“ The Enhanced Culturally and
Linguistically Appropriate Services
in Health and Health Care (CLAS)
Standards”: Another Tool To
Facilitate Health Outcomes
Guadalupe Pacheco, MSW
President/CEO, Pacheco Consulting Group, LLC
October 9, 2014
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Presentation Themes
Changing Demographics
Health Disparities/Social Determinants of Health
What is CLAS?
CLAS Awareness
CLAS Standards Enhancement Initiative
Describe the CLAS Standards 2.0
Summary/Questions
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Changing Demographics
*Sources: U.S. Census Bureau,
Population Reference Bureau, 2008
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America's estimated 2.5 million gay seniors are
twice as likely to live alone, four times less likely to
have adult children to help them, and far more
fearful of discrimination from health care workers.
Older adults may not be aware of the
services recommended for their age group or
may not know that the services are covered
by Medicare.
Young people from racial and ethnic
minority groups in the United States suffer
disproportionately from a number of
preventable diseases and health problems.
American Indians and Alaska
Natives have a lower life expectancy
than other Americans perhaps due to
economic adversity and poor social
conditions.
Disparities in America (Source: DHHS, OMH,2012)
Social Determinants of Health:
Why Are Culturally and Linguistically
Appropriate Services Important?5
• Services that are respectful of and responsive to
individual cultural health beliefs and practices,
preferred languages, health literacy levels, and
communication needs and employed by all
members of an organization (regardless of size)
at every point of contact.
• Use CLAS as a tool to eliminate/reduce racial & ethnic health disparities
What Are Culturally and Linguistically
Appropriate Services?
*Source: National CLAS Standards, HHS OMH, 2013
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CLAS Awareness
Office of the Inspector General Report on Guidance and Standards on Language Access Services (Medicare Providers/Medicaid) – 2010
National Committee on Quality Assurance-Standards & Guidelines in Multicultural Health Care Settings – 2010
Affordable Care Act (19 references to cultural competency) –2010
The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals - 2010
National Quality Forum Healthcare Disparities and Cultural Competency Consensus Standards project – 2011
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CLAS Awareness: State Level
Cultural Competency Legislation
*Source: Think Cultural Health, 2011
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CLAS Awareness: 2000-2012:
Publications/Citations
0
500
1000
1500
2000
2500
3000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Numbers of Publications and Citations
Number of Publications Number of Citations*
* Reported citations are approximated based on Web of Science® analysis
reporting.
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National Standards for Culturally and
Linguistically Appropriate Services in
Health and Health Care (CLAS)
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Launched: 2013Enhanced National CLAS Standards
Development: 2011Analysis Consultations Drafting
Research: 2010
Literature Review Public Comment Advisory Committee
11National CLAS Standards
Enhancement Initiative: Timeline
Institutions and Associations• American Medical Association
• American Nurses Association
• American Public Health Association
• Asian and Pacific Islander American Health
Forum
• Association of Asian Pacific Community Health
Organizations
• Blue Cross Blue Shield
• Institute for Diversity in Health Management
• Johns Hopkins University
• Joint Commission
• Kaiser Permanente
• Massachusetts Executive Office of Health and
Human Services Medicaid Program
• National Business Group on Health
• National Center for Cultural Competence
• National Council of Asian Pacific Islander
Physicians
• National Committee for Quality Assurance
• National Health Law Program (NHeLP)
• National Hispanic Medical Association
• National Medical Association
Institutions and Associations (con’t)• National Public Health and Hospital Institute
• Southcentral Foundation
• Texas Health Institute
• University of Albany, SUNY
• University of California, Davis
• University of Medicine and Dentistry of New
Jersey
Federal• Administration for Children and Families
• Administration on Aging
• Agency for Healthcare Research and Quality
• Centers for Disease Control and Prevention
• Centers for Medicare and Medicaid Services
• Health Resources and Services Administration
• Indian Health Service
• National Institutes of Health
• Office for Civil Rights
• Office of the Assistant Secretary for Legislation
• Office of Minority Health*
• Office on Women's Health
• Substance Abuse and Mental Health Services
Administration
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National CLAS Standards Enhancement
Initiative: Advisory Committee
*Convener
All National CLAS Standards are of equal importance:
The enhanced National CLAS Standards promote collective
adoption of all Standards to most effectively affect the health and
well-being of all Americans.
Each of the 15 Standards is equally important to an organization’s
ability to advance health equity, improve quality, and help eliminate
health care disparities.
CLAS Enhancements 13
CLAS Video
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Enhanced CLAS Standards
The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations to:
Principle Standard
1) Provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.
Theme 1) 2-4: Governance, Leadership, and Workforce
Theme 2) 5-8: Communication and Language Assistance
Theme 3) 9-15: Engagement, Continuous Improvement, and Accountability
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National CLAS Standards
Principal Standard
Governance, Leadership and Workforce
Communication and Language Assistance
Engagement, Continuous Improvement, and Accountability
1
2-4
5-8
9-15
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All National CLAS Standards are of equal
importance:
The enhanced National CLAS Standards promote collective
adoption of all Standards to most effectively affect the health and
well-being of all Americans.
Each of the 15 Standards is equally important to an organization’s
ability to advance health equity, improve quality, and help eliminate
health care disparities.
Original 2000 CLAS Standards, each Standard was designated as
a recommendation, mandate, or guideline.
CLAS Enhancements 17
Comparison – 2000 and 2012
CLAS Standards
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2000 Standards 2012 Standards
Goal: to decrease health care disparities
and make practices more culturally and
linguistically appropriate
Goal: to advance health equity, improve
quality and help eliminate health and health
care disparities.
“Culture”: racial, ethnic and linguistic groups “Culture”: racial, ethnic and linguistic
groups, as well as geographical, religious
and spiritual, biological and sociological
characteristics
Audience: health care organizations Audience: health and health care
organizations
Implicit definition of health Explicit definition of health to include
physical, mental, social and spiritual well-
being
Recipients: patients and consumers Recipients: individuals and groups
1-Principle Standard
Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.
Creates a safe/welcoming environment/appreciation of diversity/focuses on patient-centered care
Individuals receive services in a culturally and linguistically appropriate manner to enable them to meet their communication needs/understand their care & participate in their care
To eliminate discrimination and disparities
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Scale of Justice-Equal Representation-
Equal access to health care
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2: Advance and sustain governance and
leadership that promotes CLAS and health
equity through policy, practices and allocated
resources (2-4: Governance, Leadership & Workforce)
Mission statement/core values/vision statement-promoting health equity
Commitment from top board, management leadership,
Management/board set policy/program goals, development of strategic plan
of promoting organizational diversity, providing CC care, eliminating health
disparities; written policies, practices, procedures, programs, etc.
Provide fiscal, human resources, tools, skills, and knowledge to support a
culturally competent organization.
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CLAS Management 22
3: Recruit, Promote, and Support a Diverse
Governance, Leadership, and Workforce
Top Management should promote diversity throughout the organization, including board membership
Support not only recruitment but retention, and promotion as well
Use traditional and untraditional job advertisement approaches; use ethnic media, partner with minority health organizations, religious groups, chamber of commerce chapters, business groups
Work with minority serving institutions
Use social media methods (Facebook, Link-in, Twitter, etc.)
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Inclusion 24
4: Educate and Train Governance,
Leadership, and Workforce in CLAS
CLAS education and training for professionals working in health/human services must be ongoing;
Training should be based on sound educational principles (adult learning, pre-test, post-test, knowledge based, skill-based, attitude-based)
Training in the areas of effective communication, health literacy, socio-economic status, race, ethnicity, effects of cultural differences in access heath and other human services;
Applicable civil rights laws, Affordable Care Act of 2010, Title VI of the Civil Rights Act of 1964, HHS Title VI Guidance for LEP Individuals.
Integration of CLAS in agency training to ensure it becomes part of the organizational culture
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5: Offer Communication and Language
Assistance (5-8: Communication and Language
Assistance)
Establish a process to inform LEP individuals of their right to receive
language assistance at no cost to them
All notifications should be conducted the right literacy level of the LEP person
Organizations should notify LEP individuals in their preferred language of
language assistance, “I speak” cards or other new forms of technologies
(Ipad, Iphone, Apps)
Point-of entry (intake) should be used to language assistance notifications
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Inform Availability of Language
Interpreter Services27
6: Inform Individuals of Availability of
Language Assistance
Provide Organizations that receive federal funds must comply with Title VI of the 1964 Civil Rights Act, nondiscrimination provisions as it applies to LEP individuals
Oral (verbal) and Translation services (written): Interpreters/Translators
Should develop systems to provide quality interpretation services, including translation of pertinent health promotion/disease prevention and medical consent/treatment forms
Strategically should use the HHS OCR Four-factor analysis to map-out the language needs of the community
Should develop a language assistance plan to execute and monitor progress in meeting the language needs of LEP individuals
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Language Interpretation Options 29
Translations of Medical Forms 30
7: Ensure the Competence of Individuals
Providing Language Assistance
Entities should develop strategies for providing language assistance (use of trained vs untrained interpreters, bilingual staff)
Discourage the use of family or children as interpreters
Develop policies/procedures for the provision of competent language assistance services
Testing of competencies of language providers
Use nationally recognized entities for testing interpretations/translation skills (The American Translation Association, the National Council on Interpreting in Health Care, the Certification Commission for Healthcare Interpreters, and the National Board for Certification of Medical Interpreters)
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Medical Interpretation Bodies 32
8: Provide Easy-to-Understand Materials
and Signage
Purpose: To enable individuals to make informed decisions regarding their health and their care/service options: Examples of materials to translate as appropriate:
Administrative/legal documents (informed consent, living wills, emergency room/discharge releases);
Clinical information-prevention/treatment instructions, how to take medicine, how to perform self-care or self-monitoring);
Developing materials that address the literacy levels of service population
Use of multilingual signage of languages of the population
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Health Literacy34
9: Infuse CLAS Goals, Policies, and
Management Accountability Throughout the
Organization’s Planning and Operations (9-15:
Engagement, Continuous Improvement, and Accountability)
Establish CL appropriate goals and policies for the delivery of cultural competent care based on health equity concepts/ideas
CLAS should be embedded throughout various levels of the organization’s workforce (upper and lower management)
CLAS should be core elements of the organization’s identity, mission, operating principles, service focus, budget/quality improvement activities
Establish accountability mechanisms throughout the organization, staff evaluations, individuals’ satisfaction measures, and quality improvement measures
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10: Conduct Organizational Assessments
Conduct ongoing assessment (self-assessment) of the organization’s CLAS-related activities;
Conduct a cultural audit using cultural and linguistic assessment tools (structural policies, procedures, and practices—barriers to care; positive/negatives)
Use audit data to Integrate CLAS-related measures into continuous quality improvement activities
Establish feedback “loops,” internally and externally, to continuing monitor and improve on your CLAS activities (service delivery)
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11: Collect and Maintain Demographic Data
Collect demographic data such as race, ethnicity, sex, language, and disability status;
Use data to identify population groups within service area;
Ensure equal allocation of organization resources;
Use data to monitor/evaluate the impact of CLAS on health equity/outcomes/to inform service delivery.
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12: Conduct Assessments of Community
Health Assets and Needs
Conduct regular assessments of community health assets and
needs (needs assessment, resource inventory, gap analysis);
Identify potential disparities in care or services; and
Identify language and other needs of the community
Plan/implement services that respond to the cultural & linguistic
diversity of the populations in the service area
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13: Partner with the Community
Health care entities should partner w/ the community to design,
implement, and evaluate policies, practices, & services to
ensure cultural/linguistic appropriateness ( vehicle to build trust)
Health care entities should use town hall meetings, hold
community forums, and/or conduct focus groups, talking
sessions, webinars, etc. to acquire stakeholder input
Sponsor or participate in health fairs with community-based
organizations, cultural festivals, and celebrations
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CLAS Public Engagement 40
14: Create Conflict and Grievance Resolution
Processes
Create a system to address discriminatory or inequitable
practice ( unfair treatment due to race, ethnicity, sex, age,
economic status, sexual orientation, gender identity);
Create a system to meet federal/state level regulations that
address grievance procedures/appeal processes, or use of
ombudspersons.
Create conflict/grievance resolution processes that are
culturally/linguistically appropriate to identify, prevent, and
resolve conflicts or complaints;
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15: Communicating the Organization’s
Progress in Implementing and Sustaining
CLAS
Communicate to stakeholders, constituents, and general public of CLAS accomplishments;
Helps build and sustains communication on CLAS priorities/fosters trust between community and service setting
Helps meet community benefit requirements
Serves as an accountability mechanism to the community but also part of continuous improvement process
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Principle Standard:
1) Provide effective, equitable, understandable, respectful, and quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.
2) 15 CLAS Standards, Three Themes:
Governance, Leadership, and Workforce
Communication and Language Assistance, and
Engagement, Continuous Improvement, andAccountability
All the standards have equal standing.
Summary of CLAS43
“I will now take questions from the floor”
Resources
www.thinkculturalhealth.hhs.gov
www.minorityhealth.hhs.gov
www.hrsa.gov/publichealth/healthliteracy
www.cms.gov/writtenmaterialstoolkit/
www.healthcareinterpreterscertification.org
www.aamc.org/initiatives/tacct/
www.transculturalcare.net/iapcc-r.htm
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Contact Information:
Guadalupe Pacheco, President/CEO
Pacheco Consulting, LLC
1516 U Street, NW
Washington, DC 20009
(202) 352-5303
(202) 387-1732 (fax)
www.pachecoconsultinggroup.com
Power-point:©copyright 2014 All Rights Reserved,
Guadalupe Pacheco
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