The National CLAS Standards in Action - SAMHSA · PDF fileThe National CLAS Standards in Action ... sociology at the University of Texas at San ... taking some time and breaking it

SAMHSA’s Center for the Application of Prevention Technologies (CAPT)

The National CLAS Standards in Action

August 4, 2016

Facilitators: LaShonda Williamson-Jennings, Associate Coordinator, CAPT West Resource Team

Grantee Presenters: John Bartkowski, CAPT Associate; Nikki Roseberry-Keiser, PFS Grant Manager

[LaShonda Williamson-Jennings]: Today's webinar is going to be recorded and archived and will be available to all webinar participants, so please contact the webinar facilitator if you any concerns or questions. The webinar recording should be finished in about two weeks, so give it about two weeks and you'll have an opportunity to have the recording so that you can share with other colleagues or friends who may be interested in the CLAS standard services that we are offering today.

Here are our learning objectives. We are going to: (1) Define the national Culturally and Linguistically Appropriate Services (or CLAS) Standards, which will be referred to commonly through this presentation. (2) Describe the link between the national CLAS standards and SAMHSA’s Strategic Prevention Framework, which some of us actually know as the SPF. (3) We are also going to discuss best practices for evaluating the implementation of CLAS standards into prevention planning; and, finally, (4) identify CAPT Training and Technical Assistance (T/TA) resources to support the implementation of CLAS standards into prevention planning.

Your presenters today will be Dr. John Bartkowski (CAPT Associate) and Nikki Roseberry-Keiser, Partnership for Success Grant Manager from the great State of Nebraska. I want to start by sharing a little bit about those two.

Dr. Bartkowski has served as an evaluator on numerous federal and foundation grants designed to enhance the performance of community-based organizations and the delivery of services to disadvantaged populations. He is currently a professor of sociology at the University of Texas at San Antonio, where he has served on the faculty since 2008. Welcome Dr. Bartkowski!

[John Bartkowski]: Thank you.

[LaShonda Williamson-Jennings]: Nikki Roseberry-Keiser is the Partnerships for

The National CLAS Standards in Action, p. 2

Success 2013 grant coordinator and the statewide Mental Health First Aid coordinator for Nebraska Department of Health and Human Services, Division of Behavioral Health. Nikki oversees programming and implementation decisions for substance abuse prevention and mental health promotion statewide. She provides technical assistance on programatic decisions for both substance abuse prevention block grant and PFS funding. Nikki is a fast trainer. Has presented on CAPT webinars and will be speaking at the NPN Conference in September. Nikki, welcome to the call today.

[Nikki Roseberry-Keiser]: Thank you so much.

[LaShonda Williamson-Jennings]: Now, that you know a bit about what we are going to talk about today, I'm going to turn the time over to Dr. Bartkowski.

[John Bartkowski]: Thank you, LaShonda. Welcome everybody. Happy to be able to speak with you today and interact with you today, even it will be virtually through the poll questions and other opportunities that we will have to discuss the CLAS standards. Just want to first provide a little bit of background: As an evaluator and epidemiological outcomes workgroup member in Mississippi, on the evidence-based workgroup as well, I have been part of a team that has tried to really improve the capacity of cultural competence and knowledge and awareness of the CLAS standards in Mississippi. So part of what you are going to hear today is some of the training that I deliver in Mississippi, as we try to bolster cultural competence throughout the state, and we've done that now for several years and feel like it has been a strong model within the state of Mississippi. Of course, some of it might need be adapted for the particular areas that you serve; but when we talk about the CLAS standards and cultural competence, we first actually talk about the definition of the CLAS standards and, more specifically, what is the nature of culture.

So, the CLAS standards are Culturally and Linguistically Appropriate Service (CLAS) standards. They were initially developed by the Office of Minority Health, and culture is most broadly defined as a peoples' way of life. This includes beliefs, that is attitudes, also values, views about what is good and bad, or right and wrong, and practices, that is behaviors or traditions.

The language facet of CLAS is, of course, understood best as spoken and written communication, but also in the age in which we live, quite commonly visual communication. Language is a key component of culture, and language often expresses a particular world view or a perspective. So the fact that a word might be featured in one language, but not another language, often reflects the social or cultural environment within which a group of people live. And language is not just the substance of communication, but there are also stylistic differences as well. So when we think about people having a different accent in different regions of the country, for


example, it's not something we just use to communicate, but it is something that indicates identity.

A key feature of CLAS is attention to distinction, and by that we mean cultural and linguistic differences. There may be beliefs, traditions, and speech patterns (I mentioned accents, but I would also add dialects) that would seem unconventional to some people, or sometimes indicate that people are inside a particular group and outside of another group. So cultural difference and cultural and linguistic distinction are really important to consider when training on CLAS.

Finally, there is the meaning of the word ‘appropriate,’ and appropriate from a CLAS standards perspective really recognizes the standpoint of the service recipient or the client. So, it recognizes not only that there are differences, but that there needs to be an awareness of the service client or service recipient's perspective and the service content, as well as the process of service delivery, is designed to be respectful of a person's culture and their language. So rather than denigrating difference or putting it down, it elevates it and recognizes its validity and tries to meet people where they are.

It's important to recognize that the CLAS standards are closely intertwined with health disparities, or better put, with an effort to reduce health disparities. So a key CLAS standards objective is to contribute to the reduction of health disparities. Ultimately, the elimination of health disparities would be something that would be wonderful to achieve, but if that doesn’t seem like an achievable initial goal, reducing health disparities is certainly where the CLAS standards are aimed.

More specifically, CLAS aims to first advance health equity by reducing health disparities, so the idea of health equity is an important one and we are going to return to that at several points as we have our discussion today.

A second CLAS aim is to improve service quality for diverse populations, so to ensure that not only the services are accessible, but that the quality of services is suitable for different populations.

And, finally, CLAS aims to ensure that services are offered in a suitable and sensitive manner, so that the delivery of services are received in a way that respects people's cultural standpoint. There's a little quote in the textbox there that I'll read and it reads this way: “One of the most modifiable factors contributing to health inequities is the lack of culturally and linguistically appropriate services.”

Standard 1 is called ‘the Principal CLAS Standard.’ Now, there are fifteen CLAS standards, but we are going to spend a little bit of time on Standard 1, since it is the foundation of the CLAS standards, and Standard 1 reads this way: “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.”

Now, there is kind of a running joke in Mississippi, when I train on the CLAS standards, that I need to inhale pretty deeply before I read the first CLAS standard, because it is so long. Actually, it's length is, I think, a testament to the desire for this principal CLAS standard to be comprehensive, but it can also be a little bit intimidating as well. So when we train on the CLAS standards in Mississippi, one of the kind of key points of focus is to breakdown this principle CLAS standard and try to figure out what words really resonate with people, who are being trained, in terms of things that they are already doing or things that they could readily do in the near future and what might be some of the obstacles. So, some people, for instance, talk about preferred languages being something that they've already confronted and already addressed. Mississippi is often thought of as a state that has principally African American and Caucasian, or white, racial ethnic groups in it, and that is true, but there is also a significant enough Latino population, some of whom may be working on farms or in the agricultural sector; so the point being that this principal CLAS standard when you might be training local communities on it could be a little bit intimidating initially, but taking some time and breaking it down is something that is strongly recommended.

[LaShonda Williamson-Jennings]: Thank you for sharing that Standard One, Dr. Bartkowski, with us. You all, throughout this webinar, you will be invited to share through using our poll questions, so there will be radio buttons in which we hope that you will join us and push one of the buttons for your answers, but there are also some open-ended questions that we will have as a part of this presentation. So, please, throughout the presentation, I know we can't open up the lines because there are so many people here on the call today, but we can open up our chat box. So check out your chat box on the left side of the screen, and if you have a question, type a question in. Melissa Martin, she is manning that, as well as I am manning that chat box and waiting for a question to be asked, so that we can answer your question in a manner in which you leave feeling like you were heard.

So, our first question is: In your experience, what component of this definition might be pose the greatest challenge? And, when we say definition, [we are referring to] the first CLAS standard that Dr. Bartkowski read to us. So: ‘the health belief differences (attitudes),’ ‘health practice differences (behavior),’ ‘language differences (linguistic challenges),’ ‘health literacy gaps (knowledge),’ ‘other communication needs’ or ‘other.’

Looks like people are participating. I'm seeing the numbers go up and down in different areas; 19 folks are saying ‘attitudes.’ In your experience, what component of this definition might pose the greatest challenge? We are seeing ‘attitudes’ as leading. We


are also seeing ‘language differences’—that can be difficult, being sort of on one accord with languages can be difficult: I want to communicate with you, but I don’t speak the language or you don’t speak the language I speak. ‘Health literacy’ being an issue, but most of us are saying we are going to pick number one: it's ‘health beliefs and differences (attitudes)’ and then second would be ‘health literacy gaps,’ so the knowledge and understanding around health.

Thank you all so much for participating in that poll question again. There will be more poll questions as we get through this webinar—more open-ended questions, opportunities for you all to share—so thank you so much.

I want to shift back to our slide now and invite Dr. Bartkowski to talk to us and share Standards 2 through 4. Dr. Bartkowski—

[John Bartkowski]: Thank you LaShonda and I appreciate everybody participating in the poll. Standards 2 through 4 of the CLAS standards address Governance, Leadership, and Workforce. And before we begin, I wanted to actually say one of my—I don’t know that I'd call it a criticism—but maybe one of the shortcomings of the CLAS standards is that they really do focus on organization, so healthcare organizations, particularly like behavioral health organizations.

But I want us thinking beyond a kind of formal organizational context today, to think of a workgroup, a work team, a coalition in which you might be involved. So whether or not you are part of a kind of formal organization, I want you hopefully coming away from our discussion today thinking that there is something you can do individually and there is something that your work team, workgroup, coalition, what have you, can do collectively to implement the CLAS standards in the context of whatever workplace you may be working within.

Standard 2 talks about promoting CLAS and health equity in organizational governance, as well as leadership through policy, practice, and resource allocation.

Let me say a little bit of a word about this. If you are part of an SEOW, or a State Epidemiological Outcomes Workgroup, you might think, ‘well, this standard doesn’t directly appeal to me or it doesn’t necessarily apply to my workgroup,’ but I would say actually most workgroups have bylaws or operating procedures that govern their practices. So one question I would pose, or one suggestion I would make, is that if there isn't CLAS and health equity mentioned in your bylaws or operating procedures, that might be something that you might consider, whereby you would make a kind of policy change, and perhaps that would lead to a practice change within the context of your particular work team.

Standard 3, which remains part of the Governance, Leadership and Workforce cluster


of the CLAS standards, is “Recruit, promote and support culturally and linguistically diverse governance, leadership, and workforce that are responsive to the service population.”

So, here again, I would say that you might consider taking a bit of an inventory, whether it's in your organization or your coalition or whatever, and trying to determine, okay, what types of clients do you serve and to what degree does the leadership of your organization, or your coalition, reflect the clients that you serve? And that might be thought of in terms of age, race, ethnicity, gender, ability/disability—all different types of consideration. So where age is concerned, for example, if you serve a youth population or maybe a young adult population, but don’t have a youth or a young adult represented in your organization or in your work team, for instance, on an advisory board, that might be something to consider.

Standard 4 is to “educate and train governance, leadership and workforce in culturally and linguistically appropriate policies and practices.” So, in other words, it's not sufficient just to have diversity represented in governance, leadership and workforce, but there needs to be ongoing education and training for those people, so that they can be aware of what constitutes culturally and linguistically appropriate practices and can recognize and push for the adoption of policies that are culturally and linguistically appropriate.

[LaShonda Williamson-Jennings]: So, we are here at another poll question: “What kind of training on CLAS Standards have you participated in or offered during the past year?” Just take a moment to think about what have you participated or trained in.

I'm seeing two answers so far: they are saying ‘none.’ So there are ‘conference workshops’ and ‘overview training.’ I'm seeing a lot of ‘none.’ ‘This is my first one’—so welcome! So, if this is your first one, this is great. You are in the right place because what does Standard 4 say, and what did Dr. Bartkowski share with us? Ongoing education and training is absolutely important.

‘PFS webinar.’ Okay, great. ‘Cultural competency training.’ ‘Presentations from the New Hampshire Department of Health and Human Services.’ There are some webinar overviews that folks have gone to. ‘Basic overviews.’ So, we are seeing a lot of overviews. ‘Iowa Partnership for Success,’ so Iowa and New Hampshire folks are saying that ‘we are receiving training on this.’ Perfect. ‘Conference sessions and follow-up homework’—certainly it’s always important to continue to not only get educated from your funders’ webinars, but also to look into getting educated on your own.

We know when we talk about culture, it's not one of those things where one day you just arrive and you don’t have to go any further, because you are automatically


culturally competent or you've already integrated these standards into your practice; but that you have to continue to work on this as our communities continue to change.

So, great. It looks like—if this is your first webinar or training, then welcome. If you've trained before, that's fantastic. Thank you all for sharing your answers, so we are going to turn the time back over to Dr. Bartkowski.

[John Bartkowski]: Thanks again. So, we will move on now to Standards 5 through 8. Standards 5 through 8 are related to Communication and Language assistance.

Standard 5 addresses the offering of “no-cost language assistance to those with limited English/linguistic proficiency.” Standard 6 tells us to “inform all of the availability of language assistance in their preferred language, verbally and in writing.” So, in other words, it doesn’t do much good to offer the opportunity for people to have language assistance if that is not presented to them in their own language.

Continuing with Standards 5 through 8, again Communication and Language Assistance: Standard 7 discusses ensuring “competence of those providing language assistance.” Now, I know that in a lot of organizations there is not just the temptation, but probably the utilization of young people, like minors. So if there is an adult who doesn’t speak a particular language of the service provider, that adult may bring a child to translate, and really Standard 7 encourages us to move away from that model by avoiding untrained persons and minors in providing language assistance.

Standard 8 says to “provide easily understood print, multimedia materials, and signage in the service population's language.” Now, this might seem like a rather daunting prospect, but here, again, it kind of grows out of having diverse governance and leadership and workforce. So if you really have a workforce and a leadership in your organization or your work team that reflects the service population, then you will have people, ideally, with linguistic proficiency, cultural sensitivity, that they will be able to ensure that services will be provided in a way that is appropriate in a communication and language assistance sense. I would add that there are actually language assistance services that are available on-line these days. Often, they will charge an hourly rate, but that's something where CLAS resource allocation is an important consideration. Budgeting for language assistance services in a budget line is something that would be, I think, a strong application of these standards within CLAS.

[LaShonda Williamson-Jennings]: Thank you, Dr. Bartkowski. We've come to another discussion question: Which one of the standards 5-8 poses the greatest challenge to your organization? So, 5 through 8, we know are about language. Which of those poses the greatest challenge for your organization? And, then there's a follow-up question: What specific barriers have you experienced in implementing the standard you selected?


Please, join us by answering the question—the poll questions three and four. Which one of the standards, 5 through 8, poses the greatest challenge to your organization: No-cost language assistance? Inform all of availability of language assistance? Ensure competence of those providing language assistance? Or, provide easily understood materials and signage?

And, then there's the follow-up question: What specific barriers have you experienced in implementing the standard you selected? So, what specific barriers have you experienced? Those barriers could be anything from a lack of funds—we do know that that Dr. Bartkowski talked about going online and looking for some free things. So finances, after sitting through this webinar, participating, may become a little lower once you start to look at what are the resources that we have out there. ‘Staff funding.’ Perfect. ‘Lack of funds.’ ‘Funding.’ What are some of the other ones? ‘Funding technology for voice or video notification of language assistance.’

‘I work primarily in evaluation, so I guess the biggest challenge is how to be culturally aware of how evaluation is perceived, explained and used in various contexts in which we work.’ Perfect. We are waiting for some more answers. ‘Having materials translated into the right language or dialect.’ I mean, that could be difficult, right? ‘Funders want more services and don’t want to decrease the number of services to accommodate these standards.’

Okay. So, funding is sounding like it's a big challenge, and folks are saying that their greatest challenge here in poll number three is to ‘ensure competence of those providing language assistance.’ Certainly, you know, for a long time, we certainly have done exactly what Dr. Bartkowski said—we've used youth, we've used people who were in our offices, to help us with translation. So finding someone who is competent to provide that language assistance can be at times costly, but we are seeing that technology is making it less cost-prohibitive and so my hope is that once you leave this webinar today, that we can look into some of those services.

Others are saying ‘provide easily understood materials and signage.’ So, again, how do I get the most appropriate materials or signage. And then, ‘no-cost language assistance.’

Dr. Bartkowski, I would like to turn the time back over to you, unless there is something else you'd like to share about these two poll questions.

[John Bartkowski]: I guess the only thing I'd observed from the first poll question is that the idea of providing notification to people that language assistance can be made available to them—I didn’t see that anybody had selected that one, so I'm -- I'm delighted to see that. Rarely do I comment on an item that nobody has selected, but that's great. It means that people are already indicating to those that they serve that


language assistance can be provided and that that's done probably in multiple languages for whatever context people might be offering those services in.

[LaShonda Williamson-Jennings]: Thank you so much, Dr. Bartkowski.

[John Bartkowski]: Thank you. I'm going to move a little bit more quickly on Standards 9 through 15, but I will say that they are near and dear to my heart, because a lot of them have to do with evaluation, and that is something that is a principal focus for me. But we don’t want to make this a call that is just relevant to evaluators, and we don’t want anybody to be intimidated by Standards 9 through 15, so Engagement, Continuous Improvement and Accountability are the focus of CLAS Standards 9 through 15.

Standard 9 encourages us to “establish CLAS goals and policies within an organization.” I would broaden that. When writing a proposal or, again, when drafting bylaws for a workgroup or a coalition, having a CLAS goal or a CLAS policy within those contexts would be very appropriate.

Standard 10 asks us to “assess and improve CLAS activities,” so that's where it is not enough just to train people, but to make sure that the training is effective and to look for opportunities to improve that training—that’s something that Standard 10 has as a principal focus.

Standard 11 is collecting and maintaining CLAS demographic data. Now, this is so vital because we really want to know if diverse populations are being served—are they being served in an equitable fashion? If they are not, we would observe (or evaluators would observe in their data analysis) that the program is much more effective, say, for men than for women, or for people of a particular racial ethnic group than others, or for people of specific age groups. So maintaining CLAS demographic data in the context of evaluation, and even in the context of just service delivery, to make sure that there is accessibility that is equitable is really critical.

Standard 12 addresses the assessment of community health assets and needs for cultural and linguistic appropriateness. So this is where CLAS takes more of a community turn to look at the assets and needs that a community might have where cultural and linguistic differences are concerned.

Standard 13 speaks to partnering with the community to ensure successful CLAS implementation—and here is where I would just quickly add that training people on CLAS in a kind of lecture-oriented, top-down fashion is not exactly what I would recommend. Now, we have so many people on our webinar today that we can't invite discussion from everybody in a kind of verbal dialogue necessarily; but in smaller groups that is something that really works very effectively, because CLAS is about


respecting and recognizing cultural differences. And when I train in Mississippi, the experts in the room are not at the head of the table or are not the people who are delivering the training necessarily—and I would count myself among them. The people with the real expertise are those delivering services, because they know their local communities better than we do.

Standard 14 is creating a culturally and linguistically appropriate conflict and grievance resolution process. If somebody feels they are treated in an inequitable fashion, it's important that there is a redress for those individuals.

And then, 15 entails reporting organizational or coalition or work team or project progress and that may mean to the whole project team, that may mean to community stakeholders and others who have an interest in the project or the program being offered.

[LaShonda Williamson-Jennings]: Thank you, Dr. Bartkowski. Has your organization, work team, etc. established CLAS goals? This is a yes or no question. Yes? No? Not sure…I just can't recall? Has your organization work team established CLAS goals? What are your goals? Think about that. What are the CLAS goals for your organization or team?

And then the next question is, if you don’t have any, then perhaps at the next staff meeting you talk about ‘what are our goals?’ and the importance of ‘I heard Dr. Bartkowski saying it's really important that we establish some CLAS goals,’ and then go about ‘how do we do it?’ And, if you are not sure, it never hurts to ask. I have a supervisor who certainly lives by that—you know, it never hurts to ask. Find out ‘do we have CLAS goals?’ and it might be a great place for you to begin to lead the charge in helping your team or organization to establish CLAS goals.

We see sixteen people said ‘no,’ eleven said ‘yes,’ and seven said ‘not sure, can't recall.’ Thank you all for answering that question. Again, don’t forget that you have an opportunity to ask a question in the chat box, which is right below, so at any time if you have a question, please ask that question.

We are going to move back to our slide deck. Dr. Bartkowski is going to talk to you about some CAPT resources on cultural competency that you can gain access to.

[John Bartkowski]: Thank you. As you think about establishing a CLAS goal, we would really turn your attention to a CAPT resource that is available to you and that’s the CAPT cultural competency toolkit. In front of you, you see a link by which you can access the cultural competency toolkit, as well as a username and password.*

* This resource, now titled Tools from the CAPT: Increasing Cultural Competence to ReduceBehavioral Health Disparities, is available on the CAPT area of SAMHSA’s website:


Remember that this webinar and the slide deck will be provided to you, so if you are scrambling about for a piece of paper to write this down, this will be circulated to you within a couple of weeks.

And, I'm going to spend the next few minutes talking about that toolkit, but before I do, I first want to put in a plug to my CAPT colleagues, who provide excellent training and technical assistance services on the CLAS standards. So, should you need or desire technical assistance, the CAPT can provide that to you in a customized fashion. They can also provide in-person training, online webinars and courses, and then, of course, there are an abundance of CAPT tools and resources available to you.

So, often, when we train on the SPF, or the Strategic Prevention Framework, we are so focused on the perimeter—what in Mississippi we've come to call, affectionately, the ‘Apple Cobbler PIE,’ or the A-C-P-I-E portion. That's the outside, or the steps, of the SPF model. The A is Assessment, the C is Capacity, the P is Planning, the I is Implementation and the E is Evaluation.

And, then people sometimes can't remember, like, what goes on the inside of those steps? And we say well, what you need on your ‘Apple Cobbler PIE’ is ‘Sweet Cream.’ Sweet for Sustainability and Cream for Cultural Competence. And, what I want to do today is actually focus on the ‘Sweet Cream’ or really, I guess, the ‘Cream’ portion of the SPF model—so cultural competence.

Now, with the SPF model, as many of us have been trained on it, again the focus is often on the steps. They are beautifully colored around the perimeter of the model, but the central part of the SPF is sustainability and cultural competence. That is supposed to be infused into every step of the Strategic Prevention Framework. So, ideally, the Strategic Prevention Framework should be used and applied in a way that fosters cultural competence that moves towards the integration of CLAS standard and ultimately that transforms organizations and workgroups in a way that can reduce health disparities.

So, let's take these step-by-step and build linkages between the CLAS standards and each step of the SPF model.

Step one is ‘Assessment,’ and assessment, of course, involves identifying local prevention needs based on data. What you see before you is a table that is featured in the cultural competency toolkit, and it basically just connects the CLAS category of Engagement, Continuous Improvement and Accountability—those are those last several standards of CLAS—and provides an opportunity to apply the CLAS standard

https://www.samhsa.gov/capt/tools-learning-resources/tools-capt-increasing-cultural-competence-reduce-behavioral-health




in the context of assessment. So there, Standard 12 is discussed as ‘conducting regular assessments of community health assets and needs and using the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.’

Now, if you see a little bit of difference between that CLAS Standard 12 and the one that I recounted for you earlier in the slide deck, it's because I didn’t want a whole slide dedicated just to Standard 12. So we thumb-nailed those earlier on to summarize them, but this is the full CLAS standard written out.

What I like about the cultural competency toolkit is it kind of alerts you to the fact that there are also opportunities to apply this standard, that is Standard 12, in other SPF steps, so in this particular case it’s step three and step four.

Step two is ‘Capacity,’ and in the SPF model capacity refers to building and engaging local resources and readiness to address identified prevention needs. Now, the CLAS categories actually are multiple here, with respect to capacity, and you have multiple CLAS standards in which capacity—a relationship or linkage to capacity—can be built. So Standard 2, Standard 3, Standard 4 and Standard 9 provide opportunities to link back to capacity. Standard 2, for example, speaks to advancing and sustaining organizational governance and leadership processes that basically promote CLAS and health equity through changes, if needed, in policy, practice and resource allocation.

And, there you see a continuation. I'm not going to spend any time on this particular continuation table, but my point is that this is also featured in the cultural competency toolkit.

Step 3 in the SPF model is ‘Planning,’ and planning involves figuring out how to best address identified prevention needs and associated factors. Planning refers to the principal CLAS standard, which also refers back to step four of the SPF model. But the principal CLAS standard is one that should really govern the design of a project or the design of a program. Engagement, Continuous Improvement and Accountability CLAS standards are also relevant to planning, so there you see CLAS Standards 12 and 13 listed, and consulting those standards as you generate a strategic plan—that is Standards 1, 12 and 13—is something that will help you become more aware and kind of recognizing the importance of building CLAS standards into your strategic plan.

Step 4 is ‘Implementation.’ Implementation involves putting your plan into action by delivering evidence-based interventions as intended. And when we think of programming, this is always what we think of—is implementation. Back before there was a SPF model, this is pretty much what people did: they moved right to implementation. They didn’t necessarily have an assessment; they didn’t look at the resources or, you know, the capacities in the community; and they typically didn’t


develop a strategic plan.

So this one actually connects to a number of CLAS standards: You see 1, 5 and 6 are the CLAS standards that are listed in the cultural competency toolkit table there. You also see standards 7, 8 and 12 are relevant to implementation. So, for instance, 7 says: ensuring the competence of individuals, providing language assistance, avoiding the use of untrained individuals and/or minors as interpreters. So again having a plan and being able to implement that plan for language assistance, when needed, is something that is really critical.

Finally, step five in the SPF model is ‘Evaluation,’ and this involves examining both the process and outcomes of prevention intervention. So here you see that a number of CLAS standards under the rubric of Engagement, Continuous Improvement and Accountability are listed there; and the opportunity to apply the CLAS standards is featured in CLAS standards 10 and 11.

[LaShonda Williamson-Jennings]: Thank you, Dr. Bartkowski, for sharing that tool. I encourage you all to download this tool and share it widely with your team, your leadership, and use it when you—if you don’t already have CLAS goals—in the development of your CLAS goals. I mean, that could also be used if you are in the process of revising or creating a new strategic plan. So, again, thank you Dr. Bartkowski.

We have another question for you: Have you had any experience in evaluating the implementation of the CLAS standard? If so, what evaluation approaches have you used?

So, I'm seeing a ‘no.’ Several ‘no’s.’ So, Dr. Bartkowski, we are seeing several ‘no’s’ from folks. My question would be ‘if I had not had any experience, and I perhaps need to hire a new evaluator, what questions should I ask around this?’ Or, ‘what should I be looking for in an evaluator who has experience evaluating the implementation of CLAS standards?’

[John Bartkowski]: The first thing I would suggest in interviewing evaluators is to ask if they are familiar with the CLAS standards, and, if they are not, are they willing to become familiar with them and maybe to develop instruments that would measure the integration of CLAS standards into service delivery? I would also suggest approaching the CLAS standards as part of a team. So as an evaluator, perhaps, looks around, there are actually some nice surveys that are available online—whether they are checklists or other types of options—that have begun to kind of move forward and be disseminated, in terms of instruments that can be used by evaluators to assess the integration of the CLAS standards and programming.


So, you don’t have to reinvent the wheel. There are some resources online and at some point if there is a desire for more of an evaluation-oriented webinar, with respect to CLAS standards, that is something that maybe evaluators out there can chime in on or provide some feedback on.

[LaShonda Williamson-Jennings]: Thank you, Dr. Bartkowski. So, far and wide, most folks said ‘no’—that they have not had any experience in this area. But I am seeing an answer here, “survey of target audience to determine engagement of materials,” as an answer we have, and we also have “we address cultural adaptation, ask about steps taken to ensure behavioral health disparities are addressed.” Then, there's another answer here, “cultural and linguistic competence policy assessment.” So, I guess it's one of the tools that they have utilized to evaluate, or approaches that they have utilized to evaluate, implementation of the CLAS standards at their organization.

So, this is great. Thank you all for sharing. Again, if so much of this is new to you, the important part is that you are in the right place, and you are getting your feet wet today. And my hope is that you are going to not only take this presentation back to your team, but also to explore other presentations, in terms of webinars and conferences. Or even if you are at the state or tribal level, or jurisdictional level, talking to your CAPT T/TA provider about training and technical assistance in this area.

I want to go back to our slide deck. Dr. Bartkowski, I'll turn the time over to you again.

[John Bartkowski]: Thank you. So, let's continue our discussion of step-by-step linkages between the SPF model and CLAS—and we really don’t want to neglect sustainability. Again, even though some people would see it as buried rather subtly in the middle of the SPF model, it is vitally important—and it itself has connections to cultural competence. So sustainability is often understood as: continuity; persistence; maintaining long-term stakeholder support; achieving and communicating results (not only during a program, but after the program has been completed); and seeking to obtain steady funding.

Before we move to this poll question, I'd quickly like to say that one of the things that anybody can do, where sustainability is concerned, is simply to train their workforce on CLAS, because workforce training on CLAS is something that people will take forward with them into the field.

One of the things that we've done in Mississippi is not only to train people on the CLAS standards, but then to have them return and basically inquire about what ways they've tried to apply the different CLAS standards in the context of service delivery. So that's typically delivered as a facilitated discussion, where I serve as the facilitator, and there's a great deal of peer learning, whereby best practices that are applied in the


field are shared among service providers. LaShonda, I'll turn it back to you.

[LaShonda Williamson-Jennings]: Thank you. What actions will be needed for your work team, organization, or project to achieve sustainability with respect to CLAS? Remember, this is the ‘cream’ in the middle. This is the good stuff: sustainability and cultural competence. So—what actions will be needed for your work team, organization, or project to achieve sustainability with respect to CLAS?

‘Leadership buy-in.’ Leadership buy-in is hugely important—so sometimes we think, ‘How do we get the information out to the community?’ and the reality is that we need to turn inward, and get smart ourselves, and build the capacity of our leadership and the rest of our team—so I love it. I'm seeing ‘ditto.’

‘Planning,’ okay we need to be intentional about planning. Isn't that what the SPF is about? It's about being intentional. It's about planning. Alright. ‘Training providers and community coalition members.’ Certainly that is important. Training is important. ‘Engagement of community, engagement of coalition members.’ We do need to engage our community in being culturally and linguistically appropriate in terms of service delivery. ‘Building capacity of individuals or teams to implement CLAS into various aspects of the SPF stages.’ These are perfect answers. ‘Funding for necessary tools.’ Certainly, funding is important as well. ‘Inclusion of minority populations,’ so we need to include those folks. Nothing about us without us.

‘Utilizing the toolkit identified earlier’ —thank you— ‘so, that folks can look at how to integrate CLAS into the SPF process and revise plans…’ That's perfect. Exactly. I mean, if we are looking at what is my next step? I'm going to utilize the tool. I'm going to share the tool with different community members. I'm going to talk to my leadership. So you take that tool and we can begin to just sort of take our tool with us, have conversations with our community, have conversations with our leadership, have conversations within our coalition meetings and really how do we get even more smart in this area. So these are a lot of great answers that you all are providing today friends.

We are going to move on to our next slide. Thank you for your answers. Thank you for participating so heartily today during this webinar.

I told you all you would have an opportunity to hear from Nikki Roseberry-Keiser. She is a PFS—so Partnership for Success—Manager with the State of Nebraska. She is going to speak on behalf of Nebraska, talking about how they have implemented the CLAS standards in their substance abuse prevention system.

Nikki, welcome to the call, and I'm going to turn the time over to you.


[Nikki Roseberry-Keiser]: As she said, I'm Nikki Roseberry-Keiser from the great State of Nebraska, and we are a PFS 2013 grant recipient.

We are required to write a health disparities impact statement right from the get-go. And when we wrote that health disparities impact statement, what we said we would do was train staff in CLAS—and we weren’t really 100% sure what that would mean for us or for our sub-recipients when we first wrote that. We were pretty new to the idea of CLAS, so as we were getting into our second year of the grant, we thought we should really start looking into how we can address CLAS and health disparities and cultural competence within our workforce.

So we reached out to the CAPT and they were so gracious to give us the name of a consultant who could come and really help us to think about what integrating CLAS standards in Nebraska would look like. And we created a guidance document that is actually pretty similar to what the CAPT has created here with the cultural competency toolkit, and it crosswalks the CLAS standards with the SPF steps.

One of the reasons that was so important was language. Our prevention staff looked at the CLAS standards, and they said ‘This is treatment language. This was meant for the treatment providers.’ And so we wanted to find a way to speak a language that our prevention providers already spoke—and that was SPF. So we created this guidance document, and then we brought our fantastic consultant out to Nebraska and had her provide a workshop for our sub-recipients and actually have them sit and peer-share and talk about the challenges they were facing integrating the CLAS standards. And then we used her tips and tricks and the guidance document to actually incorporate CLAS standards and CLAS language into their work plans; and so those were due about two months after that workshop, and we've really found that that has made CLAS actionable for us here in the State of Nebraska.

So, it is also helpful to have those work plans for the purposes of ongoing monitoring. At the state level it is sometimes difficult to really track what goes on at each of the provider organizations, and by having those work plans it's a really easy step-by-step way for our sub-recipient organizations and our state staff to look and see what are our organizations doing and how far they are in the process of implementing CLAS.

Let's talk about just a few challenges we've experienced here in the state. So turnover is a huge thing—that's huge, I think, for everything that we do, but especially when we talk about cultural competency and integration of CLAS standards. One of the things that's really helped us to overcome the turnover issue is having that guidance document, and then, for you all, the use of the tool kit might really function in that same capacity. So we have a document that we can handout to folks who are new to our system and say ‘This is how we deal with CLAS in the State of Nebraska. This is


how we integrate it.’ And they can turn to that document when they have questions, or they can ask us for TA at the state.

Moving beyond translation of resources—so I think this I something that we do pretty well in the State of Nebraska. I have about an 86% white/non-Hispanic rate statewide, but there are pockets in Nebraska that have as much as 30% Hispanic census. So we have done really well at sort of translating some of our resources and implementing those. We hit Standards 5 through 8 pretty hard here, but it's really moving beyond that. How do we incorporate all of the other CLAS standards beyond just numbers 5 through 8? That's something that we are still working on.

We have lots of programming that we are trying to get out and we are also looking at how do we translate and use language that’s non-Spanish. So we've done a lot to engage our Hispanic community, but how do we go about working on organizational policies? So this is something that folks in the last poll mentioned was that they were having trouble gaining that buy-in from organizations, and we've seen that too. We've seen organizations who have had trouble really understanding CLAS standards, so we are hoping that by teaching not only our coalition leads, but also the members of our coalition, about CLAS and why it is so important to organizational development, that will garner buy-in through training and further information dissemination.

When we are talking about evaluating impact, that's pretty difficult—and if you guys have any awesome ideas about how to better evaluate, I would love to hear them too. I can tell you just a tiny bit about what we do here. This is something we are still working on, but we've really integrated it into our qualitative data collection through our site visits, and through looking at information about adaptations through fidelity rubrics and through the community-level instruments that are required for Partnerships for Success sub-recipients.

Also, for programs with a large enough sample, we've been able to pull out demographics to ensure that persons falling into certain categories are having the same outcomes as the participants that fall into majority demographic categories. And, also, the folks that might be outside of the demographics that a curriculum is researched with, that those are experiencing the same outcomes as everyone else.

Lastly, let's talk a little bit about some of our lessons learned. One of the lessons that I think was really helpful for us was creating a standardized training process that helps keep everyone speaking the same language despite turnover. So, we've really integrated this into our core competencies, and that we have trained all of our prevention staff on as soon as they are hired. We have also created a crosswalk of our core competencies and trainings that integrate CLAS.

We have in-person workshop sessions, peer sharing and brainstorming that allow us


to problem-solve and have a consistent impact statewide. We make sure that all of our folks know that there is a difference between cultural competencies, the CLAS standards, and health disparities—but all of those things work together toward a similar end. And then we are working to integrate CLAS effectively, but it's not easy and it's an ongoing conversation.

One of the things that many of you brought up was funding and, as a funder at the state level, we have really worked to try to incorporate CLAS into what we choose to fund through work plans and logic models; but it's not always easy, and there always isn't extra funding for that, so we are really trying to work to incorporate it into what we do already.

[LaShonda Williamson-Jennings]: Thank you so much, Nikki. There were a few folks who said they struggled to hear everything you said. You all, we will have a recording of this presentation, and hopefully we can improve in that presentation the volume. But, for those who could hear a little better than others, I want to extend an opportunity to ask Nikki questions, but not only Nikki, to also ask Dr. John Bartkowski.

What are your questions that you have for Nikki about her experience implementing, and lessons learned implementing, the CLAS standards in the State of Nebraska, or Dr. Bartkowski's experience around evaluation of the CLAS standards integration and implementation in the State of Mississippi? And so in your chat box (the chat box is to the left of the slide deck), please feel free to ask questions. The chat box is to the left of the slide deck—what are our questions?

Let's see, Julie Lane has a question, so people are asking questions. Julie Lane asks ‘the Nebraska project sounds like it has some excellent ways to look at CLAS throughout the process. It is helpful to hear how you have overcome challenges to overcome turnover and other issues.’ So, this question is for you Nikki, how have you all worked to overcome turnover and other issues when implementing class standards?

[Nikki Roseberry-Keiser]: I hope you can hear me better now. I'm so sorry. I changed phones, so hopefully this helps. So, really, overcoming turnover is about a battle I think we all face, regardless of what issue we are talking about. But for this one, the guidance document has really been a huge part of that for us. It gives us a standardized model to go back to and it can be incorporated into our SAPST training; it can be incorporated into other trainings that we do; and it's available to all of our sub-recipients all the time.

So it gave us really a standardized place to move from and so that everyone speaks the same language and has the same standards. And I would really encourage everyone on the call to look at the toolkit that the CAPT has put together—because it


sounds like it’s somewhat similar to what we've done—and to use that to really bring their sub-recipients into the fold, whether they've been there for one month or one year or ten years. I think it can really start that conversation.

[LaShonda Williamson-Jennings]: Thank you so much, Nikki, for that answer. We have another question from Robert Smith. Robert Smith's question is ‘I'd like to know best practices to inform PFS supervisors/coordinators to gather leadership and community buy-in.’ So, I think that this question really can go to the both of you, so what are some best practices to inform PFS supervisors and coordinators to gather leadership and community buy-in?

[John Bartkowski]: I will just speak—this is John—as an evaluator, trying to present people with data, whether it's published studies or reports that demonstrate the efficacy of cultural competence in the context of delivering services effectively. So I guess, true to my evaluation roots, I try to make a data-driven argument and not get too mired in the data, but talk about, you know, these are the sorts of things that have worked well, and whether it's prevention programming, treatment programming, or other types of social service provision. So organizing it around data and then, frankly, just talking about some of the ways that it might resonate with the values of leadership. A lot of people who are in service provision occupations working in the government sector or nonprofit sector are not there because they want to get wealthy, they’re mission-driven and values-oriented, so talking about the importance of values in the context of cultural competence and recognizing the value of being able to serve people of diverse needs and serve them equitably is something that appeals, I think, to a lot of people who are in the kind of social service provider sphere.

[Nikki Roseberry-Keiser]: And I would just echo that—this is Nikki. We like to say that people don’t join us because they want to get wealthy; they want to get healthy. So, we come from this perspective of health for everyone and health equity across sectors and across all disparities. We have tried to frame that for our communities in that way, that these are people who are living in your communities who don’t have the same access as other people who live in your communities.

And we've got some pretty good response from that, that if you really look at it within their organization, within their community at their level, people tend to have a better buy-in, than if we say, well, this is the total state data or this is the data for the US. If we look at just your community and at who has access and who doesn’t, people tend to respond better, and they want to know how to change that—and CLAS is how we change that.

[John Bartkowski]: I would quickly add to that, that Mississippi, for me, has provided an ideal opportunity and a stringent test of cultural competence in the CLAS


standards, because of the history of some of the racial and ethnic disparities in Mississippi. What's not known is that Mississippi is typically considered the most generous state in the nation. It leads the nation consistently in charitable giving.

So there are sometimes, you know, legacies of factors of which people are not proud, but that can be addressed by cultural competence and other values that are deeply woven into the cultural fabric of a place like Mississippi and can be used to foster cultural competence.

[LaShonda Williamson-Jennings]: Fantastic. Thank you. Absolutely great answer. I do have another question that I skipped over and it’s Lisa Coleman's question and it's for Nikki: “Is the guidance document in Nebraska available for us to view?”

[Nikki Roseberry-Keiser]: Yeah, so I spoke with my partners at the CAPT here, and I'm going to go ahead and pass it along to them, and then they'll make it available with the other materials from the webinar.

[LaShonda Williamson-Jennings]: Fantastic. So you all accessed this webinar through CAPT Connect, and so when you get the webinar recording, you'll get the slide deck, and you'll get not only that, but the decision support tool, as well as Nebraska's tool. So you'll get all of that in CAPT Connect in the next couple of weeks, so I'm sure some of you can't wait to get your hands on these resources.

We have a question from Peter. He said “I think taking the opportunity to build CLAS into existing trainings on evaluation could be a way to address building awareness of both evaluation and CLAS within evaluation activities. John, do you have any experience or thoughts on that in addition to using data?”

[John Bartkowski]: Sure. Actually, I think this is where CLAS isn't just something that is suitable for training with people who deliver services, but I think of training evaluators on CLAS—and specifically those Standards 9 through 15—that's really, really important. Because there you are talking about issues of continuous quality improvement, and really, if cultural competence is something that's the goal and reducing health disparities is the goal, you really want evaluators who are trained to be able to measure progress towards those goals.

One of the things I will say in Mississippi is that under the Partnerships for Success grant, Mississippi issues a funding opportunity announcement for prospective sub-recipients, and then they apply for the sub-grants. And we build into that an expectation that they will write an evaluation plan, and that the evaluation plan will exhibit sensitivity—cultural sensitivity and cultural competence—so that even though we know that they might not have a professional evaluator on staff, we are getting them thinking about the types of data that we will want to collect, and that we will want


them to collect in terms of, you know, racial ethnic differences, gender differences, age differences and things like that of their client population, so that we can measure the effectiveness of the services that they deliver to different client groups.

So I couldn’t agree more that evaluators could benefit from additional training on CLAS and thinking through ways to operationalize it, particularly in different areas, because cultural competence means something different perhaps in different parts of the country, given the rural areas of Mississippi versus maybe a more urban area. I often like to say that there are really, really different regions of Mississippi that are very culturally distinct. The Delta, for example, is quite different than the Gulf Coast, where gaming is something that is prevalent. So measuring CLAS in a culturally sensitive way suitable for the local community is really important and is actually a real challenge.

[LaShonda Williamson-Jennings]: Thank you so much for that answer, Dr. Bartkowski. We have another question coming in from Kelly Martin—and Peter said, ‘great, thanks.’

Kelly's question is ‘what about generational differences?’ What about generational differences in terms of thinking about CLAS standards diversity differences, so what about those?

[John Bartkowski]: I guess I can—

[Nikki Roseberry-Keiser]: I—

[John Bartkowski]: Go ahead, Nikki, if you'd like to.

[Nikki Roseberry-Keiser]: You can go first.

[John Bartkowski]: Okay, thanks, I'm sorry. I would just speak to that very quickly by saying the, you know, ‘opioid addiction epidemic,’ as many people call it, is something that really crosses generations. So Mississippi for a long time has focused on underage drinking and was very successful in reducing underage drinking as part of its SPF SIG grant that was the predecessor to Partnerships for Success. But as we see that, you know, addiction and prevention-related issues, substance abuse prevention issues, are something that are not unique to young people or to a specific age group, we really need to be thinking about CLAS in terms of generational differences.

So I would just say, for example that one of the things I think about, even with respect to some of the young people in college that I teach, is their use of language is very, very different, and, frankly, they are growing up in a world because of text messaging and other technology that is quite different than the world which I inhabited when I was in college.


So being able to reach people with, you know, prevention-oriented media materials and whatnot in a way that is suited to their circumstances is something that is really important, and this is one of the reasons, like, surveys that are distributed through mobile phones are something that a lot of evaluators are moving towards, because if they really want to get at younger populations, they are recognizing that mobile devices are the way to do that.

[Nikki Roseberry-Keiser]: So, I would echo the sentiment that communication is very different between generations, and so when we talk about CLAS standards 5 through 8, I think that those are things that we address differently when we are talking about that sort of generational difference. On a different peer-sharing call, one of the groups shared that they had done a Facebook survey and they had intended, I think, to get young adults, but they found that the majority of the folks that did their survey on Facebook were like 40 to 64-year-old woman and that was very shocking for them.

And I think that when we talk about technology and where youth are versus where, you know, older adults are, things are just different, and so part of it is really looking at how we address different groups. Communication is a huge part of that and it doesn’t have to be language, necessarily, in terms of, you know, Spanish, English, Arabic. It can be what words we use to communicate and what platforms we use to communicate that can be different generation to generation.

[LaShonda Williamson-Jennings]: Thank you so much for that answer. Kelly, I hope that the question was answered for you in a manner which was good. Well, we are going to move on. I just want to take one more pause for those who have a question and they just want to get this burning question answered before we end today.

I don’t see anyone typing, so we will move on.

So, here's a call to action: What steps can you take in the next three to six months to strengthen or enhance the implementation of the CLAS standards in your state, tribe, or jurisdiction? I'm going to ask you all to write your answer in the chat box to the left of the screen. What steps can you take in the next three to six months to strengthen or enhance the implementation of the CLAS standards in your state, tribe, or jurisdiction?

We see multiple people typing right now. What steps? As I sat through this presentation, you know, I think that I am going to go out and I'm going to seek more information. I'm going to make sure that in the next staff meeting that I have that I talk to my colleagues not only about the guide that's been put out by the CAPT, but also about what are our CLAS goals? Do we have them nicely lined out? Is there additional training that we should receive? Is there additional training that we can share? So how can we go to the next level of training and technical assistance from this presentation to the next level? Where do we help our partners go at the CAPT level?


So, I'm seeing some answers come in. It's ‘train coalition on CLAS steps.’ Perfect, Regina. Thank you so much. Lisa: ‘Review the standards and share with our community partners.’ Ah, great job, Lisa! Seeing more: ‘Review the document you shared, talk to my evaluator about how to measure CLAS, talk about CLAS at our next Michigan PFS meeting to determine what the next step is for us.’ So, talking to our evaluator, great. A good friend of mine, Linda Barovier, she said: ‘Incorporate CLAS standards into the workforce development part of the state's strategic plan and inclusion of CLAS standards into contracts.’ ‘Discuss planning and needs for training’ Lauren said.

Now, there are several things that are going in there -- into the chat box. ‘Provide training to local evaluators on standards 9 through 15.’ ‘Download the CAPT's cultural competency toolkit.’ Perfect. ‘Review standards and discuss this training at the next monthly meeting, also asking assistance of our Southeast coordinator.’ So Southeast, Lourdes, I know she is on the line today. There are going to be questions and so I want you all to know the CAPT is poised to provide training and technical assistance in this area. So please contact your CAPT contact for more information about the CLAS standards.

‘Compare CLAS standards to prevention services monitoring tool.’ All good stuff. ‘Work with our state leadership team to make sure we are evaluating the progress of those CLAS efforts/adaptations included in their work plan.’ This is all very, very good. You all—thank you so much for your time, your attention, your energy, and answering these questions and being a part of this webinar.

Many of you said that this was the first CLAS standards webinar or training that you’ve received over the course of the last year. My hope is that it is not the last that you receive. It's not the last time that you talk about this over the course of the year and that there are ideas and things that you can now do and take back to your state, tribe, jurisdiction, community, and integrate those things into the work that you do. Not only on an occasional basis, but certainly on an everyday basis.

We are here at the evaluation slide of our presentation, so please click the link below to provide feedback on this event. So, you can actually click on the slide, but also in the chat box you can click to provide feedback on today's presentation. Your feedback is certainly important, so we welcome it.

Before we go, I'd like to not only thank you all, but I'd also like to thank Dr. Bartkowski and Nikki, so thank you all. Thank you Nikki. Thank you Dr. Bartkowski, and thank you all for participating in today's webinar. We hope that the next time we have a webinar we've got such great attendance and such great responses from folks. We are sorry we couldn’t open up the line, but there were so many of you; but clearly you were


comfortable with using the technology because you shared robustly.

Thank you so much for your time, you all. Please don’t forget to evaluate this webinar. Take care.

Documents

The National CLAS Standards in Action - SAMHSA · PDF fileThe National CLAS Standards in Action ... sociology at the University of Texas at San ... taking some time and breaking it