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AC-3002 Original: 03/23/16 Revision: 03/20/19 Page 1 of 6 AC-3002 Cultural and Linguistic Competence Program 1 ALPINE COUNTY BEHAVIORAL HEALTH SERVICES P&P No: AC-3002 Approved by Gail St. James, LMFT, ACBHS Director Subject: CULTURAL AND LINGUISTIC COMPETENCE PROGRAM Effective Date: 03/26/2016 Revisions: 03/20/19 PURPOSE This policy outlines the required Alpine County Behavioral Health Services (ACBHS) cultural and linguistic competence program, including the provision of culturally- and linguistically- competent services; the Cultural Competence Committee; annual plan updates; staff training; data collection; and other related standards and processes. References: National CLAS Standards 2015; DMH Information Notice 10-02 and 10-17; CCR, Title 9, Chapter 11, Section 1810.410; MHP-DHCS Contract. POLICY ACBHS strives to deliver culturally- and linguistically-appropriate services to mental health clients and their families. This approach is reflected in the department’s mission statement, world view, informing materials, and client care plans. Cultural discussions are an integrated component of the child, youth, adult, and older adult service delivery systems. ACBHS has adopted specific standards and processes for providing and monitoring culturally- and linguistically-competent services. The goal of the ACBHS Cultural Competence Program is to promote the following objectives: Awareness of one's own cultural values Awareness and acceptance of differences Understanding of the dynamics of individual differences Development of cross-cultural knowledge and the ability to adapt skills to fit the cultural context of the consumer Providing culturally- and linguistically-competent services Cultural Competence Committee The ACBHS Cultural Competence Committee (CCC) is a cross-agency committee that has representatives from mental health, substance use disorder, and public health services. Approximately 14 people attend each meeting which is held every other month. Members include persons who are Native American, African American and Caucasian. The CCC works closely together to review data; organize cultural activities; and promote culture and healing to help balance the lives of individuals served. ---PAGE BREAK--- AC-3002 Original: 03/23/16 Revision: 03/20/19 Page 2 of 6 AC-3002 Cultural and Linguistic Competence Program 2 The goal of the CCC is to contribute to the overall planning and implementation of services in the county. The ACBHS Mission Statement is included as a part of the standard CCC agenda, to promote the vision of the department and set the focus of each meeting. The agenda also states the tasks of the CCC, as follows: 1. Recognize culturally-competent efforts and activities, and those efforts and activities that need to be improved 2. Review goals and objectives that promote culturally-competent service delivery and team culture (plan, develop, check progress) 3. Plan consumer and/or community events which focus on cultural awareness. 4. Review data reports on access, retention, and client outcomes across age, race, ethnicity, gender, income, town of residence. Make recommendations to outreach to disparate groups. 5. Make presentations to the Management Team; Behavioral Health Board; and the Quality Improvement Committee (QIC), as needed. Annual Report / Plan Update The ACBHS Director or designee, in cooperation with the CCC, completes an annual update to the Cultural and Linguistic Competence Plan (CLCP), in accordance with state standards. The CLCP provides demographic, service utilization, and penetration rate data to demonstrate cultural and linguistic competency, and to highlight trends that may need to be addressed. ACBHS reviews system-level information related to its compliance with cultural and linguistic requirements, identifies trends, and outlines mitigation efforts as necessary. A staff race/ethnicity and cultural competency assessment is conducted, and the results are included in the CLCP. In addition, a list of cultural competency training attended by staff in the previous year is included. Based on the data, system review, and identified trends, ACBHS outlines cultural and linguistic competency goals and objectives for the coming year. ACBHS strives to complete its CLCP annual update prior to the annual External Quality Review. National Standards on Culturally and Linguistically Appropriate Services The CCC promotes the National Standards on Culturally and Linguistically Appropriate Services (CLAS), in an effort to provide services that meet the needs of clients: 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. ---PAGE BREAK--- AC-3002 Original: 03/23/16 Revision: 03/20/19 Page 3 of 6 AC-3002 Cultural and Linguistic Competence Program 3 2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices and allocated resources. 3. Recruit, promote and support a culturally and linguistically diverse governance, leadership and workforce that are responsive to the population in the service area. 4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. 5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. 9. Establish culturally and linguistically appropriate goals, policies and management accountability, and infuse them throughout the organizations’ planning and operations. 10. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities. 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. 13. Partner with the community to design, implement and evaluate policies, practices and services to ensure cultural and linguistic appropriateness. 14. Create conflict- and grievance-resolution processes that are culturally and linguistically appropriate to identify, prevent and resolve conflicts or complaints. 15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents and the general public. ---PAGE BREAK--- AC-3002 Original: 03/23/16 Revision: 03/20/19 Page 4 of 6 AC-3002 Cultural and Linguistic Competence Program 4 Staff Training and Recruitment A. At least annually, ACBHS provides cultural competence training to ACBHS staff and providers, including administrative and management staff, direct service providers, and clerical/front office staff. Training disseminates the CLAS Standards; enhances cultural and linguistic respect and sensitivity; and promotes culturally- and linguistically-appropriate services to ensure positive outcomes. Training may be conducted via online sources or on-site instruction. Topics covered may include cultural diversity and sensitivity; using an interpreter; culture-specific approaches to treatment and recovery; understanding client culture; and other subjects. Completed training is documented in the Training Log, which is maintained by a designated QI staff member. Periodic review of the Training Log by the CCC and QIC help to assess staff training needs. B. ACBHS contract providers are also expected to train their staff in cultural competency, and report these training events to ACBHS C. Each bilingual/bicultural person who functions as an interpreter for clients receiving behavioral health services obtains training prior to serving as an interpreter. Interpreters are tested for bilingual competency by a designated staff member, prior to receiving a county bilingual pay differential. For staff who are not interpreters, annual training is scheduled on the use of bilingual/bicultural staff and other interpreters to address the cultural and linguistic needs of clients. o Training on the Language Line is available any time through a video and an instructional handout, and is included as part of initial training for all new staff. D. ACBHS is an equal opportunity employer and encourages bilingual and bicultural persons to apply for available positions. Provider Directory A. Cultural competency training is listed in the ACBHS Provider Directory. Cultural competence training is noted for each staff person and network provider listed in the ACBHS Provider Directory. Contract providers submit their updated information or are contacted by ACBHS to obtain changes. B. The ACBHS Provider Directory is updated by ACBHS. ---PAGE BREAK--- AC-3002 Original: 03/23/16 Revision: 03/20/19 Page 5 of 6 AC-3002 Cultural and Linguistic Competence Program 5 Quality Improvement Activities On a regular basis, the CCC reports collected information, data, and trends relevant to standards of cultural competence and linguistic preferences to QIC. Issues are identified and mitigated to ensure compliance with Medi-Cal and CLAS standards. PROCEDURES A. Cultural Competence Committee Meetings 1. The CCC meetings are held at least every other month. 2. The CCC conforms to the goals and objectives of the Cultural Competency Program by regularly providing training, workshops, and educational materials to staff, providers, and consumer/family members. B. Clients’ Right to Free Language Assistance Services 1. Clients have a right to free language assistance services. 2. Staff are required to inform clients of this right when language assistance is requested or required. 3. Clients are also notified of this right through ACBHS brochures and other informing materials. C. Language Assistance Services 1. If a client has language needs other than English, ACBHS utilizes the Language Line. 2. It is prohibited to expect family members to provide interpreter services. However, family members or significant others may be used as interpreters, if a client requests this option AND this option is also clinically appropriate. 3. Minor children are never used as interpreters. D. Written Informing Materials 1. ACBHS is committed to providing written materials available in English and Spanish to allow individuals requesting services, as well as the community in general, to be informed about the availability and access to mental health and substance use treatment services. 2. ACBHS informing materials are written in a manner and format that is easy to read and understand. ---PAGE BREAK--- AC-3002 Original: 03/23/16 Revision: 03/20/19 Page 6 of 6 AC-3002 Cultural and Linguistic Competence Program 6 3. For those clients who have hearing, visual, or reading limitations, ACBHS offers materials in large print (18+ font) and audio, in both English and Spanish. E. Client Data 1. Basic demographic data is collected via the Access Log when an individual initially contacts ACBHS for services. a. This Access Log data is reviewed by the QIC to ensure timeliness and quality of care. b. Requests for interpreters or other language assistance services are also logged and reviewed to identify trends and any issues. 2. As a component of the intake process, ACBHS staff collect additional client demographic information, including primary language(s), race/ethnicity, and other cultural data. a. This data is also reviewed by QIC to identify issues, areas for improvement, and strategies for ensuring compliance with Medi-Cal and CLAS standards around access, language assistance, and quality of care. F. Staff Training Records 1. Trainings are documented in the Training Log, which is maintained by designated QI staff. 2. Periodic review of the Training Log by the Cultural Competence Committee and QIC help to assess staff training needs. 3. Contract providers report training to ACBHS 4. Designated ACBHS staff update the ACBHS Provider Directory with current staff and network provider cultural competence training information.