Addiction Exchange
News from the worlds of research and clinical practice
Volume 3, No. 11: Office of Minority Health's CLAS Standards
July 15, 2001

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Funded by Center for Substance Abuse Treatment, SAMHSA

Welcome to Addiction Exchange, a forum for the exchange of clinical practice and research information among clinicians, scientists, educators, and administrators in the field of addiction.  This issue discusses the recently released Office of Minority Health’s national standards on Culturally and Linguistically Appropriate Services (CLAS) in health care.  The Standards should be of interest to researchers, practitioners, health care organizations, policymakers, educators, accreditation and credentialing agencies, purchasers of health benefits, patients, advocates and anyone else with an influence on health care and/or substance abuse treatment.

Cultural competence, a set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups, is a critical component of effective substance abuse treatment.  It includes sensitivity to various cultures’ values, beliefs and traditions, an awareness of differences among each cultural group, and knowledge of its language.

The U.S.’s four major racial/ethnic groups (African Americans, Hispanic Americans, Asian Americans/Pacific Islanders, and American Indian/Alaska Natives) now make up about one-fourth of the population and its fastest-growing segments.   In Virginia and North Carolina alone, the Hispanic and Asian populations are exploding in size and will continue to do so for at least the next 25 years.  Other culturally diverse populations include, among others, the disabled, women, adolescents, criminal justice clients, rural and urban populations, individuals with varying sexual orientations, and religious groups.

Cultural competence needs to be implemented at many levels, from attitude and practice to policy and structure.  However, there are often no policies, budget allotments, or training to support this implementation, something of which administrators, policymakers, educators and others need to be cognizant.  Researchers, too, should be aware that further research is needed relevant to minority patients’ lives, particularly in health literacy, quality of care, access to services, cultural preferences, and service delivery. 

To address the inequities that exist in the provision of health services and make treatment more responsive to the individual needs of all patients, the U.S. Department of Health and Human Services’ Office of Minority Health (OMH) oversaw the creation of national standards on Culturally and Linguistically Appropriate Services (CLAS), a set of 14 mandates, guidelines and recommendations for the field of health care.  As explained in the Preamble to the standards, “Culture defines how health care information is received, how rights and protections are exercised, what is considered to be a health problem, how symptoms and concerns about the problem are expressed, who should provide treatment for the problem, and what type of treatment should be given . . . health care is a cultural construct, arising from beliefs about the nature of disease and the human body . . .”

Although disparities between and within cultural groups prevent a simple, one-size-fits-all approach to substance abuse treatment of minorities, the literature shows that the effects of variables such as age, level of acculturation, gender and sociodemographic data on substance abuse tend to be similar among all four racial/ethnic groups (“Prevalence of /Substance Abuse Among Racial and Ethnic Subgroups, SAMHSA, Office of Applied Studies, Rockville, MD, 1998; SAMHSA Technical Assistance Bulletin, “Following Specific Guidelines will Help You Assess Cultural Competence in Program Design, Application and Management,” On-line Technical Assistance Bulletin series,1994; CSAT, 1999). Additional concerns that have been found to be cross-cultural may include an attitude of distrust toward health practitioners in general because of negative cultural stereotypes, the importance of family and community, and indigenous healing practices based on diverse spiritual beliefs. (CSAT, Cultural Issues in Substance Abuse Treatment, 1999).  Minority clients typically encounter problems such as transportation, distance, poverty, illiteracy, institutional racism, language, negative past experiences, lack of diverse staff, knowledge of help, denial, and cultural skepticism (CSAT, 1999).

The CLAS standards are organized by three themes: (1) Culturally Competent Care (standards 1-3), (2) Language Access Services (standards 4-7), and (3) Organizational Supports (standards 8-14).  Within this framework, they are broken down into three levels of stringency: mandates (intended for all recipients of Federal funds), guidelines, and recommendations. The 14 standards are listed below.

Standards 1, 2 and 3 (Culturally Competent Care “Guidelines”): Health organizations should:
1) ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language;
2) implement strategies to recruit, retain, and promote at all levels of the organization diverse staff and leadership that are representative of the demographic characteristics of the service area;
3) ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery;

Standards 4, 5, 6 and 7 (Language Access Service “Mandates”): Health organizations must:
4) offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation;
5) provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services;
6) assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff.  Family and friends should not be used to provide interpretation services (except on request by the patient/consumer);
7) make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area;

Standards 8-14 (Organizational Supports for Cultural Competence “Guidelines”): Health organizations should:
8) develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services;
9) conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations;
10) ensure that data on the individual patient’s/ consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated;
11) maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.
12) develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities;
13) ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers;
14) (“Recommendation”): Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS Standards and to provide public notice in their communities about the availability of this information.

To read about the CLAS Standards in more detail, go to: http://www.omhrc.gov/clas

To read articles about the standards in the Office of Minority Health’s newsletters, Closing the Gap, go to: http://www.omhrc.gov/omh/sidebar/omh-publications.htm

Go to http://www.mid-attc.org/wwwboard/wwwboard.shtml to discuss this topic on the Addiction Exchange Forum.

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Mid-Atlantic Addiction Technology Transfer Center
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Substance Abuse and Mental Health Services Administration
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