Hello and welcome to our presentation on Why Culturally and Linguistically Appropriate Services. My name is Darci Graves and I am with the Health Determinants and Disparities Practice at SRA International, Inc. We work to support the Department of Health and Human Services Office of Minority Health Think Cultural Health Initiative.

The Health Determinants and Disparities Practice has over 50 years of combined experience in the areas of culturally and linguistically appropriate services, health disparities, and health equity.

Let.s get to the question at hand. Why Culturally and Linguistically appropriate services. Culturally and linguistically appropriate services matter for many reasons. Some of these reasons have to do with numbers and the bottom line, and this is the business case for CLAS. Other reasons have to do with issues of equality and humanity, and this is the social justice case for CLAS.

The business case for CLAS asserts that culturally and linguistically appropriate services help a health care organization.s bottom line and competitiveness in the marketplace. I.ll highlight a couple of these reasons:

One- Litigation: Research shows that good communication helps avoid cases of malpractice due to diagnostic and treatment errors, which can cost millions of dollars in liability or malpractice claims. Culturally and linguistically appropriate services can reduce the possibility of such errors.

There.s also Accreditation: Accrediting bodies such as The Joint Commission and the National Committee for Quality Assurance have established accreditation standards that focus on improving communication, cultural competency, patient-centered care, and the provision of language assistance services.

And there.s also the Cost of Disparities: Research shows that eliminating health disparities for minorities would have reduced direct medical care expenditures by $230 billion between the years 2003 and 2006.

I.d also like to mention legislation as an important incentive for implementing culturally and linguistically appropriate services. Most significantly, the Affordable Care Act contains several provisions related to culturally and linguistically appropriate services. In addition, Title VI of the Civil Rights Act of 1964 details some requirements related to the provision of language access services by organizations receiving Federal funds. Furthermore, several states have passed legislation related to cultural and linguistic competency.

On the other hand, the social justice case for CLAS is based on the premise that CLAS can help reduce healthcare disparities. As former Secretary Sebelius put it: .Minority and low-income Americans are more likely to be sick, and less likely to get the care they need.. There is a huge amount of literature that exposes the many disparities experienced by diverse communities. CLAS is an important way to help eliminate health care disparities because CLAS helps overcome cultural and linguistic barriers, which can lead to miscommunications and therefore poorer quality of care.

Therefore, an organization may choose to implement CLAS because it has a mission to promote equity and/or reduce health disparities and/or improve quality of care.

In terms of demographics, the U.S. is becoming more culturally and linguistically diverse everyday, but the healthcare workforce is not diversifying as quickly. This is widening the cultural and linguistic differences between health professionals and patients, making miscommunications much more likely. Thus, an organization may choose to implement CLAS to better respond to changing demographics in its service area.

Now that we.ve talked about some of the why, lets make sure that we are clear on what CLAS or Culturally and Linguistically appropriate services are. CLAS is services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs and employed by all members of an organization (regardless of it.s size) at every point of contact.

Now that we.ve talked about Culturally and Linguistically appropriate services and we.ve talked about what they are and why they are important, lets also make sure what know what do we mean when we say culture. The way that we define culture with the National CLAS Standards and within CLAS, within this discussion is that culture is the integrated pattern of thoughts, communications, actions, customs, beliefs, values and institutions associated wholly or partially on racial, ethnic, religious, spiritual, linguistic, biological, socioeconomic, geographical or sociological characteristics.

Some examples include racial and ethnic groups that are include but not limited to those defined by the US census and other communities. Religious and spiritual characteristics include beliefs, practices and support systems related to how an individual finds and defines meaning in their life.

Other characteristics could include sexual orientation, gender identity and physical ability, mental health, whether someone lives in an urban area or a rural or suburban area. Whether English is their first language. What dialect they speak. And when and where did they learn it.

There are numerous other characteristics that we could also discuss, but more of that is available in the National CLAS Standards Blueprint document, which I will discuss later in this presentation.

Now that we.ve discussed some of the terms and what they mean, lets return to the why this is important. And one of the key reasons is that, the issues around litigation, as a result of medical errors, miscommunication and so this case which is well known is often referred to as the Intoxicado Case, or the Intoxicado Incident. Intoxicado, in this care refers to Willie Ramirez who was taken by ambulance to a South Florida hospital in a comatose state. He became quadriplegic as a result of a misdiagnosed intracerebellar hemorrhage that continued to bleed for more than two days as he lay unconscious in the hospital.

In the course of the law suit, it was asserted that Willie could have walked out of the hospital had the neurosurgeon been called in earlier. No neuro consult was ordered for two days because the Emergency Room physician and the doctor covering Willie in the ICU erroneously believed that Willie had suffered an intentional drug overdose and had treated him accordingly. The misdiagnosis was based on the physical exam which initially pointed to a drug overdose, and on complete confusion regarding the medical history. At the heart of this confusion, was the Spanish word .intoxicado. which is NOT equivalent to the English word .intoxicated..

Intoxicado simply means feeling nauseous, or sick to one.s stomach. The result of this litigation was a $71 million settlement in favor of Ramirez family. Legislation, regulation, and accreditation. National health care policies and legislation, such as the Affordable Care Act, have also helped to redefine and underscore the importance of cultural and linguistic competency as vital to providing quality health care and services.

In addition, state agencies have embraced the importance of cultural and linguistic competency in the decade since the initial publication of the CLAS Standards. A number of states have proposed or passed legislation pertaining to cultural competency training for one or more segments of their state's health professionals. At least six states have moved to mandate some form of cultural and linguistic competency for either all or a component of its health care workforce.

The map illustrated on this slide comes from the Think Cultural Health site, and helps denote where states are in their legislative process, and provides links to the legislation itself. In addition to legislation, accrediting bodies such as The Joint Commission and the National Committee for Quality Assurance have established accreditation standards that focus on improving communication, cultural competency, patient-centered care, and the provision of language assistance services.

An example of this is, National Committee on Quality Assurance published Multicultural Health Care: A Quality Improvement Guide to provide a QI (or quality improvement) framework for health care organizations seeking to promote more culturally appropriate care, provide equitable access for individuals with limited English proficiency and reduce health care disparities.

The Joint Commission has several standards that support the provision of care, treatment, and services in a manner that is conducive to the cultural, language, literacy, and learning needs of individuals. The Joint Commission has also developed Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals to guide hospitals in integrating concepts from the fields of communication, cultural competence, and patient- and family-centered care into their services.

Finally, other accrediting bodies such as the National Committee on Quality Assurance (NCQA), the Liaison Committee on Medical Education (LCME), the Accreditation Council for Graduate Medical Education (ACGME), and the Accreditation Council for Continuing Medical Education (ACCME) have embraced cultural and linguistic competency.

We mentioned previously that disparities is another driving factor of why Culturally and Linguistically appropriate services are important. There is an abundance of literature out there that discussed disparities across numerous populations and across numerous states. We.ve just listed a couple of examples here of health disparities that could benefit from culturally and linguistically appropriate care. Poor communities are at a greater risk for environmental toxins that have a negative impact on health. Knowing an individual.s socioeconomic status and understanding their living conditions can help improve the accuracy and timeliness of diagnosis and creating a true and accurate medical history.

Another examples of a disparity is African American older adults living in urban areas seem to be less likely to exercise for reasons including: family responsibilities, lack of safe environment, perceptions of little benefit from exercise, sedentary lifestyle. Again, understanding the individual.s framework from which they are acting and reacting is important.

Finally, Patients. beliefs about the origin and meaning of symptoms, expectations for the professional behavior of caregivers and the willingness to disclose the impact of symptoms on daily functioning can be shaped by military culture and current military status. Culture is defined by so many things, as we.ve already discussed; so understanding again their framework is critical to knowing how an individual perceives and receives the information that you are providing as a provider, or as a health care system.

The delivery of CLAS will assist health and health care organizations to provide an open and welcoming environment to groups that have historically faced barriers to care. Diverse communities face discrimination and unique barriers to care and implementation of CLAS can help address discrimination and overcome such barriers which can directly impact your place within the market space and the marketplace within your community and your mission may help drive how this is interpreted and exemplified by your organization within a community.

Culturally and linguistically appropriate services can also help health and health care professionals and organizations gain a competitive edge in the marketplace. Although the implementation of culturally and linguistically appropriate services certainly requires resources, there are numerous business-related advantages to investing in these resources. By implementing culturally and linguistically appropriate services . including the provision of communication and language assistance, as well as partnerships with the community . an organization can develop a positive reputation in the service area and therefore expand its market share.

Hospitals. An example is hospitals increased their market share among individuals with limited English proficiency (or LEP) by creating individual maternity suites with a substantial culturally competency component within their design. In addition, Organization may have a mission to serve the community, promote equity, reduce health disparities, not discriminate, or improve quality of care. All of these things can be improved and enacted and infused by Culturally and Linguistic Appropriate Services.

An example of the need to address discrimination, a study by Lambda Legal surveyed 4,916 LGBT patients and found that more than half of them felt that they had been treated disrespectfully and did not receive the care they needed. So, again making sure that individual receive the care, and are treated in a respectful and responsive manner, can all help increase your market place and help you achieve the mission of your organization.

Changing demographics is also an often sited reason for the importance and the need for Culturally and Linguistically appropriate services. There have been rapid changes in demographic trends in the U.S. in the last decade. For example, Hispanics now constitute over 16 percent of the U.S. population. And in 2012 for the first time, the majority of babies born in the U.S. were members of racial and ethnic minority groups. And the nation is projected to grow increasingly diverse.

By 2060, the U.S. population is projected to be 43% non-Hispanic White; 31% Hispanic; 15% Black; 8.2% Asian American; 0.3% Native Hawaiian and Pacific Islander; and 1.5% American Indian/Alaska Native.

Finally, improving quality of services if another reason why Culturally and Linguistically services are important. Adoption and implementation of a framework such as the National CLAS Standards, offers an organization the opportunity improve communication and help ensure services meet the needs of the populations they are attempting to serve. Some examples include:

Quality of Care:Staff education and the introduction of interpreter services in the Labor and Delivery department of a large teaching hospital showed improving the quality of care that was delivered. Patient Adherence:Effective provider-patient communication impacts patient outcomes , including measures such as increased patient satisfaction with care, increased trust between patients and providers, greater patient adherence to recommended therapy, and receipt of recommended preventive services. Preventive Services: For many LGBT people, fear of coming out to their health care provider and a general lack of LGBT cultural competency in the health care system prevents them from accessing vital services, particularly primary care and prevention services. Medical Errors: Limited English proficient (LEP) patients who may not be able to communicate effectively with their health care providers may be at greater risk for medical errors. Length of Stay: Length of a hospital stay for Limited English Proficient patients was significantly longer when professional interpreters were not used at admission or both admission/discharge.

Communication errors increase the likelihood of medical errors. In addition, poor communication and a lack of cultural and linguistic competence can lead to higher rates of readmission and increased lengths of stay in the hospital.

So where can you learn more about CLAS, the National CLAS Standards, and how to implement and address these issues within your organization. You can visit think cultural health initative of the HHS Office of Minority Health, which is dedication to advancing health equity at every point of contact. The National CLAS Standards, which offers framework for implementing Culturally and Linguistically appropriate services, there guidance document, A Blueprint for advancing and sustaining CLAS policy and practice is available online and for download at think cultural health.

In addition, there are continuing education programs available for your teams for physicians, nurses, disaster personnel, and oral health professionals, and numerous other resources. We encourage you to visit and to share Think Cultural Health as your go to resource for CLAS related information. And if you have any stories to share, any documents that you think could be helpful to disseminate widely, and if you have any questions about the National CLAS Standards, advancing CLAS, or how CLAS can impact your organization please feel free to email us at Advancing CLAS@thinkculturalhealth.hhs.gov . Thank you again for visiting and we hope you enjoyed today.s presentation.