Planning Culturally and Linguistically Appropriate Services

The Centers for Medicare & Medicaid Services (CMS) commissioned this guide, as well as a companion guide, Providing Oral Linguistic Services (select for Summary). Both were developed by a contractor of the Agency for Healthcare Research and Quality (AHRQ).

Disparities and Improvement of Cultural and Linguistic Competence

For decades, the prevalence of racial and ethnic disparities in health care delivery and outcomes in the United States has been increasingly recognized. Culturally and linguistically diverse groups and individuals of limited English proficiency typically experience less adequate access to care, lower quality of care, and poorer health status and outcomes. This was shown in recent reports by the Institute of Medicine and the Commonwealth Fund.

Select for Definitions of Cultural and Linguistic Competence.

2003 CMS Project for M+COs

Each year, CMS identifies a topic for a national quality assessment and performance improvement (QAPI) project that Medicare+Choice Organizations (M+COs) must conduct to comply with program requirements. In 2003, M+COs have a choice of conducting a QAPI project that addresses either clinical health care disparities or provision of culturally and linguistically appropriate services (CLAS). M+COs may seek assistance in developing and conducting projects that focus on clinical health care disparities from their State Quality Improvement Organizations.

To help M+COs conduct projects that address CLAS, CMS arranged for a contractor from AHRQ's Integrated Delivery System Research Network to develop two guides for managed care plans. (Select to access a summary of the other guide, Providing Oral Linguistic Services.)

Why Should M+COs Care About CLAS Improvement?

It makes good business and health care sense for M+COs to undertake a CLAS quality improvement program in the areas of linguistic competence, cultural competence, and/or increased workforce diversity. Plans and their providers are subject to major cost constraints, so they are understandably concerned about cost-benefit issues when considering a new initiative. In addition, plans may feel that their current approach to the provision of services is adequate and meets the needs of their members. Further, M+COs may not recognize the serious adverse health impact that lower levels of cultural competence may have on their LEP and multi-ethnic members.

The Business Case for CLAS in Managed Care

There is a plausible business case for plans to initiate CLAS quality improvement programs to improve their cultural and linguistic competence. The changing racial/ethnic demographics of the nation and managed care as well as regulatory and legal incentives drive this business case. Although managed care was initially confined primarily to the private and commercial sector, recently it has expanded into large public programs such as Medicare and Medicaid, which serve much more diverse and vulnerable populations.

There has also been a marked increase in plan enrollment by racial and ethnic minorities, reflecting a similar trend in the nation's demographics. The U.S. population is shifting from a predominantly Western European background to one that consists of a potpourri of ethnicities, races, and languages. In the year 2000, racial and ethnic minorities comprised approximately 25 percent of the U.S. population. By 2050, the proportion of "minorities" will approach 50 percent. Culturally and linguistically diverse group members currently comprise 50 percent of managed Medicaid plan membership and 15 percent of M+CO membership. Managed care plans can ill afford to ignore this trend from a financial, quality-of-care, or ethical perspective.

What Does This Mean for Plans and CLAS?

It is good business for managed care to market effectively to potential members from LEP and culturally diverse groups, since they represent such a rapidly increasing share of the managed care market. Furthermore, a plan that institutes CLAS improvements will be more likely to attract and retain multi-ethnic members, since it will be easier for these members to navigate and use plan services appropriately.

As increasing numbers of multi-ethnic members join plans, it will become important to assist them in using cost-effective preventive services that reduce costly managed care utilization and are important to managed care accreditation performance (e.g., HEDIS). Cultural competence education in one unpublished study has shown higher patient trust, satisfaction, and treatment adherence. Racial, ethnic and linguistic concordance between providers and patients appears to have a positive impact on appropriate service utilization, treatment participation, and receipt of some services. In this case, good business typically goes hand in hand with improved managed care delivery and outcomes.

In sum, there are multiple reasons for plans to undertake improvements in CLAS.

• To improve services, care, and health outcomes for current members (improved understanding leads to better adherence and satisfaction).
• To increase market penetration by appealing to potential culturally and linguistically diverse members.
• To enhance the cost-effectiveness of service provision.
• To reduce potential liability from medical errors and Title VI (Civil Rights Act) violations.

Purpose and Goals of This Guide

The overarching purpose of this guide is to assist M+COs that choose a quality improvement project associated with improving CLAS for their 2003 national QAPI project. The primary goals are to assist M+COs in:

1. Assessing the diversity of their population and their current level of cultural and linguistic competence.
2. Identifying feasible priority areas for improvement of CLAS based on the assessment.
3. Developing a plan to implement cost-effective and manageable interventions to address these priority areas.

This guide presents the journey toward cultural and linguistic competence in two parts:

• Part 1: The CLAS Assessment.
• Part 2: Three Broad Areas of Focus for Improving CLAS.

The pursuit of cultural and linguistic competence is an ongoing process of assessing and understanding the needs of multi-ethnic members, and then continuously seeking to improve services to meet these needs. The CLAS Assessment section of the guide offers detailed information on how to conduct a comprehensive CLAS assessment. Three Broad Areas of Focus for Improving CLAS provides an overview of what organizations should consider in choosing to improve linguistic services, cultural competence, and workforce diversity.

Part 1: The CLAS Assessment

Part 1 of the guide addresses four aspects of the assessment process:

• Preparing the CLAS Assessment and Planning Team.
• Assessing the Diversity of Members and the Community.
• Assessing the Managed Care Plan.
• Identifying Gaps, Determining Priorities, and Briefing Senior Leaders.

Planning for culturally and linguistically appropriate services begins with an awareness of the increasing diversity among a plan's membership. Because the pursuit of CLAS may be a brand new concept to some plans, the first section of Part 1 provides information on preparing the CLAS assessment and planning team. Careful thought is required behind:

1. Selecting the CLAS planning team.
2. Educating the team about CLAS.
3. Including the community perspective. This will help ensure that the critical information needed is collected and that the team members have the background to make appropriate decisions as the CLAS plan is developed.

Assessment is a central emphasis. It is clearly easier to target areas for improvement armed with an understanding of the diversity of race, ethnicity, and language in the population served and an evaluation of the existing level of cultural competence of the plan. A comprehensive assessment alone may well be an excellent first choice for a quality improvement project for many plans just beginning the CLAS journey.

Once the assessment of the population and plan is complete, priority areas to improve CLAS are selected. The final section of Part 1 offers guidance for identifying gaps and issues to consider when setting priorities.

Part 2: Three Broad Areas of Focus for Improving CLAS

Part 2 of the guide offers an overview of three areas of concentration for improving CLAS:

1. Providing Linguistic Services (oral and written).
2. Improving Cultural Competence.
3. Developing a Diverse Workforce.

The information presented about these areas is not meant to be exhaustive but provides an introduction and resources for study.

Even plans with extensive experience in developing CLAS have not "done it all" in the areas of language services, cultural competence, and developing a diverse workforce. The essential message is simply to get started on the journey to improve the provision of CLAS in your organization. Selecting a focused area for improvement and achieving an early success will stimulate enthusiasm for further CLAS development.

A number of topics to consider for quality improvement projects are presented in this guide. Plans interested in pursuing a specific area of CLAS can find further details by investigating the citations in the guide's Resource List. Many of the citations can be downloaded from the Internet. Case scenarios from plans interviewed for this guide are presented as real-life examples to consider. Many of these plans have benefited from working collaboratively with other managed care plans to develop strategies and improve services to multi-ethnic members. Background information describing each plan can be found in Appendix D of the guide.

The pursuit of cultural and linguistic competence is an ongoing process that begins with an awareness of the increasing diversity among a plan's membership. Plans that wish to meet financial and quality goals will recognize that members have different customer-service and health-care needs based on their cultural backgrounds. For multi-ethnic members, the health care system presents formidable barriers to both accessing and receiving care. Proactive plans will develop and continuously improve services and processes that meet the cultural and linguistic needs of all members.

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