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Cultural Competence – More Than Just a Compliance Issue

“Diversity”, “underrepresented”, “underserved” – these are terms that we often use to describe populations that require cultural and linguistic considerations in service provision. Counties and their contracted providers choosing to participate in the California Department of  Health Care Services (DHCS) Drug Medi-Cal Organized Delivery System (DMC-ODS) demonstration project through the State Medicaid Plan waiver are responsible for compliance with the provisions of the Code of Federal Regulations Section 438 (42 CFR 438) pertaining to Medicaid managed care health plans. These requirements include specific instructions for oral and written communication with enrollees in non-English languages and enrollee access to culturally competent services. (DHCS) also, requires counties to comply with National Standards for Culturally and Linguistically Appropriate Services (CLAS) established by the federal Office of Minority Health. These seem like reasonable DHCS provisions for publicly-funded substance use disorder (SUD) service providers.

Let’s look more closely at what DHCS actually requires in DMC-ODS and CLAS. The provisions explicitly require health care organizations to address categories of governance, leadership and workforce; communications and language assistance; and engagement, continuous quality improvement, and accountability. Health care organizations are expected to “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.”

California’s population is tremendously diverse in terms of culture and language. No single ethnic or racial group holds the majority. Over 18 percent of the State’s adult population reports speaking English less than “very well.” However, individual county populations with limited English speaking ability range from 3 percent to over 30 percent according to the 2015 American Community Survey. Factoring in sexual orientation, intergenerational differences, urban-rural differences, and other socioeconomic differences makes for an extremely complex mix.

So how do the State, counties, and community-based SUD service providers address the service needs of this tremendously diverse population in a culturally and linguistically appropriate and competent manner? What can these entities do to better include individuals from historically “under-represented” and “underserved” groups? Over the course of the next few months, with the support of CIBHS, I will be conducting field research to learn more about how this is being done. The study will focus particularly on low-income adults meeting Medi-Cal eligibility requirements. A white paper describing my findings and recommendations will be presented to CIBHS to share with the SUD services field in Fall 2017.

Meanwhile, you can read more about 42 CFR 438 and CLAS at the following links:

A fact sheet on CLAS by the Federal Office of Minority Health

https://www.thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedNationalCLASStandards.pdf

A summary in table form of 42 CFR 438 provisions by URAC

https://www.medicaid.gov/medicaid/managed-care/downloads/mce-checklist-state-user-guide.pdf

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