Implementing the CLAS Standards to Reduce HIV Disparity – Part 2

1. An Overview: Strategies for HIV/AIDS Providers Implementing the CLAS Standards to Reduce HIV Disparity – Part 2 Co-Presented by: Tawara D. Goode, MA, Director, National Center for Cultural Competence (NCCC) Wendy Jones, M.Ed.,. MSW, Director, NCCC, Children and Youth with Special Health Care Needs Project Georgetown University Center for Child and Human Development National Center for Cultural Competence, Georgetown University Medical Center

2. Learning Objectives At the completion of this webinar each participant will: • state the importance of the 14 CLAS Standards and their relevance to HIV/AIDS care and treatment. • identify at least one implementation strategy relative to HIV/AIDS care and treatment for each of the 14 Standards.

3. CLAS Webinar Series • Part 2 of this Webinar series discusses Standards 6-14 and strategies organizations and their personnel might pursue to implement CLAS. • We will use a case study to illustrate various points. • This Webinar series is designed to increase your awareness and knowledge of how you deliver care that is responsive to the cultural and linguistic characteristics of populations impacted by HIV/AIDS.

4. CLAS Standard 6 Ensure the competence of language assistance provided to limited English proficient clients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the client/consumer).

5. CLAS Standard 6: Implementation Strategies • Use professional medical interpreters or trained and qualified bilingual/multilingual staff or volunteers. • Use telephone or video interpreting technology as an alternative to on-site interpretation, especially for low incidence languages.

6. CLAS Standard 6: Implementation Strategies • The organization should critically review and keep abreast of the evidence against using family, friends, minors, and untrained interpreters in the provision of health and mental health care and related services and supports. • Use this evidence to inform policy and procedures as to whom can provide interpretation services for the health/mental health care organization.

7. CLAS Standard 6: Implementation Strategies • The organization must have established policy and specific procedures to assess the competency of staff, contractors, and volunteers providing language access services. This may include assessment of: • English and foreign language proficiency. • Knowledge of health and mental health terminology and key terms specific to HIV/AIDS (e.g. terms for sexual practices and behaviors, substance abuse, medical procedures, medications). • Awareness of colloquialisms used by cultural groups (e.g. slang, street terms).

8. CLAS Standard 6: Implementation Strategies • The organization must have established policy and specific procedures to assess the quality of language access services. • Assess patient/client and provider satisfaction with the accuracy and quality of interpretation services received. • Analyze patient/client and provider satisfaction data to inform quality improvement efforts. • Inform patients/clients and staff how data will be used to improve services and supports. • Ensure that the organization’s contracts for interpreters and translators have quality provisions.

9. CLAS Standard 7 Make available easily understood, client-related materials, and post signage in the languages of the commonly encountered groups and/or groups represented within the service area.

10. CLAS Standard 7: Implementation Strategies • Develop and/or adapt patient/client materials and resources that address the literacy and health literacy of the patient populations served. • Design alternative approaches to provide information to those patients/clients who may neither be literate in English nor their language of origin. • Provide training to staff in the use of literacy and health literacy tools and strategies (e.g. REALM-SF, SAHLSA-50, “Teach Back,” “Ask Me 3,” & “Plain Language”) to assess and respond to patient needs.

11. CLAS Standard 8 Develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.

12. CLAS Standard 8: Implementation Strategies • Integrate the delivery of culturally and linguistically competent HIV/AIDS care, treatment, and related services into the organization’s strategic plan. The strategic plan should include implementation of all CLAS standards. • Involve people living with HIV/AIDS across demographic groups, their families, and advocates in the development of the strategic plan (e.g. race, ethnicity, culture, age, gender, gender identity, sexual orientation, socio-economic status, education). • Ensure that the plan includes establishment of a work group or team responsible for the provision of culturally and linguistically competent, care, treatment, and related services to all patients/clients, including those with HIV/AIDSand their families.

13. CLAS Standard 8: Implementation Strategies • Set SMART goals and objectives for the delivery of HIV/AIDS care, treatment and related services. • Report to the organization’s board, staff and patients/clients on progress towards meeting these goals and objectives.

14. CLAS Standard 9 Conduct initial and ongoing organizational self-assessments of CLAS-related activities. (Organizations) are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations.

15. CLAS Standard 9: Implementation Strategies • Establish a structure and dedicate resources (personnel and fiscal) to plan and conduct CLAS-related self-assessment activities. • Identify and select instruments, tools, data sources, and processes for self-assessment of CLAS-related activities. Embed measures for cultural and linguistic competence in the organizations internal auditing, evaluation, and quality improvement processes.

16. CLAS Standard 9: Implementation Strategies • Collect and analyze data from multiple sources. Develop reports and data summaries. Share findings with staff, patients/clients, board members, and contractors. Discuss their implications for policy, practice, and community engagement. • Monitor data that demonstrate the degree to which the organization as a whole, and individual departments/programs, are progressing toward the goals and objectives of the strategic plan for cultural and linguistic competence. Ensure that data sharing processes and reports are accessible to patients/clients (in plain language) and are provided in multiple formats (translation, oral presentations, large print/Braille).

17. CLAS Standard 10 Ensure that data on the individual client's/consumer's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information systems, and periodically updated.

18. CLAS Standard 10: Implementation Strategies • The organization’s information systems should have the capacity to collect data on race, ethnicity, and language. Capacity should include, but is not limited to: • Patients’ or clients’ primary language (written, spoken, & sign) , and preferred language for service delivery. • Need for an interpreter. • English language ability(i.e. ability to speak, read, and understand English). • Literacy and health literacy levels.

19. CLAS Standard 10: Implementation Strategies Communicate (in writing and verbally) the organization’s policy and practices for confidentiality to all patients. • Advise patients/clients that data collected will be used to improves services and reduce disparities in health and health care based on race, ethnicity, and language. Inform patients/clients that they have the option to share or not share racial, ethnic, and language data, and that their choice will not in any way affect their ability to receive services. Determine the extent to which the collection of granular data will enhance service delivery to patient populations. Granular data based on cultural factors may include sexual orientation, gender, gender identity or expression, country of origin, cultural identity.

20. CLAS Standard 11 Maintain a current demographic, cultural, and epidemiologic profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.

21. CLAS Standard 11: Implementation Strategies Ensure that policy, procedures, and practices are in place to monitor: • current and emerging demographic trends in the geographic area served (e.g. race, ethnicity, languages spoken, age, immigrant and refugee data). • incidence, prevalence, and future projections for HIV/AIDS in the service area. (e.g. age, gender, gender identify, sexual orientation, race, ethnicity, country of origin). Analyze these data to determine their implications for planning, delivering, and evaluating culturally and linguistically competent services and supports. Update periodically.

22. CLAS Standard 11: Implementation Strategies • Conduct asset and need assessments of the geographic area to determine the range of community resources that provide services and supports to people living with HIV/AIDS. Attend to the capacity of the community based resources to address culture, language, sexual orientation, gender identity or expression, and other characteristics of the population of people living with HIV/AIDS. • Consult the National Minority Quality Forum (www.nmqf.org) website for current epidemiological data based on zip code.

23. CLAS Standard 12 Develop participatory, collaborative partnerships with communities, and utilize a variety of formal and informal mechanisms to facilitate community and client/consumer involvement in designing and implementing CLAS-related activities.

24. CLAS Standard 12: Implementation Strategies Ensure that the organization’s: • mission values communities as essential allies in achieving its overall goals. • policy, procedures, and practices delineate community and consumer and participation in planning, implementing, and evaluating services and supports for people living with HIV/AIDS. • policy and procedures allow the provision of fiscal resources and in-kind contributions to community partners, agencies or organizations. • policy, procedures, and practices support community engagement in languages other than English. Data Source: Goode, T. (2001). Policy Brief 4 – Engaging Diverse Communities: Culturally Competent Approaches. National Center for Cultural Competence. Retrieved from http://nccc.georgetown.edu/documents/ncccpolicy4.pdf

25. CLAS Standard 12: Implementation Strategies continued Suggested community and patient/client engagement strategies include but are not limited to: • Determine areas of mutual interest, benefit, and collaboration for partner organizations and agencies. • Legitimize formal partnerships with memoranda or agreements. • Collaborate with partners, where appropriate, to achieve goals, objectives, and desired outcomes in the provision of culturally and linguistically competent care to people living with HIV/AIDs and the communities in which they live. • Establish a structure for collaborative activities and resource sharing specifically for the provision of services and supports to people living with HIV/AIDS (e.g. referral network, exchange of best practices and lessons learned, joint grant proposals, shared patient education and related materials, joint training/professional development). • Issue joint reports on the outcomes of collaboration to partnering organizations, their boards, staff and patients/clients, and to the community at large. • Assess satisfaction with partnerships and revise partnering agreements as appropriate. • Identify and collaborate with informal, natural networks of support within culturally diverse communities to enhance services and supports to people living with HIV/AIDS. • Ensure patient/client voice and choice to plan, implement, and evaluate collaborative efforts (e.g. community engagement, public education, health fairs, representation on boards, media campaigns, training/professional development, HIV clinical trials and participation in research).

26. CLAS Standard 13 Ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by clients/consumers.

27. CLAS Standard 13: Implementation Strategies Suggested approaches for conflict and grievance resolution include, but are not limited to: • Obtain patient/client and staff input to craft grievance policy and process. • Create a policy and process that is responsive, inclusive, and equitable and that leads to prompt resolution of grievances in a culturally and linguistically responsive manner. At a minimum, the process must address literacy, English ability, individuals with disabilities, and unfamiliarity or reluctance of some cultural groups to make formal complaints. • Ensure that the organization’s data system has the capacity to document and track complaints, their status, and resolution for both patients/clients and staff. • Provide training to all new staff on the grievance policy and process. Ensure all staff, volunteers, patients/consumers are informed of the policy and process. • Update the grievance policy and process as appropriate.

28. CLAS Standard 13: Implementation Strategies • Consider using an ombudsperson in the resolution of grievances where appropriate. The ombudsperson should be knowledgeable of the cultural and linguistic contexts in which services are delivered and the population served. Additionally, the ombudsperson should be experienced in working with interpreters (sign and foreign language). • Provide notice to patients/clients in a prominent location on how to file a grievance. Include assurances that patients/clients have the right to file grievances without fear of recriminations. Notices should be written in the languages of the populations served. • Monitor adherence to the grievance procedures, including tracking resolution rates, as part of the overall quality improvement process. • Assess patients’ or clients’ satisfaction with grievance processes as part of the overall periodic patient satisfaction query efforts.

29. CLAS Standard 14 Regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards, and provide public notice in (the organization's) communities about the availability of this information.

30. CLAS Standard 14: Implementation Strategies • Disseminate progress toward implementing CLAS to diverse constituents on at least an annual basis. Dissemination may include a variety of formats and audiences including: (1) reports tailored for staff, patients/clients, board members, or community partners (2) presentations for community meetings/forums; (3) multimedia displays in waiting areas; (4) website postings, and (5) use of ethnic media such as radio and newspapers.

31. Case Study Appropriateness of Family Members Serving as Interpreters Matilde, a 42 year old Latina, reported for the results of her HIV test three months after being tested. She has limited ability to speak and understand English, so she brought her two teenage sons, Miguel and Javier along to interpret for her. The clinic neither has bilingual staff nor contract interpreters. The counselor feels uncomfortable about sharing the results of Matilde’s HIV test with her two sons but has no other way to communicate the results. As the counselor begins to inform the sons that their mother has tested positive for HIV, Miguel begins to cry. Javier, interprets the results to his mother, and accuses her of sexual promiscuity. What are some of the issues that are reflected in this case study? Which of the CLAS Standards could provide guidance in addressing this situation?

32. As a culturally competent I am capable of interacting positively with people who do NOT look like, talk like, move like, think like, believe like, act like, live like... ME!!! Data Source Multnomah County Department of Health. Modification from Mike Magy, Massachusetts Department of Mental Health, November 2005 . Slide Source: National Center for Cultural Competence, 2011

33. AETC NMC at Howard University Office of Minority Health National Center for Cultural Competence Center for Multicultural Mental Health National Minority Quality Forum The Cross Cultural Healthcare Program DiversityRx Ethnomed www.aetcnmc.org www.omhrc.gov http://nccc.georgetown.edu/ www.cmmh-cmtp.com/index.php www.nmqf.org/ www.xculture.org/ www.diversityrx.org www.ethnomed.org Internet Resources

34. Thank You National Center for Cultural Competence, Georgetown University Medical Center