Mercy Maricopa Integrated Care Cultural Competence Plan FY

Transcription

1 Mercy Maricopa Integrated Care Cultural Competence Plan FY GSA 6 CC Lead/Administrator: Teresa Peña Page 1

2 Introduction Mercy Maricopa Integrated Care believes that as our community continues to grow and becomes more ethnically diverse, the care that we provide is constantly evolving and becoming more complex. In our system of care, providers are encouraged to become more culturally competent, as well as to recognize the importance of health literacy. This means to be able to understand different cultures, especially those of our members, and how they view and access services. That means that the care our providers deliver should be in accordance with recipient s race, color, creed, gender, religion, age, national origin, preferred language and respecting their cultural beliefs, sexual preference, as well as traditional healing practices. In the same way, paying special attention to cultural issues for integrated care models is a high priority and one Mercy Maricopa takes very seriously. Addressing member s concerns according to their literacy and culture, as well as providing language access services and culturally competent care are the priorities of Mercy Maricopa s Cultural Competence department. To achieve this, Mercy Maricopa has developed a Cultural competence Plan that addresses the diverse needs of our system, fosters internal and external collaboration, and ensures provision of high quality language services at no cost to the member. Additionally, Mercy Maricopa ensures member materials are available in the preferred language of the individual and are easily understood. Explain your goals and objectives related to the following: Education and Training: Collaborate in the development and monitoring of trainings for CC, CLAS and LEP to ensure and increase CC awareness, including underrepresented and underserved populations. Collaborate with Training Department to create and implement mandatory, refresher, and elective trainings for RBHA and Provider staff. To increase the number of individuals trained on diverse populations. To increase awareness of needs and gaps related to diverse populations in our system Culturally Competent Services/Care: Mercy Maricopa believes the provision of high quality services requires fostering an environment of collaboration and respect for differences, preferences, language needs and cultural backgrounds within our communities. Therefore, the mission of Mercy Maricopa s Cultural Competence Department is to support the provider network in achieving cultural competence throughout all levels of their operations as evidenced by culturally and linguistically responsive programs that demonstrate positive health outcomes. Language Access Services (Interpretation and Translation Services): In collaboration with our finances and procurement departments, a robust array of language services providers will be engaged via a language services liaison to ensure the linguistic need of our service area are met. Procurement department will be tasked with developing a contracting system in which capacity and qualifications of potential language vendors are addressed and verified. Currently, the language vendors previously utilized are being considered as the primary candidates in order to ensure continuity of care and respecting member preference. Additionally, rigorous training pertinent to the RBHA system and reporting mechanisms are being put in place as part of the contracting process. Family-Centered Care: In collaboration with the Children s system of care, Mercy Maricopa is ensuring that culturally and linguistically appropriate services are delivered to families that come in touch with our system of care. Cultural Competence Department and OIFA, as well as the Children s System of Care have partnered and continue to partner in the planning an execution of Spanish only family forums, as well as ensuring full family participation in their preferred language and respecting their cultural needs and beliefs. Describe your method(s) for assessing and evaluating throughout the GSA: Cultural diversity among service providers Mercy Maricopa maintains quality improvement at the core of its operations. Input is received via diverse stakeholder sources, including the member satisfaction survey and provider monitoring results. Additionally, demographic data is a key component in the decision making of strategy creation and implementation. To this effect, data such as penetration rates, language utilization information and Data Demographic are utilized and analyzed on a regular CC Lead/Administrator: Teresa Peña Page 2

3 basis. CLAS standards monitoring data is obtained and analyzed on a monthly basis and support and technical assistance are provided as necessary to contracted providers in need. Additional resources for evaluating performance are but not limited to: Language Services report CLAS standards monitoring Performance Improvement Plans Systems of Care monitoring Performance thresholds Data Demographics information Potential service needs among diverse populations Information on these areas will be monitored for needs and gaps in the system and utilized to enhance policies and procedures to ensure compliance with Federal, State and local mandates for cultural competence. Outline your process to identify: Service gaps and/or needs In partnership with the Quality Management department, Mercy Maricopa Cultural competence will monitor compliance via monthly audits of contracted providers. These audit result shall inform the analysis of needs and gaps within the system and addressed according to the type of need. Actions to be taken to correct identified deficiencies Technical assistance is offered to providers on a regular basis and via an open door policy. That is, providers can call at any time, either in preparation for audit visits or to address audit findings. Furthermore, the advisory committees are another venue to discuss system needs and address them by making recommendations and assist in the creation and review of corrective action plans to contracted providers and also for the RBHA to self-regulate and create and implement corrective measures. Describe your processes to adhere to the Federally-mandated CLAS Standards throughout the GSA: Implementing During FY , Mercy Maricopa will roll out implementation of all 15 CLAS standards. The process to achieve this is to closely work with the quality management team and providers. The goal is to provide technical assistance and education to contracted providers on the revised standards and assist them in identifying implementation strategies, mainly based on the OCA results. Monitoring Ensure system s adherence to federally mandated CLAS standards. To this effect, Mercy Maricopa Cultural competence will collaborate with Mercy Maricopa QM department to ensure needs and gaps are addressed with providers who score low in CLAS standards compliance. This will happen by analyzing data obtained during record review, utilizing a review tool created by both departments Mercy Maricopa also ensures system adherence to federally mandated CLAS standards. To this effect, Mercy Maricopa Cultural Competence will collaborate with Quality Management to address needs and gaps detected in the system. Technical assistance will be provided to contracted providers who score below the threshold for CLAS standards compliance. This will happen by analyzing data obtained during record review. Tracking The cultural competence plan is constantly monitored, and analyzed on a regular basis. All the sections in the plan are monitored and updated as needed during these reporting periods. This constant monitoring allows for open communication and feedback channels with collaborating departments and earlier detection and resolution of arising issues within the system. CC Lead/Administrator: Teresa Peña Page 3

4 Community stakeholder input, including providers and service recipients, and the Cultural Competence CLAS Advisory Committee are additional channels to obtain system evaluation and feedback and allow for adjustment and modifications to enhance service delivery. Member satisfaction survey regarding the respect for language and cultural needs is another way to evaluate and monitor system effectiveness. CC Lead/Administrator: Teresa Peña Page 4

5 CC Program Goal 1: Ensure the delivery of services in a culturally and linguistically competent manner throughout the system in Maricopa County Initiative: To engage providers continued and active participation in delivery of services in a culturally and linguistically appropriate manner for all members 1. Strategy 1.1: Ensure that workforce is trained throughout the system, both existing staff and new hires High Level Tasks Measurements Outcomes Progress Update Provide ongoing training on Cultural Competency 101: embracing diversity; and brown bag seminars targeting diverse populations and system wide topics of interest Participate in initiatives to deliver training for advance knowledge in LEP, CLAS standards, Deaf and Hard of Hearing and DUG elements 109 and 110, disabilities Participate in Statewide efforts to review CC Curriculum as needed and support implementation efforts Participate and support at least four local and statewide efforts for conference planning on issues related to Cultural competence, diversity and family inclusion - Number of trainings offered - Number of individuals trained in the system, new hires and current staff - Number of learning opportunities available to staff in GSA 6 - Number of individuals participating - Revised curriculum when applicable - Number of participants per event - Analysis of satisfaction survey results At least 80% of new hires trained within 90 days of employment and 100% of individuals employed in the system trained by end of FY Score of 80% or more on knowledge level by individuals taking trainings 100% of workforce in GSA 6 are trained in CC Attendance at conferences is at capacity and conference surveys results are incorporated for following year s planning Status: Competed /Not Completed Target Date CC Lead/Administrator: Teresa Peña Page 5

6 Initiative: Support and promote Cultural competence initiatives throughout the system Strategy 1.2: Assist in RBHA wide efforts to reduce health disparities High Level Tasks Measurements Outcomes Progress Update Assist in the creation and revision of member materials and social marketing efforts to educate members about integrated health and how to access services and assist in dissemination of member materials Ensure all member materials created is translated into Spanish and other identified/requested languages utilized in GSA 6 Collaborate with Tribal Relations to ensure appropriate service delivery to Tribal Communities - Number of member materials created - Number of member materials disseminated - Number of translated materials 100% of RBHA materials are translated into threshold languages 100% of RBHA materials are translated into threshold languages and others as requested - N/A Tribal Relations Liaison Will participate in 80% of all CLAS/Cultural Competence Advisory Committee meetings to highlight needs and gaps to be addressed Initiative: Monitor Language Services and CLAS standards adherence Strategy 1.3: Monitor language thresholds in GSA 6 High Level Tasks Measurements Outcomes Progress Update Generate and analyze quarterly report on languages spoken within - Number of members who speak another To establish baseline for number of identified members who speak another language and ensure they Status: Competed /Not Completed Status: Competed /Not Completed Target Date Target Date CC Lead/Administrator: Teresa Peña Page 6

7 GSA 6 membership language receive appropriate and timely language services Generate and analyze - Number of languages 100% of contracted providers quarterly report on Provider utilized in the system effectively utilize language utilization of language services when needed services on GSA 6 Strategy 1.4: Collaborate with QM department in tool creation, implementation and evaluation for CLAS standards monitoring of contracted providers in GSA 6 In conjunction with QM department, create and implement a tool to monitor provider compliance with CLAS standards (New and revised 15 standards) - CLAS standards review tool To ensure 100% of contracted providers deliver culturally and linguistically appropriate services Hold regular meeting with QM to determine needs and updates of the review tool Ensure all 15 CLAS standards are included in review tool Review results of CLAS standards monitoring and collaborate with the implementation of Performance Improvement Plans Provide Technical Assistance on CLAS standards to contracted providers who score below the threshold as needed or as requested - Number of providers measured with CLAS standards review tool - Number of providers Performance Improvement Plans reviewed - Number of TA sessions provided - Number of providers scoring below threshold 100% of Performance Improvement Plans containing CLAS standards section are reviewed by CC and providers score at least the 85% threshold 100% of providers who request TA receive it in a timely fashion CC Lead/Administrator: Teresa Peña Page 7

8 Monitor Service plans using the QM SMART Audit Tool to ensure inclusion of cultural considerations and linguistic needs - SMART tool results At least 85% of ISPs reflect inclusion of cultural considerations and linguistic needs Strategy 1.5: Identify languages spoken by membership and diverse groups represented and ensure needs are met High Level Tasks Measurements Outcomes Progress Update Monitor Complaints related to Cultural Competence/Diverse populations Collaborate with Finances department to develop and implement Language Access Plan Interpretation and Translation Services Ensure translation of vital materials and written communications into languages spoken by 5% or 1,000 members (whichever is less) of members enrolled who are LEP. Vital materials include, but not limited to: - Notices of Denial - Reduction, - Number of complaints issued - Number of complaints resolved - Language Vendor s contract - Number of materials translated - Policy on translation of vital materials Establish baseline on number of complaints to create strategies geared towards decreasing member complaints in GSA 6 related to language services and cultural needs not met at least by 20% Interpretation and translation mechanisms will be disseminated to 100% of contracted providers. 100% of vital materials and written communications will be translated into languages meeting threshold Status: Competed /Not Completed Target Date CC Lead/Administrator: Teresa Peña Page 8

9 Suspension or termination of services - Service Plans - Consent forms - Communications requiring response from healthcare recipient - Grievance notices Ensure translation of materials when a language is spoken by 3,000 or 10% (whichever is less) of members enrolled who are LEP Ensure RBHA and providers have written notices in members preferred language informing them of their right to receive interpretation services at no cost to the member, including languages spoken by 5% or 1,000 members (whichever is less) Ensure RBHA website contains updated version of PM and member handbook in org/providers/training/cultur e - Policy on translation of vital materials - Member notification of their right to receive language services at no cost - Updated and revised website and member handbook Policy for translation of vital materials will be implemented after approval Member handbook and provider manual will be updated, as necessary Initiative: Utilize assessments to identify cultural competency trends and compliance with national standards Strategy 1.6: Implement CC Organizational Self-Assessment once it is released from DBHS and ongoing CC Lead/Administrator: Teresa Peña Page 9

10 High Level Tasks Measurements Outcomes Progress Update Establish strategies to roll out OCA to provider community once received from ADHS/DBHS and implement those strategies - Identify and deploy at least two strategies for implementation - Number/percentage of surveys completed At least 80% of contracted providers to participate in survey Strategy 1.7: Implement Consumer Satisfaction Survey to identify needs and gaps in the system Assist and collaborate with implementation of the Consumer Satisfaction Surveys to assess for linguistic and cultural needs and gaps - Number of surveys completed - Number of surveys that reflect cultural and linguistic needs met At least 80% of respondents will indicate satisfaction with cultural and linguistic needs being met Initiative: Creation, Implementation and Monitoring of a Cultural Competence Plan Strategy: 1.8: Create and implement a Cultural Competence Plan and evaluation strategies Develop and implement a Cultural Competence Plan and its components based on the needs of the service area and considering RBHA implementation needs Develop the Annual Review of Effectiveness of the Cultural Competence Plan focusing on establishing baseline metrics and comparison with available data from previous year - Cultural Competence Plan - Annual Review of Effectiveness Cultural Competence plan will reflect contract deliverables Analysis of ARE will generate at least two new strategies for the upcoming year Status: Competed /Not Completed CC Lead/Administrator: Teresa Peña Page 10 Target Compare results from - Annual Review of To utilize end of year data to drive

11 previous year to determine goals for the upcoming FY and identify gaps and needs in the system and include any modifications made to the CC Plan Effectiveness at least two new strategies for the upcoming year Goal 2: To assist in RBHA efforts to successfully integrate physical and behavioral health Initiative: Collaborate with Health Integration, Community Relations, and OIFA Departments to promote education and awareness of health integration Strategy 2.1: Collaborate with efforts to establish culturally and linguistically appropriate health integration services for diverse populations High Level Tasks Measurements Outcomes Progress Update Assist in the creation and revision of member materials and social marketing efforts to educate members about integrated health and how to access services Assist in the identification of strategies to outreach members of diverse backgrounds and LEP to inform them about health integration and their rights to receive services in their preferred language - Number of member materials created - Number of member materials disseminated - Number of materials created and disseminated in languages other than English - Number of strategies implemented - Number of individuals outreached To increase member awareness and knowledge regarding integrated services by disseminating materials to 100% of the Direct Care Clinics To increase member awareness and knowledge regarding integrated services, particularly for diverse populations by 20% after determining baseline Status: Competed /Not Completed Target Date CC Lead/Administrator: Teresa Peña Page 11

12 Actively participate in the Member Advisory Committee (OIFA Committee) to ensure peer s voices are included in the creation of member related health literacy materials that are informative, easy to read and visually appealing - Number of materials discussed To increase member participation to bringing peers voices to the development and implementation of member materials with at least one member material per quarter Strategy 2.2: Collaborate with efforts to develop Promotora (Cultural Navigators) model to be used in GSA 6 Collaborate with Community Relations and System of Care in the development of a Promotores (Cultural Navigators) program Assist RBHA efforts to identify and train partners in the Promotores (Cultural Navigators) program - Promotores Program To develop a Promotores program utilizing promising practices or best practices models N/A To offer subject matter expertise on populations with highest representation in our system: Hispanic/Latino, African American, Asian, Native American, and Refugee populations, for program development Strategy 2.3: Collaborate with efforts to engage Culturally Competent strategies from MIHS to enhance RBHA service delivery Collaborate in efforts from SOC and Community Relations to increase capacity for service delivery that is culturally and linguistically competent in health integration by exploring mechanisms with MIHS, specifically with the N/A To develop a plan to utilize MIHS Refugee Women s Clinic s expertise to enhance service delivery to diverse populations in GSA 6 CC Lead/Administrator: Teresa Peña Page 12

13 Refugee Women s Clinic for service delivery Ongoing Activities: You have the option to provide the ongoing activities in narrative format or use the template above. CC Lead/Administrator: Teresa Peña Page 13