Incorporating Cultural Competence into Program Priorities: States

Rick Horrell: Good afternoon. I hate being the last one of the day because you all are ready to get out of here. What I want to try to do for you is talk to you a little bit about cultural competency in Missouri, how we set things up and how we did a few things. This is Missouri, Lake of the Ozarks, no, I’m kidding. In Missouri, we don’t have mountains, but we have large hills and lakes and things, but I thought it was a pretty picture, so we kind of have this theme of mountains and climbing uphill, I thought it was just kind of a neat thing to put in there. Let me tell you a little bit about our plan here. We’re going to talk a little bit about our Missouri’s operational plan, and that plan is such that it drives the organization from beginning to end, and it’s designed to have a mission, vision, and values. We set this up yearly, and it’s structured so that you have goals, objectives, and strategies and activities to meet things, and we are trying to integrate cultural competency within that plan. So my plan is about eight pages long, and the entire organization has a copy of that plan and understands what that plan’s all about. You may notice that our goals are the six goals that I don’t have to tell you about. The new Freedom Initiative from the President--and we’re focused, and this is basically on a one-page document, our annual objectives are pretty straight-forward, but this essentially drives the organization and integrates the cultural competency to the thing that we do. Let me tell you a little bit about our plan. We have some goals that we decided on right up front, and essentially improving our capacity to achieve cultural competence. How are we going to do that? And these goals are--we have to identify our resources for use by staff and our contractors. We do contract some services out, so it’s important to recognize what our staff can do, what our contractors can do. The second thing is to improve our cultural knowledge base of our staff and contractors, and we’re trying to do this through a variety of training efforts. In addition, you know, how do we meet these goals? Well, it’s pretty straightforward. My background is such that we do--I have background in Business Administration, Health Services Management, Health Care Administration, so I’m very much a planner, kind of organizer person. So, essentially, I established a plan. We looked at activities and design to improve capacity levels. We implemented a plan, and we’re evaluating the plan. It’s a simple process. It sounds silly, but that’s the way my brain thinks sometimes. So you have to start with something and build it and implement it and evaluate it, and it’s a constant loop. So how do we choose our path? This looks like a fun little path, although I don’t know that I could do that, but you got to start somewhere, and you have to figure out what you need to do to move down the path of cultural competency. So what we did was--we had a work team developed, and we set goals for that work team. Essentially, we looked at a framework for evaluations. We tried to increase coordination of our staff efforts to address cultural competency and we integrated cultural competency in our operational plan. As I showed you in the very beginning that one page--well actually it was on two slides, but it was a one-page document--with our mission, vision, and values, and integrated in that is cultural competency, so that’s the foundation of what we do. In our framework, we really had to look at the new Freedom Initiative, the four public health functions, the Title V pyramid, and what MCHB is doing. We tried to integrate that throughout our thinking and planning process. When we talk about our work team, we look at our action steps, and the first action step was really looking at inventory of activities, and what it is that we’re doing now. What should we be doing, kind of, what is the latest and greatest, and we use the inventory tool to collect that information. We looked at program components, services, state agencies, organizations, committees. We looked at and tried to figure out performance measures, outcomes that we wanted to achieve. It’s a very--kind of a systematic process and here’s kind of an example of an investment inventory. Some of these things pretty much came from the National Center of Cultural Competency. A lot of this we didn’t just make up ourselves. We used tools that are already out there and tried to address things that we knew was good, and actually, about a year and a half ago or so is when I first invested some time in learning about Georgetown and the National Center. So this is just an example of one of the tools that we used in each of our programs, basically worked through a process of working this tool out. When we identified our second step it was really to look at that data that we received from our tools, and kind of look at assessment to guide and address our goals and strategies and activities. We clearly looked at the block grant and what the priorities are for Missouri, and there are three main components that we found where cultural competency fits into our priorities with our block grant: health care access, child adolescent injuries, and child abuse and neglect. Our third action step was looking at sources of cultural competency information. I can tell you the foundation of our program is really centered around the National Center of Cultural Competency in Georgetown. Thank you. I appreciate that. We spent a lot of time looking at the information. We looked at the guide to quality and culture, which is a document that the center puts out, and that helped to give us some great guidance. We also looked at local training development based upon our needs. Missouri is getting more and more diverse every day. For example, in Kansas City, Missouri, which is one of the two larger cities in the state of Missouri on the western part of Missouri, there’s the Don Bosco Community Center, and essentially that center is designed to resettle refugees from around the world. And they get a lot of influx of different folks into that center, and we’ve been able to create a relationship with that organization to help refugees out and settle into the Kansas City, Missouri area. Another local training development was with the Jewish Vocational Service, who provided us and our staff with a lot of training, and essentially it came out of a discussion of folks, some of our staff attended some meetings. One of the ideas in their plans--business plans--is to actually go out and visit and partnership with other people, and this became a great partnership for us as well. In addition, we try to do training for our staff and contractors. We’re doing more and more of that every day. We have four of our staff that are actually in various language classes to help themselves in working with the multi-diverse communities that we seem to work in. A fourth action step is identifying opportunities within the organization. Increase the coordination of resources. There’s a lot of information out there, and how can we pull that together and be a little bit more focused in the work that we’re doing. We try to invest our resources and services to promote cultural competency instead of being kind of a shotgun approach, we’re trying to take a very much a laser beam approach, and we’re trying to assure the needed health services are provided. In Missouri our main cultural folks are Spanish, Vietnamese, Bosnian, and Russian. In St. Louis we have more of the Bosnian and Russian influence, we have a big German community. Actually, the Bosnian, Serbian and Croatian folks are fairly large in St. Louis metropolitan area in Missouri, and actually, I’m part Croatian, so I talk funny and do weird things sometimes, but I’m Croatian so it works out pretty good for me. Raising awareness, what are some recommendations in moving towards cultural competency, and these are the recommendations our work team came up with. We came up with a report. Program planning calendars. Essentially, each one of our--we have regional offices--designed a plan to integrate cultural competency based upon their region. So in St. Louis, we have folks working with the Serbian-Bosnian populations, the Vietnamese populations. In Kansas City, Missouri, we have folks working with the Hispanic communities, so we’re very much targeted to specific areas and need. We did administer a cultural competency investment inventory, organization self-assessment and cultural competency, and it worked out very well. We looked at plans, action steps, laws, various worksheets, check lists, and it seems to be a step-by-step process. We identified priorities to initiate cultural competency as well. In raising awareness, we also looked at showcasing examples; we’re still working through that process. We published lessons and effective practices and guides in eliminating disparities. We’re looking into forming staff of various websites of which Georgetown, the National Center is a focal site for us, a foundation site. We’re trying to also communicate health care rights of non-citizens and immigrants. We do have a lot of that population moving into the state. And finally, guidelines for staff and contractors, referencing federal mandates and influence. We’re trying to provide a lot of information for a lot of people. Additional recommendations about allocating resources, we’re very involved with new partnerships across community-based organizations and state and local systems. We’re building on our current partnerships with other state agencies, we’re sharing success stories between agencies, we’re providing support for allocating funding for professional schools to enhance more curriculum related to cultural competency. We actually have staff coming in and training our staff on cultural competency, and we’re very much looking at analyzing county level data. This comes from some of the census information to figure out what type of populations Missouri is having. In addition, we’re expanding our use of current resources, we’re enhancing our website. Right now we do have some material in Spanish, Also, Bosnian, Russian, and Vietnamese, where if people want to enroll in our programs we have that material already set up. We’re looking at creating a website, so in a matter of a click of a button, it would be all converted into Spanish. We’re not quite there yet, but our WIC program has that capacity already where you simply click on one button, and the whole website becomes in Spanish, and we’re working on other languages as well. We’re trying to do more with media, just from brochures, to all kinds of things, and we’re trying to definitely train our staff so they get a better handle and understanding of what we’re talking about. We’re also looking at our contracts, you know, looking at contracting language and doing our research into cultural competency, again, our foundation is the national center. When we talk about our recommendations, clearly, we came up with our leaders and our organization have to value cultural competency and essentially, since I’m the leader and it’s part of my position, we have been doing that and it’s in our mission and our vision, so it seems to work very well. We’re including families in our decision-making and trying to get cultural competency ingrained into the work that our family partners are doing. Essentially, our Family Voices person, and our Family Partners, which is a Children with Special Health Care Needs group of people, are integrated, and we’re always looking at new opportunities with them. We’re also trying to assure cultural competence by working with our Office of Minority Health in a section of community health systems and support. We’re trying to address some of the areas that we’ve identified so far, transportation, interpreters with medical expertise, it’s great to have an interpreter, but if they don’t understand some of the medical issues that we’re dealing with, it can be somewhat confusing, so we’re trying to work with that group a little bit better, and cultural variations within cultures, there’s differences as well. What about successful programs? What is it that it takes to have a successful program and cultural competency? Obviously, defining a cultural--broadly valued client’s cultural beliefs is very important, recognizing complex language and interpretation and facilitating learning between providers and communities. We’re very much integrated within our communities and part of our staff’s structure is to go out into the communities, find resources, and integrate people a lot more than what they have in the past. We’re very much involved in the community. We’re collaborating with other state agencies as well as local agencies and we’re also trying to professionalize our staff hiring and training, so we’re actually going to be contracting to have some folks come in and work with us on cultural competency. In addition, link residents to culturally and linguistically appropriate health care and social services, teaching individuals and communities about health and health care, what we can do with those folks, and educating providers about community needs, cultural norms, and their family. That’s kind of a summary of what we’re doing. Oh-oh. I missed a slide, I think. Oh well. Is that it? Oh, okay. I’m off one. Yes, what was the one before that? Oh, okay. Essentially, you know, at the end of the day when you climb that mountain, you have to really look and assess ourselves and assess our system. You have to determine your next move and prepare a plan, implement and evaluate things. Our cultural competency system, you know, when you reach that summit, the top of that mountain, you know, what’s your next step? Well, you’ve got to come down the mountain, and your next step is taking a ride like this. It’s a constant process, right? And sometimes you feel like you’re jumping off the edge of a cliff, but you’re not. It’s a step-by-step kind of process, and it’s important to recognize that. I can tell you that one-step at a time is the only way to do this. When you develop partnerships and relationships with others, it’s incredible. The MCH folks that we have here. You guys are a great group of people. You deal with some of the most challenging individuals out there. You’re very compassionate. You have such a caring attitude that I’m privileged to be a part of this type of system. Just to be successful, create your plans, implement them, and evaluate them. That’s all you have to do and we can be culturally effective if we do that. So that’s basically my story about Missouri. I hope it was helpful for you. So, thanks a lot.

Dianne Denboba: You know, we started late and, you know, if there are questions that you’d like for everyone to hear, that’s fine if you’d like to come up. I know there was a question in Arizona about defining cultural competence. You have to define it in one sentence.

Rick Horrell: Okay. I’ll give it a shot. It’s a long sentence, though. Cultural competency is defined as a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations. It reflects the ability—pardon me?

Dianne Denboba: That’s two sentences.

Rick Horrell: Oh, okay. Sorry. My apologies.

Wendy Jones: Put a semi-colon in there.

Rick Horrell: Semi-colon?

Wendy Jones: Semi-colon.

Rick Horrell: Semi-colon. Oh, okay. I’ll continue. It reflects the ability to acquire and use knowledge of the health-related beliefs, attitudes, practices, and communication patterns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps and health status among diverse populations. How’s that?

Dianne Denboba: And you know, what we—

Unidentified Speaker: (inaudible).

Dianne Denboba: --what we found, too, is that you have a basic definition, you know, make sure that you want the skills and, you know, knowledge, and whatever, and your attitudes. But a lot of people have to discuss that so they can come to a consensus and take ownership of it. You know, they may modify, but if they have the skills and the attitudes, and the knowledge, you know, that something will change because of what you learn, I think that’s the important thing.

Glen: I just wanted to share something (inaudible) and I don’t have an exact citation, but if you’re having issues in your state about certain immigrant children and their families, and (inaudible). You might want to get your hands on--that allows folks to (inaudible) and so it’s good to find legislation like that. I just wanted to share that (inaudible). Do you know what I’m talking about?

Wendy Jones: Yes. I know exactly what you’re talking about. I don’t have the reference, but I can get the bill number.

Glen: It did pass.

Wendy Jones: Yes.

Glen: And so that’s why (inaudible).

Unidentified Speaker: I just wanted to ask; you highlighted three areas that you said cultural competence was important for health care access and injuries and (inaudible).

Rick Horrell: Yes.

Unidentified Speaker: I was wondering why you kicked out those three and why you would be trying to be culturally competent in all programs?

Rick Horrell: Well, essentially, we are doing it in all areas. What that was referenced to was trying to make some linkages into out MCH block grant application on our priority areas. We have seven priority areas. Actually, those are three of the seven that we made some direct linkages to but we are trying to make the cultural competency program as integrated throughout the organization. So we’re just trying to make a better connection with what the block grant’s all about and since we’re limited in our priority areas we picked out those three.

Unidentified Speaker: What about the other four, then? I mean, (inaudible).

Rick Horrell: I can’t remember what the other four are off the top of my head, but I think what we try to do is say, “Okay, we don’t know if we can get all of this right away, this first year, this go-round.”

Unidentified Speaker: (Inaudible).

Rick Horrell: Right. So let’s pick out the top three and go for those, and then we’ll do the next, next time. That’s also part of the planning process. We knew we couldn’t do everything, so we kind of took bits and pieces and did one step of a time, so--you bet.

Dianne Denboba: Do we have any other questions? Well, you’ve been a great audience, thank you. And again, for the speakers.

Rick Horrell: Thank you.