Prevention and Cultural Competency: Improving, Access, Safety and Standards of Care for Hispanic/Latino Communities Through Mandated (CLAS) Specific Prevention

Initiatives

NHMA, Leadership Fellows, Class of 2013

Presented to : Elena V. Rios, M.D., M.S.P.H and the NHMA

BOD

March 15, 2014

Tammy Rosado Gruenberg, MD, Maritza Irizarri, MD,

Eduardo Montaña, MD, MPH, MBA, Richard (Sal) Salcido,

MD, Ed.D & Michelle Soto, MD

Goals of the Discussion• Provide background for CLAS Standards

– Current National CLAS Policy Initiatives

– Demographics/Need

– Cost

• CLAS Policy Initiatives

– Fragmentation

– Policy Implementation Conundrum

– Patient Safety: Limited English Proficiency

– Prevention Services

• HHMA/NHHF STRATEGIC GOAL CLAS PROPOSAL

– Cultural Competency Training for Provider Licensure

– National Health System Recommendations

– Proposal for FQHCs Designation

• CLAS STANDARDS THE WAY FORWARD

2

Cultural Linguistic Appropriate Standards

• A stated goal for The U.S, health system is achieving health

equity.

• A key determinate in achieving health equity is effective

communication

– Between the person accessing health care and the provider to

enhance safe and effective patient centered care.

• A major initiative towards achieving better health related

communication is through implementation of National Culturally

and Linguistically Appropriate Services (CLAS) Initiative.

3

CLAS POLICY INITIATVES

• DHH Services, Office of Minority Health, IOM, Accreditation Agencies & The Joint Commission

• Some Insurers and State Health Plans supported CLAS for beneficiaries.

• Communication deficits translates to disparities of health, alterations in QOL for individuals, neighborhoods, communities and public health.

• CLAS recognized as effective in improving the quality of care and services. 4

A DEMOGRAPHIC NEED• U.S. Census Bureau estimates (July 1, 2011)

– 52.0 million Hispanics in the U.S., representing 16.7% of U.S. population,

– People of Hispanic origin largest ethnic or race minority.

• U.S. Hispanic pop. July 1, 2050 is 132.8 million, constituting approximately 30% of the U.S. population.

• State Demographics– Largest Hispanic population , California (14.4 million), and the highest

percentage of Hispanic population was New Mexico (46.7%).

• Demographically–– a compelling case– For HCO’S, Insurers and providers to ensure effective communication

for large segment of American society who may not be fluent English speakers.

5

THE COST: Joint Center for Political and Economic Studies (2009)

• Disparities in health care, access & quality escalate health care costs.

– Inequitable care cost $1.24 trillion (LaVeist et al., 2009).

• Three measures to extrapolate cost ; – Direct medical costs of health inequalities,

– Indirect costs of health inequalities

– Costs of premature death.

• The study concluded:– Eliminating health disparities reduce expenditures by $229.4 billion for

the years 2003-2006;

– 30.6% of direct medical care expenditures for African Americans, Asians, and Hispanics were excess costs due to health inequalities.

– Eliminating health inequalities reduced indirect costs associated with illness and premature death by more than one trillion dollars between 2003 and 2006.”

6

THE POLICY IMPLIMNETATION CONUNDRUM: CURRENT CONDITIONS

• Implementation of CLAS is a challenging

endeavor for the American Health Care System

– reasons including; a movement towards a

pluralistic society made up of diverse communities,

cultures, languages, ethnic origins and the political

realities inherent in a democratic society.

– lack of policy consensus, and uniform policy

implementation of the CLAS standards.

7

Limited English Proficiency: Patient Safety• In U.S., 55 million speak a language other than English

– Failing to provide CLAS creates significant health risk

– Translation services are estimated at $2.5 Billion (Youdelman 2010)

• TJC study, from 1995 to 2002, communication – root cause of almost 65% of sentinel events, unexpected events, which caused death or serious physical or psychological injury.

– Analyzed 1,083 adverse incident reports from six Joint Commission-accredited hospitals for English speaking vs. LEP patients for 7 months in 2005

– Greater percentage of LEP patients experienced physical harm versus English-speaking patients, 49.1% and 29.5% respectively.

– LEP patients, higher levels of physical harm ranging from moderate temporary harm to death, 46.8% and 24.4% respectively.

8

CLAS POLICY BACK GROUND

• Numerous agencies: multiple, policies, directives and statues that promulgate or have imperatives to implement (CLAS);– The U.S. Department of Human Health Services (DHHS),

(OMH) “National Standards” for CLAS – “Mandates” and alludes to requirements for all

recipients of federal funds. – A juxtaposition published by the DHHS (July 2010),

emanating from OIG states that that the “CLAS Standards are not mandatory”.

• Title VI of the Civil Rights Act of 1964– institutional language barriers (failure to provide understandable

healthcare interaction between patients and providers) may violate Civil Rights which provides the right against discrimination for of all citizens including those accessing publically funded health care services.

9

Title VI of the Civil Rights Act of 1964

• Prohibits discrimination on the basis of national origin,

which may include limited English proficient (LEP)

people.

• Beyond Title VI, there exist an Executive Order 13166,

requiring Federal agencies to insure that LEP individuals

have meaningful access to services provided by federally

funded agencies including health services1.

• Few states have LEP/CLAS and cultural competency

training standards

10

Recent Initiatives

• National Standards for CLAS in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice.

• The HHS OMH /National CLAS Standards Enhancement Initiative from

2010 to 2012– “to recognize the nation's increasing diversity, to reflect the tremendous

growth in the fields of cultural and linguistic competency over the past decade, and to ensure relevance with new national policies and legislation, such as the Affordable Care Act. A decade after the publication of the original National CLAS Standards”, This initiative(2013) is published in the Federal Register3.

• The Affordable Care Act: Healthcare reform, as outlined by the Affordable Care Act (Patient Protection and Affordable Care Act, H.R. 3590, signed into law by President Obama in March (2010)

11

Prevention Services: PPCA

• Investing in public health

– Grant programs, contracts, support and infrastructure : national prevention,

health promotion and public health strategy, and coordinate federal programs;

• Educating the public through prevention education campaigns aimed at

improving health and wellness, and learning from experience through

research and demonstrations;

• Requiring that evidence-based preventive health care services be

covered in both Public and private health coverage, without cost-

sharing for all health care providers, hospital and clinics receiving

federal assistance (Medicaid/Medicare)

12

Promote Prevention Services and Training

among Physicians caring for Hispanic Communities • Initiatives /Agendas: Avoid Fragmentation

– Integration of National Prevention and Cultural Competency

Agenda

– Improving Standards of Care by mandated CLAS- specific

prevention initiatives within an intra agency platform

(ACGME, CDC, HRSA, JCI and AHA)

• National Prevention and Cultural Competence Consensus Conference

with Inter-professional education

– for health service providers of all levels (physicians, nurses, physician’s assistants,

administrators, students of public health and medicine.

– Perhaps a “Fall” NHMA National CLAS Consensus Conference could highlight the NHMA

as unifying venue to provide the intersection between public policy and advocacy13

HHMA/NHHF STRATEGIC GOAL PROPOSAL

• (NHMA/NHHF) should promote and

recommend legislation

– for establishment of a new federal requirement

that all health care providers, hospital and

clinics must provide Prevention Services

(USPSTF)that are Culturally Competent and

Linguistically Appropriate by 2016.

14

Cultural Competency Training for Provider Licensure

• Only 3 states (CA, NJ, WA) have passed or are evaluating

legislation mandating cultural competency training for

initial provider licensure

• NHMA/NHHF recommends that Federal Legislation be

enacted requiring states to abide by the CLAS standards,

• DOJ/OCR mandates and Executive Order 13166 of the

Clinton Administration guaranteeing all citizens access to

culturally and linguistically sensitive health care services.

15

PURPOSE: NHMA/NHHF STRATEGIC GOAL• Augmentation of CLAS Trained Health Professional Workforce

- Effective Diversity Training in Preventive Medicine Care

interventions c/w

minimal standards (USPSTF).

– Effective Chronic Disease Management care using Culturally and

Linguistically Appropriate Services

– Empowerment and Engagement of Minority Populations most at

risk through aligned “Prevention and Behavioral Health Strategy

– NHMA/NHHF Role as Promoter of National Agenda Directing

Adoption of Prevention and Cultural Competency Standards for the

United States Health Care System.

16

NHMA/NHHF STRATEGIC NATIONAL GOALS• A Patient/Consumer Focused U.S. Health Care Delivery System Driven by

the ACA and supported by Intra –Agency collaboration .

• Definable Outcome Measures of Effective Prevention Services Utilization

by minorities Receiving CLAS trained HC Services

• Measureable Increase in Patient/Consumer satisfaction with U.S. Health

Care.

• Demonstrable Improvement in Health Care Providers Efficiency and

Comfort with providing Preventive Services that are CLAS sensitive

• Financial Incentive for Physician Providers and clinics providing cultural

competent training and financial incentives

• Increased Workforce of Health Care Providers in all categories that are

Trained, Proficient and Rendering culturally competent care to Hispanics

and other minorities.

17

IMPLENTATION• NHMA/NHHF promotes and supports interagency, interdepartmental

collaboration (CMMS, NCQA, CDC and HHS)

– Current certification standards for the Patient Centered Medical Home (PCMH)

to be revised including CLAS and minimum Prevention Standards.

– A “MUST PASS” element for award designation.

– NHMA/NHHF supports Expansion of Federal Funding for Expansion of the Office

of Minority Health (OMH).

– ONLY Federal Agency office offering online CME training for cultural

competency.

– Integration of Federal system Online Sites to eliminate Fragmentation and

Duplication of Efforts.

– Combing Federal Efforts to meet Executive Order 13166 (LAP), DOJ/OCR and

OMH mandate for Cultural and Linguistic competency training and services.

18

IMPLENTATION• Federal Legislation should be considered

– Mandating all federal agencies participate in this integration and develop policies if

currently not present in the agency (CDC, DOD).

• Federal Monitoring of the agencies effectiveness in implementing CLAS competency

training/ services

– Centralized in DOJ and a intra agency

– “Executive Committee” would be assigned by the President to assess federal agency

compliance and regulate funding restrictions for those agencies not fully complaint.

• Licensure of Health Providers

– Federal legislation should be considered requiring all state medical and health boards

to require proof of minimum Prevention Standards /CLAS competency training and

services as required for initial or recertification of licensure to practice.

19

Proposal for FQHCs Designation

• “MUST PASS ELEMENT “ for all NCQA’s Patient

Centered Medical Homes (PCMH) applications.

• Financial Incentives for PCMH for

Institutions/Providers - enhanced re-imbursement

for Medicaid and Medicare patients.

• Core Competency of PCMH requires basic

communication and coordination functions.

 

20

National Health System Recommendations

• Governmental Initiatives and Agendas to promote Prevention Services and Training among Hispanic/Latino communities and health providers serving them

• Consideration of a National Prevention and Cultural Competence Conference with Inter-professional education for health service providers

• Bring Prevention of Chronic Diseases in Minority and Underserved Populations to the top of the Federal PACA agenda

• Stimulate a private sector corporate partnerships with Office of Minority Health

21

National Health System Recommendations • Engage NGO’s around the initiative to improve the minority health

through supporting

• NHMA/NHHF support an expanded role of academic, governmental and NGO institutions to increase funding and resource efforts in support of further Hispanic Health Research.

• NHMA/NHHF promotes and engages all media outlets to embrace the issue of a minority, multicultural epidemic of chronic illnesses, and partner in widespread dissemination of messaging that will further enhance the effective delivery of Prevention/Culturally Competent health care to Hispanic/Latino and minority populations.

• Utilization of innovative technologies (ie smart phones) for messaging and tracking minority health parameters can be harnessed by working with private organizations currently successfully implementing this method of chronic disease prevention.

22

NEXT STEPS• NHMA/NHHF is committed to being the lead US medical association

providing surveillance and analysis of the societal impact of our – National Initiative for Prevention and Culturally Competent Health Services and Training, with

the ultimate goal of making cultural competency awareness and training the Gold Standard of graduate medical education.

• NHMA/NHHF collaboration:– Federal agencies, the private sector and non-profits, capitalize on established collaborations

– Track the success of the National Initiative for Prevention and Culturally Competent Health Services and Training programs.

• Creation of NHMA/NHHF Program Dashboard – To allow all stakeholders to follow the intra-agency and cross industry compliance and participation and

non-participation, success and failures.

– Transparency for legislators and stakeholders to instantly assess the effectiveness and cost savings of a specific preventive or CLAS measure guiding policy decisions and funding.

• NHMA/NHHF is dedicated to the medical and public health education– Of those Future providers who will care for the burgeoning population of citizens of mixed race and

ethnicity.

– Our Commitment is to improve the quality of life and well-being of the diverse US population through lasting improvements in culturally sensitive education. 

 

  

23