2012

Ensuring Cultural Competency in New York State Health

Care Reform

New York State Office of Mental Health

Bureau of Cultural Competence

Nathan Kline Institute

Center of Excellence in Culturally Competent Mental Health

New York State Psychiatric Institute

Center of Excellence for Cultural Competence

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Acknowledgements The following individuals contributed to the report.

New York State Office of Mental Health, Bureau of Cultural Competence

Marisol Núñez-Rodríguez

Hextor Pabón

Emy López-Murphy

Elatisha Kirnon

Frances Priester

Deirdre Goss

Nathan Kline Institute Center of Excellence in Culturally Competent Mental Health

Carole Siegel

Lenora Reid-Rose

Gary Haugland

Judy Samuels

Jennifer Hernández

New York State Psychiatric Institute Center of Excellence for Cultural Competence

Roberto Lewis-Fernández

Leopoldo Cabassa

Jennifer Humensky

Andel Nicasio

Marit Boiler

Neil Aggarwal

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Dear colleagues:

Please read and consider closely this paper on cultural competence and health reform–with a special

emphasis on behavioral health. The paper provides an excellent briefing on changes underway in health

care and behavioral healthcare, as well as an expert summary of key issues and recommendations in

Cultural Competence. These perspectives are integrated in a report that leaders at every level can use to

improve care.

In mental health, quality care cannot be delivered without cultural competence. There is no better way

to describe this than by quoting former Surgeon General Dr. David Satcher: "When it comes to mental

health, culture counts" (emphasis added). Mental health concerns are expressed in thinking, emotion

and personality. They are strongly linked to our history, our family, our experiences. We need mental

health care that is aligned with who we are.

Perhaps some of the time, cultural competence can be unconscious…for example, if a therapist is

treating a consumer who has the same background and experiences that she does, their shared culture

may provide a good starting point. But in a state as diverse as New York, we must also work to build

cultural competence…by respecting diversity, attracting a health care workforce as diverse as the

communities we serve, assuring linguistic accessibility for our services–as Governor Cuomo has

directed–and making cultural competence a foundation of our approach to recovery. I hope you find

this paper a valuable resource.

Sincerely,

Michael F. Hogan, Ph.D.

Commissioner

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xecutive Summary New York State (NYS) has initiated health care system reform in

accordance with mandates found in the federal Patient Protection and Affordable Care Act that

are expected to transform the organization and delivery of mental health care services. The

Medicaid Redesign initiative aims to improve quality of care and reduce costs by transitioning Medicaid

clients to managed care plans and enrolling those with complex needs and high costs into newly formed

integrated care models. Regional Behavioral Health Organizations have been introduced to facilitate

the transition and local Health Homes to deliver the care. Given the growing diversity of the population

of NYS, cultural competency (CC) should be at the forefront of reform activities. Care of clients from the

traditionally underserved racial/ethnic groups may be unnecessarily compromised if these service

models are not culturally competent. The White Paper summarizes the current evidence showing that

CC activities help improve these groups’ access to, engagement with, and retention in mental health

care as well as enhance the quality of their care. We also review evidence indicating that CC activities

help lower costs through the use of bilingual clinicians and culturally adapted interventions, and reduce

the risk of medical errors and malpractice. To help ensure cultural competence in the various service

components of the emerging models, the Paper provides specific recommendations for activities that

should be undertaken to ensure cultural competence. Organizational activities that set the stage for

cultural competency include having a CC plan, organizing a CC advisory committee, recruiting and

hiring culturally diverse staff (including peers), and providing training on CC to staff at all levels. More

specific activities that are recommended include:

For RBHOs and HHs serving clients from underserved cultural groups

 Enhance data collection systems to allow more specific identification of cultural groups

 Develop centralized interpreter services

 Translate relevant documents

 Disseminate CC health promotion materials to communities in coverage areas

 Disseminate ‘vetted’ training materials for CC training to community providers/network partners

 Assess performance measures of the quality of care provided by community providers/network partners

specifically with respect to underserved cultural groups

 Assess CC of community providers/network partners and provide them with actionable feedback

 Promote the use of evidence-based practices (EBPs) that have evidence for the cultural populations

served

 Assist providers in adopting and adapting culturally-relevant EBPs

For HH Network Partners serving clients from underserved cultural groups  Conduct client and family cultural assessments

 Ensure language and communication competencies of staff

 Develop programmatic strategies for trust building and stigma reduction

 Provide services in culturally appropriate milieus

 Involve family or consumer-valued persons in the care process, as desired by consumer

 Ensure that referrals for care and social supports are CC

 Provide linkages to culturally-valued community supports (e.g., churches, clubs)

 Monitor outcomes by cultural group

E

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Chapter I. Rationale for Cultural Competence in Health Care Reform

A. Introduction

New York State has initiated health care

system changes in compliance with mandates

found in the Federal Patient Protection Affordable

Care Act (PPACA) that will lead to

transformations in the organization and delivery

of mental health care services. Ensuring the

cultural competence of the emerging service

models is particularly important for persons with

behavioral health care disorders, as their

engagement and retention in care may be

unnecessarily impeded if cultural

accommodations are not included. Given the

growing diversity of the population of NYS,

cultural competency needs to be at the forefront

of reform activities.

The goals of cultural competence in the

delivery of health care are consonant with the

‘Triple Aims’ of health care reform articulated by

Donald Berwick, former director of the Center of

Medicaid and Medicare Services (Berwick, 2008):

namely, to improve population health, increase

quality of care, and reduce costs. Providing prevention care that is culturally competent care is

essential for the improvement of a population’s mental health. Cultural competence increases access

and engagement into needed services for members of underserved racial and ethnic groups and for

persons with limited English proficiency. Providing culturally competent care improves service

quality and outcomes because diagnoses are more accurately made, consumer – caregiver

communication is improved, and services are tailored to consumer needs and preferences. While

implementation of certain cultural competence activities, such as interpreter services, may result in

additional initial costs, these will be more than offset by benefits accrued from increased engagement,

such as lower outreach costs, fewer missed visits, decreased use of possibly inappropriate and

expensive care, such as emergency and inpatient services, increased consumer productivity, and

reduced family burden.

PPACA has included several broad-based and fundamental provisions for introducing cultural

competence activities that should help reduce disparities in health care delivery, beginning with the

requirement to include consumers’ race, ethnicity, and language in all data collection. These data will

help fulfill requirements for stratified data analyses of quality measures required of federally

sponsored programs. There are also various federal grants with provisions to increase the number of

underrepresented minorities in the health care workforce; to support innovative prevention and

treatment strategies; and to conduct outreach to underserved and minority populations (Legal Notes,

Cultural Competence:

Culture refers to integrated patterns of

human behavior and cognition that

include the language, thoughts,

communications, actions, customs,

beliefs, values and institutions of a

particular social group (e.g., ethnic or

racial group, faith community, language

group).

Cultural Competence in an individual or

organization implies having the capacity

to function effectively within the context

of the cultural beliefs, behaviors, and

needs presented by consumers and their

communities.

Adapted from Anderson et al., 2003

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George Washington University School of Public Health and

Health Services, Vol 3 Issue 1, 2011).

The purpose of this White Paper is to demonstrate

why health care reform in New York State must include

implementation of culturally competent care. This paper

also discusses ways in which cultural competence activities

can be integrated from inception into the State’s newly

emerging care delivery models and how this imperative

enhances the likelihood of achieving PPACA goals.

The rationale for attending to cultural competence

in New York State is discussed below in terms of the

diversity of the population and the federal and state legal

and regulatory requirements. A brief summary is given of

current health care reform initiatives at the federal level and

in New York State that will need to incorporate cultural

competence in their design. Chapter II describes the

scientific evidence for cultural competence activities in

promoting access, quality, and lower costs. Chapter III

suggests ways in which the goals of these reform initiatives

can be achieved by ensuring the infusion of cultural

competence into reform models. Chapter IV contains the

report’s conclusions.

B. Rationale

i. Diversity of the New York State Population

The rationale for the promotion of cultural

competence (CC) in health care reform in New York State

(NYS) is clear. NYS is an increasingly multicultural state.

According to the 2010 Census, about 18% of the NYS

population is Hispanic/Latino, 16% African American, 7%

Asian American, and 11% other non-White, non-Hispanic

race or two or more races; these groups together comprise

52% of the State’s population. Furthermore, the immigrant

population is growing: about 22% of the NYS population is

foreign-born, up from 16% in 1990.

Cultural groups that require special attention from a

health care system (see box) comprise an ever-increasing

proportion of the persons served in the NYS public mental

health system. Service organization and delivery often need

to be tailored culturally in order to facilitate these groups’

engagement in and benefit from services. In the non-inpatient system, in 2009 in a typical week,

approximately 174,000 persons were served, of whom 24% were Black, non-Hispanic, 22% Hispanic,

Cultural Group that should

be the special focus of a

health care system:

Cultural Group is a group of

people with shared activities,

ideas, and traditions, which

are reinforced by members of

the group (Collins, 2009).

Cultural Group of special

focus of a health care system

The interaction between the

current procedures and

services of the health care

system and the socio-cultural

features of the group result in

limitations in service access

or participation by members

of the cultural group.

Examples include:

underserved racial/ethnic

groups; lesbian, gay, bisexual,

and transgendered

communities, limited English

proficiency populations, and

rural communities.

Persons with Limited

English Proficiency:

Individuals who do not speak

English as their primary

language and who have a

limited ability to read, speak,

write, or understand English

(US LEP, 2012).

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and 2% Asian, non-Hispanic. Non-inpatient annual treated prevalence rates for Blacks and Hispanics

exceed those of Whites (Siegel, et al. 2011). Average daily census figures for inpatient services indicate

substantially higher population-based rates of Blacks than other groups in inpatient care (Donahue, et

al, 2011).

ii. Federal and State Policies and Regulations

Federal and state policies and regulations ensure that the health care provided in New York

State is culturally competent (Carter-Pokras, et al, 2004). Relevant federal regulations include Title VI

of the Civil Rights Act of 1964, which states, in part, that “no person in the United States shall, on the

grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or

be subjected to discrimination under any program or activity receiving Federal financial assistance”

(Civil Rights Act, 1964). The US Department of Health and Human Services (HHS) requires that

entities receiving financial assistance from HHS provide “meaningful access” for patients with limited

English proficiency (LEP) at no cost to the client (US DoJ, 2000). In December 2000, the HHS Office of

Minority Health published standards for culturally and linguistically appropriate services (CLAS) (US

DHHS, 2000). Adherence to the HHS CLAS standards is a requirement for the accreditation of

hospitals and medical schools (Carter-Pokras, et al, 2004). Moreover, reducing health care disparities is

a goal of the PPACA (US Congress, 2010). In addition to federal regulations, national governing bodies,

including The Joint Commission (TJC) and the National Committee for Quality Assurance (NCQA), also

have standards for cultural competence that facilities and managed care plans, respectively, must

adhere to as part of their accreditation process.

NYS has repeatedly renewed its commitment to providing culturally competent care, as recently

demonstrated by Governor Cuomo’s October 2011 directive requiring that all state agencies provide

essential public documents (e.g. forms, instructions) in the six most common languages spoken in NYS,

as well as access to interpreter services in the constituent’s native language. Furthermore, state agencies

are required to submit a Language Access Plan (90 days after issuance of the order, and every two years

thereafter) detailing the agency’s compliance, including documentation of interpreter access, number of

forms translated and number of languages, the number of bilingual employees, and employee training

plans (New York State Office of the Governor, 2011). Additionally, in 2010, NYS adopted a Patient’s Bill

of Rights which stipulates that patients have the right to be active participants in their health care. This

is defined to include the ability to review and have access to all important and appropriate treatment

information, delivered in a manner the patient can comprehend and can utilize to make an informed

decision. Furthermore, addressing disparities and improving language access are key components of

the New York State Office of Mental Health (OMH) Strategic Plan (NYS OMH, 2012), and have been

incorporated into the recent Medicaid Redesign (Cohen and Karpati, 2011) and Health Home initiatives

(NYS DOH, 2012a).

To better understand and meet the needs of the cultural groups served by the NYS public mental

health system, OMH has provided infrastructure for increasing the CC of its services. It has established

a Bureau of Cultural Competency as well as two Centers of Excellence in CC Mental Health at the

Nathan Kline Institute and New York State Psychiatric Institute. The Centers develop and disseminate

numerous products such as assessment tools, instruments, new services, and educational materials to

provide specific steps, desirable behaviors, and considered responses for improving services for cultural

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groups at the organizational, program, intervention, provider, and consumer levels of a health care

system. All these products as well as new ones that will need to be developed for new service models

have an important place in health care reform.

C. The New Landscape Under Health Care Reform

To contextualize the recommendations for CC activities to be incorporated into health care

reform, a description of these reform efforts is provided. This

chapter describes these efforts at the federal level (PPACA) and

current steps being taken at the state level (Medicaid reform,

including the new organizational entities Regional Behavioral

Health Organizations and Health Homes).

i. Patient Protection and Affordable Care

Act (PPACA

Signed into law in March, 2010, PPACA proposes a

wide array of changes to the US health care system that impact

all members of the population, including those with and

without existing health insurance coverage. To improve

access, PPACA proposes ways to increase coverage for all

economic strata of the population: introducing expanded

eligibility criteria for Medicaid enrollment; proposing models

for increasing availability of health insurance for those without

insurance through federal or state-organized health benefit

exchanges, and reforming the delivery and payment of

Medicare services. With respect to persons with complex

health and mental health needs –including persons with

severe psychiatric disorders—PPACA proposes models of care

that coordinate the multiple components of care they require

(Kaiser Family Foundation, 2010) with the goal of improving

quality and reducing costs.

ii. Medicaid Reform in New York State. In compliance with impending mandated changes and aiming to reduce costs, New York State

(NYS) has embarked on a redesign of its Medicaid program, currently the largest single item in the state

budget. In 2009, approximately $50 billion was spent on Medicaid by the state, county, and federal

governments (Medicaid Institute, 2010), serving almost 5 million beneficiaries. Twenty percent of these

beneficiaries account for 75% of the program’s expenditures and among these 40% are diagnosed with

mental illness and chemical dependency (Rosenthal, NYAPRS, 2011). The NYS Department of Health

(DOH) estimates that there are 975,000 high-cost Medicaid enrollees with multiple chronic illnesses

(NYS DOH, 2011b). Over 400,000 are Medicaid recipients with behavioral health problems, and at

Recommendations of MRT Health Disparities Work Group of most relevance to persons with behavioral health conditions

 Enhance data collection/metrics to measure disparities

 Improve language access

 Promote language accessible prescriptions

 Conduct targeted CC training for health care workforce

 Ensure full access to Medicaid mental health medications

 Enhance services for youth in transition with psychiatric disabilities

 Promote population health through coverage of community-based chronic disease preventive services

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least half of these are people of color. Complex cases have high costs and cross-sector health care

needs requiring coordination across multiple provider agencies.

A Medicaid Redesign Team (MRT) was formed to provide an action plan to lower health care

costs, improve patient outcomes and reduce health disparities. Care coordination, particularly of the

high cost users, and reduction in spending are critical elements of redesign. Towards this end, the plan

aims to end the state’s Medicaid fee-for service system and replace it with a variety of integrated care

management systems. Phase I of reform which has begun includes the initiation of a global Medicaid

Spending Cap. (NYS DOH, 2012c). In 2011, slightly fewer than three million of Medicaid-eligible

beneficiaries, or 66% of all NYS Medicaid recipients, were enrolled in managed care plans (NYS DOH,

2011b).

An MRT subcommittee examined opportunities for disparity reduction. In their final report,

they made 14 recommendations, seven of which (see call out box) are directly applicable to persons

from cultural groups with behavioral health conditions (NYS DOH, 2011a). In this report, we suggest

other activities to promote CC for inclusion into emerging health care models in NYS. Given the

multicultural composition of the NYS Medicaid population, CC activities will work to ensure that

PPACA goals are met for all.

NYS has begun the process of integrating services by developing an organizational framework

for the delivery and funding of health care. Health

Homes (HHs) are being selected for the management of

integrated and coordinated care for persons who are

considered to be complex cases because of their co-

morbidities and consequent need for simultaneous

behavioral services, other health care services, and other

community-based support. Regional Behavioral Health

Organizations (RBHOs) are being put in place across the

state to oversee these new delivery entities particularly

by monitoring the utilization and delivery of Medicaid-

covered services. Future steps in NYS include moving

all Medicaid behavioral health services into specialty

managed care.

Figure 1 depicts the structural organization of

Medicaid managed care services for complex cases

expected to be fully implemented by 2014. Cultural

competency activities can promote the achievement of

PPACA goals and are require