Hello, my name is Crystal, and I.m a senior research analyst in the Health Determinants and Disparities Practice at SRA, International. I.m glad to be with you today to talk about cultural and linguistic competency in mental health.

The field of mental health is experiencing a convergence of research and innovations around strategies to advance health equity. As many of you are aware, the mental health system has not effectively addressed the needs of culturally and linguistically diverse populations, which has contributed to significant disparities in mental health access, availability, and utilization.

Today, we.ll explore strategies for understanding clients. and communities. cultural and linguistic needs and adapting mental health services to fit those needs. I will discuss the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. These Standards were developed by the HHS Office of Minority Health, and they provide you with a blueprint for advancing health equity, improving quality, and helping to eliminate disparities.

So, before we begin talking in depth, I want to go over a few terms and talk about Cultural Competency, CLAS, and the National CLAS Standards.

First, Cultural and linguistic competency. Cultural and linguistic competency is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enable that system, agency, or professionals to work effectively in cross-cultural situations.

Cultural and linguistic competency helps a provider better respect and consider a client.s cultural background, from the diagnostic interview to the formulation and implementation of a treatment plan to which the client can better adhere. This respect and consideration lays the foundation for a trusting relationship, which is vital for the success of treatment.

Cultural and linguistic competency also helps create an system for recognizing communication barriers and taking steps to reduce those barriers. For example, a culturally and linguistically competent mental health system will collect data on language needs and preferences of its consumers at intake, and then ensure that clients who have limited English proficiency have trained and qualified interpreters available to them.

For those unfamiliar with the term, lets talk about Culturallu and linguistic appropriate services or CLAS. CLAS are services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs and are employed by all members of an organization (regardless of size) at every point of contact.

CLAS is just another way to think about cultural and linguistic competency. When we talk about CLAS and cultural and linguistic competency, we are talking about the same concepts and strategies.

The HHS Office of Minority Health has developed a framework for operationalizing cultural and linguistic competency and CLAS. It.s called the National CLAS Standards. You can use these Standards as a blueprint for implementing culturally and linguistically appropriate services. Operationalizing cultural and linguistic competence is essential to implementing it and assessing it, and the National CLAS Standards aim to guide you in doing just that.

The National CLAS Standards were first developed by the HHS Office of Minority Health in 2000, and in 2010, the Office of Minority Health launched an initiative to update the Standards. The Standards were re-published in 2013 following an update period, which included a public comment period, a literature review, and ongoing consultations with an advisory committee comprised of 36 experts.

So, what is the purpose of the enhanced National CLAS Standards? The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities. Again, the Standards establish a blueprint for health and health care organizations and providers to implement and provide culturally and linguistically appropriate services.

I now want to talk about each of the Standards briefly. The National CLAS Standards are structured to include a Principal Standard (#1) that serves as the foundation for all the other Standards. The Principal Standard reads:

.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..

The remainder of the Standards fall under three themes: The first theme, Governance, Leadership, and Workforce comprise Standards 2-4: this theme emphasizes that implementing CLAS is the responsibility of the entire system. Implementing CLAS really requires the investment, support, and training of all individuals within an organization.

The second theme, Communication and Language Assistance encompasses all communication needs and including sign language, braille, oral interpretation, and written translation.

And the third theme, Engagement, Continuous Improvement, and Accountability comprises Standards 9-15 and focuses on the supports necessary for adoption, implementation, and maintenance of culturally and linguistically appropriate policies and services regardless of one.s role within an organization or practice.

So, what do the National CLAS Standards have to do with you? The National CLAS Standards again help organizations better understand a community.s cultural and communication characteristics.

And the Standards also help organizations increase the cultural and linguistic competency of their infrastructure and services.

In many settings, there may be some existing overlap between a community.s needs and preferences and the services being provided to them. In this diagram, we can conceptualize this overlap, which represents the extent to which that organization is culturally and linguistically competent.

Implementing the National CLAS Standards will help an organization better align its mental health services and infrastructure with the cultural and communication characteristics of a community by providing specification that an organization can take to achieve its cultural and linguistic competency goals.

Theoretically, when there is a great deal of overlap between the two, an organization will have a high degree of cultural and linguistic competence. As a framework for implementing CLAS and increasing cultural and linguistic competence, the National CLAS Standards can help mental health systems achieve this goal.

Let.s look at each of these elements in more detail and discuss how the National CLAS Standards may fit into the process of becoming more culturally and linguistically competent.

There are essentially two components in an organization that are important to consider when discussing cultural and linguistic competence.

The infrastructure component has to do with how the organization functions, such as what are the organization.s values, policies, governance and leadership structure, planning and evaluation services, human resources development, and community participation.

The services component has to do with the access, availability, and utilization of services offered.

.A culturally competent organization seeks compatibility between and within infrastructure and direct service domains.. (Hernandez et al 2006, pg. 13)

The National CLAS Standards support an organization.s efforts to develop and maintain a culturally and linguistically competent infrastructure.

For example, let.s take a look at the Standards pertaining to Governance, Leadership, and Workforce, or theme 1.

Again as Hernandez and colleagues explain, .Organizational values, policies, procedures and governance contribute to cultural competence when they promote compatibility with the community served and provide support for staff to carry out needed culturally competent service practice.. (Hernandez et al 2006, pg. 13).

In addition, a few of the Standards pertaining to Engagement, Continuous Improvement, and Accountability, and those Standards in theme 3, also support infrastructure.

.Planning and evaluation processes contribute to cultural competence when they include communities of color as fully contributing partners with shared responsibilities, and when they collect data that reflects the diversity of the community..Methods of outreach to communities and opportunities for community participation are important mechanisms that can lead to greater compatibility..

The National CLAS Standards also support the access, availability, and utilization of services.

For example, the Standards pertaining to Communication and Language Assistance, or those Standards inTheme 2, help an organization.s capacity to meet the linguistic needs of the community, which gets at the heart of availability.

The National CLAS Standards can guide organizations in aligning their infrastructure and services with the cultural and communication characteristics of a community.

Implementation of the National CLAS Standards will vary depending upon a number of factors, such as the size of the agency, subpopulations served, and the types of mental health services offered. The goal of their implementation is a resultant service system that .provides 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. (HHS OMH, 2013, p. 46).

While mental health agencies may not implement all of the 15 Standards collectively, the Standards can be used as a guide to modify existing policies and procedures , and to improve the care and services delivered to culturally and linguistically diverse populations,. The Standards can also be used to advocate for increase funding to support such efforts.

Now, I.d like to take a moment to check in. Now that you have learned about CLAS and The National CLAS Standards, I encourage you to think about your own organization. What policies and practices does your organization currently adopt to address CLAS or cultural and linguistic competency? Some of these policies and practices may include: having a Culturally and linguistically diverse staff and workforce, Providing communication and language access services, having Leadership supported initiatives and outreach programs targeting culturally diverse populations, or Collecting and using client demographic data such, as gender, race, ethnicity, language preference. What are some other policies and practices your organization adopts?

Recall that Standards from Theme 1 can help support an organization.s efforts to develop and maintain a culturally and linguistically competent infrastructure.

Some organizational level strategies that you can use to advocate and support implementation of the Theme 1 Standards in your organization, include the following:

Collaboration- your organization can collaborate, for example, with historically Black colleges and universities (HBCUs), Hispanic-Serving Institutions, and Tribal Colleges and Universities to build potential workforce capacities and to recruit more culturally and linguistically diverse providers and staff. Evidence shows that there is still cultural and linguistic underrepresentation in the mental health educational pipeline (Holliday et al., 1997). Mental health has been largely unsuccessful in attracting culturally and linguistically diverse individuals (Suinn & Borrayo, 2008). For example, while African Americans comprise approximately 13% of the U.S. population (Census Bureau, 2011), they constitute about 3% of psychiatrists and 2% of psychologists , according to 2012 data (SAMHSA, 2012). Similarly, while Hispanics comprise approximately 16% of the U.S. population (Census Bureau, 2011), they constitute approximately 4% of psychiatrists and 2% of psychologists (SAMHSA, 2012). Improved partnerships between academic and mental health agencies can help identify potential recruits already in the educational pipeline and provide them with additional academic support, mentoring, and guidance necessary to enter the field (Smedley, Butler, & Bristow, 2004).

Another organizational-level strategy that may be pursued, is the provision of specific training opportunities related to cultural and linguistic competency, or the provision of incentives to complete such trainings. Training topics may include how and when to access language services for individuals with limited English proficiency (Wilson-Stronks & Galvez, 2007), or delivery of services to particularly underserved populations such as individuals in rural communities, or individuals from various backgrounds. Incentives could include offering wage supplements, special work release time, or certification for those who complete such trainings (Huang, Macbeth, Dodge, & Jacobstein, 2004).

And finally, your organization can ensure that it has the necessary fiscal and human resources, tools, skills, and knowledge to support culturally and linguistically competent policies and practices. For example, in one community clinic all new employees were trained in cultural and linguistic competency during orientation, all staff were granted access to information via a website and resource manual, a resource library was also developed with materials on medical interpretation and cultural and linguistic competency, and interpreter training was made available throughout this organization (Martinez et al., 2004). Such education and training opportunities may also increase buy-in for cultural and linguistic competency across the agency since it demonstrates a recognition that culture and language play an important role in the provision of care and services (Rose, 2011).

Recall that the Standards in Theme 2 (Communication and Language Assistance) can help support the access, availability, and utilization of services, particularly through enhancing an organization.s capacity to meet the linguistic needs of the community.

The provision of mental health care is highly collaborative and participatory, and is shaped by multiple cultures interacting, such as the culture of the client, the culture of the provider, the culture of mental health, and the culture of the agency. There are often significant consequences when cultural norms are violated, even if the violation is unintentional (Cross et al., 1989). Misunderstandings can occur on both sides of the client-provider interaction, the effects of which can include lack of therapeutic alliance, misdiagnosis, poor adherence to treatment plans and recommendations, and ultimately, poorer clinical outcomes (e.g., Cross et al., 1989; Flores, 2006; Kagawa-Singer & Kassim-Lakha, 2003). Use of cultural brokers can help facilitate effective, cross-cultural communication (National Center for Cultural Competence, 2004).

Research suggests that clinical care is improved when trained interpreters are used (Karliner, Jacobs, Chen, & Mutha, 2007). Organizations can ensure that language assistance services are provided appropriately by offering interpreter skill development training, translating all written materials into Spanish, developing training curricula for community members to educate them about their rights, and developing internal language proficiency testing for all providers who self-identify as bilingual (Martinez et al., 2004).

An organization implementing the Standards in Theme 2 should consider adopting a multifaceted approach. For example, agencies can provide language assistance via both trained bilingual staff or dedicated language assistance (such as through a contracted interpreter, telephone interpreters, or video remote interpreting), these can help the agency develop a flexible system to facilitate client-provider communication. Investing in a shared remote interpreter service, for example, has been found as a low cost adjunct to providing language access services when in-person qualified interpreters are not available (Jacobs, Leos, Rathouz, & Fu, 2011).

Finally, lets focus on theme 3 and recall that many of the Standards in Theme 3, or Engagement, Continuous Improvement, and Accountability, help an organization.s infrastructure to provide culturally and linguistically appropriate services. These tools can provide guidance to determine whether the core structures and processes such as management, governance, delivery systems, and customer relation functions necessary for providing CLAS are in place (HHS OMH, 2013).

Use information and knowledge gained from individual and agency-level assessments and evaluation to create culturally informed and relevant mission, vision, and goals for the agency and to tailor services that are relevant to the community served. Cultural self-assessments, whether formal or informal, may focus on clinical competencies, agency resources, and capacity to serve the community, or may focus on administrative infrastructures and processes (Rice, 2007). Assessment activities can include the administration of self-assessments of cultural knowledge and culturally relevant practices facilitate the identification of factors that either enable or impede a mental health agency.s effectiveness and performance. Identification fosters increased introspection and intrapersonal awareness of one.s own culture, which enables more effective, culturally relevant delivery of mental health services. Self-assessment is also important in planning, implementing, and evaluating the quality of any kind of mental health service delivered.

Pilot test material and forms that have been created is also a useful strategy to use when implementing the Standards in theme 3. For example, agencies could convene focus group discussions with community members to help identify content in existing material that might be offensive, inaccurate, or embarrassing. Community members and key community gatekeepers can also serve as consultants to suggest cultural practices that provide more appropriate examples, and assess whether graphics and language used reflect the diversity of the target community. Organizations may consider providing financial compensation or in-kind services to community members who help translate and review materials (HHS OMH, 2001).

Regular meetings and retreats is an important way to evaluate how goals, objectives, and timelines that have been implemented are responsive to the cultural needs of the community and the clients served. Meetings also ensure that there are opportunities to discuss cultural and linguistic issues that are arising in everyday clinical encounters (Wilson-Stronks & Galvez, 2007). For example, in one Community Clinic efforts to engage leadership and the community, meetings with the executive management team to discuss how CLAS was being infused in the organization, these meetings led to the development of strategic plans, and the presentation of a systems change proposal that led to the updating of the organization.s policies.

Other types of mechanisms to use to improve accountability can include staff evaluations, individuals. satisfaction measures, and other quality improvement measures (QSource, 2005).

Now lets talk about Evaluation and the Implications of the National CLAS Standards in Mental Health.

So, how can you evaluate the National CLAS Standards? Two primary ways include: Systematic data collection, either using existing data collection resources, or creating new data collection measures and using existing measures of Cultural and Linguistic Competency.

In addition, you can have more planned evaluation which includes efforts such as including Case studies to examine operationalization and implementation of the National CLAS Standards, focusing on the measurement of Individual Standards, and Identifying the .best practices. around adoption and implementation.

The National CLAS Standards are very much related both to the HHS Action Plan to Reduce Disparities and the Affordable Care Act.

Cultural and linguistic competency is essential to the success of the provisions and endeavors the Affordable Care Act has set forth . so much so that it includes numerous provisions related to cultural and linguistic competency. The ACA also only includes provisions related to disparities reduction, data collection and reporting, and quality improvement . all of which are addressed in the National CLAS Standards.

The HHS Action Plan builds upon the ACA. The Action Plan proposes a set of priorities, strategies, and actions to achieve strategic goals for the Department. The vision of the HHS Disparities Action Plan is: .A nation free of disparities in health and health care.. The National CLAS Standards provide a framework to help health systems work to achieve this goal. In fact, the enhancement or the updating of the National CLAS Standards was a specific task outlined in the HHS Action Plan.

The HHS Office of Minority Health.s National CLAS Standards provide clear action steps through which mental health agencies and organizations can become increasingly culturally and linguistically competent, thereby enhancing their ability to address mental health care disparities

Together, we can fulfill many aims of other relevant health policies through implementing the Standards in day-to-day practices, and ultimately achieve the Standards. aims to advance health equity, improve quality of care, and help eliminate disparities.

Now that you know what the National CLAS Standards are, where can you find out more information about how to use them?

A Blueprint for Advancing and Sustaining CLAS Policy and Practice . simply referred to as The Blueprint . is a guidance document for the National CLAS Standards that discusses implementation strategies for each Standard.

The Blueprint explains the case or the rationale for CLAS, the enhancements or the update process, and the concepts found throughout the Standards. In addition, it provides many resources found online for additional information and guidance.

The Blueprint and other resources relating to the National CLAS Standards are available on the HHS Office of Minority Health Think Cultural Health website at www.ThinkCulturalHealth.hhs.gov.

Think Cultural Health is a trusted website for health professionals to turn to for information and education related to CLAS and health equity. I encourage you to visit the website to access The Blueprint and other resources, including e-learning programs for health and healthcare professionals, based on the National CLAS Standards.

Successful implementation of the National CLAS Standards will depend on you! We look forward to collaborating with you to promote, implement, and assess these Standards in the future!

Thank you!