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The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Tool for Tribal Communities

In this live webinar sponsored by the HHS Substance Abuse and Mental Health Services Administration, a panel explores the National CLAS Standards as a tool for tribal communities' efforts to advance health equity and reduce health care disparities. The webinar presents real-life examples of providing CLAS in tribal communities.

[Connie O'Marra] This Webinar is sponsored by SAMHSA and we have a quick disclaimer slide that would like you to review about the views expressed in the Webinar. You can kind of read this slide yourself. And then we also want to provide acknowledgment to SAMHSA and to Tribal Tech. Our two points of contact are Lori Keane from Tribal Tech and Gloria Golliher from Hoffman & Associates.

And our contacting officer representatives are Marine Madison and Marianne Pierce.

So moving on to the next slide I would like to introduce our wonderful speakers to talk to us about these tools for the Cultural Linguistic Appropriate Services Standards.

Our first presenter is Darci Graves. She.s a Senior Health Education and Policy Specialist Health Disparities Practice with SRA International.

And she.s a wealth of knowledge about these standards working in a number of states across the nation.

We also have our Tribal Training and Technical Assistance Consultant, Gary Neumann. He.s (inaudible) and he works all across the Indian country and has a great deal of experience with helping communities with these standards.

And we also are honored to have Esther Tenorio from San Felipe Pueblo. She.s a Project Director at Health and Wellness Department and on the Systems of Care Project that they have in their community.

And she has graciously offered to share some of the work they.re doing in their community on the CLAS Standards.

I.d also like to acknowledge our GTA Directors, Sepriano Lacario and I.m going to introduce myself a little bit more. I.m Connie O.Marra and I Tribal - I.m a TTA Coordinator for the center here and a member of the Ll itizen Potawatom Ibu Nation.

I worked of Albuquerque and I try to help doing a lot of Webinars and on-site training. And I.m going to go ahead and let Sepriano introduce himself and then we.ll move on to our presenters.

[Sepriano Lacario] Thank you. Hello everybody and thank you for joining us on today.s Webinar call. First off I.d like to say thank you to our presenters and facilitators for their efforts in supporting CLAS Standards information dissemination out to Indian countries.

I am a proud member of the Danain Nation and have the opportunity of supporting and training and Technical Assistance Center alongside Connie O.Marra and the rest of our team and we just want to say thank you very much for the opportunity to come in together today and thinking about prevention and wellness in our communities. Thank you Connie.

[Connie O'Marra] Thank you Sepriano. Before I move on to letting our presenters introduce themselves I.m also going to let you know that you are able to ask questions using the chat function, you know, as you.re online and we.ll get to those questions at a couple of points during the presentation. And then have - we.ll open up the line so you can actually ask questions out loud towards the end. We.ll try to allow adequate time for that.

So without further ado I.d like to go ahead and have Darci, Gary, and Esther in that order introduce themselves a little bit more and we can move on with our presentation.

[Darci Graves] Thank you so much Connie. As Connie said my name is Darci Graves and I serve as the Senior Health Education and Policy Specialist with the Health Determinants and Disparities Practice at SRA International.

We are a part of the team that helps manage the Think Cultural Health Project for the Department of Health and Human Services Office of Minority Health and I.ll talk a little bit about that later. And with that I.ll turn it over to Gary.

[Gary Neumann] Hello. This is Gary Neumann and I.m in the beautiful state of Montana right now. I am a member of the Confederated Salish & Kootenai Tribe.

And it.s been an honor to be involved with the TPA Center and the efforts for the last 20 years that have brought us to doing this important work. With that I.ll turn it over to Esther.

[Esther Tenorio] Hello. (Foreign Language Spoken) My name is Esther Tenorio I.m from the Pueblo of San Felipe Pueblo, work within the Health and Wellness Department. And I am in charge of the assistance of care Hopa Project for our community.

We.ve been doing CLAS Standards here for a few years now and we.ve work through some kinks. We.re not perfect but we are really working on the Standards and incorporating the Standards in our health work. Thank you for having me on this call.

[Darci Graves] Yes well thank you both so much.

Just to give you a little bit of an overview of the presentation; we will be talking about some of the fundamentals or the concepts that underpin the National Standards for Culturally and Linguistically Appropriate Services in health or health care or more commonly known as the National CLAS Standards.

And then we will move into the Standards themselves and with the assistance of Esther and Gary we.ll be interspersing that discussion with some real life examples of implementation in tribal communities.

So just a little bit of housekeeping before I get to that meat of the presentation, the Health Determinants and Disparities Practice which I am a part of it SRA International is we really conceive of ourselves as bring Culturally and Linguistically appropriate services or CLAS and equity to systems impacting health.

We have over 50 years of combined experience in the areas of CLAS health disparities and health equity and as I mentioned one of our clients is the HHS Office of Minority Health.

And their mission is to improve the health of racial and ethnic minority populations through the development of health policies and programs that aim to eliminate health disparities.

The Office of - the National CLAS Standards from the Office of Minority Health align with a broader HHS initiative, which is the HHS action plan to reduce racial and ethnic health disparities.

This aims to promote health equity and address racial and ethnic health disparities across the country. It involves all of the agencies across HHS in a department-wide effort to reduce and eliminate disparities.

In fact a goal of the HHS Disparities Action Plan is to strengthen the nation.s health and human services infrastructure and workforce.

[Darci Graves] The enhancement of the national CLAS Standard is specified as a task under this goal. The enhancement initiative took place from 2010 to 2013 and I will discuss the results of that process with you in a few minutes.

Just to be - to make - to ensure that we are all on the same page so to speak when we talk about CLAS what do we mean?

CLAS is the acronym for Culturally and Linguistically Appropriate Services and we conceive of that as being defined as 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 its size at every point of contact.

It.s important to note that every healthcare encounter or health encounter is a cross-cultural interaction. You can - should consider not only your client.s culture or your patient.s culture but also your culture and the culture of your institution or organization.

Keep this in mind as you seek to respond effectively to the health needs of diverse communities within your service area.

Every point of contact may seem very broad but as we know clients, patients and our communities intersect with our - intersect and interact with organizations at a variety of different points.

[Darci Graves] This particular diagram illustrates what it might look like if you were making an appointment as a patient or a client seeking services.

And so we know that the client experience is much broader than one specific patient or provider interaction.

Every healthcare encounter is a cross-cultural encounter and communication challenges may not be - may be related to more than just language barriers health literacy levels, dialects, hearing abilities and other communication needs which aren't necessarily apparent at first glance, influence and interaction between a health professional and a client.

It.s important that when we think about cultural and linguistically appropriately services we think about it when, you know, what is the initial point of contact with your client? How does your client or patient learn of your organization, how do they, how are they able to call or contact you to make an appointment? Is that system in and of itself culturally and linguistically appropriate?

And as you see we can go through and see, you know, in preparing for the visit, frequently our systems require a great deal of paperwork to be completed ahead of time.

Is that paperwork and is the identification and knowing about that paperwork culturally and linguistically appropriate?

How do you enter and navigate your healthcare - health or healthcare organization when you.re waiting in the lobby? What does that reflect in terms of the community, in terms of who is welcome and who is being seen?

Is the signage, the way finding, the multimedia, are all of those pieces easily understood to a variety of individuals?

You know, and then also discussion and referrals, billing, the pharmacy, reminders and follow-up communication as well as patient feedback.

Depending on what kind of organization or institution you belong to, there are different points of contact and it.s just important as you - as we move through the National CLAS Standards to be thinking about all of those different points with which the public interacts or intersects with you and making sure that all of those points are culturally and linguistically important appropriate and not just within the provider patient interaction.

[Darci Graves] The Office of Minority Health has developed this framework for operationalizing CLAS and we call it the National CLAS Standards.

The Standards are an important tool for promoting and implementing culturally and linguistically appropriate services.

The National CLAS Standards were first developed by the HHS Office of Minority Health in 2000. In 2010, the Office of Minority Health launched an initiative to update the standards which we call the Enhancement Initiative which incorporated public comment, a literature review and ongoing consultations with an advisory committee comprised of 36 experts representing a variety of disciplines and organizations.

In April of 2013, we were very excited to release the enhanced National CLAS Standards at the White House. There are 15 Standards each of which is an action step that guides professionals and organizations in their implementation of culturally and linguistically appropriate services.

Let.s walk through some of the concepts that underpin the National CLAS Standards.

And so when we talk about culture within the Standards it encompasses race, ethnicity and linguistics as well as geographical, religious and spiritual, biological and sociological characteristics.

Culture is defined as the integrated pattern of thoughts, communications, actions, customs, beliefs, values, and institutions associated wholly or partially with racial ethnic or linguistic groups as well as those characteristics I mentioned earlier.

Culture is dynamic in nature and individuals may identify with multiple cultures over the course of their lifetime.

This definition attempts to reflect the complex nature of culture as well as the various ways in which culture has been defined and studied across multiple disciplines.

This definition of culture includes gender, includes age, includes sexual orientation. It is a very broad definition and it tends to be very inclusive recognizing that we all come to the table or we all just simply as ourselves identify across many multiple cultural identities.

[Darci Graves] We use the Venn diagram to illustrate this because we all carry with us a race and ethnicity biological characteristics, linguistic characteristics, and some sort of religious or religion or a spiritual - spirituality characteristics.

So we all come to the table carrying these things and we experience all these things through all of these lenses simultaneously so we don.t - we conceive of this as a holistic approach and not something to necessarily just be teased apart.

The definition of health that we use so when we.re talking about health and health care organizations we.re talking about wellness and health. We.re talking about physical, mental, social and spiritual well-being.

And we believe that this definition of health reflects the fact that many aspects of health influences one.s well-being over all.

The National CLAS Standards are intended for health and healthcare organizations and I would even extended it further to any kind of organization that can impact one.s health.

So this definition includes medicine, behavioral health, mental health, public health, social work, community health centers, emergency health centers and many, many more.

Because of this when we talk about in the Standards when we talk about the audience we talk about the health or healthcare organizations, which are any public or private institutions addressing individual or community health and well-being.

The purpose of the National CLAS Standards or their intention is to advance health equity, improve quality and help eliminate health care disparities.

The Standards establish a blueprint for health and healthcare organizations to implement and provide culturally and linguistically appropriately services.

In health and health care we tend to have a lot of jargon where we use terms like cultural competency or cultural and linguistic competency but don.t always know what that might look like.

And the National CLAS Standards attempt to operationalize these in some - in concrete ways so that organizations have a roadmap or a blueprint for systematically integrating adopting and maintaining and sustaining Standards or services, which are culturally and linguistically appropriate.

Before we segue into the National CLAS Standards themselves I just wanted to take a moment and see if there were any questions either by the chat box or on the phone so please let Sylvia know or Sylvia if we have any questions please let me know.

[Coordinator] Thank you. If you.d like to ask a question press Star 1. Remember to unmute your phone and record your name clearly when prompted. Please stand by for the first question.

[Connie O'Marra] And Darci also this is Connie again. And I just wanted to let folks know that if you want to type a question in the Q&A box online as you.re watching the Webinar you can do that and we will definitely address your questions later if you prefer to do it that way. Thanks.

[Darci Graves] Thank you Connie.

[Coordinator] And there are no questions in the queue at this time.

[Darci Graves] Okay. They we.ll go ahead but please if there are any other any questions that come up please use the Q&A box as Connie indicated and we.ll pause again at the end of the presentation that we - so we can talk further.

So the National CLAS Standards are comprised of 15 Standards that inform and facilitate the implementation of culturally and linguistically appropriate services.

This slide illustrates the organization of the Standards. There is a principal Standard or Standard number one that serves as the framing for all of the other Standards.

The rest, the remainder of the Standards are structured into three overall themes -- governance, leadership and workforce, communication and language assistance, and finally engagement, continuous improvement and accountability.

The principal Standard shown here frames the essential goal of all of the Standards. Conceptually if the other 14 Standards are adopted, implemented and maintained then the principal Standard will be achieved.

Providing effective equitable, understandable and respectful quality care and services helps to create a safe and welcoming environment at every point of contact that fosters appreciation of the diversity of individuals and provides patient and family centered care and ultimately can help improve the perceived access to care.

It can help meet communication needs so that individuals understand the health care and services they are receiving, can participate effectively in their own care, and make informed decisions.

And hopefully it will help to eliminate discrimination and disparities.

Governance leadership and workforce are - is the first theme within the Standards and this theme emphasizes that implementing CLAS is the responsibility of the entire system that you work within or the entire organization.

Implementing CLAS really requires the investment, support, and training of all individuals within an organization.

The impetus for implementing CLAS can and often comes from the bottom up. However an organization.s leadership shapes the culture of an organization through its priorities, expectations and the behavior that it models. Therefore the impetus for implementing CLAS should also come from the top down.

The Standards in this theme teach us that implementing CLAS at every point of contact is a critical way to improve quality of care and avoid detrimental situations.

Standard number two underscores that CLAS must permeate every aspect of the organization from the top down and from the bottom up.

We know that leadership in large part determines whether the organization.s culture will embody quality, safety and CLAS.

[Darci Graves] Standard two is aimed to help organizations provide adequate resources to support and sustain CLAS initiatives and model an appreciation and respect for diversity, inclusiveness and all beliefs and practices.

And I believe Esther has some examples of how Standard two has been used in your community.

[Esther Tenorio] Yes Darci thank you. In most tribal organizations these Standards are already met by its tribal government.

Though these Standards are not written it is recommended that some type of leader within the community be a part of the management team to inform the organization of these Standards.

Many of these are incorporated in to the traditional systems within tribal communities. So it is really important to get the permission but also to know who in tribal government or who in the leadership roles could assist with programming.

In San Felipe Pueblo we have hired a cultural and linguistics competence coordinator who is a former war chief to inform projects working on or providing health care services.

And some of these examples is that he informs us with the development of employee training that includes an introduction of the cultural and linguistics Standards to be implemented across all tribal programs.

Then we also provide trainings on the side to subsidize or supplement the projects where they.re having problems with culture or linguistic appropriate service interpretations.

So training is ongoing but it.s - in San Felipe it.s been wonderful in that we have had the generosity of our tribal leadership to inform us and a lot of it is done orally at the beginning of each new year when our tribal administration changes.

And in the Pueblo country most of the tribal administrations change annually. That.s it Darci.

[Darci Graves] Thank you Esther. So that would take us to Standard three which is to recruit, promote and support a culturally and linguistically diverse governance, leadership and workforce that are responsive to the population in the service area.

This - it will help the organization create an environment in which culturally diverse individuals feel welcomed and valued and a few list multicultural perspectives into planning, design and implementation of CLAS.

Standard number four has to do with educating and training the governance leadership and workforce throughout an organization and Esther just some great examples that relate to the ongoing training of workforce and staff members.

And it really helps the organization to prepare and support a workforce that works well with diverse populations meeting their needs and expectations.

And it helps to assess the project of staff in developing cultural, linguistic and health literacy competency so in turn they can better serve their patients or clients.

Communication and language assistance, the second theme, provides guidance on how to effectively meet patient.s communication needs.

That may include sign language, braille, oral interpretation or written translation.

The Standards in this theme can help organizations comply with federal requirements such as Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act of 1990 and other relevant federal, state and local requirements to which they may need to adhere.

Poor communication can have tragic consequences. There is one such example is the case of Willie Ramirez where the misinterpretation of a single word led to a potentially - lead to a case of potentially preventable quadriplegia.

Willie was a Spanish-speaking 18-year-old and one day he had stumbled into his girlfriend.s home and told her that he was (intoxicado) and then he collapsed.

He was taken to the hospital in a comatose state. When the girlfriend and the mother repeated the term the non-Spanish speaking paramedics took it to mean intoxicated. The intended meaning in Cuban Spanish is actually nauseated.

After more than 36 hours in the hospital being worked on for a drug overdose Willie was reevaluated and given a diagnosis of inter-cerebral hemorrhage.

An emergency operation followed. However at this point his hemorrhage had been bleeding for too long and the brain damage left Willie a quadriplegic. The hospital ended up paying a $71 million malpractice settlement.

And while we hope that these - that the Willie Ramirez case is a tragic example and we hope that it.s certainly one that is not repeated but it just underscores the importance of making sure that communication and language assistance is in place.

The Standards within this theme includes Standard number five which has to do with offering communication language assistance.

And this helps organizations make sure that individuals with limited English proficiency and/or other communication needs have equitable access to health services and helps to improve patient safety and reduce medical errors related to miscommunications.

And what that I.ll open it back up to Esther who has another - has some additional insight to share.

[Esther Tenorio] In our community of San Felipe, 87% of our tribal members are fluent in our Keresan language. So as we move with health education or health communication services it is our mission to ingrain in all of our procedures the importance of having language interpretation services.

Some of our examples is within our systems of care project our staff are trained individuals and most of them are tribal members who are capable of communicating effectively with clients and community members to get them the assistance they need. And assistance is across all health programming interpreting letters that they get from their hospitals or insurance or even to read labels for prescriptions.

And we have hired individuals under our health system who are proficient with medication management issues so pairing these individuals with Keresan speaking providers.

And we.ve recently trained and certified ten community support workers within San Felipe who provide this type of assistance for our behavioral health programming.

And then also with the valuation and when we.re trying to gather information when we establish focus groups to conduct data collection we have to incorporate special considerations. And they must be built into the process where we ensure that the data and information collected has fidelity.

So we are constantly and continuingly checking on our processes and in how we develop instruments or how we incorporate services to be effective across our communities. That.s it.

[Darci Graves] Okay. That.s a lot Esther so that.s great. And I just want to acknowledge we have had a question come in regarding the implementation of a National CLAS Standards and I just wanted to let you know that we.ll be talking about that a little bit later on in the presentation in some documents and implementation guides that exist in those areas.

Standard number six has to do with informing individuals of the availability of language assistance services which help organizations inform individuals with limited English proficiency in their preferred language that language services are readily available at no cost to them.

And it helps to facilitate access to language services across the organization.

So it.s essential that when these services are available that all staff members know how to access them because if they are - if the staff doesn.t know then it.s - can also be a disconnect in making sure that the patients and/or clients or community members are able to access them.

Esther I believe you had an example for this as well?

[Esther Tenorio] Yes I did and I think I covered most of it in a previous question but in fact those efforts have been ongoing with dissemination.

We.re working with nutritionists. We.re working with various providers to make sure that when language assistance is needed that they contact us or they contact someone within that particular program who has access to the Keresan language interpretation services.

But also when we post our events we have several marquees within the community. We.re mindful of how we present the messages and that we are very careful about enticing the community with the types of information that we would choose to put on the marquee as well as the brochures and flyers. They.re written to accommodate with a tribal members in mind and to provide information that the tribal members would be used that would find useful.

So we do screenings of our brochures prior to putting them out there. And as much as possible we.ve been using resources such as Wardell. And we.ve somehow articulated, you know, our Keresan language by sounding it out even though our Keresan language is not written.

And we have used some of those tools to help bring forth some of the messaging that we.ve been wanting to provide to our tribal members.

Also the visuals that we have developed to convey messages such as PSAs and digital stories that are being created by our youth have bought us tremendous resources for our tribal members to engage in health programming or to bring the clients and the tribal members on board so that they inform us with what is appropriate to give back to the community.

And it - one of the examples is that in December at a community meeting where we have had - where we had 1,500 tribal members, we had provided education to one of our tribal youth leaders.

And a PowerPoint presentation was created using data, diabetes data within our region in New Mexico and in our County, Sandoval County and in our Pueblo in particular working with our primary providers within our clinic.

And we were able to develop a PowerPoint presentation along with a PSA. And we had - we trained our youth to talk to their family members or community members.

And what we got from this presentation was tremendous support to fight Type II diabetes in San Felipe.

And out of that we got pledges. We got people to sign up for services.

And this is just one example using youth and families with language and visuals to bring forth messages whereby we engage and we bring community to the table to help us deal with some of the health disparities. That.s it Darci.

[Darci Graves] Fantastic, thank you so much.

Standard - I think that takes us to Standard 7 which has to do with ensuring the competence that the individual.s providing a language assistance to make sure that organizations provide accurate and effective communication with - between individuals and providers as well as empowering individuals to negotiate and advocate for important services by effective and accurate communications with health and healthcare organizations.

And I think some of the examples that Esther just is shared also really talk - address the concepts put forth in Standard 8 and I hope that someday we can all see the example that Esther was talking about in terms of the digital stories and images that they.ve held to create because Standard 8 has to do with providing easy-to-understand materials and signage that help the organization make sure the readers of other languages and individuals with various health literacy levels are able to understand and access care and services and enable all individuals to make informed decisions regarding their health and their care and services and service options.

And as Esther indicated just knowing about the services, making sure that the messages are inviting and that you want, that the patient or client or community member wants to engage -- all of those things are so essential and often require community input which is an excellent segue to theme number three which is engagement, continuous improvement and accountability.

This theme underscores the importance of establishing both individual and organizational responsibility for implementing CLAS.

[Darci Graves] Effective delivery of CLAS demands actions across an organization. This theme focuses on supports necessary for the adoption implementation and maintenance of culturally linguistically appropriate policies and services regardless of one.s role within an organization or practice.

All individuals are accountable for upholding the values and the intent of the National CLAS Standards.

A study published in the Journal of Healthcare Management described a good example of a health organization using the principles of this theme to improve communication and care.

A hospital had discovered that their Latino mothers were making frequent emergency department visits for their children.s earaches because they did not understand how to take the children - the child.s temperature.

The hospital.s response was to develop kits that included a thermometer and easy to follow instructions. The CEO noted that instead of spending $400 an hour in the emergency department we were able to give them a kit that cost $3.

This was a good example of how a health system engaging with a particular community to seek ways to better serve the community and holding itself accountable to serve the community well according to its health and communication needs.

The first Standard within this theme is Standard number 9 which has to do with infusing CLAS throughout the organizations planning and operations.

It will help organizations make CLAS central to the organization service administrative and support of functions. And helps link CLAS to other organizational activities including policies, procedures and decision-makings related to outcomes accountability.

What this really means is that it.s not necessary to have a CLAS policy and procedure handbook in and of itself but rather to examine the organization.s policy and procedure handbook and make sure that those policies and procedures are culturally and linguistically appropriate.

When I used to teach in a medical school and in higher education I used to say that this is - that the cultural competency or CLAS isn.t simply a general education requirements so that you get to go history check, math check, CLAS check.

But really we.re talking about making sure that history is culturally and linguistically appropriate that the math is culturally and linguistically appropriate and is truly infused throughout an organization at every point of contact both internally and externally.

I believe that Esther has some real-life examples for this Standard as well.

[Esther Tenorio] Yes. And we have been working with our tribal leadership to inform us relative to what would be appropriate to incorporate within program initiatives.

And we do have in our Systems of Care project a tribal resolution that encourages us to incorporate cultural and linguistic appropriate service standards.

And within - and because FOC is there to work on children.s mental health issues we have within our behavioral health policies and procedures included language to - that encourage us - to encourages all of our providers to have cultural and language competence.

And so in our recruitment processes and in our what is it called, in our, when we train our staff in our tribal protocols and procedures we must touch on the language and cultural standards and what the expectations are. And those are reiterated by our tribal leadership every time we have a meeting.

But going further we have developed Memorandums of Understanding and Memorandums of Agreements with schools, with tribal courts in various projects across our community to make sure that there is mindful consideration for cultural and language consideration across all of our programming in San Felipe Pueblo.

As, you know, having tribal leadership direction and directives is really helpful when we.re doing this.

[Darci Graves] Thank you Esther. You know, and another important thing is to take into account what Standard 10 begins to address which is the conducting of ongoing organizational assessments to help organizations assess performance and monitor progress in implementing the National CLAS Standards and the concepts embedded within and to obtain information about the organization and the people that it serves which can be used to tailor and improve services across the board.

And I believe Esther you had some - had a story or an example to attach to this as well?

[Esther Tenorio] We do. With our intake assessments we have also adopted or adapted to include multiethnic identity measures.

And, you know, we.ve work closely with our evaluation teams out of the University of New Mexico and they.ve helped us access some of these measures.

So as we.re moving with our work in children.s mental health, you know, we do do data collections in this area.

And one thing interesting as we.re working with our youth and we got some feedback on our National Helper Program and our Project Venture Program these are projects that are under our suicide prevention initiatives.

In their our youth answered questions such as their - they want to be more informed about our San Felipe culture, our San Felipe standards or they want to know what spirituality means for them.

So this measure helps us look at some of the areas or develop some of the areas or lessons for them so that we can be able to do better training and give them access to the information that they.re requesting.

The other thing is that monthly in our task force meeting we talk about evaluation and we talk about CQI, you know, with quality improvement and how we gear our instruments relative to our services to make sure that the information that we are providing or the services that we are providing is received in a friendly way. And that we then give them, give our stakeholders or our clients feedback as to what how they answer their questions or how they see our services so that, you know, we can do better for them.

And just having this component in our projects with evaluation has really been invaluable going forward with writing proposals or even to write our reports as, you know, reports are required for all funding - projects funded by the federal agency and even tribal - to tribal government also. Thank you.

[Darci Graves] Thank you. And some of Esther.s examples dovetail nicely with the Standard as well which is aimed at collecting and maintaining the demographic data of the individuals who are being served so that you can accurately identify population groups within a service area and monitor individual needs, access utilization, quality of care, and outcome patterns, which can also be of assistance when providing those reports to the federal government or applying for grants or funding sources from various organizations.

Standard 12 has to do with connecting assessments of community health assets and needs. And I believe that kind of dovetails with some of what Esther just said as well.

Standard 12 helps to determine the service assets and the needs of the population in the service area or the needs assessment.

It helps to identify all of the services that are currently available and not available to the populations in the service areas, which referred to as a resource inventory and a gap analysis.

It helps to determine what services to provide and how best to implement them based on the results of your community assessment.

Esther did you have more that you would want to talk about in terms of this?

[Esther Tenorio] Maybe just to mention that, you know, in our projects we try to incorporate process evaluations on a regular basis to provide to participants and feedback is used to shape subsequent activities and projects hosted by the community.

So these process evaluations that are incorporated in our program is very valuable and then most grants or federal projects come with cross site evaluation technical assistance.

And but, you know, the ability to have a local evaluation built-into these funding agreements is really, really very helpful.

[Darci Graves] Excellent thank you. Standard 13 has to do with partnering with community to help organizations provide responsive and appropriate service delivery to that community and helps empower members of the community in becoming active participants in the health and healthcare process.

Gary wanted to specifically highlight some of the aspects of consulting with tribal elders and other key stakeholders. Gary did you want to share?

[Gary Neumann] Sure, thank you Darci. I think it.s real important in bringing in consultants from other communities to help with this work.

I think it.s important to keep in mind that we want to bring in Native American consultants who are familiar with the customs and values and the beliefs of the Native American community.

I think it helps instill trust between the community and consultant, a consultant who is familiar with the importance of preserving the heritage and culture and understanding how historical and generational trauma has played a role in destructive behaviors or a community or individuals need to perhaps self-medicate and also to keep in mind mentoring someone in the community to take over these roles.

And using consultants I think that have a clear understanding of the communities they work in it helps the population to be - feel that they are important and are involved in the design of whatever it is you.re doing.

And it also helps ensure that what you.re doing is responsive to that particular communities need, you know, consultants that understand shared values, attitudes and beliefs.

And also can help get the work done much quicker because you don.t have to spend so much time building that lengthy relationship between an outside individual and someone that understands decision-making process and communities and how we live in our communities.

I think it.s just something that we want to keep in mind as we.re doing this work. Thank you.

[Darci Graves] Thank you Gary. This brings us to Standard 14 which is - which pertains to creating conflict and grievance resolution processes that are culturally and linguistically appropriate which can help organizations facilitate open and transparent two-way communication and feedback mechanisms between individuals and organizations as well as to help them anticipate, identify, and respond to cross-cultural needs.

When I present this Standard at - when I presented this Standard in the past to other organizations I always point out that it.s very important to realize that just because you haven.t received any conflict or grievance reports that doesn.t mean that there aren.t concerns out in the community.

Because if your system isn.t culturally and linguistically appropriate than there isn.t a way for your diverse community members to let you know that there are problems if the system itself they can.t enter or they can.t access.

I think Esther has some - had an example about the difficulty in sometimes creating a conflict and grievance resolution process.

[Esther Tenorio] Yes Darci, thank you. I - for us this has been the most difficult process in the work that we.re doing. And it.s because our tribal members cannot identify, you know, what those conflicts are or how the, you know, the processes that they.re dealing with they don.t know how to convey it.

And the - what has helped us is doing the Native American historical trauma education within the community for our providers for our youth and other groups that provide services to the community.

And that with that help and developing an understanding for oppression and conflicts within the tribal communities and even within organizations that has bought us quite a bit of clarity to understand the need of our tribal community and therefore, you know, partnering with organizations such as universities or TAs, Technical Assistance projects out there, you know, we.ve really explored trauma informed care.

And looking through the lens of trauma informed lenses then we are able to see better to plan for the needs of our tribal members within the community in the areas of health as well as other projects within San Felipe Pueblo.

But I think that this type of work in order to move communities forward is really essential because so much has happened to our native people.

And, you know, having the people within the community, having an understanding of what that is or what that looks like helps them deal with issues in a better way.

And I.ll give you an example. When we did this training for our tribal youth I believe we trained 15 teenage youth. And we had Dr. Maria Yellowhorse Braveheart do this training for us.

And then we did the training with health and wellness staff a few days prior to the youth training.

We saw a different response from the youth in the way that they perceived the training. And out of the youth response we got an energy in that youth were really interested in substance abuse prevention, violence prevention.

And they were really ready to step up to look at how they could help, you know, future generations and then, you know, partner with elders in looking at some of the issues from the elder perspective and then being a partner as a youth to move some of the programming forward.

So I believe that, you know, looking at some of these considerations and looking at the conflicts that may not be spoken can be resolved by doing this type of education for tribal programs. Thank you Darci.

[Darci Graves] Great, thank you Esther. And I think Gary has an excellent point to make in terms of making sure that there is a feeling of safety around these sorts of issues. Gary?

[Gary Neumann] Yes. I think in communities it.s important that there is that sense of safety and also validation that people if they bring a grievance or a concern up that there is validation that they didn.t do something wrong or that it.s appropriate to do that.

Because I see evaluation in these kinds of things only as a way to make something better and not something that.s going to punish somebody.

So keeping in mind that safety is an important factor in this as well.

[Darci Graves] Great, thank you. Thanks to both of you for sharing this very important insights.

And I think that again that.s an excellent segue into the 15th and the last Standard which has to do with communicating the organization.s progress regarding cultural - culturally and linguistically appropriate services to the community which helps organizations convey information to intended audiences about its efforts and accomplishments in meeting the National CLAS Standards and help to build and sustain communication on CLAS priorities and foster trust between the community and the service setting.

Again if they know, if your constituents know that you.re trying to reach them in the most responsive and respectful way possible and that conversation and those connections can be made and individuals can feel safe and open and then there.s trusted members who can help convey those messages all of those things help both the organization as well as the community.

This slide reflects the implementation document that we published almost a year ago. It.s hard to believe that it will be a year next month but this document, a blueprint for advancing a sustaining CLAS policy and CLAS practice which we commonly refer to as at The Blueprint is a guidance document for the National CLAS Standards that discusses implementation strategies for each Standard.

So it walks you through each individual Standard. It kind of highlights some of the purpose of the Standards which I.ve touched on a little bit during the course of this presentation.

But then it delves into what we mean when we.re talking about those standards and kind of provides some of the literature and some of the references and helps explain the individual, the nuances within each individual Standard.

It provides insight into some strategies for implementation and also identifies some resources for implementation.

[Darci Graves] That said this - The Blueprint also explains the case for CLAS or, you know, why is CLAS, there is a compelling need for CLAS and the National CLAS Standards, what changed between the 2000 Standards that I referenced earlier in the Standards which were released again last year and the concepts found throughout the Standards so an in-depth discussion of culture and health and those sorts of pieces. In addition it lists many resources found online for additional information and guidance.

The only caveat that I.ll say is that we wrote The Blueprint with a broad audience in mind understanding that what the National CLAS Standards will look like in a community-based organization in Des Moines or in San Felipe play below or a large hospital in Manhattan or a small clinic in Oakland the National CLAS Standards are going to look different on the ground so to speak in each of those venues.

But we think that the strategies that we.ve included in The Blueprint will help individuals and organizations get an idea of how they can adopt and adapt the CLAS Standards to the organizations based on their mission, their size, the resources available and the populations that they.re trying to reach.

You can access The Blueprint, the National CLAS Standards and more at the Think Cultural Health Web site. Think Cultural Health is a valuable resource for you as you continue to learn about and implement the National CLAS Standards.

We.re a trusted site for health and healthcare professionals to turn to for information and education related to CLAS and health equity.

Think Cultural Health houses the National CLAS Standards and The Blueprint which describes each Standard and its purposes I said.

It also houses various resources relating to the National CLAS Standards such as e-learning programs, a CLAS Clearinghouse as well as all of the resources that are listed in The Blueprint are available in the CLAS Clearinghouse so you.ll have quick and easy access to them.

The Web address for Think Cultural Health in case there is anyone who is just on the audio portion of this Webinar is www.ThinkCulturalHealth.hhs.gov.

[Darci Graves] We have a couple of questions. Do culturally and linguistically appropriate services apply to the LGBT community members in tribal communities as well?

Absolutely. In our concept in our definition of culture we absolutely include the LGBT community, we include sexual orientation, gender identity, two spirit all of those, any individual with those characteristics or that those identities are absolutely included and represented by the National CLAS Standards.

I think we have - Gary has another example of what the state of Montana has done to talk about the integration of culture and cultural competency into treatment.

And then after that I think we.ll be able to open it up for any additional questions that our audience may have. Gary?

[Gary Neumann] Thank you. The state of Montana Chemical Dependency Treatment Program approached I think they approached this in a different manner.

I think they realized that in the field of substance abuse for example American Indians going to a treatment facility might be re-traumatized when they.re sent to this particular facility that might not be local, regional or even provide historical or cultural understanding as to why maybe they self-medicated in the first place.

Knowing that American Indians experience high rates of sexual abuse, neglect, trauma related incidents resulting in, you know, a widespread impact devastating effect on themselves and their families and their communities consuming a lot of health and human service dollars.

And what they did is they realized that American Indians who engage in substance treatments don.t typically sign on for the tasks the Western cultural assimilation and struggle with that Western medicine model.

And the state was realized that the concept of health is understood differently. The Western model perhaps repairs an individual.

And a holistic Native American approach is about making the person better rather than just repairing them. So it was important that they did understand that health is understood differently.

And what happened was a several day cultural awareness and understanding provided by Native Americans to the directors and the treatment staff of the treatment center.

What.s happened over the last couple of years as a result of that if individuals that are Native American go into a treatment center are feeling more welcome and safe and being allowed to smudge and continuing practicing some of their ceremonies or even being reintroduced to some of these ceremonies that maybe they left because of the behavior that they.ve been doing, you know, in the past.

So the Montana I think took a step ahead and I think there.s some great results. And if anyone is interested in some of those summaries or those outcome evaluations that came from the state of Montana I.d be happy to share that.

[Darci Graves] Great. Thank you so much Gary. With that Sylvia I think we can open up the phone lines or offer to open the phone lines if anyone has any questions.

[Coordinator] Thank you. If you.d like to ask a question press Star 1 on your phone. And just remember to un-mute your phone and record your name clearly when you ask your question.

[Darci Graves] Okay well if we don.t have any additional questions at this time which I.m guessing is the case Sylvia?

[Coordinator] Yes ma.am. We do not have any questions at this time.

[Darci Graves] Okay. Well I offer my email address if you have any questions that I can answer. I don.t know if the other facilitators are able to share their emails as well or if you want to contact our host today. And I.m sure they can make sure that the questions get directed to the individuals who can be of assistance.

There is a second email address up there AdvancingCLAS@ThinkCulturalHealth.hhs.gov and this is really for anything, questions about the Standards, your, you know, stories on how you.ve begun to implement them as your organization, if you have any advice for us or for others who are working in the area of the National CLAS Standards, and the lessons that you.ve learned as you implemented them.

And with that oh and here are the - all of our email addresses. And with this I.ll turn it back over to Connie to bring this Webinar to a close. Thank you all so much.

[Connie O'Marra] Thank you so much Darci. I would love - I just wanted to - love to say that I really appreciate this fantastic information that was shared by the three of you from our three presenters Darci Graves, Gary Neumann, and Esther Tenorio.

It was such a wonderful overview and provided some real practical information for how these Standards are being implemented in our native communities and even at the state level.

And so I just want to thank you so much for being our presenters and also our guests today.

If you do need more information or want any contact information in addition to this contact information just go ahead and email me and I.ll be happy to provide you with a copy of my PowerPoint and any other information.

We.re also recording this so you.ll be able to, you know, get a copy of the link and provide, you know, this will be available for you to use in your community as well.

So I just want to thank everybody for joining us today. We look forward to having you on future Webinars and we again we thank our wonderful presenters. Have a great day.

[Coordinator] This concludes today.s conference. Participants may disconnect at this time.

  • Presented 03/26/2014
  • Presenter Darci Graves; Esther Tenorio; Gary Neumann