Local, regional and national journeys to cultural and linguistic competence

Local health departments (LHDs) are especially responsible for delivering health care in a culturally and linguistically appropriate manner since many of the communities they serve carry the heaviest burden of disease in this society.  Many racial and ethnic minorities make up these communities and encounter barriers relating to cultural misunderstanding and miscommunication.  Serving a county of 1.4 million people and staffed with 1500 employees, the Suffolk County Department of Health Services (SCDHS) represents a diverse racial/ethnic and linguistic population.  Over the past ten years, Suffolk has experienced a 70% growth in the Latino/Hispanic population, which now comprises nearly 11% (largely made up of Migrant and Seasonal Farm Workers (MSFWs)) of the County’s population.  Local outreach/support organizations serving MSFWs estimate that 90% are uninsured and 100% speak Spanish as their primary language. The African-American/Black population has also risen by 19% and now comprises nearly 7% of the population; combined with the Latino/Hispanic community, minorities now comprise 26% of Suffolk’s population. In addition, the race/ethnicity of the County’s uninsured population differs markedly from the insured population. While 7% of the total insured population is African-American, they represent 16% of the uninsured population; and for Latinos, they represent 13% of the insured residents but 24% of the uninsured. The majority of primary health care services for the uninsured and underinsured in Suffolk County are provided by the SCDHS Health Center System.  SCDHS operates eight community health centers (CHCs) and three satellite sites, all located within areas of medical under-service.  Approximately 49% of SCDHS health center patients are Latino/Hispanic and 20% are African-American/Black. 

Launched in 2005, the SCDHS Office of Minority Health (OMH) has sought to address existing health inequities among these populations.  The USDHHS OMH in 2001 created the Culturally and Linguistically Appropriate Services (CLAS) Standards as a means 'to correct inequities that currently exist in the provision of health services' with the ultimate aim 'to contribute to the elimination of racial and ethnic health disparities'.  However, much guidance does not exist for the process of CLAS implementation for LHDs.  In spite of this, SCDHSOMH felt it was beneficial to begin adopting policies to better comply with the growing “standard of care” – cultural competence.  In 2006, the SCDHSOMH developed and adopted an action plan in order to provide a systematic strategy for the implementation of the CLAS Standards.  This was accomplished despite limited resources within the organization and guidance on the process of implementation.

Uniquely, by relying on collaborations, SCDHSOMH was able to conduct assessments, training, and evaluations, provide materials, and obtain a consultant at no cost to the SCDHS.  OMH focused initial staff training efforts on increasing knowledge about cultural competency.  SCDHSOMH staff conducted workshops on Health Disparities in Suffolk County, as well as the need and importance of cultural competency to the staff at the CHCs, the Jail Medical Unit, the SCDHS Executive Level, and the Family Planning Division, reaching 250 staff in total.  Post evaluations revealed that 95% of participants found the workshops mostly to extremely useful to their work.  Next, the Island Peer Review Organization (IPRO), the New York Medicare Quality Improvement Organization (QIO), through their initiative Practice Cultural Quality Leaders (PCQL) provided staff training and baseline self-assessments of the current level of CLAS activity at each CHC.  The majority (N=258) of clinical staff (nurses and physicians) completed the on-line tool, A Family Physicians Guide to Culturally Competent Care created by the USDHHS OMH and received CME/CEU credits.  Participant feedback was favorable with results for content quality, value to job, time spent on activities, and practice relevance rating good-excellent for 93-100% participants.   In order to fulfill all training domains, SCDHSOMH collaborated with the Stony Brook University Center for Public Health Education and the NY/NJ AIDS Education and Training Center (AETC) at Columbia University to conduct attitude and skill-based training workshops utilizing their Building Bridges to Cultural Competency Program funded by a HRSA grant.  The original 1-day program structure was modified to four 1-hour workshops at the CHCs in order to better accommodate the CHCs’ patient schedules.   Even though funding was for clinical staff training, all staff members (frontline, clinical, janitorial, etc.) in each CHC participated.  To date, four CHCs (N=270 staff) have received training.   For the remaining CHCs, Stony Brook University, Columbia University, and the SCDHS are conducting a research evaluation project of the Building Bridges Training Program, assessing perspectives of both the provider and the patient.  In addition, through a Robert Wood Johnson Funded Research Project at University of Florida Department of Psychology, a patient-centered evaluation tool was tested at one of the CHCs.  

To assist the CHCs in fully implementing CLAS, especially standards dealing with language services, the CLAS Leadership Team comprised of two representatives from each CHC was created and is developing a long-term strategic plan for the CHCs.  With the approval and assistance of the Health Commissioner, CLAS language was incorporated into the SCDHS mission statement. Committees on Workforce Development and Workforce Enhancement, made up of executive level staff, were established to address issues of cultural competency and diversity training and recruitment of racial and ethnic minorities were established, and department-wide policies for all new and current employees to receive training on the CLAS Standards have been proposed. With the help of an in-kind consultant from a hospital affiliate of one of the CHCs, SCDHS has begun to revise its policy for Limited English Proficiency (LEP) Patients.  Future efforts are geared towards collaborating with this hospital affiliate, who has an existing medical interpreter training program with over forty trained staff members, to begin a pilot project to improve language assistance services at one CHC.  Best practices will be replicated in the remaining health centers.

SCDHSOMH continues to overcome the significant challenge of limited resources for training, evaluations, and consultants through collaborations.  Another challenge during CLAS implementation included obtaining buy-in from executive staff and CHC staff since many had never heard of the CLAS Standards and did not want “more work”.  Fortunately, the Commissioner demonstrated his support of these efforts by verbal appreciation and reaffirmation to the executive level staff of the need to incorporate CLAS into the SCDHS on multiple occasions that was best exemplified by incorporating CLAS into the mission statement and strategic plan for the SCDHS over the next two years.  In addition, when presenting to staff focusing more attention on the legal obligations and ramifications, as well as the economic benefit of CLAS during presentations overcame resistance that was initially given by the staff.  The main lesson learned was that when funding is scarce to support CLAS implementation efforts, LHDs should seek out opportunities to collaborate with other agencies dealing with cultural and linguistic competent services to overcome assessment, training, evaluation and material costs.  To the reverse, in addition to creating in-house evaluation tools, the evaluation process can be expanded through collaborations and LHDs should accept opportunities presented from outside agencies to participate in research opportunities to support the LHDs own CLAS needs.