CULTURAL COMPETENCE: QUALITY CASE MANAGEMENT

1. CULTURAL COMPETENCE: QUALITY CASE MANAGEMENT May 17, 2005 Cathy Cave Director, Cultural Competence New York State Office of Mental Health 518-408-2026 ccave@omh.state.ny.us End

2. We don’t see things as they are, we see them as we are. Anais Nin

3. Connections Disconnections

4. It is much more important to know what sort of a patient has a disease, than what sort of disease a patient has. William Osler

5. FOUNDATION FOR DISPARITIES: • Stereotyping influences how we interpret a person’s current, past, and future behavior. • Marginalization: Historical and current actions and attitudes that serve to relegate others to the social, political, and economic margins by viewing them and their interests as inferior and unimportant. • Racism and Oppression

6. *people with disabilities *who are LGBT *people who are homeless* “The Club” Culture, Community, or Social Group with Power and Privilege *people who are elderly* are women* *adolescents* immigrants* *people with limited education *limited English Proficiency* *people who are poor* *who have mental illness* *people of color*

7. Early Years Misinformation Missing History Biased History Stereotypes Socialization CYCLE REINFORCED BY Stereotypes, Omissions, Distortions, People, Systems, and Institutions That We Know, Love, and Trust Family and Neighborhoods Education Media Government Houses of Worship FEELINGS ENGENDERED ANGER GUILT CONFUSION ALIENATION Cycle of Oppression Cycle Continues WE COLLUDE Oppressed and Oppressor We Have Internalized the Process We View the Misinformation as Truth Difference = Different but Equal Difference = Wrong or Abnormal Internalization Take a Stand Dismantling Racism, 2000

8. RACIAL AND ETHNIC DISPARITIES • U.S. population is increasingly diverse • Documented health care disparities include: • Less availability and access to services • Lower likelihood of receiving services • Greater likelihood of receiving poorer quality of care • Under representation in mental health research (DHHS,2002) • Disparities Elimination: Goal of the transformed mental health system (New Freedom Commission on Mental Health, 2003)

9. NYSOMH GOALS Improved quality Increased effectiveness Best science Increased access Increased accountability

10. TITLE VI • Office for Civil Rights – and Limited English Proficiency • Office of Minority Health Culturally & Linguistically Appropriate Services (CLAS) Standards (DHHS 2001)

11. CULTURE “The shared values, traditions, arts, history, folklore, and institutions of a group of people that are unified by race, ethnicity, nationality, language, religious beliefs, spirituality, socioeconomic status, social class, sexual orientation, politics, gender, age, disability, or any other cohesive group variable” (Singh, 1998b).

12. Cultural Considerations: Primary and Secondary Dimensions Employment Community Networks Geographic Location Family/Extended Family Immigration Status Class Income Economics Political Context Country of Origin Race Ethnicity Sexual Orientation Self-identification Language Cultural + Historical Knowledge/Experience Marital Status Military Experience English Language Proficiency Gender Age Parental Status Perceptions of Physical Qualities Physical Abilities Education Literacy Primary dimensions influence “who” an individual is. Spiritual Beliefs Secondary dimensions influence an individual’s participation. (adapted from Rasmussen, 1996)

13. MENTAL HEALTH BELIEFS Cultural factors influence beliefs? Cause of illness What helps? Who helps? Where is help?

14. CULTURAL COMPETENCE IDENTIFIED AS MEANS OF ELIMINATING DISPARITIES(U.S. Public Health Services, Office of the Surgeon General, 2001; Smedley. Stith, & Nelson, 2002) Cultural Competence: • “ . . a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations.” (Cross, Bazron, Dennis, & Issaacs, 1989)

15. USE WHAT YOU KNOW… Knowledge, Information and Data Fromand About Individuals andGroups Integrated & Transformed INTO Clinical Standards Skills Service Approaches Techniques Marketing Programs that match the individual’s culture and increase both the quality and appropriateness of health care and health outcomes. (King Davis)

16. RECOGNIZE OTHER CULTURAL GROUPS AND BE ABLE TO EFFECTIVELY WORK WITH THEM.(Sue, 1998)

17. A PRACTICAL LOOK • Intake • Consent • Diagnosis • Medications • Adherence to Treatment

18. UNDERSTANDING CONSUMER’S IDENTITIES: SOME QUESTIONS FOR CAREGIVERS • How would you describe yourself? • Primary/preferred language. Language spoken at home, with friends and at work. • What was your spiritual or religious upbringing? Do you have a religious or spiritual practice now? • Who/Where do you go to for comfort?

19. STRATEGIES FOR ONGOING CULTURAL ASSESSMENT • Consider all consumers as individuals first. • Never assume a person’s ethnic identity tells you anything about his or her cultural values or patterns of behavior. • Treat all “facts” you have ever heard or read about cultural values and traits as hypotheses, to be tested anew with each client. TURN FACTS INTO QUESTIONS

20. STRATEGIES For ONGOING CULTURAL ASSESSMENT • All individuals within a minority group are at least bicultural. Conflicts involved in being bicultural may override any specific cultural content. • There are many cultural considerations. • Some aspects of a consumer’s cultural history, values, and lifestyle are relevant to your work with the client. Do not prejudge what aspects are relevant. • Do identify strengths in a consumer’s cultural orientation which can be built upon and include them in the treatment plan.

21. STRATEGIES FOR ONGOING CULTURAL ASSESSMENT • The culture is not the problem. It is the task of caregivers to assist consumers to navigate their individual path to recovery. This entails personal awareness, cultural knowledge, and flexibility. • Engage consumers actively in the process of learning what cultural content should be considered. • Keep in mind that there are no substitutes for good skills, empathy, caring, and a good sense of humor. Nancy Brown, “Social Work Services to Urban Indians,”

22. CONSIDERATIONS FOR CAREGIVERS ONCE YOU KNOW… • What can you do prior to meeting? • What can you do improve engagement? • Which questions will be helpful? • What else do you need to know?

23. TREATMENT PLANNING

24. CASE MANAGEMENT • Assess language use and provide language assistance services for anyone with Limited English Proficiency-interpreter services, translated vital documents and materials. • Institutional accommodation-physical environment, hours of operation, staff training about the populations served and found in the community, use of cultural assessments. • Cultural brokering; understand community roles, include family in care, use local resources and spiritual resources per the wishes of consumers.

25. MEASURING CULTURAL COMPETENCY • Know we are doing the right thing! • Assess cultural competence at the organizational and individual provider levels. • Find out from consumers what works!