Community Support

Notes from a Roundtable on Conceptualizing and Measuring Cultural Competence

Appendix C: Cultural Competence Prerequisites for Managed Behavioral Health Care Programs

Joseph M. Torres, Ph.D.
Consultant for Equal Employment Opportunity
Massachusetts Department of Mental Health

December 1998

Introduction

The primary purpose for the strategic implementation of the national Core Cultural Competence Standards for Managed Mental Health Care Programs is to promote the systematic development of culturally competent public and private systems of care. The projected implementation of the proposed cultural competence standards will require public and managed care organizations to develop strategic cultural competence implementation plans. Additionally, the systematic implementation of the cultural competence plan will concurrently require the development and implementation of a supportive and dynamic program evaluation plan to measure the progress and effectiveness of the cultural competence plan. The gradual development of an effective cultural competence evaluation plan will require a continuous linking and active collaboration of specialists with cultural competence and specialists with program evaluation expertise. The evaluation plan will include appropriate cultural competence indicators or outcome measures and the appropriate methodology to assess any progress in the implementation of the cultural competence plan and its effectiveness over a specified period of time.

An Overview of Cultural Competence Standards

The Americans with Disabilities Act of 1990 and Title Vl of the Civil Rights Act of 1964, as amended, both mandate accessibility to programs and the facilities at which services are dispensed. It is therefore critical for public and private agencies to be staffed with culturally competent and appropriately qualified bicultural and bilingual personnel. To help meet this requirement, the Cultural Competence Standards recommend that cultural competence training be provided to all direct care staff and those with management oversight responsibilities. The goal of the training program is to promote the systematic development of culturally competent systems of care.

The national Core Cultural Competence Standards were developed through the collaboration of national African American, Asian and Pacific Islander American, Latino, and Native American Behavioral Health Workgroups with the recognition that, in order to provide individualized mental health services, consumers must be viewed within the context of their cultural group and their experiences from being part of that group. Consequently, training of staff to enable them to understand the cultural background and need of a consumer is a critical element of a culturally competent system of care. Cultural competence training is intended to help the service provider from another culture become better able to understand and communicate with the consumer who is from one of many national origins or ethnic backgrounds. It will not, of course, permit an individual to take two or three courses and become totally competent in understanding and treating someone with different life experiences, language and cultural background. Acquiring cultural competency is a long?term developmental process from an individual, professional, and organizational level.

The "ideal" culturally competent system of care demonstrates a value for diversity, has the capacity for cultural self?assessment, shows awareness of the dynamics inherent when culture interacts, institutionalizes cultural knowledge, and develops adaptations to diversity. Ultimately, the culturally competent system incorporates the concept of equal and nondiscriminatory services and further includes the concept of responsive services matched to the unique cultural and linguistic needs of consumers.

The Program Evaluation Plan

The Program Evaluation Plan and the Cultural Competence Plan should be concurrently developed and implemented to insure that the essential principles and values which generated the cultural competence standards are accurately represented by the evaluation protocols. The preferred approach to develop the Evaluation Plan would be to utilize specialists with expertise in cultural competence and also in program evaluation to develop and implement both plans. Most likely, however, it will be necessary to utilize a collaborative planning process which allows different specialists to integrate their expertise in the area of cultural competence with expertise in the area of program evaluation competence. Regardless of the planning process utilized, the emphasis should be on flexibility, strategic planning and the practical use of available resources.

The national Core Cultural Competence Standards primary interest areas for evaluation planning are listed in Table I below. These cultural competence standards and primary interest areas should be used as the basis or key factors for determining the cultural competence performance indicators and the outcome measures for the evaluation plan.

Similar to the Cultural Competence Standards which need to be systematically validated and refined through appropriate pilot testing, the initial phase of program evaluation should place emphasis on an assessment of behavioral impacts that does not depend on experimental research design or random assignment. Emphasis should be placed on assessment of operational procedures which focus on services delivery to cultural and linguistic groups and on quality assurance measures and utilization reviews. More rigorous experimental research evaluation should be done on a limited basis when the cultural competence system in an organization is more firmly established.

Table I
National Core Cultural Competence Standards
Primary Interest Areas For Evaluation Planning

Core CC StandardsPrimary Interest Areas	Cultural CompetencePerformance Indicators	Outcome Measures
Cultural Competence Planning
Governance
Benefit Design
Quality Monitoring & Improvement
Decision Support & MIS
Staff Training & Development
Provider Competencies
Access & Service Authorization
Triage & Assessment
Care Planning
Treatment Services
Case Management
Linguistic Support

The Cultural Competence Plan

A Cultural Competence Plan for both public and private sectors should be developed and integrated within the overall organization or provider network using an incremental strategic approach to implement elements of cultural competency and to assure attainment of cultural competence within manageable but foreseeable time frames. The Plan should be developed by a team involving representation from top and middle management, direct care staff, consumers, families, and community stake-holders. The Cultural Competence Plan should designate a culturally competent executive level manager who will have the necessary authority to implement and monitor the implementation of the cultural competence plan. Each individual manager in the system of care should be accountable for the success of the Cultural Competence Plan.

Cultural Competency Basic Requirements

Some of the essential elements which are required in a culturally competent mental health care delivery system and which must be reflected system?wide include:

An unbiased attitude and organizational policy that values cultural diversity in the population served.
A fundamental belief that all services and service providers must be culturally competent.
An awareness that cultural differences may impact the effectiveness of mental health care delivery.
Skills to communicate effectively with diverse populations and application of those skills in cross?cultural interaction to ensure equal access of quality health care.
Knowledge of disease prevalence in specific cultural populations whether defined by race, ethnicity, socioeconomic status, physical or mental ability, gender, disability or age.
Programs and policies that address the mental health needs of diverse populations.
Ongoing evaluation of the effectiveness of programs and policies that address the health needs of diverse populations and cultures.

Administrative Requirements to Develop Cultural Competency

Organizational culture and behavior are learned by staff through attitudes communicated by key level administrators. To insure clear communication to staff about the importance of cultural and linguistic competency, an organization such as a State Department of Mental Health (DMH) should integrate throughout their administrative policies these priorities:

Cultural competency must be evident in the DMH mission and values.
DMH must establish and maintain a system?wide process to evaluate and determine the need for special initiatives related to cultural competency
DMH must include recruitment and retention initiatives to ensure organization-wide staffing that is reflective of the communities served.
DMH must assess the cultural competence of its staff and contract providers on a regular basis.
DMH should establish a special Office or designated staff to develop, direct and coordinate the integration of cultural competency standards throughout the Department. Responsibilities should include establishing mechanisms to appropriately meet the cultural and linguistic needs of DMH consumers. The office or designated staff should also coordinate these services with cultural competence efforts by other State or Federal agencies.
DMH must have an array of communication tools to distribute information to staff relating to cultural competency issues (e.g., those tools generally used to distribute other operational policy-related issues.)
DMH must participate with government, community and educational institutions in matters related to best practices in cultural competency in managed health care to ensure that the Department maintains current information and an outside perspective on its policies and practices.
DMH must have information systems capable of identifying and profiling cultural and linguistic specific client data (e.g., eligibility criteria, client tracking, diagnostic services, treatment outcomes etc.).
DMH should evaluate the effectiveness of its strategies and programs in improving the health status of culturally defined populations.

These guidelines should be used by DMH to establish performance measures and initiatives throughout the Department to support integration of cultural and linguistic differences in mental health care delivery and operations.

Education and Training Concepts

Active and ongoing staff training and education regarding cultural competency further communicate the priority the organization places on this issue. Quality Improvement (Ql) feedback and assessment measurements should be used on an ongoing basis to assess the effectiveness of the cultural competency education and training initiatives. A comprehensive staff training and education program includes components for orientation sessions, ongoing education and training, assessment of the educational program, sharing of ideas and resources and dissemination of materials.

Continuity of Planning For the Cultural Competence Standards:

The National Latino Behavioral Health Workgroup has continued the strategic planning process to refine the Latino Cultural Competence Standards through pilot testing and by developing methods for implementation of the standards in an inclusive manner with other multicultural groups and mental health authorities. The ongoing planning and implementation effort emphasizes the use of culturally competent total quality management approaches and public managed care principles of quality care.

The following additional priority issues and problems in mental health care services delivery were identified as significant for Hispanic consumers:

Cultural Competence: Requires a highly specialized developmental, long term, multi-stage process to implement. Should be viewed as a way to improve quality, not penalize staff.

Representative Participation in Workforce: A major issue is the recruitment, employment, retention and promotion of qualified bilingual and bicultural Hispanic professionals to plan, staff and manage appropriate mental health services for Hispanic consumers.

Quality and Design of Programs: Existing mental health treatment resources are often limited and frequently inappropriately designed and inadequately staffed to respond to the special needs of Hispanic consumers.

Qualified Interpreters: Mental health programs, services and activities must use, in the absence of appropriate bilingual/bicultural staff, qualified interpreters to facilitate communication at all levels between consumers and providers of mental health services.

Quality Care: A requirement under the Civil Rights Act of 1964, as amended. The following are critical issues and concerns :

Accessibility of services.
Models of Care and Components of Care.
- Integrated primary care, mental health, substance abuse, etc.
- Community based organizations
- One stop shopping / single entry point into system
- Design and development of appropriate systems of care
- Gate-keeping
Service utilization and outcome data
Meet needs of special populations (children, geriatric, rural, dual diagnosis, disabled, undocumented persons)
Quality of translators

Community Improvement and System Change: Use Total Quality Management. The following are critical issues and concerns:

Ensure culturally competent managed care systems through regulation and enforcement.
Responsiveness of local health care system to community needs.
Empowerment of Hispanic community to impact significantly the development and formulation of managed systems of care.
Consumer empowerment and activism.
Discrimination and lack of parity in services for Hispanic persons.

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