Incorporating Cultural Competence into Program Priorities: States

Wendy Jones: “…just in case.” But anyway, welcome. It’s a pleasure to be here with you this afternoon.

Dianne Denboba: I Should have known.

Wendy Jones: Yes. Okay. This is our logo for the National Center for Cultural Competence, and I’m going to start a little bit backwards, I guess, and talk to you about some of the things that we’ve been doing over the past nine years. So our major activities include training, technical assistance and consultation, networking, linkages, and infoarmation exchange, as well as knowledge, and product development, and dissemination. You have a really, really new product on your table, right? Underneath your handouts. It’s not hot any more, but it was really hot off the presses, like, Friday. And it’s actually something to help in looking at your program in terms of where you are for infusing, or incorporating, cultural linguistic competence into your service delivery system, so those are the activities that we engage in. I think that our major emphasis has to do with policy development, policy development specifically around cultural and linguistic competence. We provide assistance in conducting cultural competence organizational self-assessments, and have with several states that you’ll hear some discussion about maybe later. And also, providing some strategic approaches, or planning strategic approaches, or methods to incorporating cultural competence into policy, structure, and practices and behaviors. Okay? So all of that having been said, our mission is to increase the capacity of health care and mental health programs to design, implement, and evaluate culturally competent service delivery systems. Our mission is right in keeping with sort of the big picture in terms of cultural competence in MCHB and children with special health care needs, in particular, and Diana’s going to hit on a couple of points there, and then I’ll be back in a minute.

Dianne Denboba: This is going to be really hard because a couple of us are going to get up and talk together. We’ll just pick it up. We’re going to get up. Wendy was talking about the big picture, and that’s the big picture in terms of cultural competence in general. Are we there yet? I don’t think too many of us are, but we keep hiking--thank you--and we’re getting closer. Peter talked about the new strategic plan that we have at the bureau, and he did go over the vision statements. Just to bring your attention to the one about equal access for all, to comprehensive care in a supportive, culturally competent environment, which is family-centered and community-based, and then we also believe that health disparities by racial, ethnic, geographic area and economic status should be eliminated. That’s our vision. We also think that our programs, including the Bureau, should exemplify the highest standards of excellence, and employ a highly qualified, diverse work force, and that we should be working in a respectful and supportive environment. There are also guiding principles in that new strategic plan. There are principles for leadership roles and responsibilities. We feel that our leadership should be effective, developing collaborative partnerships, good communication. In terms of performance, we have high expectations and I know you have high expectations of yourself and your programs, but it’s very difficult in these economic times. And in terms of accountability, there is an accountability process in terms of the block grant applications--their performance measures in there. All of our grantees will soon have performance measures and we would like for the partners that we work with to begin to share our guiding principles and vision. I won’t go into this. You can read this for yourself but we do want our systems and services to reach our ever increasingly diverse MCH population, and we want our care to be culturally competent and delivered by a cultural diverse work force. We want to work as a team all together. Now you know, this has come up “To be, or not to be.” That is not the question. For MCH, is cultural competence an add-on or not an add-on? That seems to be the question and Wendy will talk about that further. Okay. We’d like a little conversation going, and talk about if you have any activities going on in terms of your block grant needs assessment that you think might reflect the needs of diverse populations, or any other needs in your systems in terms of delivering services. Anybody have any ideas or activities? The mic is on. Oh come on. Okay, thank you.

Unidentified Speaker: Well, I think the very basic (inaudible) in your communication with your printed document that you make sure that you have them available (inaudible). That would be part of it. And then, again, I think that the basics of having diversity amongst your teens and your, you know, whatever projects you’re working on.

Dianne Denboba: Great. Thank you.

Unidentified Speaker: I think we’re from the same place.

Dianne Denboba: Okay.

Unidentified Speaker: We’re trying to develop programs (inaudible) from on cultural competence and (inaudible) success and how do we define it?

Dianne Denboba: Yes. Okay. We may have a discussion about that a little later. Len?

LEN: Well, it’s throughout all of our work, because (inaudible) to talk about what we’re doing around transition and adolescence (inaudible) that work. We can look at transition issues, but if we don’t look at the issue of immigrants in transition, it’s a whole other world (inaudible).

Dianne Denboba: Yes.

LEN: They don’t have the opportunities that other youth might have just by law and so we need an evaluation of assessment (inaudible) service plan for, for youth and services and it’s also in Spanish. So I think that that instrument is--it really has come (inaudible) social work. So we might have thought, “Oh we’re running this program,” in fact, historically what was done was, you know, the kids that grew up with the social worker talking to the parents and not necessarily talking to the youth. (Inaudible) in several ways there. And as they started to answer questions from the (inaudible) the social workers were pretty much blown away by what they heard and what they knew, but we needed to learn and we found that we needed to go to Mexico and so that’s been probably one of the most (inaudible). And separate from that, (inaudible) and for this teaching cultural competence (inaudible) and so there are a number of social workers who (inaudible) are involved in that (inaudible). So we’re working on many (inaudible).

Dianne Denboba: Thank you, and what state are you with?

LEN: Arizona.

Dianne Denboba: Oh. Hi. Hi. Yes.

Unidentified Speaker: One of the things we’ve been trying to do because we were struggling with competence, I mean, we lost a part of our office building where (inaudible) of course the Hispanic population is increasing, and we have, well, similar issues (inaudible), but one of the things that we did, we developed this kind of community profiles and we took the unincorporated areas in Arizona and tried to show the differences between the communities so that we could get (inaudible) launch some programs so that they could tell us what they wanted, instead of us going in there all the time and saying, “This is your problem, and this is what we’re going to do.” And we never accomplished anything because we haven’t had the money.

Dianne Denboba: Great. Congratulations. Part of that is with an integrated services grant? Okay. Great. Do any of you have particular outreach strategies that you use that you developed for certain populations? No, actually, you could just raise your hand if you do, if you don’t feel like talking. No? Arizona does.

Unidentified Speaker: I’m sorry, we were talking because we were (inaudible) some programs that we, I’ll show you.

Dianne Denboba: No. This is, you know.

Rick Horrell: Interactive part.

Dianne Denboba: Yeah. This is interactive. Anybody can speak. You have an outreach program?

Unidentified Speaker: Yes, we do.

Dianne Denboba: I figured. Okay and so your strategies revolve around which population?

Unidentified Speaker: Well we also recently got a (inaudible) grant from the CDC.

Dianne Denboba: Yes.

Unidentified Speaker: And one of the things that we’re doing--we kind of all tied all of the southern counties together and we brought them in, and each one of them has their own issues. We brought the county health centers and the community health centers, which (inaudible) also funds--asked them. We’re trying to guide them in the direction of diabetes and asthma and obesity and physical activity and those types of things, but we’re trying to find out what is going to work in the communities. And Anthony was telling me about--with the Office of Children with Special Health Care Needs--they just got the (inaudible), they have an integrated approach (inaudible). Pardon? No, and one of the things that they’ve done that we’re are very proud of is that we had outreach teams that (inaudible) that she’s responsible for and she’s one of the functions but we have built up family groups in different communities throughout the state to kind of rally and support for the children with special needs. I think we’ve found that to be very, very successful.

Unidentified Speaker: I think, in particular, around the Native--we have a lot of Native American population in the northern areas on the city, and then also of course, our Hispanic population going into some communities that are--primarily, that’s the only language that they speak is Spanish, so it’s been very interesting to see. Because we have 11 communities throughout the state, and to see the differences in what their needs are that they’ve identified and some of the resolutions that there needs to be to, to take down the barriers. And we’re also using a lot of, now, videoconferencing to do communications among all of the communities as well as at the state level.

Dianne Denboba: Great.

Unidentified Speaker: (Inaudible) grant work at the University of Arizona School of Medicine put together a (inaudible) where you can communicate with a lot of the rural areas. One of the things I heard this morning, (inaudible) this is important for us--

Dianne Denboba: Yeah.

Unidentified Speaker: --and I don’t think the other states--some of the other states may have to deal with that. I know that Mexico does. One of the things that we’ve been--I heard this morning when we were talking about issues--we’ve got Native Americans in Arizona. We have 21 federally recognized tribes and each one is an independent nation.

Dianne Denboba: Wow. I mean, thank you for sharing all of that. Anybody have in-service training for new workers? Or pre-service training? I see you shaking your head, but you don’t want to talk about it, do you?

Unidentified Speaker: Please help us out.

Unidentified Speaker: Of course we do, I’m sure that (inaudible).

Dianne Denboba: Okay. But they don’t want to talk about it, but if you do and you incorporated things about the different communities and families that come to your service, then that’s--all of these are pieces of what cultural competence is. I don’t think there’s anybody that’s doing everything, but we’re all doing pieces and we’re striving towards it, and in that respect, it’s not an add-on, it’s a part of what you do to reach the populations that you should be serving. So you go step-by-step, ridge-by-ridge, and you go with partners. Now, I’ve used this slide at a Family Voices meeting, and unfortunately, they were too young to even remember Sunset Boulevard, but, okay, take it, Rick.

Rick Horrell: Okay. You’re Norma Desmond. You used to be in silent pictures. You used to be big.

Unidentified Speaker: I am big. It’s the pictures that got small.

Rick Horrell: Oh.

Dianne Denboba: So this is our entrée into our skit. It’s a dramatization and it’s featuring players from the Tom Gloss school of Acting. Now, if you know Tom Gloss, then you know this should be pretty dramatic. I guess we need to stand up. We were going to come up front. We can carry this.

Rick Horrell: We can?

Dianne Denboba: Right? (Inaudible). No it’s taped.

Rick Horrell: Okay.

Dianne Denboba: Well, we can just pick it up.

Rick Horrell: Okay. Oh, well.

Dianne Denboba: Maybe we can’t pick it up.

Rick Horrell: Well, you got to take this with you.

Dianne Denboba: Well, no, I’m just--shucks.

Jennifer Cernoch: Here. Why don’t I hold it?

Dianne Denboba: Oh, thank you. That’s teamwork.

Wendy Jones: Partnerships.

Dianne Denboba: (Inaudible).

Rick: I’ll hold this. I’m behind you.

Unidentified Speaker: Okay.

Rick Horrell: I’ll be right here.

Dianne Denboba: Okay.

Wendy Jones: There we go.

Dianne Denboba: I’m an intake worker at a clinic. Oh girlfriend, I am so glad to see you. You know, in this clinic, it used to be all for us, you know? Us African Americans? And now, I turned around and everybody, you know, speaking Spanish, the staff, we have Spanish-speaking people. I don’t know what’s going on. It’s like we’re losing our community clinic. Do you know what I’m talking about girlfriend?

Wendy Jones: (Foreign language).

Dianne Denboba: Oops. Looks can be deceiving.

Rick Horrell: Miss-

Dianne Denboba: Uh-oh.

Rick Horrell: --Delova, can I speak with you for a minute? I couldn’t help but overhear you. Do you have a concern?

Dianne Denboba: Well, yes. You know, I think we’re pushing African Americans out of this clinic. It originally was for our community and a lot of our community--oh, please have a seat. I’m trying to be, see, I dissed her before, so I’m trying to--and it used to be for African American communities and the staff could get hired here. But now it seems that things are changing, and I don’t know if I like that. I think we’re being left out.

Rick Horrell: Well I’ve just scheduled a staff meeting for tomorrow. I should have done this sooner, and with all of the staff, you know, I don’t know, so that you could know the reasons for the changes and have input into what’s going on. That was my plan. I mean, Title V completed a census review this past summer, and shared the results with me. It looks like the community is changing, have you noticed?

Dianne Denboba: Well, yes, I have, actually.

Rick Horrell: Well, we’ve had a growing number of migrant workers from Mexico stay here in this county to live and many are becoming residents of this community. Through a needs assessment Title V conducted, it looks like many children were not immunized for school, especially children with special health care needs. So they worked with the church leaders in the community to publicize this fact, while identified parent leaders helped to conduct a focus group. We found that many children from Mexico have had immunizations, but the parents did not bring documentation here, and secondly, many families did not feel at home here. No one spoke Spanish, knew about their foods, when discussing nutrition or about traditional remedies. There were no pictures or signage that they related to. In addition, many families felt some intake workers--

Dianne Denboba: Moi?
Rick Horrell: --spoke too loudly, and their business was getting out.

Dianne Denboba: Who, me?

Rick Horrell: Yes.

Dianne Denboba: Well, I guess sometimes I can do that and I need to start respecting people’s privacy. You know, I’ll work on it.

Rick Horrell: Very good. Title V, the community, and parent leaders are developing some training for staff here. I will ask if any of our staff would like to be involved and explain the situation. We’ll do some strategic planning and include these issues. I should have involved staff first off like I did with families in the community.

Dianne Denboba: Well, yes, and I’d also like to be a part of that group.

Rick Horrell: That sounds great. Yes, we are also working with the Bi-national Commission on Health and Health Care Delivery on a process to enable our families to access their health records electronically.

Dianne Denboba: Hey, that sounds like a good idea.

Rick Horrell: You know I’ve really never considered the feelings of staff here.

Dianne Denboba: Yeah, like—

Rick Horrell: So--

Dianne Denboba: --I didn’t know that?

Rick Horrell: Huh?

Dianne Denboba: Excuse me, yes.

Rick Horrell: About the changes I started making. I never considered the historical importance of this clinic to the community. If we are really going to improve things and change with the times, I need to look at issues from both perspectives--our clients, and staff. We want everyone to understand why we do what we do. We need to work with the African American community, too.

Dianne Denboba: Well, you know, thanks for listening. You’re a very understanding administrator. What do you think that we should call this effort that we’re undertaking?

All: I’d say the Cultural Competence Express.

Dianne Denboba: Cultural Competence Express. That’s a 2010 end joke. Cut that, cut that out, okay? Well, thanks. We thought we would just break it up a little bit and just role-play for you things that I know you’re doing in your state, but also some of the issues and misconceptions that come up. But we all, you know, slide and we make mistakes, but we just have to pick ourselves up and keep on moving, trying to get to that cultural competence pass, and remember you need other partners to go with you. So what does the future hold? We are looking at developing a monograph with National Center for Cultural Competence that looks at model approaches that states have taken, anywhere from baby steps to state-wide implementation, we’re developing a list of mentors, or champions. We’d like to track progress and eventually, I think, we have an understanding with DISH that we will have something in the block grant the next time it’s revised. We can do it.

Wendy Jones: Thanks, Rick. What I want to talk with you about now is this selected findings from a query. The NCCC, that’s short--or NCQ, as some person called us the other day, the National Center for Cultural Competence--actually hired an outside evaluation service--Public Research and Evaluation Service--to conduct a query. Not a survey, not an interview, but a query, with Children with Special Health Care Needs directors across the country, and of the 53, 29 responded. And raise your hand if you see your state. All right. Now, I will not be giving names, but I would like to share some of those findings with you. And so there were actually about 70 questions, I’m not going to go through every one, although if you looked at the PowerPoint, it might look that way. I’m going to give you the highlights of some of the areas that you see listed there, there’s sort of eight. And also ask you to share some, if something appears--if something comes to mind for you that you’d like to share, as well as Rick to share something from his state. That may come up. So one of the questions that was asked, was where is your state in terms of planning, implementing services that reflect cultural and linguistic competence. And if you take a look at the chart, you can see about 72.4 percent of those 29 people that responded are in some mode--are either planning, or mid-planning, early implementation, mid-implementation, or full implementation of some sort of activities or program project that involves cultural linguistic competence. Twenty-four point one percent--making the total sort of 96.5--are doing planning. Very small number of that 29 are actually not--or they responded that they weren’t yet doing planning or implementing cultural competence. Okay next question asked about policies or guidelines, practices, and some structures that would enable the incorporation of cultural and linguistic competence and to service delivery. And so the thing that was most evident was that most of the states have some type of policy or guideline that supports translation or interpretation of materials--pretty, the critical ones. Some states even acknowledge that this was a concern for them. One in particular, I thought, had something real--a nice something--so I’m going to share that with you. I’m not going to say the state, because I didn’t ask permission. But at any rate, they stated that they felt that linguistic competence was really a critical issue for them, and that they felt that, in some ways, they were responding to the needs of the needs of Hispanic-Latino community within the state, but felt that they were not quite at the same level for other populations that were approaching almost as high a threshold, and so one of the things that they were doing was that they were using, not face-to-face interpretation, but phone service, and also written materials. One of the things that this Children with Special Health Needs Director herself developed, which I thought was really neat, was something called a CMS card. This is a CMS card that’s disseminated to Spanish-speaking families, that on one side talks about, or explains all the services that are covered, and also provides the number that they need to call if they require translation services--or interpretation services actually--while they’re interacting with a provider. The back side of the card also is in English, and also lets the providers know that if they need an interpreter, they can bring this such-and-such number and get hooked in quickly, and I thought that was kind of neat. Another thing in this same state--that the nurses and social workers, who are out doing a lot of direct service activities, were actually doing research and writing up information about the specific cultural groups within this area, and had made it available to other staff. So sort of a sharing of information going on internally, which often, there are people collecting information, and you don’t know it, and it may be there, and others were working within the communities. They actually identified five different cultural groups and they were very specific to call them cultural groups and not ethnic or racial groups, from which staff were having volunteers come in to share information about the culture for those people who are going to interact. Okay. The thing that the next question was around, again, guidelines, policies, and what have you, but specifically, whether or not the agency had a mission or a vision or guidelines that supported cultural competence or that “demonstrated a firm commitment” were actually the words, and some of the 29 respondents said that “yes,” they had something or other. I pulled out those two in particular, again, not telling you the state, but it’s a big one, and there are some people in this room from it. At any rate--right to my other side, so now you know who it is--but at any rate, this virtual office on health and disability, which brings up topics and keeps people current around issues of cultural competence, not only for ethnically or culturally diverse peoples, but also bringing in the disability issues, which is deemed key or was reported as being deemed key. Okay? Another one that I thought--I’m sorry? Yes, was this cabinet for health services again in a state that I’m not naming, but at any rate, the thing that I thought was key was that they had representation from across divisions, and that these people come together and inform the policy makers and help with getting things on-board and changed. Okay? In terms of the question around in-service, pre-service or staff development, it was interesting that a lot of states reported that they were providing such training, and training was happening in a range of venues and being supported fiscally by a range of collaborations. One in particular, with an Office of Minority Health that actually got funds from the original Office of Minority Health to provide, again, training, and this training, I thought, again was another one of these key aspects that they were going into the community to get people to come in to train, and also partnerships with refugee health. Bi-lingual staff, I think, we saw a lot. Okay. That a lot of the training had to do with diversity issues or cultural awareness and some were even pretty ethnic-specific. That policy and outreach materials were adapted to meet the needs of those people who have low literacy, or who are not literate. There was also a provision for leave for staff to take Spanish classes in a certain area, though it wasn’t funded. They had to pay for it on their own. In terms of questions for contractors, what kind of requirements were contractors required? Almost across the board, most of the 29 states that responded, that contractors were required to provide translation and interpretation services for families, or to make it available. And many even--a couple of states did say that they had language that was being used across Department of Health wide, not just something that was specific to children with special health care needs, but that all contracts had common language that included cultural competence. Yes. Yes. Thank you. In terms of collaborations, I think only one of the 29 states talked about working with other states, or connecting with other state bureaus to try to get information. Others almost all had some type of community collaboration, whether it was an informal, or a more formal community group, or community-based group, or ethnic-specific group. And a lot of the input that was taken was--or the way that these collaborations were working, was, one, in terms of an education agency, or a family support agency to help with the translation and interpretation piece, or to help with learning more cultural information about the groups in the area. Another one that I thought was really nice was not only allowing the community to come in to train, or to teach, to share their expertise, but also allowing them when there was structured training going on that was sponsored by the Department of Health, allowing folks to come in and get that information also. Sort of not keeping it a secret, but sharing knowledge. When you ask about what’s going on in terms of evaluation and job-postings and personnel kinds of issues, one of the things that came clear was that few states had specific evaluations or standards that incorporated language around cultural competence. Like, if you were evaluating a staff performance, it might not have been in there--a staff member’s performance--something about cultural competence might not have been included. Others reported that it was sort of in--cultural competence was blended in around all of everything in terms of aspects and interactions with families and groups, and then we also asked about assessment. How are you looking at cultural competence? Were you doing organizational self-assessment? Some states have reported having doing organizational self-assessment. Many reported convening focus groups with families for the purpose of modification of service delivery for--and changes in service hours, or when they were open and available, to sort of making the services more accessible for families. I was ahead of myself. Those are the ones that I sort of just said. Okay. So when we look at all this information, and believe me, there’s like reams more that I didn’t even put on here that came out of the query. I think the important thing to understand is that yes, states are doing something. People are at different ends of the continuum. When we talk about cultural competence we often talk about a continuum, moving from one side to the other. And what’s really key is recognizing and acknowledging where states are, or states and this programs that are supporting, as you look at the fact that most states are providing services for contractual agreements. That it’s where you begin, and as long as you keep moving in a positive direction, that that’s super (inaudible) votes on someone that I know. That’s a good thing. And that also, this adaptive challenge and technical challenge that you see there is from the literature around leadership and (inaudible) is sort of the person that we’re sort of quoting here. And the idea is that often when we meet a challenge, or something, there’s some change to happen, that we look at it from a sort of quick fix. What can we do immediately to try to help it? I might call it a band-aid, okay, and that’s one kind of way of attacking--or trying to--and make some change in the process, or to make things fit. But what happens when you usually put a band-aid on something? The band-aid comes off. It’s only a temporary fix. So the idea of attacking something as though it were--I’m going to confuse them because I always do, so let me stick with my quick-fix routine--so that if you attack something and do just a quick fix, you’re going to have to come back and take a look at it again, revisit it, because it may need more. And so this is when we get into looking at what are the pieces that need to be in place and working towards getting the right--or the pieces that are most appropriate for your community in place in order to make the change a lasting change, something that’s sustainable. That’s it. There’s three more slides, but we’re going to go through them as--we’re trying to make sure there’s enough time. You want to switch?