Written by Vetta Sanders Thompson, the E. Desmond Lee Professor of Racial and Ethnic Diversity and Associate Dean for Diversity, Inclusion & Equity at the Brown School; and co-director the Center for Community Health Partnership and Research at the Institute for Public Health
In 1997, the Office of Minority Health (OMH) undertook the development of national standards to provide organizations and providers with guidance on the implementation of culturally and linguistically appropriate services. Three years later, the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS) were entered into the Federal Register [1].
The CLAS standards were organized by themes: culturally-competent care, language access services, and organizational supports for cultural competence. There were three types of standards.
- Mandates- All recipients of federal funds were required to following these; they were comprised of four language access services standards. Given their status as mandated, communication and language issues became the most prominent elements of this effort. While a great deal of attention focused on addressing the needs of non-English speaking patients and consumers, these standards also covered sensory-related communication needs, including those of individuals who are deaf, hard of hearing and blind, as well as those with health-literacy challenges [2].
- Guidelines- These consisted of nine cultural-competence service provision and training standards that OMH recommended federal, state, and national accrediting bodies adopt.
- Recommendations- The final type of standard was voluntary and was a recommendation for public reporting on the progress of CLAS implementation.
After a decade of use, the CLAS standards have now been updated and revised [3]. The new standards are about more than language and communication!
The Enhanced CLAS standards are now broader and are intended to apply to every point of contact in health-promoting systems, explicitly including mental, social, and spiritual health, in addition to physical health. The enhanced standards encompass services to individuals and group consumers of healthcare services [1] and the earlier references to mandates, guidelines, and recommendations have been removed.
The Enhanced CLAS standards are designed to be consistent with and support other national health policies, including the Affordable Care Act, beginning with a Principal Standard that calls for “effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural-health beliefs and practices, preferred languages, health literacy, and other communication needs” [3]. To achieve this principle standard, the remaining 14 standards must be implemented, evaluated, and met. These standards are organized into three themes:
- governance, leadership, and workforce, providing guidance on developing leadership capacity for promoting and sustaining CLAS;
- communication and language assistance, with a focus similar to the 2000 version of CLAS; and
- engagement, continuous improvement, and accountability [3].
The third theme acknowledges the role of social determinants of health in the production of health disparities [4] and the intersection among health disparity categories and social determinants. Engagement, continuous improvement, and accountability standards 12-14 provide guidelines for community engagement and include recommendations on conducting community assessments [3]. Standard 12 is focused on determining the needs of the populations in service areas, identifying community assets and the services available and not available to populations, determining what services to provide and how to implement them based on the results of the community assessment, and ensuring that organizations obtain demographic, cultural, linguistic, and epidemiological data regularly to better understand the populations in their service areas. Standard 13 calls on those concerned with public health to partner with the community to establish appropriate and effective programs and services, and finally, Standard 14 sets standards for resolving conflicts and grievances that may arise as organizations and communities interact around improved public health [3].
To assist in effective implementation of the Enhanced CLAS standards, OMH has produced National Standards for CLAS in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice Standard [5]. This resource makes it clear that implementation efforts are a continuous process of implementation, evaluation, refinement, and improved service delivery and intervention [5]. Communities needs and community engagement efforts will vary. Engagement activities may include building coalitions with community partners to increase reach and impact in identifying and creating solutions, participation on joint steering committees and coalitions, offering education and training opportunities, convening town-hall meetings, community forums, and community-based participatory strategies when evaluating needs, and developing services, research and other activities to empower the community [5].
The focus of the Enhanced CLAS on community engagement and acknowledgement of the role of social determinants in creating inequity in health pushes organizations to examine hiring and contracting practices and ways that these can be made more equitable. The standards also explore ways to hire community members to participate in the health promotion and healthcare delivery system [5]. Training and hiring community-health workers, advisors and/or promotores are examples of these efforts.
For more information and ideas on the implementation of all components of CLAS, visit the HHS website.
References cited
1. Office of Minority Health. “National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: National CLAS Standards Fact Sheet,” Office of Minority Health, U.S. Department of Health and Human Services accessed May 22, 2016, https://www.thinkculturalhealth.hhs.gov/pdfs/NationalCLASStandardsFactSheet.pdf.
2. Paasche-Orlow, Michael K., and Michael S. Wolf. “The causal pathways linking health literacy to health outcomes.” American Journal of Health Behavior 31, no. Supplement 1 (2007): S19-S26.
3. US Department of Health and Human Services. National standards for culturally and linguistically appropriate services in health and health care: A blueprint for enhancing and sustaining CLAS policy and practice. (Washington, D. C.: Office of Minority Health, 2013).
4. Marmot, Michael, Sharon Friel, Ruth Bell, Tanja AJ Houweling, Sebastian Taylor, and Commission on Social Determinants of Health. “Closing the gap in a generation: health equity through action on the social determinants of health.” The Lancet 372, no. 9650 (2008): 1661-1669.
5. Office of Minority Health. “National standards for culturally and linguistically appropriate services (CLAS) in health and health care: A blueprint for advancing and sustaining CLAS policy and practice,” Office of Minority Health, U.S. Department of Health and Human Services accessed May 22, 2016 at https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf