticultural Health,California Department of HealthServices.

40 (California) DMH Information Notice No:97-14. Addendum for implementation plan for phase IIconsolidation of Medi-Cal specialty mental health serv-ices--cultural competence plan requirements; 1997.

41 Mock MR. The imperatives of cultural compe-tence:acknowledging culture in psychotherapy.Progress:Family Systems Research and Therapy.Encino (CA):Phillip Graduate Institute, University ofCalifornia; 1998.

42 DiversityRx News 10/98. URL:http://www.diversityrx.org

43 Diversity Rx is sponsored by: The NationalConference of State Legislatures,Resources for CrossCultural Health Care, The Henry J. Kaiser FamilyFoundation. See also,URL: http://www.diversityrx.org

44 URL: http://www.bphc.hrsa.dhhs.gov

45 Woloshin S, Bickell NA, Schwartz, LM, GanyF, Welch G. Language barriers in medicine in the U.S.,Journal of American Medical Association,1995;273(9):724-8.

46 Substance Abuse, Mental Health ServicesAdministration, Center for Mental Health Services,TheWestern Interstate Commission for Higher Education.Cultural competence standards in managed care, mentalhealth services for four underserved/underrepresentedracial/ethnic groups. Rockville (MD): SAMHSA,CMHS; 1998.

47 Western Interstate Commission on Higher Edu-cation. Cultural competence assessment tools. Boulder(CO):WICHE; 1996.

48 Mason J. A practical guide for the assessmentof cultural competence in children's mental healthorganizations. Technical Assistance Center for theEvaluation of Children's Mental Health Systems,Port-land (Oregon) State University; 1995.

49 Weiss CI,Minsky S. Program self-assessmentsurvey for cultural competence:a manual. Trenton(NJ):New Jersey Division of Mental Health Services,CN727; 1996.

50 SAMHSA, CMHS. Cultural competence reportcard items. Rockville (MD): SAMHSA, CMHS; 1998Jan.

51 Abt Associates,Inc. Research approach for rec-ommendations for measures to support efforts toimprove cultural competence. Cambridge (MA): AbtAssociates; 1998.

52 Chin JL. Developing a cultural competencyplan. Presented at: The Quality Forum,MassachusettsBehavioral Health Partnership,1998.

53 Eliminating Racial Disparities Initiative. URL:http://raceandhealth.hhs.gov

54 Chin JL. Quality of Care guidelines for con-ducting culturally valid assessments. Presented at: TheConference on Conceptual,Methodological and Practi-cal Issues in the Mental Health Assessment of AsianAmericans,University of California,Davis, 1998.

55 Mason J. Cultural competence self assessmentquestionnaire:a manual for users. Portland (OR) StateUniversity, Research and Training Center on Familysupport and Children's Mental Health; 1995.

56 Hernandez M,Isaacs MR. Promoting culturalcompetence in children's mental health services. Balti-more:Paul H. Brookes Publishing Co.; 1998.

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