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ExecutiveSummaryThe Pediatric Integrated Care System (Ped‐I‐Care) at The University of Florida (UF) and the South Florida Community Care Network (SFCCN) operate as one plan under contract to the Children’s Medical Services Network (CMSN) of Florida. Ped‐I‐Care and SFCCN are Provider Service Networks (PSNs) for children with special health care needs (CSHCN) whose families qualify by income. Fundamental to the provision of quality medical services is its commitment to culturally and linguistically competent services. As legislated by the Patient Protection and Affordable Care Act (ACA) of 20141, and as stipulated specifically in the Medicaid Managed Assistance (MMA) contract between the Integrated Care Systems (ICSs) and CMSN, this plan describes how members’ needs are met using appropriate tools, training items, support materials, and methods of annual evaluation. Cultural competence is more than a bureaucratic exercise; it is an authentic grasping of the attitude that every individual has worth and as such their dignity must be respected and preserved.2 In pursuit of this vision, Ped‐I‐Care and SFCCN and leverage a 4‐pronged approach to the provision of culturally and linguistically competent services. This approach involves:

Appropriate Delivery of Care and Services o Both ICS plans are well‐staffed to meet the known linguistic preferences of its members.

Additionally, its staff are representative of the larger populations within which they are situated. Staff and leadership are actively involved in a variety of community‐based activities.

Linguistic and Communicative Tools o Language lines, translation services, and TTY/TTD services are used to meet the linguistic

needs of members.

Education and Training o Ped‐I‐Care and SFCCN employees, as well as providers, may choose from 3 training

sources made freely available online and via hard copy. o A resource toolkit of supplemental sources and support is also made available to

enhance the CLC efforts of all who interact with CMS clients.

Continued Research o The ICS plans are actively involved in furthering the progress of CLC care, by way of self‐

examination, regular evaluation of scholarly and industry material, and contributions to local, regional, and national discussions on the topic. The conceptual footprint described in this plan have been presented and discussed at national conferences and made available for Continuing Medical Education credits at a 2014 Association of American Medical Colleges’ (AAMC ) meeting.3

Annual evaluation of this plan will be conducted using the Cultural & Linguistic Competence Self‐Evaluation and Measurement Form (CLC‐SEM©), data from the annual Consumer Assessment of Health Providers & Systems (CAHPS) annual survey conducted by The Institute for Child Health Policy (ICHP) at UF, and member feedback.

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Who We Are: ICS Leadership & Staff Ped‐I‐Care, SFCCN, and its sub‐networks have staff available to meet the cultural and linguistic needs of its populations. These staff members provide culturally sensitive information and the linguistic skills required for meeting the needs of members. If staff are not available for a non‐prevalent language, outside interpretation services are used to meet the need of the individual enrollee. Ped‐I‐Care and SFCCN capture member feedback relating to cross‐culture issues, which are reviewed and addressed by the Quality Improvement departments within each organization. Network providers are educated on the availability of interpretation services. The organizations’ Provider Credentialing Applications also capture each provider’s self‐identified ethnicity, culture, and race (if provided). The application also includes a question about other languages spoken by providers to indicate their linguistic diversity – this information is used in the provider directory for informational purposes to enrollees. This information is available via the CMSN, Ped‐I‐Care, and SFCCN websites are updated periodically. The delivery of care and services is examine through the lens of cultural and linguistic competence via quality methods such as Performance Improvement Plans (PIPs), medical record reviews, member satisfaction surveys, and provider satisfaction surveys. Who We Serve: Our Member Population The Institute for Child Health Policy (ICHP) at UF annually surveys CMSN members and their families, querying demographics, customer satisfaction, patient‐centered care, and other domains inclusive within the Consumer Assessment of Healthcare Providers and Systems (CAHPS)8 assessment. In so doing, it also captures demographic information for assistance in understanding the cultural and linguistic characteristics and needs of its member population. As shown in Figure 1 from the most recent ICHP report9, reflecting combined demographic information for Duval and Broward counties the 2012‐2013 contract period,

72% of caregivers spoke English as their primary language, 19% spoke Spanish as their primary language, and 9% spoke a language other than English or Spanish as their primary language;

59% of caregivers were Hispanic;

80% of caregivers reported at high school diploma/GED or higher level of educational attainment;

90% of respondents were female; and

53% of caregiver respondents were of a single‐parent household. Respondents additionally noted they were interested in support and guidance relevant to parenting issues; they would like to be informed of youth mentoring programs that may be of benefit to their children; and they are interested in other resources to help their families become increasingly independent.

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o SFCCN’s member services departments are able to communicate with enrollees in English, Spanish, and Creole, as Spanish and Creole languages and cultures are the most prevalent in the SFCCN service area. The interpreter phone service is a secondary language access service that allows the health plan to communicate with those non‐English, non‐Spanish, or non‐Creole enrollees. Each of the subnetworks of SFCCN uses a different interpreter phone service vendor which is listed below: Memorial Healthcare System uses Optimal Phone Interpreters (1‐877‐746‐4674) Broward Health uses Language Line Services (1‐866‐874‐3972) Public Health Trust uses Language Line Services (1‐866‐874‐3972)

o SFCCN’s first contact with each enrollee begins with a welcome Letter. The mailings are in English and Spanish, the prevalent languages in Miami‐Dade and Broward Counties. Within each letter is a special adage that states that materials are available in other languages or formats if needed.

o Websites available to assist all CMSN members and providers with translation services, including but not limited to: A U.S. Census Bureau document entitled, “I Speak,”10 that has the following

statement in 38 languages: “Mark this box if you read or speak (language).” This is available at http://www.justice.gov/crt/about/cor/Pubs/ISpeakCards.pdf.

The Florida Agency for Workforce Innovation offers a document with the following statement in 21 languages: “If you do not speak English, or if you are deaf, hard of hearing, or sight impaired, you can have interpreter and translation services provided at no charge. Please ask for assistance.”11 This is available at http://www.floridajobs.org/PDG/PostersforEmployers/IS%20Poster%2011x17.pdf.

An online resource that provides an index to more than 6,900 known living languages12 is http://www.ethnologue.com/web.asp.

Education and Training o The goals of this plan are such that CMSN employees and its network of providers,

liaisons, and affiliates will be able to access the same basic training and growing list of health literacy and cultural competency resources. The aim is to increase awareness and appreciation of customs, values and beliefs, and the ability to incorporate them into the assessment of, treatment of, and interactions with enrollees. CMSN strongly entreats providers and staff to share or utilize their own cultural diversity to improve the services provided to our enrollees.

o Training has been developed to educate employees and providers in the requirements of laws and standards; definitions and understanding of the nature of CLC; and how CLC intersects with PCC for the provision of high‐quality, efficient, and appropriate care. This training13 is freely available, online, at http://pedicare.peds.ufl.edu/media/Cultural‐and‐Linguistic‐Competence‐Training‐Spring‐2013.ppt. ICS staff members are required upon hire to complete Cultural and Linguistic

Competence training. Contracted Providers’ offices are responsible for providing cultural competency training for all office personnel and staff; 3 training resources are made available to providers for their use if they choose. There is no cost to access this training.


o Employees and providers may additionally access educational and support materials listed in the resource toolkit. This toolkit is organized to include web‐based, print, and telephonic sources relevant to CLC goals.

Continued Research o CMSN will complete an annual evaluation of the effectiveness of its CLC plan. This will

involve consideration of provider and member feedback via the CLC complaint resolution tool; annual ICHP survey results; and the CLC‐SEM tool.

o When appropriate and feasible, Ped‐I‐Care and/or SFCCN employees will contribute to local, regional, and/or national scholarly discussions on the topic of CLC.

GoalsandEvaluationfor2014‐2015 In response to the above review and findings, CMSN will take on a new activity in 2015 to support members and their families. The plan will develop a resource guide for each of the 67 counties in its Florida; the guide will be made accessible to members, providers, CMS Nurse Care Coordinators, and others via the ICSs’ website. The guide will be organized to include items which directly address member feedback on the annual satisfaction survey, as well as each of the areas of quality enhancement described in the pending Medicaid expansion project. The resource guide topics will include:

Parenting support

Youth mentoring

Language assistance

Pregnancy prevention

Prenatal care

Tobacco cessation

Assistance for those who are homeless

Prevention of domestic violence and assistance for its victims

Prevention of and treatment for juvenile delinquency

Prevention and treatment of alcoholism

Financial guidance and support

Prevention of and assistance with addressing obesity

CMSN will additionally continue to:

Update its Resource Toolkit;

Require all new employees to complete CLC training;

Hire additional Spanish‐speaking member services staff as necessary;

Provide member materials at the fourth‐grade level;

Maintain a website that is Section 508 compliant;

Offer member services assistance in the language of member preference, at no charge;

Maintain a TTY/TDD line for members with hearing impairments;

Follow the scholarly literature; and

Make its plan freely available online and in hard copy format at no charge.

Evaluation

Annual evaluation of this plan will be conducted using the Cultural & Linguistic Competence Self‐Evaluation and Measurement Form (CLC‐SEM©) as well as data from the annual CAHPS survey. It is noted that while the annual surveys are routinely conducted to evaluate the previous year, the detailed data reports encapsulating these findings are not distributed to the ICSs until the following service year.


As such, there will not be a one‐to‐one chronological correlation to match with the plans’ annual self‐evaluation. The data are nevertheless rather valuable, and used to guide policy and decision making regardless of the time at which they are received. Data for evaluation of the 2015 service year would likely be delivered to the ICS plans 6 months to 1 year after the 2016 revised CLC plan is due. Ped‐I‐Care and SFCCN both track and trend cross‐cultural complaints and grievances and are prepared to implement interventions as concerns are brought to the attention of staff members. Through a comprehensive set of evaluations for both plans, examining the 2013‐2014 period, no issues of this nature have been identified. CMSN will continue to promote cultural competent communication and service delivery within, throughout, and across our networks.

SummaryWith strong individual foundations in CLC and long‐standing, positive relationships amongst SFCCN, Ped‐I‐Care, and CMS, the CMSN is well‐poised to move forward along the cultural competence spectrum. In the 2014 – 2015 contract year period, members will enjoy access to information on community‐based resources designed to meet needs across various facets of their lives. As a means by which to connect members and families to mentoring and support services, the county‐by‐county resource guide will additionally align CMSN activities with Quality Enhancement stipulations named in the MMA contract. As such, the cultural and linguistic competence plan for CMSN addresses members’ and families’ health care and other needs.

References1. Office of the Legislative Counsel for the Use of the US House of Representatives. Compilation of

Patient Protection and Affordable Care Act. Available at http://housedocs.house.gov/energycommerce/ppacacon.pdf. 2010.

2. Giunta N, Saliba H, Osakwe O. Beyond the Basics: A Proactive Approach to Culturally‐Appropriate Client Communications and Service Delivery. 2010.

3. Saliba H, Rathore M, and Giunta NM. Cultural & Linguistic Competence (CLC) in Healthcare: How to Write, Implement, & Evaluate Your CLC Plan. Workshop presented at Association of American Medical College’s (AAMC) Southern Group on Educational Affairs (SGEA) annual meeting in Miami, March 2014.

4. Saliba H, Osakwe O, and Giunta N. Cultural Competency in the Healthcare Setting: Navigating the Now, Negotiating What’s Next. Poster presentation at Southern Group on Educational Affairs’ annual meeting in Lexington, Kentucky. 2012.

5. Cross et al. Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. 1989.

6. National Center for Cultural Competence at Georgetown University. Website: http://nccc.georgetown.edu/.

7. National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health. US Department of Health and Human Services. Website: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15.

8. Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Agency for Healthcare Research and Quality (AHRQ). Website: https://cahps.ahrq.gov/about‐cahps/index.html.

9. Knapp et al. Children’s Medical Services Network Evaluation of Non‐Reform and Reform Healthcare for Title XIX Enrollees / Contract Period 2012‐2013. Report Prepared by the Institute for Child Health Policy at the University of Florida, August 2013.

10. I Speak reference card, U.S. Census Bureau. Available at http://www.justice.gov/crt/about/cor/Pubs/ISpeakCards.pdf.

11. Interpretive Services resource. The Florida Agency for Workforce Innovation. Available at http://www.floridajobs.org/PDG/PostersforEmployers/IS%20Poster%2011x17.pdf.

12. Ethnologue online language resource. Available at http://www.ethnologue.com/web.asp. 13. Saliba H, Rathore M, Brunner N, and Giunta NM. Cultural and Linguistic Competence Training for

CMS/Ped‐I‐Care Employees, Providers, and Practices. Available at: http://pedicare.peds.ufl.edu/media/Cultural‐and‐Linguistic‐Competence‐Training‐Spring‐2013.ppt. 2013.

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