Community Support

Notes from a Roundtable on Conceptualizing and Measuring Cultural Competence

Appendix C : Practical Measures for Population Based Planning "A Prerequisite in Developing Culturally Competent Services

Josie Torralba Romero, LCSW
JTR & Associates

December 1998

This paper attempts to address two elements which in this author's opinion are a prerequisite if one is to measure "Cultural Competency of Individuals and Organizations." I will briefly provide an overview of what I believe are essential elements in establishing a baseline knowledge from where to measure developmental growth in individuals and Organizations. These two planning elements also provide what I believe is the "context" from where all planning and training must be derived. The two elements I will describe are not new to the literature of Cultural Competence; however, I will relate them to the context of measuring Cultural Competency. These are Population Based Planning and Organizational Self Assessment as they relate to the findings of the populations in their particular community, region, county, etc.

We will assume that all current literature is correct about the specific cultural and ethnic groups who over-utilize higher level and more restrictive care, who underutilize and/or are underserved by mental health services. This information is clear and is documented by utilization data; however, what these data do not tell us is how we can correct these inequities in view of managed care and cost-effective services. It is the opinion of this author that one way of addressing this is to assess the population we need to serve and the programs and staff who serve them from a different vantage point; that is, from strengths-based and true "inclusion" perspectives. These two perspectives are also not new; however, seldom are they done in the true sense of the word - by applying the guiding principles of the Cultural Competency model. The Cultural Competency Model provides an imaginary continuum from:

Cultural destructiveness
Cultural blindness
Pre-competence
Basic Cultural competence
Advanced Cultural Competence

Several tools exist that attempt to assess an organization along this continuum. (See addendum.) Again, this is only an imaginary continuum that provides what I believe is the beginning in measuring some developmental growth.

A baseline of existing agency strengths and weaknesses is needed in the areas of skills and knowledge to further develop the organization toward a positive continuum. Cultural competency has been described by Cross, et al, as "The ability of individuals and organizations to work effectively across cultures." Because cultures are dynamic and change throughout time, it is important for organizations to plan for culture competence as part of their strategic planning process. Integration of cultural competence principles is critical for the overall success in the inclusion of culturally diverse populations in a service delivery system.

I. How Do You Measure the Developmental Progress of Effective and Appropriate Culturally Competent Services?

One has to start with two basic and fundamental elements.

A population-based assessment which determines the most current population demographic profile residing in a particular region, county or community. These demographics should include - age, ethnicity, social economic levels, primary language, Medicaid eligibility, unemployment rates, education levels, immigration status, etc.
An agency cultural competence self assessment to establish a strength baseline of skills and knowledge and strengths to match those needed to service the population identified in the population-based assessment.

These two planning elements form the context for the developmental growth toward cultural competency. This paper will briefly detail the elements of population-based planning, agency self-assessment, and the domains recommended for measurements.

II. What is Population-based Planning and Why is it Important in Measuring Cultural Competency?

Population-based planning is not a new concept. This concept was very popular in the late 60's and 70's. How does it differ in the late 90s? Population-based planning has replaced, to a degree, what we know as "community needs assessments" which utilized the approach of "assessing deficits or needs of a particular region, community, ethnic groups and might be age specific ." This approach was narrow in scope for two reasons:

It looked only for problems and did not recognize what I call "el oro del barrio," (i.e., "the gold nuggets in the community"). It did not look for natural and effective healing practice resources used in the community. The process did not acknowledge and/or invite community leaders/elders to join the assessment/ planning process as equal partners in educating systems and actually share what worked for them and what needed improvement with suggestions on how to improve services.
The needs assessment process was done by mental health staff with questions which were already formulated to look for problems. The system would take the responses and on their own, again "using the system knowledge," would design, plan and implement programs and services to meet the needs identified. These programs were "more of the same" traditional mental health services and only added language skills and changed locations closer to communities of color. If, when these programs did not render increased utilization of services, no assessment was done to determine why and find ways to improve. Measurement of effective services was based solely on quantitative measures.

III. How is Population-based Planning Different?

Population-based planning utilizes two dimensions. One is assessment of the population profiles of a particular community through the eyes and ears of consumers, family members, potential consumers, (i.e., Medicaid eligible) community stakeholders, which includes leaders, elders, community-based organizations, religious group representatives, etc.

The second dimension is administering an agency cultural competence self-assessment for administration and staff. This tool allows the agency to assess itself in terms of its strengths, skills and knowledge in relationship to serving the population identified in their community profile. There are several tools on the market to do self assessments. In this abstract I will discuss one particular tool that I am most familiar with.

These two dimensions of population-based assessments establish a baseline of strengths and knowledge/skills, by assessing two populations: consumers/families/ community and the program and staff which would serve them. This baseline analysis is what I believe establishes the "context" for measuring an agency's cultural competency through time, consistent with the developmental process which is the philosophical base of the cultural competence model. Because culture is dynamic and changing through time, assessments need to be organized bi-annually, at a minimum.

IV. What are the Elements of a Population-based Assessment?

I have identified the elements I consider critical for conducting a population-based assessment which identifies strengths and program gaps. The following census related information should be looked at to get a historical view of change in population profiles:

demographic profiles are most accurate when you get them from school districts, social service agencies, federal, state, county, government entities such as planning departments, local/state public health divisions and criminal justice.
demographic profiles from local business chambers of commerce
employment/unemployment data
local news organizations, TV, newspaper, radio, etc.

These are a few of the groups where population based data can be acquired. In addition to the gathering of traditional data, a population-based assessment must also include activities such as community based focus groups which can render demographic information. A special invitation can be issued to community leaders, elders, civil groups, religious leaders, and ethnic specific community based organizations to come and share knowledge of their communities from a strength base and also share their perspective of the mental health system, responsiveness to the specific ethnic community and suggested ways to improve them.

The success of getting these individuals to come to you will depend on the established/existing relationships of the mental health system with their communities. If no relationship exists, identifying key community persons who are credible and respected needs to be the first step. Going to these individuals and meeting them in their territory is very important. These are the first steps of true population based assessments, where relationships and partnerships begin to take form. The information gathered here is both anecdotal and emotional. Community leaders are passionate about their communities, and provider systems must be prepared to hear what they have to say about mental health services and the need for culturally syntonic services.

V. What are the Elements of an Agency/Provider Competence Self Assessment?

While there are several cultural competence tools in the market, one of the most practical and the one that I'm most familiar with is Dr. James Mason's "An Organizational Cultural Competence Self Assessment." This tool assesses existing skills and knowledge in seven domains. These domains cover both the organizational and individual levels, renders a baseline of existing strengths and clearly identifies gaps in knowledge of the organization. The gaps identified are the basis for the training/staff/organizational developmental plans. Developmental growth can be measured by using baseline scores and organizational policies/structure reviews and reassessing for developmental milestones/growth. The assessment domains include the following:

Knowledge of Communities. This assesses the individual staff's knowledge of who lives in the community in which they work, by ethnicity, language, cultural strengths, values and beliefs and utilization rates, etc.
Personal Involvement. This assesses the individual's involvement beyond one's own cultural groups, from where we shop and spend recreational time, to feelings of safety.
Resources and Linkages. This domain assesses the agency's ability to identify/link with formal and informal community resources, and evaluates its ability to institutionalize cultural knowledge through literature availability, collaboration, partnerships and relationships with community based organizations, and civil groups, etc.
Staffing. This domain assesses agency staffing patterns at all levels of the organization, which includes staff skills, languages, and reflection of community based populations; in addition to representation of Board of Directors, Mental Health Boards, contractors from the diverse community in the region, etc.
Service Delivery and Practice. This domain looks at culturally specific assessment tools, culturally syntonic interventions, family involvement, multi-dimensional assessments of quality of life issues such as housing, employment, educational, etc.
Organizational Policy and Procedures. This domain assesses existing policy and procedures, and determines the absence of policies which value and support culturally syntonic practices, structures, partnerships, collaborations, staff training and development, etc.
Reaching Out to Communities. This domain assesses the marketing tools used to inform ethnic communities about the services and benefits available to them; outreach, education about culturally syntonic presentations, mental health promotion practices, inclusion of multi-cultural families in the agency's brochures.

These domains assess the staff and agency's base knowledge/skills/strengths. These are matched to the community's potential consumer base identified in the population based assessment to determine the baseline from where the progressive growth and development can be measured.

Conclusion

This brief abstract outlines two key population based assessments (i.e., community and agency staff assessments), to determine a baseline of knowledge/skills from where development of cultural competence can be measured. These two population based assessments provide the beginnings of "inclusion" of two critical stakeholder groups which will determine the cultural competence needed by an organization/individual. This population based assessment provides the "context" from where measurement can be determined or identified. The "inclusion" of consumer/community and providers provide the first level of buy-in necessary to establish the measurements of developmental growth in skills and knowledge which can help an organization move towards a proactive continuum of cultural competency, and eventually to quality and cost effective services for the underserved populations.

References

Cross T., et al. "Towards a Culturally Competent System of Care," Vol. I National Technical Assistance Center for Children's Mental Health, Georgetown University, Wash. D.C. 1989.

Davis, King, Ph.D. "Exploring the Intersection Between Cultural Competency and Managed Behavioral Health Care Policy" Dec. 1997, NTAC, State Mental Health Planning.

Mason, James, Ph.D. "Cultural Competency Self Assessment" Portland, Oregon.

Romero, J.T. "Operationalizing Cultural Competence in a Managed Care Environment" Nov. 1996. Focal Point - A National Bulletin on Family Support and Children's Mental Health. Portland, State University.

WICHE. Cultural Competence Guidelines in Managed Mental Health Services for Latino Populations. Boulder, CO: WICHE, December 1996.

WICHE. Cultural Competence Standards in Managed Mental Health Care of Four Underserved/Underrepresented Racial/Ethnic Groups. Boulder, CO: WICHE, April 1998.

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