DCS Comprehensive Health Plan

Cultural Competency and Language Access Requirements

Statement/Purpose

The Arizona Department of Child Safety Comprehensive Health Plan (DCS CHP) promotes accessible, high quality services in an integrated, family/member centered manner to meet the health literacy needs of members inclusive of those with Limited English Proficiency (LEP) and diverse cultural, ethnic, geographic, social, spiritual and economic backgrounds, medical, developmental, emotional, environmental and financial needs, disabilities/special health care needs, race, color, national origin, age regardless of gender, sexual orientation, gender identity.

Definitions

Culture: The integrated pattern of human behavior that includes language, thought, communication, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group(s). Culture defines the preferred ways for meeting needs and may be influenced by factors such as geographic location, lifestyle, and age.

Cultural Competency: A set of congruent behaviors, attitudes and policies that come together in a system, agency, or among professionals, which enables that system, agency, or those professionals to work effectively in cross-culture situations. Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by members and their communities. This includes consideration of health status, national origin, sex, gender, gender identity, sexual orientation, and age.

Designated Representative (DR): An individual parent, guardian, relative, advocate, supporter, friend, or other individual, designated orally or in writing by a member or guardian who, at the request of the member, assists the member in protecting the member’s rights and voicing the member’s service needs.

Family-Centered: Care that recognizes and respects the pivotal role of the family in the lives of members. It supports families in their natural care-giving roles, promotes normal patterns of living, and ensures family collaboration and choice in the provision of services to the member. When appropriate the member directs the involvement of the family to ensure person-centered care.

Health-Related Social Needs (HRSN): Non-medical factors that impact health outcomes including but are not limited to increasing access to safe and affordable housing, nutritious food, utility assistance, education, employment, transportation, connection to others in the community, as well as physical, environmental, and interpersonal safety. Also known as Social Determinants of Health (SDOH) or Social Risk Factors of Health (SRFOH).

Health Literacy: Degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. These skills support individuals to take control of their own well-being, improve their communication with providers and give them information they need to advocate for themselves or dependents in a health setting.

Health Care Decision Maker (HCDM): An individual who is authorized to make health care treatment decisions for the patient. As applicable to the situation, this may include a parent of an unemancipated minor or an individual lawfully authorized to make health care treatment decisions as specified in ARS Title 14, Chapter 5, Article 2 or 3; or ARS 8-514.05, 36-3221, 36-3231 or 36-3281.

Language Access Assistance: Services as specified in 45 CFR 92.4, including, but not limited to:

• Oral language assistance, including interpretation in non-English languages provided in-person or remotely by a qualified interpreter for an individual with limited English proficiency, and the use of qualified bilingual or multilingual staff to communicate directly with individuals with limited English proficiency,

• Written translation, performed by a qualified translator, of written content in paper or electronic form into languages other than English, and

• Taglines.

Limited English Proficiency (LEP): Individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English may have LEP and eligible to receive language assistance for a particular type or service, benefit or encounter as specified in 42 CFR 457.1207, 42 CFR 438.10.

Linguistic Need: The necessity of providing services in the member’s primary or preferred language, including sign language, and the provision of interpretation and translation services.

Member: An eligible individual who is enrolled in AHCCCS, as specified in ARS 36-2931, 36-2901, 36-2901.01 and ARS 362981. Also referred to as Title XIX/XXI member or Medicaid member. When applicable, member may also or alternatively refer to an enrolled individual's health care decision maker (HCDM) or designated representative (DR). Refer to Health Care Decision Maker and Designated Representative.

Member Information/Vital Materials: Written materials that are critical to obtaining services which include, at a minimum, the following:

• Member Handbooks

• Provider Directories

• Consent Forms

• Appeal and Grievance Notices

• Denial and Termination Notices

Qualified Interpreter: An interpreter who via a Video Remote Interpreting (VRI) service, over the phone, or an on-site appearance: Adheres to generally accepted interpreter ethical principles, including client confidentiality; has demonstrated proficiency in speaking and understanding both spoken English and at least one other spoken language; and is able to interpret effectively, accurately, and impartially, both receptively and expressly, to and from such language(s) and English, using any necessary specialized vocabulary, terminology and phraseology as specified in 45 CFR 92.4.

Qualified Translator: A translator who: adheres to generally accepted translator ethic principles, including client confidentiality; has demonstrated proficiency in writing and understanding both written English and at least one other written non-English language; and is able to translate effectively, accurately, and impartially to and from such language(s) and English, using any necessary specialized vocabulary, terminology and phraseology as specified in 45 CFR 92.4.

Social Determinants of Health (So): The World Health Organization defines SDOH as the conditions of the community in which an individual is born, grows, works, lives, and ages, and the wider set of forces and systems shaping their conditions of daily life, including economic policies and systems, development agendas, social norms, social policies, and political systems. These are also known as Social Risk Factors of Health (SRFOH).

Special Health Care Needs (SHCN): Serious and chronic physical, developmental, or behavioral conditions requiring medically necessary health and related services of a type or amount beyond that required by members generally; that lasts or is expected to last one year or longer and may require ongoing care not generally provided by a Primary Care Provider (PCP).

Policy

DCS CHP and its contracted MCO implements and promotes the delivery of services in a family/member centered, culturally and linguistically competent manner to all members, including those with Limited English Proficiency (LEP) and diverse cultural and ethnic backgrounds, disabilities, race, color, national origin, age, and regardless of sex, gender, sexual orientation, or gender identity as specified in 42 CFR 457.1230(a), 42 CFR 457.1201(d), 42 CFR 438.206(c)(2), 42 CFR 438.3(d)(4), and 45 CFR Part 92.

Procedure

Family-Centered and Culturally Competent Care

DCS CHP and its subcontracted MCO provide family-centered care in all aspects of service delivery for members with Special Health Care Needs (SHCN). Contractual obligations require collaboration with individuals, groups, providers, organizations, and agencies charged with the administration, support, or delivery of services for persons with SHCN.

Support of family-centered care includes, but is not limited to:

• Recognizing the family as the primary source of support for the member’s health care decision-making process. Service systems and personnel are made available to support the family’s role as decision makers.

• Facilitating collaboration among families and health care providers for the:

  • care of the member,

  • development, implementation, evaluation of programs, and

  • policy development.

• Promoting a complete exchange of unbiased information between caregivers and healthcare professionals in a supportive manner at all times.

• Recognizing cultural, racial, ethnic, geographic, social, spiritual, and economic diversity and individuality within and across all families.

• Implementing practices and policies that support the needs of members and families, including medical, developmental, educational, emotional, cultural, environmental, and financial needs.

• Participating in Family Centered Cultural Competency trainings for health plan staff, at new employee orientation and annually thereafter.

• Facilitating family-to-family support and networking.

• Promoting available, accessible, and comprehensive community, home, and hospital support systems to meet diverse, unique needs of the family.

• Acknowledging that families are essential to the members’ health and well-being and are crucial allies for quality within the service delivery system.

• Appreciating and recognizing the unique nature of each member and their family.

Translation and Interpretation Services

DCS CHP and its contracted MCO ensure member access to oral interpretation, translation, sign language, disability-related services, and provide auxiliary aids and alternative formats upon request, and at no cost to the member including translation of documents written in English into the member’s preferred language. Translation and interpretation services are accurate, timely, and protect the privacy and independence of the individual with LEP.

Translation and interpretation services for those with LEP are provided in accordance with Title VI of the Civil Rights Act and Section 504 of the Rehab Act.

Translation and interpretation services are provided by a qualified interpreter/translator. Members are permitted to use an adult who is accompanying the member with LEP interpretation only in the following circumstances:

• in an emergency when there is no qualified interpreter immediately available or

• when the member with LEP requests and the accompanying adult agrees to provide the communication assistance, and reliance on the accompanying adult for assistance is reasonable under the circumstances. Members are not permitted to rely on a minor child for translation and/or interpretation except in an emergency when there is no qualified interpreter or qualified translator immediately available.

Translations and interpretations are provided as follows:

• All written materials for members are translated into Spanish regardless of whether or not the materials are vital. Written materials that are critical to obtaining services (also known as vital materials) are made available in the prevalent non-English language spoken for each LEP population in the service area as specified in 42 CFR 438.10(d)(3). Oral interpretation services, as applicable, do not substitute for written translation of vital materials.

• Oral interpretation services are available at no cost to the member. This applies to sign language, the use of auxiliary aids and all non-English languages, not just those identified as prevalent. Information on which providers speak languages other than English is provided to members as required in compliance with ACOM Policy 404 (for additional information regarding language, readability, and oral interpretation requirements).

• Member information materials are provided in compliance with ACOM 404. [See DCS CHP Policy OP-MS-01 Website and Member Information Requirements].

DCS CHP and its contracted MCO utilize licensed interpreters for the deaf and the hard of hearing and provide auxiliary aids or Arizona licensed interpreters that meet the needs of the member upon request. Auxiliary aids include but are not limited to computer aided transcriptions, written materials, assistive listening devices, or systems, closed and open captioning, and other effective methods of making aurally delivered materials available to persons with hearing loss.

The Arizona Commission for the Deaf and the Hard of Hearing provides a listing of licensed interpreters, information on auxiliary aids, and the complete rules and regulations regarding the profession of interpreters in the State of Arizona.

Cultural Competency Program and Plan

The DCS CHP Cultural Competency Program is inclusive of those with LEP and diverse social, cultural, linguistic and ethnic backgrounds, SHCN, race, color, national origin, age, and regardless of sex, gender, sexual orientation, or gender identity. The program includes measurable and sustainable goals that are outlined in a written Cultural Competency Plan.

The DCS CHP Cultural Competency Plan (CCP) describes how care and services are delivered in a culturally competent manner and includes all the information specified utilizing Attachment A, which is also inclusive of the required components of the Language Access Plan.

DCS CHP and its contracted MCO designates key staff in the role of the Cultural Competency Coordinator responsible for the implementation and oversight of all requirements for the Cultural Competency Program and the Cultural Competency Plan as specified in Contract. Additionally, the provider workforce is required to adhere to all cultural competency requirements as specified in ACOM Policy 405.

The CCP includes the following:

• Description of the method(s) used for evaluating the cultural diversity of DCS CHP membership to assess needs and priorities to provide culturally competent care to its membership.

• Evaluation of its network, outreach services, and other programs to improve accessibility and quality of care for its membership.

• Description of the method(s) used for evaluating fair health care access and addressing health disparities within the DCS CHP’s service delivery.

• Description of the provision and coordination needed for linguistic and disability related services.

• Description of education and training that includes:

  • Methods used to train staff to ensure that services are provided in a culturally competent manner to members of all cultures,

  • Training is customized to fit the needs of health plan staff based on the nature of the contacts with providers and/or members,

  • Cultural competency training for all staff during new employee orientation and annually thereafter, and

  • Methods used for providers and other subcontractors with direct member contact. The education program is designed to make providers and subcontractors aware of the importance of providing services in a culturally competent manner and understanding of health literacy. DCS CHP and its contracted MCO make additional efforts to train or assist providers and subcontractors with how to provide culturally competent services. Provider participation in cultural competency training courses is tracked and reported.

Cultural Competency Plan Assessment

DCS CHP and its contracted MCO perform an annual assessment to evaluate the efficacy of the CCP. Based on the results of its annual assessment, modifications as appropriate are included in the CCP. The CCP Assessment includes but is not limited to:

• Linguistic Need.

• Provision of family-centered care.

• Comparative member satisfaction surveys.

• Outcomes for cultural groups.

• Translation and interpretation services and utilization.

• Member complaints and grievances.

• Provider feedback.

• Contractor employee surveys.

• Communicating progress in implementing and sustaining CCP goals to stakeholders.

Identified issues are tracked and trended, and actions taken to resolve the issue(s).

Language Access Plan

DCS CHP and its contracted MCO prepare a Language Access Plan that outlines how the needs of members with LEP are met. The Language Access Plan addresses the following elements:

• Needs and Capacity: processes to regularly identify and assess the language assistance needs of members, and potential members, as well as the processes to assess the capacity to meet those needs.

• Language Assistance Services: established point of contact for members who need language access services is well established; processes to provide member information in an easily understood language and format when requested by a member. Considerations include members with LEP or limited reading skills, those with diverse cultural and ethnic backgrounds and those with visual or auditory limitations. These processes are used to ensure that the interpreters used are qualified to provide the service and understand interpreter ethics and member confidentiality needs as specified in 45 CFR 92.4 and 45 CFR 92.101.

• Written Translations: processes to identify, translate, and make accessible in various formats vital materials (written materials critical to obtaining services) in the prevalent non-English language spoken for each LEP population in the service area as specified in the 42 CFR 438.10(d)(3) and inaccordance with assessments of need and capacity conducted as specified in assessment. This includes the requirement for provision of all written materials for members to be translated into Spanish whether or not the written materials are considered vital as referenced in ACOM Policy 404 for additional requirements.

• Policies and Procedures: written policies and procedures ensuring members with LEP have meaningful access to programs and activities.

• Notification of the Availability of Language Assistance at No Cost: processes to ensure meaningful access to care, including notifying current and potential members with LEP about the availability of language assistance (e.g., translation/interpretation services and auxiliary aids utilized by members who are deaf and hard of hearing) at no cost. This includes access to oral interpretation, translation, sign language, disability-related services, and provision of auxiliary aids and alternative formats on request. Notification methods may include multilingual taglines in member materials as well as statements on forms including electronic forms such as agency websites. Results specified in the Needs and Capacity Assessment above are used to determine the languages in which the notifications are translated.

• Staff Training: description of staff training to ensure management and staff understand and can implement the policies and procedures of the Language Access Plan (LAP).

• Access and Quality Assessment: processes to regularly assess the accessibility and quality of language assistance activities for members with LEP, maintain an accurate record of language assistance services, and implement or improve LEP outreach programs and activities in accordance with member need.

• Stakeholder Consultation: process for engaging stakeholder communities to identify language assistance needs of members with LEP, implement appropriate language access strategies to ensure members with LEP have meaningful access in accordance with assessments of member need and evaluate progress on an ongoing basis.

• Subcontractor Assurance and Compliance: processes for ensuring subcontractors understand and comply with their obligations under civil rights statutes and regulations enforced by AHCCCS related to language access.

Roles/Responsibilities

All DCS CHP function areas and the contracted MCO are responsible for identifying and addressing gaps/barriers to cultural competency during program development and evaluation. DCS CHP and its contracted MCO collaborate to:

• Evaluate the cultural diversity of membership by assessing needs and priorities in order to provide culturally competent care and reduce disparities;

• Evaluate network, outreach services and other programs to improve accessibility and quality of care;

• Collect Social Determinants of Health data;

• Complete annual assessments to evaluate members, understand their care needs and operate programs designed to help meet those needs. The assessment includes but is not limited to the following:

  • Age distribution

  • Gender

  • Top diagnoses

  • Readmission rates

  • Specific needs of children and adolescents, individuals with disabilities and members identified with serious and persistent mental illness

• Collect data on race and ethnicity during member health risk assessments and identify members at high risk of adverse outcomes or with gaps in care.

• Provide and coordinate for Linguistic and Disability Related Services

• Provide educational training and learning opportunities for employees, contractors, providers’ workforce, and the community.

• Address members’ concerns according to a member’s literacy and culture by monitoring member grievances, satisfaction surveys, provider audits, member demographic reports, and other pertinent information;

• Implement practices to enhance the ability to meet language, culture, health literacy and disability needs of members and providers.

Reporting

The DCS CHP Cultural Competency Plan Assessment with a completed ACOM 405 Attachment A – Cultural Competency Plan Assessment Reporting Checklist as specified in the Contract, Section F, Attachment F3, Contractor Chart of Deliverables is reported to the AHCCCS Division of Health Care Management within 45 days of each contract year.