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Cultural Competence Standards
in Managed Care Mental Health Services:
Four Underserved/Underrepresented
Racial/Ethnic Groups
II. Overall System Standards and Implementation Guidelines
Cultural Competence Planning
Standard
A Cultural Competence Plan for both public and private sectors shall be developed and integrated within the overall organization and/or provider network plan, using an incremental strategic approach for its achievement, to assure attainment of cultural competence within manageable but concrete timelines.
Implementation Guidelines
The Cultural Competence Plan shall include:
- Development and integration with the participation and representation of top and middle management administrators, front-line staff, consumers and/or their families, sovereign tribal nations, and community stakeholders;
- An individual at the executive level with responsibility for and authority to monitor implementation of the Cultural Competence Plan;
- Individual managers accountable for the success of the Cultural Competence Plan based on his/her level within the organization;
- A process for integrating the Cultural Competence Plan into the overall state and/or department plan, and for including the principles of cultural competency in all aspects of organizational strategic planning and in any future planning process;
- A process for determining unique regionally-based needs and ecological variables within the communities/populations served using existing agency databases, surveys, community forums, and key informants;
- Identification of service modalities and models which are appropriate and acceptable to the communities served (i.e., urban, frontier and rural), population densities and targeted population subgroups, (e.g., children, adolescents, adults, elders, sexual minorities, and individuals with co-occurring conditions);
- Identification and involvement of community resources, (e.g., tribal and community councils or governing bodies, family members, clans, native societies, spiritual leaders, churches, civic clubs, and community organizations) and cross-system alliances (e.g., corrections, juvenile justice, education, social services, substance abuse, developmental disability, primary care plans, public health, and tribal health agencies) for purposes of integrated consumer support and service delivery;
- Identification of natural supports (e.g., family members, religious and spiritual resources, traditional healers, churches, civic clubs, community organizations) for purposes of reintegrating the individual within his/her natural environment, keeping in mind that for some, this may also include migratory patterns to and from a reservation or reservations, state to state, or country to country;
- Assurance of cultural competence at each level of care within the system (e.g., crisis, inpatient, outpatient, residential, home-based, health maintenance, community health liaison services);
- Stipulation of adequate and culturally diverse staffing and minimal skill levels (including gender, ethnicity, and language as well as licensing, certification, credentialing, and privileging) for all staff, clerical through executive management;
- The use of culturally competent indicators, adapted for specific minority cultural values and beliefs, in developing, implementing, and monitoring the Cultural Competence Plan;
- Development of rewards and incentives (e.g., salary, promotion, bonuses) for cultural competence performance, as well as sanctions for culturally destructive practices (e.g., discrimination). Cultural competence performance shall be an integral part of the employee-provider performance evaluation system, and provider organization performance evaluation system;
- Development of a plan to integrate ongoing training and staff development into the overall Cultural Competency Plan; and
- Development and ongoing plan monitoring of indicators to assure equal access, comparability of benefits, and outcomes across each level of the system of care and for all services provided through the Health Plan.
Recommended Performance Indicators
- Presence of a Cultural Competence Plan and defined steps for its integration at every level of organizational planning.
- Presence, within the Cultural Competence Plan, of related policy/procedure changes.
- Percentage/number of staff receiving initial and ongoing cultural competence training.
- Presence of established links with community resources.
- Demonstration of staff knowledge and skills regarding group values, traditions, expression of illness, cultural competence principles (e.g., credentialing and performance based testing).
- Demonstration of a cultural competence system evaluation (e.g., Mason, 1995, Cultural Competence Self Assessment Questionnaire: A Manual for Users).
- Demonstration of staff and consumer awareness and acceptance of the Cultural Competence Plan.
- Presence of a plan for recruitment, retention, and promotion of staff of racial/ethnic backgrounds representative of target population served.
Recommended Outcomes
- Percentage of consumers from the four groups compared to overall representation in the community.
Benchmark: Comparable to overall general population.
- Percentage of consumers from the four groups served by or under direct supervision of culturally competent staff.
Benchmark: 100% served.
- Consumer satisfaction with services, measured in culturally competent manner.
Benchmark: 90% satisfaction.
- Proportionality of access to, and length of service of, the full range of treatment services offered.
Benchmark: Comparable to overall service recipients for access to specific levels and types of services.
- Reduced restrictiveness of placement (including incarceration/detention) for consumers from the four groups.
Benchmark: Comparable restrictiveness to the general population and overall reduced restrictiveness.
Governance
Standard
Each Health Plan's governing entity shall incorporate a board, advisory committee, or policy making and influencing group which shall be proportionally representative of the consumer populations to be served and the community at large, including age and ethnicity. In this manner, the community served will guide policy formulation and decision making, including Request for Proposals development and vendor selection. The governing entity responsible for the Health Plan shall be accountable for its successful implementation, including its cultural competence provisions.
Implementation Guidelines
The Health Plan shall:
- Include formal procedures for decision-making related to policies, practices, and grievances in accordance with state and Federal law with racial/ethnic community and professional input, participation, and involvement at all levels, including fair hearings. Consumers shall be informed of this procedure in their own language at intake and supported linguistically at the time of any steps in the complaint and grievance process;
- Make available a culturally competent group of ombudspersons (minimally comprised of consumer, family member, and regional representatives) to be involved in all appeals and concerns from the community served. The group of ombudspersons shall have independence from the Health Plan, and there shall be formalized procedures for resolving differences of opinion between the ombudsperson and the Health Plan administration's governance;
- Have a governing entity that shall determine for each Health Plan an equitable percentage of profit or savings to be reinvested in racial/ethnic community-based services and preventive programs on an ongoing basis. A financial penalty or termination of contracts is applicable when inequities exist to access and/or comparability of benefits;
- Develop interagency and cross-system agreements or pooled funding to coordinate services with other agencies (e.g., public health, social services, corrections and juvenile justice, youth services, education, substance abuse, developmentally disabled services);
- Distribute financial and liability risks for the Health Plan such that culturally competent smaller scale providers and organizations will be able to continue to deliver services;
- Develop policies governing practitioner ethics and behavior (e.g., gift giving by consumers, interactions with consumers outside the service setting, confidentiality) that shall provide for differences relevant to the context of racial/ethnic cultural values; and
- Provide that contract continuation and renewal shall be contingent upon successful achievement of performance standards which demonstrate effective service, equitable access and comparability of benefits for populations of the four racial/ethnic groups.
Recommended Performance Indicators
- Racial/ethnic consumer awareness of and participation in Health Plan benefits, appeals procedures, and ombudspersons, as demonstrated by the comparability of the rate of grievances and complaints.
- The percentage of complaints and grievances of individual practitioners tracked and factored into performance evaluations.
- Presence of culturally-informed policies of practitioner behavior and performance-based demonstrations of implementation.
Recommended Outcomes
- Final disposition of grievances and appeals for consumers from the four groups.
Benchmark: Comparable to overall service population..
- Percent of consumers from the four groups receiving blended, coordinated, or wrap-around services.
Benchmark: Comparable to overall service population and increasing over time.
- Percentage of reports of unethical practitioner behavior for practitioners serving populations of the four groups.
Benchmark: Comparable to overall service population..
- Sanctions and incentives reinforce progress toward the delivery of culturally competent services.
Benchmark: Decreased rates of sanction over time.
- Composition of the governing board, advisory committee, other policy-making and influencing groups, and consumers served reflects service area demographics.
Benchmark: 90% of expected representation.
- Consumer awareness of plan.
Benchmark: 80% of surveyed respondents aware of plan.
- Culturally-based policies shaping practitioner behaviors and measuring performance.
Benchmark: Presence of policies.
Benefit Design
Standard
The Health Plan shall ensure equitable access and comparability of benefits across populations and age groups. Coverage shall provide for access to a full continuum of care (including prevention programs) from most to least restrictive in ways which are comparable, though not identical, acknowledging that culturally competent practice provides for variance in individualized care.
Implementation Guidelines
The Health Plan shall:
- Make no arbitrary restrictions and limitations in benefit level. For example, in some regions, post traumatic stress disorder (PTSD) has been eliminated from the eligible list of treatable disorders. Southeast Asian refugees who suffer disproportionately from PTSD are therefore not eligible for treatment. Cost-effectiveness shall be accomplished through care management and utilization review mechanisms;
- Have coverage incorporating and integrating innovative treatment modalities, including alternative healers, and primary prevention and health promotion to all levels of care to enhance the acceptability and cost-effectiveness of care;
- Have coverage incorporating services delivered by qualified racial/ethnic mental health specialists when available, or non-minority culturally competent mental health specialists when culturally competent specialists from the appropriate racial/ethnic group(s) are not available;
- Have coverage incorporating the coordination of services across service agencies and systems serving the consumer in order to ensure cost sharing for consumer services;
- Provide to consumers and families in their primary language(s) information, community education, and written and oral materials regarding covered services and procedures for accessing and utilizing services. Such information shall be made available through partnerships with community organizations in addition to conventional means of dissemination. Written correspondence or audio presentations regarding eligibility shall be in consumers' and families' primary language(s), with alternative methods of communication also developed and utilized;
- Develop eligibility and level of care criteria for service provision and/or receiving services by or under the guidance of culturally competent bilingual, bi-cultural providers. These criteria shall be defined primarily by the assessment of behavior and functioning and secondarily by diagnosis, given the limitations of diagnostic systems in cross-cultural applications. Utilization review and eligibility determinations shall be performed by culturally and linguistically competent staff;
- Provide for consumer choice of individual provider. All providers shall be responsible for comparable levels of service to sponsored (insured) and unsponsored (uninsured) persons;
- Provide for the needs of both sponsored and unsponsored populations of the four groups and shall provide access for service to unsponsored individuals in proportion to general industry standards and practice;
- Make provisions in the benefit design for people who leave the Health Plan, including service planning and a transition process to new plans;
- Work with private plans to provide for instances when a privately insured individual becomes uninsured and probably will require services from the Public Health Plan; and
- In order to ensure adequate funding for more intensive services, provide benefits that include adequate culturally competent risk-adjustment strategies specifically for consumers at-risk for serious and persistent mental illness, emotional disturbance and/or other multiple, long-term service needs.
Recommended Performance Indicators
- Culturally competent eligibility and level of care criteria are formally established.
- Eligibility determinations and service planning are performed by, or under the supervision of, linguistically and culturally competent bilingual/bi-cultural specialists.
- Consumers from the four groups receive direct services provided by or from culturally competent bilingual/bi-cultural personnel, or by personnel supervised by culturally competent bilingual/bi-cultural racial/ethnic mental health specialists.
- Consumers receive consumer-friendly bilingual materials on Health Plan benefits.
- Percent of consumers receiving services by traditional healers.
- Treatment plans incorporate individual, familial, and community strengths and appropriate interagency resources.
- Prevention strategies and action plans are implemented.
- Use of flexible funding for consumers from the four groups, comparable across groups.
Recommended Outcomes
- Benefit distribution and service provision for consumers from the four groups.
Benchmark: Comparable to overall service population.
- Percent of covered consumers who know benefits and how to access them.
Benchmark: 80%, as measured by consumer survey.
- Consumer and family satisfaction with services.
Benchmark: 90% satisfaction.
- Proportionality of racial/ethnic consumer access to full range of benefits.
Benchmark: Comparable to overall service population.
- Focused prevention, education, outreach & services planning for consumers from the four groups.
Benchmark: Increased specialized and preventive services to at-risk consumers.
Prevention, Education, and Outreach
Standard
Each Managed Care Mental Health Plan shall have a prevention, education, and outreach program which is an integral part of the Plan's operations and is guided in its development and implementation by consumers, families, and community-based organizations.
Implementation Guidelines
Managed care plans shall:
- Develop mechanisms that increase the provider's knowledge of what the community wants and needs, how and in what form it obtains new information, and its experiences with existing services;
- Ensure that the location of behavioral health services shall be a joint decision between managed care plans, providers and consumers;
- Document, before the development of prevention, education, and outreach programs, how they assess and plan to apply information and knowledge about risk factors associated with consumers from the four groups and their families;
- Ensure that prevention, education, and outreach approaches include specific services for at-risk youth in the family of the primary consumer;
- Provide consumers from the four groups and their families with education and information about the available service benefits and how to access them;
- Ensure that prevention, education, and outreach approaches consider the family and community systems in which the primary consumer lives;
- Ensure that prevention, education, and outreach plans and methods include linkages with religious organizations in the community and training of members of the faith community to assist in educating consumers about mental health service;
- Offer programs to educate professionals and consumers about how consumers and their families from the four groups can be more responsible for their own health and preventing illness; and
- Develop and maintain an updated listing of community resources that may be beneficial in providing prevention, education, and outreach services to consumers from the four racial/ethnic groups and their families.
Recommended Performance Indicators
- Activities and material, including an updated listing of community resources, are provided in the language(s) of the population(s) being served.
- Education and training linkages are made with faith-based organizations in the community.
- The Managed Care Mental Health Plan assesses the existence of racial/ethnic groups in the population being served, assesses the needs and risk factors associated with those populations, and takes these factors into consideration in prevention, education, and outreach activities.
- The organization coordinates education and outreach activities with community cultural organizations.
Recommended Outcomes
- Documentation that activities and material are provided in the proportion of the primary language(s) in the population served.
- The Managed Care Mental Health Plan maintains a list of cultural community organizations and documents the utilization of these organizations to assist in education and outreach.
Quality Monitoring and Improvement
Standard
The Health Plan shall have a regular quality monitoring and improvement program that ensures (1) access to a full array of culturally competent treatment modalities, (2) comparability of benefits, and (3) comparable successful outcomes for all service recipients.
Implementation Guidelines
The Quality Monitoring and Improvement Plan shall include:
- Sampling approaches of current and past utilization patterns, by modality (including pharmacological therapy), and level of care;
- Quality improvement teams with proportionate representation of consumers from the four groups and culturally competent specialists which review data from quality indicators relating to these populations. Procedures shall be in place to ensure that if irregularities or deficiencies in care are found, special quality studies and corrective actions shall be undertaken to identify causes and address root causes/processes;
- Consumer satisfaction surveys, translated orally and in written format into local languages and dialects, implemented by members of the community independent from the Health Plan. Surveys shall be available in various formats to facilitate the participation of consumers at all socioeconomic and educational levels. Sampling shall include involvement of Health Plan drop-outs. Evidence of a pattern of discrimination shall be a reason for termination of contract;
- Periodic assessment of functional outcomes which are valid and applicable to populations of the four groups, for consumers and families receiving services, as well as the entire covered population. Outcomes shall be quantifiable objectives, not just process variables, and shall be collected independent of agency billing records;
- Quality and outcome data related to service provision for consumers from the four groups and their families that are identified by the provider. Data shall be reported on a regular basis to the governing entity and used as a basis for determining contract renewal;
- Credentialing and privileging standards, specific to various disciplines, which include cultural and linguistic competence, knowledge, skills, and attitudes relevant to the racial/ethnic population. These standards shall include a continuing education requirement and performance based competency evaluation;
- A record of, and regular reporting on, all appeals, grievances, and law suits, as well as informal complaints, differentiated by ethnicity of the complainant and the specific provider. Disproportionate trends by ethnicity shall require measurable and timely corrective action;
- Criteria for the removal of providers from provider panels and tracking for providers and practitioners which are open for review, analyzed by ethnicity and gender of provider and able to account for differing service needs of diverse populations;
- Tracking of consumer movement across levels of care, of the use of intrusive, specialized or restrictive interventions, and of unusual occurrences by age, gender, ethnicity, and specific practitioner, with sanctions for desirable and unacceptable performances; and
- Identification and tracking of high-cost consumers resulting in the review and adaptation of their individualized treatment plans to more effectively address their needs.
Recommended Performance Indicators
- Presence of a Quality Improvement Plan.
- Proportional representation of consumers from the four groups, providers, and community members on the quality improvement team.
- Occurrence of quality studies focusing on the use of best practice in resolution of deficiencies in the care of consumers from the four groups.
- Linguistically and culturally factored consumer satisfaction surveys which are independently administered and include Health Plan drop-outs and short term recipients.
- Regular reporting of racial/ethnic specific quality assurance data to the governing entity, including appeals and grievances.
- Systematic tracking of high-cost consumers with support to treatment teams to identify and implement successful interventions.
- Systematic tracking and open reporting of persons, removed from provider panels, by ethnicity.
Recommended Outcomes
- Consumer and family satisfaction with services for the four groups.
Benchmark: Comparable to overall service population.
- Rates of drop-out, grievances, restrictive care, unusual occurrences, and adverse events for consumers from the four groups.
Benchmark: Comparable to overall service population.
- Match between level of care/restrictiveness of modality and level of treatment need for consumers from the four groups.
Benchmark: Level of match comparable to overall population.
- Functional outcomes in domains of daily living (e.g., housing, access to primary health care, family role, vocational/educational/employment, community tenure).
Benchmark: Improvement over time, rates comparable to overall community.
- Comparability of access and benefit from service.
Benchmark: Comparable rates of access, consumer satisfaction, and clinical results across overall service population.
- Rates of recidivism into restrictive level of care or other restrictive placements.
Benchmark: Comparable to overall population served and significant reductions where inequities exist.
Decision Support and Management Information Systems
Standard
The Health Plan shall develop and maintain a database which shall track utilization and outcomes for the four groups across all levels of care, ensuring comparability of benefits, access, and outcomes. The Health Plan shall also develop and manage databases of social and mental health indicators on the covered population from the four groups and the community at large.
Implementation Guidelines
The Health Plan shall:
- Manage a database that includes qualitative and quantitative data that accurately reflect the four groups and are collected and interpreted in a culturally competent manner at national, state, and local levels. Findings from these data shall be used in a culturally competent manner to continually assess, improve, and inform strategic planning for services to racial/ethnic group consumers and families;
- For purposes of accountability, report to the governing entity, in a regular and timely manner, performance and outcome data specific to consumers and families from the four groups;
- Establish aggregated data linkages by ethnicity with primary care plan, public health, substance abuse, developmental disability, education, courts, corrections, and juvenile justice to provide cross-system utilization information on the mental health status of the four groups as the federal, state, and local levels;
- Ensure that data are current, accurate, and include gender, age, ethnicity, socioeconomic status, linguistic proficiency, geographic area, sexual orientation (at the consumer's option), and health insurance status;
- Ensure that, for purposes of data collection, each of the four groups is broad and inclusive, including a capacity to code all and multiple subgroups and those of mixed race/ethnicity. Each of the four categories shall be distinct and monitored separately even when consistent with U.S. Census Bureau practice;
- Collect and track (independently from billing data) aggregated diagnostic and assessment information, service utilization trends and costs, drop-outs, and utilization patterns, and behavioral and functional outcomes. Each category shall be computed across modalities, using standardized units of measurement across modalities;
- Ensure that individual consumer data are kept confidential with data sets coded in such a manner that clients cannot be readily identified; and
- Seek formal input from the consumers' communities on adequacy of proportional mix of culturally competent mental health professional staff, including adequacy of culturally competent staff from their own racial/ethnic group.
Recommended Performance Indicators
- Presence of a data system inclusive of the above mentioned elements.
- Use of a unified clinical record across all levels of care that legally allow for sharing of information to facilitate data collection and tracking.
- Regular reporting to the governing entity of performance and outcome indicators.
Recommended Outcomes
- Timely and accurate consumer data which provides for tracking across age and race ethnicity.
- Timely transition of data to enhance continuity of care.
Benchmark: Real time authorizations for services.
- Focused preventive and service planning for consumers.
Benchmark: Increased specialized and preventive services to at-risk consumers.
Human Resource Development
Standard
Staff training and development in the areas of cultural competence and racial/ethnic mental health shall be implemented at all levels and across disciplines, for leadership and governing entities, as well as for management and support staff. The strengths brought by cultural competence form the foundation for system performance rather than detracting or formulating separate agendas.
Implementation Guidelines
The Health Plan shall:
- Ensure that certification of Mental Health Specialists is done locally and is based on performance-based qualifications as determined by a local panel of culturally competent experts consistent with state, local, and tribal laws.
- Have a clinical workforce that includes and makes special effort to recruit and retain at least a proportional representative percentage of mental health professionals from each of the four groups and their subgroups being served;
- Establish career ladders for the development and advancement of racial/ethnic staff and for clinical and administrative supervisory and senior positions;
- Develop and implement differential pay rates for specialized skills in cultural and linguistic competence in general, and for racial/ethnic Mental Health Specialists in particular;
- Provide regularly required cultural competence training for all staff (see section on Cultural Competence Planning). Funding shall be designated for this purpose;
- Establish specific continuing education requirements and performance-based standards for the development, maintenance, and continuance of clinically and culturally competent mental health providers to serve individuals from any of the four groups; and
- Advocate that all states that license or certify providers of mental health services shall require cultural competency training prior to licensing or certification and for renewals. States shall establish accreditation standards for licensing bodies.
Recommended Performance Indicators
- Establishment and evaluation of a credentialing process for racial/ethnic Mental Health Specialists.
- Recruitment, retention, and career development plan for racial/ethnic and other culturally competent mental health professionals.
- Use of language fluency examinations to determine the level of competence of clinicians and interpreters to provide comprehensive clinical and preventive care.
Recommended Outcomes
- Percentage of consumers from the four groups served in their preferred language.
Benchmark: 100%.
- Percentage of consumers from the four groups served by, or under the supervision of, culturally competent bilingual/bi-cultural Mental Health Specialists.
Benchmark: 100%.
- Proportionality of racial/ethnic staffing to the needs of the four populations.
Benchmark: There is a 1:1 match between need (not strict percentage of population) and staffing.
- Percentage of staff receiving at least five hours of training annually in cultural competence awareness.
Benchmark: 100%.
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SMA00-3457
1/2001
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