# CULTURAL COMPETENCY

# RESOURCE GUIDE

## For Beneficiary Counseling & Ombudsman Programs

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**Developed by the Office of Healthcare Information and Counseling, Administration for Community Living (ACL)**

## July 2022

This ACL FAI Technical Assistance project is supported by funding through an Interagency Agreement from the U.S. Centers for Medicare & Medicaid Services, Department of Health and Human Services, Washington, D.C. 20201. Points of view and opinions do not, therefore, necessarily represent official Centers for Medicare & Medicaid Services policy. This educational product was current at the time it was published or uploaded onto the web. Guidance is continually updated and links to the source documents have been provided within for reference.

ContentsContents	2Introduction	3CMS FAI Background	3Defining Cultural and Linguistic Competency	4What are Health Disparities?	4Helping an Organization Become Culturally Competent	4Resources	5Culturally and Linguistically Appropriate Services (CLAS)	5Data and Data Collection	6Disparities and Equity	6Focus Area: Asian American, Native Hawaiian, and Pacific Islander Communities	7Focus Area: Disability Community	7Focus Area: LGBTQ+ Community	8General Cultural Competency	8Glossaries	9Language Access and Health Literacy	10Long-Term Services and Supports	10Nondiscrimination Laws	10Understanding Bias	11Endnotes	11

# Introduction

Cultural and linguistic competency are critical to promoting health equity, reducing health disparities, and improving access to health care that respects and responds to diverse needs. This guide is for organizations ready to pursue or evolve competency processes and procedures. It provides resources and tools to understand federal nondiscrimination laws and regulations, view health disparities data, involve diverse voices in developing goals and action plans, learn relevant terms, assess implicit bias, and tailor outreach and services. This guide focuses on plans, policies, and programs for individuals with limited English proficiency (LEP) and people with disabilities – including people who are deaf, hard-of-hearing, deaf-blind, or blind – and may be covered in an organization’s plan addressing regulation and legislation such as Title VI of the Civil Rights Act of 1964, Title VI regulations, Section 504 and the Section 508 Amendment to the Rehabilitation Act of 1973, and Title II and Title III of the Americans with Disabilities Act (1990).

Additionally, Executive Order 13985 *Advancing Racial Equity and Support for Underserved Communities Through the Federal Government* calls on agencies to advance equity through identifying and addressing barriers to equal opportunity that underserved communities may face due to government policies and programs. The U.S. Department of Health and Human Services Equity Plan adopts several strategies, including “Focusing on civil rights protections and laws will help address barriers to heath care and human services, such as those individuals with limited English proficiency face in obtaining information, services and/or benefits from HHS federally conducted and federally assisted programs.”

The Administration for Community Living (ACL) Office of Healthcare Information and Counseling (OHIC) compiled this guide as part of its technical assistance support to Centers for Medicare & Medicaid Services (CMS) Financial Alignment Initiatives (FAI) Ombudsman and State Health Insurance and Assistance (SHIP) grantees. CMS FAI grantees serve Medicare beneficiaries simultaneously enrolled in Medicare and Medicaid, known as dually eligible individuals. There are more than 12 million dually eligible individuals – including older adults and younger people with disabilities, serious mental illness, intellectual and developmental disabilities, and/or end-stage renal disease (ESRD).[endnoteRef:2] They experience high rates of chronic illness and social risk factors, which are powerful predictors of poor quality outcomes.[endnoteRef:3] In demographic terms, nearly half of dually eligible individuals (47.5%) are from a racial or ethnic minority group, over half are female (59.6%), and nearly 40 percent are under age 65.[endnoteRef:4] [2:  Centers for Medicare & Medicaid Services, People Dually Eligible for Medicare and Medicaid, March 2020.]  [3:  Office of the Assistance Secretary for Planning and Evaluation, December 2016.]  [4:  Centers for Medicare & Medicaid Services, Data Analysis Brief: Medicare-Medicaid Dual Enrollment 2006-2018.] 

While dually eligible individuals may be covered by both Medicare and Medicaid, the eligibility requirements, benefits, and payment rules in each program function separately. Cultural competence is a powerful tool in addressing this complexity, including to provide alignment and support across the benefits to address the vulnerabilities dually eligible individual encounter. While this resource guide is developed for programs that provide support to dual eligible individuals, it may also be beneficial to other audiences. 

## CMS FAI Background

As part of its FAI, CMS works to address longstanding barriers for beneficiaries enrolled in both Medicare and Medicaid by testing innovative demonstration models with states. These models improve care coordination through better alignment of program financing and the integration of primary, acute, behavioral health, and long-term services and supports. CMS provides grantees with funding for beneficiary ombudsman and one-to-one assistance programs, as well technical assistance from ACL through an interagency agreement.

Ombudsman programs provide person-centered assistance to help beneficiaries resolve problems. They also inform states, plans, CMS, and other stakeholders about trends within their findings and identify areas for improvement. Additionally, State Health Insurance Assistance Programs (SHIP) grantees conduct outreach, education, and options counseling for beneficiaries on health insurance options. 

Grantees must provide culturally and linguistically competent services for groups including, but not limited to, people of varying ethnicities, functional and cognitive abilities, and English language proficiency. To support grantees in these efforts, this guide combines:

· A variety of public resources to build cultural and linguistic competency, reduce implicit bias, and address health equity; and

· Guidance on how to create an action plan, develop goals, and use existing data to complete the CMS Health Disparities Impact Statement (described later in this guide).

# Defining Cultural and Linguistic Competency

Services that are culturally and linguistically competent are respectful of and responsive to the beliefs, practices, and needs of individuals of diverse backgrounds and abilities. 

Cultural competence is a developmental process that evolves over an extended period of time. 

Linguistic competence is the capacity of an organization and its people to provide services in a way that communicates effectively and conveys information in a manner that is easily understood by diverse groups, including persons of limited English proficiency, those who have low literacy skills or are not literate, individuals with disabilities, and those who are deaf or hard of hearing. 

This competency is especially important as the “percentage of people living in the U.S. who are racial and ethnic minorities and who speak a primary language other than English continues to grow rapidly.”[endnoteRef:5] The population of Americans with disabilities is also growing, estimated at 13 percent in 2019.[endnoteRef:6] Culturally and linguistically appropriate services can help address health inequities and create positive health outcomes and experiences for diverse populations.[endnoteRef:7] [5:  Cultural and Linguistic Competency. Office of Minority Health, U.S. Department of Health and Human Services.]  [6:  Annual Report on People with Disabilities in America: 2020. Rehabilitation Research and Training Center on Disability Statistics and Demographics.]  [7:  Culturally and Linguistically Appropriate Services (CLAS). Think Cultural Health, U.S. Department of Health and Human Services.] 

## What are Health Disparities? 

Healthy People 2020 defines a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”[endnoteRef:8]  Health disparities in services may include and are not limited to disparate treatment, discrimination, bias, insurance, eligibility, etc. [8:  Healthy People 2020: Disparities. Foundation Health Measures Archive. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services.] 

**What is Health Equity?**

Healthy People 2030 defines health equity as “the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and social determinants of health — and to eliminate disparities in health and health care.”

## Helping an Organization Become Culturally Competent

Becoming culturally competent is an ongoing process that begins with awareness and a commitment to developing inclusive policies, budgets, and processes at every level of an organization. The following steps can help to develop a plan for building an organization’s competence. Approaches are most effective when regularly assessed and adjusted based on lessons learned.

### STEP 1

Start by learning more about cultural and linguistic competency. There are many trainings available that can introduce you to concepts, teach relevant terms, and help you to assess implicit bias on both the individual and organizational level. Completing cultural competency training as an organization is encouraged. While all resources are aimed at improving cultural competency and may link to additional education and training materials, resources with a star («) are existing training content.

### STEP 2

Involve stakeholders in the process. Consider who should be involved at an organizational level (e.g., management, staff, volunteers) and make every effort to include representatives of the population you seek to learn more about. Ensure logistical support, as well as a dedicated staff member or oversight or advisory committees, that can support lived experience engagements.[endnoteRef:9] [9:  Methods and Emerging Strategies to Engage People with Lived Experience. Office of the Assistant Secretary for Planning and Evaluation. (2022, January 4).] 

### STEP 3

Complete the CMS Disparities Impact Statement (DIS). The DIS walks you through a process to identify vulnerable populations in your service area and learn about the population(s) you currently serve. Compare your data with other available sources, such as:

· CMS’ Mapping Medicare Disparities (MMD) tool, which provides data on health outcome measures, including health disparities, among different populations; 

· Resources for Integrated Care: Data Collection and Analysis;

· County Health Rankings; and,

· Tools available from your state or local health department.

### STEP 4

Take reasonable steps to provide meaningful access to limited English proficient (LEP) individuals and make reasonable modifications to policies, procedures, and practices to provide individuals with disabilities access to your organization’s health programs and activities. Establish culturally and linguistically accessible complaint procedures. 

### STEP 5

Plan for when and how your organization will monitor and update its plan, policies, and procedures to ensure that needs are met and that there is a framework for continuous quality improvement. 

# Resources

## Culturally and Linguistically Appropriate Services (CLAS)

Think Cultural Health

*Information and continuing education for health professionals to learn about**CLAS**.*

National Culturally and Linguistically Appropriate Services (CLAS) Standards

*Blueprint for organizations to advance equity and quality and help eliminate health care disparities.*

**CMS CLAS and Language Access Planning Resources**

· Guide to Developing a Language Access Plan

· A Practical Guide to Implementing the National CLAS Standards: For Racial, Ethnic and Linguistic Minorities, People with Disabilities, and Sexual and Gender Minorities

· Providing Language Services to Diverse Populations: Lessons from the Field

· How Healthcare Providers Meet Patient Language Needs: Medscape Survey Highlights

· Achieving Health Equity (Medicare Learning Network training) «

*Defining health disparities and health equity, addressing disparities in organizations, fostering a culture of equity, and creating processes to build organizational responses.*

## Data and Data Collection 

Inventory of Resources for Standardized Demographic and Language Data Collection (CMS)

*Repository of resources on demographic and language data collection.*

Enrollment Data: Medicare and Medicare Savings Programs (NCOA)

*Enrollment in dual-eligible programs at the state and county level.*

Limited English Proficiency Low-Income Medicare Beneficiaries (Tableau Public)

*Data visualization by county.*

Health Equity Data (CDC)

*Multiple data dashboards on health equity among the U.S. population.*

Minority Health Social Vulnerability Index (CDC, ATSDR, OMH)

*Identifies communities at risk for disproportionate impact by COVID-19 and beyond.*

Medicare COVID Snapshot (CMS)

*Aggregate data and visualizations of claims, encounters, and enrollment information.*

## Disparities and Equity

HHS Equity Plan (HHS)

*2022 strategic plan on advancing equity*.

Disparities Impact Statement (CMS OMH)

*Tool for organizations to identify, prioritize, and take action on health disparities.*

Equity Plan for Medicare (CMS)

*Priority areas encompassing both system- and community-level approaches to achieving equity.*

Achieving Health Equity: A Guide for Health Care Organizations (IHI)

*White paper on reducing health disparities related to factors historically linked to discrimination.*

Health Equity: Promoting Fair Access to Health (CDC)

*Overview of social determinants of health, promoting equity, and COVID-19 disparity data.*

Benefits Outreach to Underserved Populations Best Practices (NCOA)

*Resources, tools, and practices to ensure everyone can age with health and financial security.*

DiversityRx

*Trainings, resources, and information designed to improve the accessibility and quality of health care for minority, immigrant, and indigenous communities.*

Strategy Initiative: Advancing Equity (Justice in Aging)

*2021 framework on advancing equity.*

## Focus Area: Asian American, Native Hawaiian, and Pacific Islander Communities

Asian American and Pacific Islander (AAPI) Beneficiaries Toolkit (NAPCA)

*A comprehensive approach to maximize interactions with AAPI older adults and caregivers.*

****AAPI Cultural Competency Course (NAPCA) «

*One-hour free course on how to integrate competence into work with AAPI older adults.*

Training Module: Native Hawaiian and Other Pacific Islander (NHOPI) Older Adults (Stanford) «

*Demographics, patterns of health risk, health assessment, and treatment**of NHOPI older adults.*

Research Brief: Mistreatment of Asian Pacific Islander Elders (NCEA)

*Information on AAPI elder mistreatment and strategies for intervention.*

Southeast Asian Resource Action Center: Resources on Eligibility and Access to Aid (SEARAC)*Information on access to health care, economic relief, and emotional and mental support.*

## Focus Area: Disability Community

Charting the LifeCourse (Institute for Human Development, University of Missouri-Kansas City)

Framework to help drive better health care service support outcomes in areas like primary medical care, mental/behavioral health care, health education, substance abuse, and case management.

Improving Access to Care for People with Disabilities (CMS)

*Resources dedicated to equal access to care and services by improving communication with individuals with disabilities.*

· Improving Communication Access for Individuals who are Blind or have Low Vision

· Improving Communication Access for Individuals who are Deaf or Hard of Hearing

· Increasing the Physical Accessibility of Health Care Facilities: Issue Brief

· Modernizing Health Care to Improve Physical Accessibility: Resources Inventory

· Modernizing Health Care to Improve Physical Accessibility: A Primer for Providers

· Navigating Health Care with a Disability: Our Stories, a Focus on People with Disabilities

*Three-minute video of stories about working with providers and obtaining needed care.*

· Navigating Health Care with a Disability: Our Stories, a Focus on the Provider

*Two-minute video to help dcuates providers ask questions to understand a patient’s needs.*

Health Disparities Chart Book on Disability and Racial and Ethnic Status in the United States (Institute on Disability)

*Summary report from analyses of Behavioral Risk Factor Surveillance System (BRFSS) data highlighting health disparities’ impacts on the disability community.*

Paralysis Resource Guide (Christopher & Dana Reeve Foundation)

*Free guide for everyone living with or impacted by paralysis, portions available in 14 languages.*

Wallet Cards (Christopher & Dana Reeve Foundation)

*Cards for individuals living with autonomic dysreflexia, deep vein thrombosis, or sepsis to educate themselves and others about commonly co-occurring conditions with paralysis.*

Race and Ethnicity Disparities in Limb Loss (Amputee Coalition)

*A fact sheet on racial and ethnic disparities in limb loss.*

Community Connections (Amputee Coalition)

*A searchable database to locate community resources for individuals impacted by limb loss.*

Research Brief: The Extra Costs of Living with a Disability in the U.S. (National Disability Institute) 

*Highlights the extra indirect and direct costs of living with a disability and provides evidence that the largest extra costs experienced are for personal assistance services and health care.*

Research Report: Chronic Conditions Chart Book (CMS)

*Summarizes the chronic health conditions most prevalent among dually eligible individuals.*

## Focus Area: LGBTQ+ Community

Improving Health Care Quality for LGBTQ People (CMS Medicare Learning Network) «

*Training on terminology use and data collection related to beneficiaries who identify as LGBTQ.*

National Resource Center on LGBTQ+ Aging (SAGE)

*Compilation of resources aimed at improving services and supports for LGBTQ+ older adults.*

LGBTQ+ Aging Facts (SAGE)

*Repository of products to increase cultural competency when working with LGBTQ+ older adults.*

Disability and LGBTQA+ Resource Guide (University of Arizona LGBTQ Affairs)

*Compilation of resources and supports for LGBTQA+ individuals with disabilities.*

Long-term Care Considerations for LGBT Adults

*Educational resources for LGBT individuals planning for future care needs.*

Living with Limb Loss in LGBTQ Community (Amputee Coalition)**«

*Webinar recording from three organizations sharing their expertise on available services.*

## General Cultural Competency

Office of Minority Health (HHS)

*Starting point to learn about health disparities and tools around diverse population health.*

#### ********National Center for Cultural Competence (Georgetown University)

*******Materials and courses for self-assessment, building knowledge, skills, and abilities, including the**Curricula Enhancement Module Series**.*«

Cultural Competence Overview and Resources (RIC)

*Educational materials, guides, and topic-specific resources for providers and plans.*

Protocol for Culturally Responsive Organizations (Coalition of Communities of Color)

*Review of organizational aspects of cultural responsiveness.*

Cultural Competence in Mental Health Service Settings (Temple University Collaborative)

*Overview of cultural competence in delivery of community services and supports.*

Not in Our Town: Working Together for Safe and Inclusive Communities (PBS)

*Information and stories on the national pro-tolerance movement.*

Cultural Competence Info Brief (National Center on Law & Elder Rights)

*Introduction to cultural competency and strategies for legal assistance providers.*

COVID-19 Resources on Vulnerable Populations (CMS)

*Resources to assist partners who work with those most vulnerable.*

Certified Peer Visitor Program (Amputee Coalition)**«

*Training resource to become a Certified Peer Visitor that incorporates cultural competency.*

Cultural Competence and Patient Safety (Agency for Healthcare Research and Quality)

*Resources available from the Patient Safety Network on cultural competency.*

Cultural Competence in Health and Human Services (CDC National Prevention Information Network)

*Resources and links to cultural competency, awareness, and sensitivity definitions; case studies; and resources from federal government agencies.*

Cultural Competence: An Important Skill Set for the 21st Century (University of Nebraska)

*Resources to build skills of active listening, empathy, and effective engagement to create a welcoming environment and appreciate similarities and differences among cultures.*

Trauma Informed Care (SAMHSA)

*Key Ingredients for successful trauma-informed care implementation.*

Guidance to the Aging Services Network: Outreach and Service Provision to Holocaust Survivors (ACL)*Provides State Units on Aging, Area Agencies on Aging, and local service providers with information and considerations when performing outreach to and serving Holocaust survivors.*

## Glossaries

· Understanding Racial Terms and Differences (NIH ODI) 

· Sexual & Gender Minority Terms and Definitions (NIH ODI) 

· LGBTQ Media Reference Guide (GLAAD)

· Disability Glossary (Anti-Defamation League)

· Disability Language Style Guide (National Center on Disability and Journalism) 

## Language Access and Health Literacy

The Center for Dignity in Healthcare for People with Disabilities (The University of Cincinnati Center for Excellence in Developmental Disabilities)

*Coalition offering resources to promote health equity for people with intellectual and developmental (ID/DD) disabilities.*

Ten Things You Should Know About Language Access Advocacy for Older Adults (Justice in Aging)**

*Tips and considerations for addressing language barriers.*

Understanding Communication and Language Needs of Medicare Beneficiaries (CMS)

*Supports development of training/outreach plans (pages 23-38: common language by state).*

Health Literacy and Patient Safety: Help Patients Understand (AMA Foundation)

*Video on barriers to communication in a health care setting.*

## Long-Term Services and Supports

Cultural and Linguistic Competence: What it Means for Ombudsman Programs (ACL) «

*Webinar offering definitions and conceptual frameworks for cultural and linguistic competence.*

Tribal Elders and Ombudsman Services (Long-Term Care Ombudsman Resource Center)

*Resources and information to increase effectiveness in serving tribal elders.*

Ombudsman Services to Tribal Elders (Long-Term Care Ombudsman Resource Center)

*Communication tips and information on specific tribal culture and practices.*

#### Culturally Competent Long-Term Services and Supports: Spotlight on Keiro Northwest (RIC)

*Spotlight on culturally specific services for older adults using long-term services and supports.*

## Nondiscrimination Laws

*Recipients of federal financial assistance (FFA) from the U.S. Department of Health and Human Services (HHS) must administer their programs in compliance with federal civil rights laws that prohibit discrimination on the basis of race, color, national origin, disability, age, and, in some circumstances, religion, conscience, and sex. This includes ensuring programs are accessible to persons with limited English proficiency. The following links to the HHS Office of Civil Rights outline requirements in detail.*

· Civil Rights for Providers of Health Care and Human Services

· Civil Rights for Individuals and Advocates

· Conscience Protections

· Religious Freedom

## Understanding Bias 

The Impact of Microaggressions: An Introductory Training (University of Nebraska)

*Free training on microaggressions.*

Implicit Bias User Guide and Bibliography (American Bar Association) 

*Overview of concepts like implicit bias and microaggressions, as well as related links.*

Speak Up: Responding to Everyday Bigotry (Southern Poverty Law Center)

*Ideas for confronting bigotry based on hundreds of stories and experiences from real people.*

Ableism 101 (Access Living)

*“What it is, what it looks like, and what we can do to fix it.”*

# Endnotes

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