Culturally Responsive Care Using CLAS to improve quality of care

1. Culturally Responsive Care Using CLAS to improve quality of care 2018 TXACC Conference Round Rock Texas April 20, 2018 Rosanna Barrett, DrPH, MPH Director, Health Equity

2. Learning Objectives • Explain the role of culture in providing equitable services and care • Explain the ethical and practical reasons for CLAS • Describe the components/major themes of CLAS and strategies for implementing them in your organization/program • Explain the benefits of adopting and implementing CLAS CLAS = National Cultural and Linguistic Appropriate Services

3. Activity # 1: Ice-Breaker PERSONAL IDENTITY

4. Differences in Perceptions

5. Definition of Terms

6. Definition of Terms Equality Vs. Equity Healthcareservices should be provided based on need to ensure that all persons have opportunities for attaining optimal outcomes – Targeted interventions for effective use of resources. Source: http://www.communityview.ca/

7. CLAS STANDARDS Source: CLAS Blueprint: https://www.thinkculturalhealth.hhs.gov/clas/blueprint, April 2015

8. Understanding the Basics Advancing Health Equity in Texas through Culturally Responsive Care (CLAS)  Module Office of Minority Health and Health Equity Center for Elimination of Disproportionality and Disparities Health and Human Services Commission http://www.txhealthsteps.com/cms/?q=office-of-minority-health-and-health-equity

9. Defining the Culture in CLAS

10. Layers of Culture Source: Recognizing Deep Culture’s Influence on Communicative Behavior by Stephen B. Ryan

11. Understanding Culture What is culture? Learned and shared values, beliefs, and behaviors of a group of interacting people. What are intercultural communications? Face-to-face interaction between people whose cultures are significantly different from one another. Source: Intercultural Communication Institute, 2011

12. Activity # 2: Inter-Cultural Interactions Video:https://www.youtube.com/watch?v=XUO59Emi3eo Watch the short video, then answer the questions below: ______________________________________________________________________________________________________________________________________________________________ • ____________a person’s beliefs or cultural practices can erode away the trust you have with them. • Judging b) Examining c) Discussing d) Honoring • What is one of the ways to overcome communication barriers? • Assume that you understand what the person is saying • Concentrate solely on body language • Focus only on the verbal communication • Ask questions when unsure of what is being stated • Which of these is based on actions motivated by opinions without evidence? • Prejudice b) Norm c) Stereotype d) Assumption • Which of these best describes a widely held, sometimes fixed, and oversimplified image or idea of a person? a) Generalization b) Stereotype c)Insensitivity d) Prejudice

13. Understanding Culture What are cultural generalizations? A generalization is most appropriately based on research, held lightly as a hypothesis, and carefully tested by observing the individual from another culture nonjudgmentally. What are cultural stereotypes? Stereotypes are frequently based on limited experience, unreliable sources, hearsay, or media. Source: Intercultural Communication Institute, 2011

14. Intersectionality of Culture

15. Cultural Identity • Sources of Diversity: • Race and ethnicity • Country of origin • Immigrants and refugees • Degree of acculturation • Generation • Age • Educational level attained • Cognitive abilities and limitations • Environment and surroundings • Health practices • Linguistic characteristics (e.g., language, dialects, regional variants) • Family and household composition • Socioeconomic status and social class • Sexual orientation • Gender identity • Disability • Rurality

16. CLAS: Blueprint for Health Equity • Alignment with National Plans: • HHS Action Plan to Reduce Racial and Ethnic Health Disparities (HHS, 2011) • National Stakeholder Strategy for Achieving Health Equity (National Partnership for Action to End Health Disparities, 2011) • Intended Purpose & Audience: • Promote health equity through providing clear plans and strategies • Promotes better health and health care in the United States • Useful for all organizations that serve clients/customers

17. Ethical & Practical Reasons • To respond to demographic changes • To eliminate long-standing racial and ethnic health disparities • To improve the quality of services and care • To meet legislative, regulatory and accreditation mandates. • To gain a competitive edge in the market place. • To decrease the likelihood of liability or malpractice claims.

18. Demographic Changes Sources: US Census Bureau & American Community Survey, November, 2016

19. Demographic Changes Texas Population by Race and Ethnicity, 1980-2040

20. Evidence of Health Disparities

21. Disparity Ratio Disparity Ratio = Rate A/Rate B = 11.9/5.8 = 2.1

22. Improve Quality of Services & Care “Culture influences health beliefs and practices, as well as health seeking behavior and attitudes” (IOM, 2003).

23. Cultural Competence/Responsiveness Cultural competence, the ability to interact effectively with people of different cultures, helps to ensure that the needs of all community members are addressed. Source SAMHSAhttps://www.samhsa.gov/capt/applying-strategic-prevention/cultural-competence “Cultural responsiveness is the ability to learn from and relate respectfully with people of your own culture as well as those from other cultures.” Source: National Center for Cultural Responsive Education: www.niusileadscape.org/.../culturally responsive.../Culturally%20Responsive%20Pedag...

24. Legislative, Regulatory & Accreditation Mandates CLAS-Related Legislations by States, 2012 Red= legislation was referred to committee and/or is currently under consideration. Blue= legislation requiring (WA, CA, CT, NJ, NM) or strongly recommending (MD) cultural competence training that was signed into law Yellow= legislation that died in committee or was vetoed (TX, FL)

25. Legal Authority of CLAS Standards Source: Lyons, J. J. (1990). The past and future directions of federal bilingual-education policy. American Academy of Political and Social Science, 508, 66-80.

26. Gain Competitive Edge in the Market Place “A loyal consumer base helps organizations avoid costly problems, such as high turnover, low utilization rates, and unused capacity” (AMA, 2006, p. 112)

27. Decrease the Risk of Liability Case: A first responder in Florida misinterpreted single Spanish word, “intoxicado,” to mean "intoxicated" rather than its intended meaning of "feeling sick to the stomach. " This led to a delay in diagnosis, which resulted in a potentially preventable case of quadriplegia, and ultimately, a $71 million malpractice settlement (Flores, 2006).

28. Activity # 3: Personal Beliefs

29. Adaption & Implementation of CLAS

30. H A N D O U T

31. Think-Speak- Act Cultural Health https://www.youtube.com/watch?v=E4k8YWqkjqo Video:

32. CLAS: Principal Standards Adapted from American Congress of Obstetricians & Gynecologists: Committee Opinion, 2011(Reaffirmed 2013)

33. CLAS: Governance, Leadership & Workforce Standards 2-4: Having a culturally and linguistically diverse workforce that are responsive to the needs of racial, ethnic and culturally diverse service populations.

34. Texas Health Care Workforce Race and Ethnicity of Primary Care Physicians (PCP) Texas, 2015 Ratio of Texas Population to PCP by County, 2015 Source: Texas Department of State Health Services: http://www.dshs.texas.gov/chs/hprc/Publications/2015FactSheets.aspx: 34

35. Texas Health Care Workforce Race and Ethnicity of Registered Nurses (RN) Texas, 2015 Ratio of Texas Population to RN by County, 2015

36. Texas Health Care Workforce Race and Ethnicity of Community Health Workers (CHWs) Texas, 2015 Ratio of Texas Population to CHWs by County, 2015 Source: Texas Department of State Health Services: http://www.dshs.texas.gov/chs/hprc/Publications/2015FactSheets.aspx: 36

37. CLAS-Related Strategies • Recruit and retain a culturally diverse workforce • Promote and support cultural diversity in the workplace • Provide training to increase cultural awareness, knowledge, and skills • Increase the capacity of staff to provide services that are culturally and linguistically appropriate • Incorporate cultural competency and CLAS into staff evaluations

38. CLAS Communication & Language Assistance Standards 5-8: Ensuring effective communication with persons with limited English proficiency and other communication needs.

39. Linguistic Competence Language Spoken by Texans 18 Years and Over , 2015 Sources: US Census Bureau & American Community Survey, November, 2016

40. Cultural Assessment • What is your ethnic affiliation? • Your country of origin or of your ancestors • Ethnic/cultural group you identify with • Length of time in this country • What are your primary and secondary languages • What is your speaking and reading ability in your secondary language? • How would you prefer to be addressed? • How would you prefer to communicate? • Use of interpreter, written, spoken, or sign language • Who is your major support person? • Who is the decision maker in your family? • How will you meet your financial needs? • Health insurance, self-pay, etc.

41. CLAS Communication & Language Assistance Scenario # 2: Language Barrier 13-year-old who served as her family’s interpreter, developed severe abdominal pain, her parents took her to the hospital. Unfortunately, she was too sick to interpret for herself. Her Spanish-speaking parents were told, without the aid of an interpreter, to bring her back immediately if her symptoms worsened, and three days. However, what her parents understood was that they should wait three days to see the doctor. After two days, with their daughter’s condition deteriorating, the parents could no longer wait and rushed her back to the emergency department. Doctors discovered she had a ruptured appendix. She was airlifted to a nearby medical center in Phoenix, where she died a few hours later.

42. Communication Styles • Variations in Communication: • Conversational Style and Pacing • Eye Contact • Personal Space • Touch • Time Orientation Video: https://www.youtube.com/watch?v=XUO59Emi3eo

43. CLAS: Engagement, Continuous Improvement & Accountability Standards 9-15: Collecting accurate and reliable demographic data to respond to cultural and linguistic changes and to ensure equitable delivery of service in a transparent and accountable manner.

44. Patient/Client Experience & Perception

45. CLAS-Related Strategies • Ensure that health and health care organizations obtain demographic and cultural-related data • Develop strategies for collecting race, ethnicity, sex, language, and disability status data in a sensitive manner • Determine the health assets and needs of the populations in the service areas (needs assessment) • Determine services to provide and how to implement them

46. Advance & Sustain CLAS

47. CLAS Assessment Questions Does your agency/organization? * Note: Add other questions as needed

48. CLAS Assessment Questions Is your agency/organization? * Note: Add other questions as needed

49. CLAS: Summary • Create a safe and welcoming environment at every point of contact with patients/clients • Ensure that all individuals receiving health care and services experience culturally and linguistically appropriate encounters • Implement strategies to meet communication needs so that individuals understand the health care and services • Allow individuals to participate effectively in their own care, and make informed decisions • Ensure that CLAS-related goals and measures are infused in planning and operation to achieve health equity

50. What's Next • Assess the readiness of your organization/program to adopt and implement the CLAS • Commit to improving quality of service • Recognize the role that you and others have to collaboratively play to effectively implement the CLAS • Connect with others who are implementing CLAS to share ideas, tools, and technique –Join our CLASinTexas Listserv.