NEW MEGA REGS POLICY & PROCEDURE (P&P) APPROVAL REQUEST FORM I. P&P INFORMATION Assigned Policy Name: Assigned Policy Number: Cultural Competency and Non-Discrimination 7500 Mega Regs Policy Area(s): Mark All That Apply Plan Administration and Organization Provider Network Scope of Services Documentation Requirements Financial Reporting Requirements Coordination and Continuity of Care Management Information Systems Beneficiary Rights Quality Improvement System Beneficiary Problem Resolution Utilization Management Program Program Integrity X Access and Availability of Services Reporting Requirements Submitted by: Victor Ibabao Date: 3/29/2018 Policy developed by: MariaEva Pangilinan Attach P&P Document For Review In this Section II. APPROVAL Section A: HHS Compliance and County Counsel HHS Compliance: Date: 4/2/2018 County Counsel: Review and Approval by BHSD Directors Section B: BHSD Executive Director BHSD Executive Director: Date: Date: 4/3/2018 4/5/2018 Note - A copy of the Approved Mega Regs P&P Form will be emailed to: BHSD Compliance Unit
Approved/Issue Date: Last Review/Revision Date: Behavioral Health Services Director: Next Review Date: Inactive Date: REFERENCES: 42 C.F.R. 438.206(c)(2) Availability of services: Access and cultural consideration. 42 C.F.R. 440.262 Access and cultural consideration. 42 CFR 438.3(d)(1) Accept beneficiaries in the order they apply 42 CFR 438.3(d)(3) Non-Discrimination on the basis of health needs/status 42 CFR 438.3(d)(4) Non-Discrimination on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability County Behavioral Health Directors Association of California: Framework for Advancing Cultural, Linguistic, Racial & Ethnic Behavioral Equity (Updated 2016). National Culturally and Linguistically Appropriate Services (CLAS) Standards. (2000; 2013). State of California Cultural Competency Plan Requirements (CCPR). (1997; 2000; 2010). Betancourt, J., Green, A., Carillo, J. & Ananeh-Firempong, O. (2003). Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care. Public Health Reports, 118, 293-302. Page 1 of 9
POLICY: Cultural Competence BHSD shall participate in the state's efforts to promote the delivery of services in a culturally competent manner to all beneficiaries, including those with limited English proficiency and diverse cultural and ethnic backgrounds, disabilities, and regardless of gender, sexual orientation or gender identity. BHSD shall accept beneficiary applicants in the order they applied and shall not discriminate regardless of health status or need for health care services, race, color, national origin, sex, gender, sexual orientation, gender identity, or disability, and ensure high quality services that are equitable to underserved, accessible and responsive to socially disadvantaged and ethnically diverse groups, which include culturally and linguistically appropriate services. BHSD shall uphold the national CLAS standards. Nondiscrimination 1. BHSD will not engage in any unlawful discriminatory practices in the admission of beneficiaries, assignments of accommodations, treatment, evaluation, employment of personnel, or in any other respect on the basis of race, color, gender, gender identity, religion, marital status, national origin, age, sexual orientation, or mental or physical handicap or disability. BHSD will not discriminate against providers that serve high-risk populations or specialize in conditions that require costly treatment. 2. BHSD will comply with the provisions of Section 504 of the Rehabilitation Act of 1973, as amended, pertaining to the prohibition of discrimination against qualified handicapped persons in all federally assisted programs or activities, as detailed in regulations signed by the Secretary of Health and Human Services, effective June 2, 1977, and found in the Federal Register, Volume 42, No. 86, dated May 4, 1977. 3. BHSD will include the nondiscrimination and compliance provisions of this contract in all subcontracts to perform work under this contract.. Page 2 of 9
DEFINITIONS: Beneficiary. A Medi-Cal recipient who is currently receiving services from BHSD or a BHSD contracted provider. Provider. A person or entity who is licensed, certified, or otherwise recognized or authorized under state law governing the healing arts to provide specialty mental health services and who meets the standards for participation in the Medi-Cal program as described in California Code of Regulations, title 9, Division 1, Chapters 10 or 11 and in Division 3, Subdivision 1 of Title 22, beginning with Section 50000. Provider includes but is not limited to licensed mental health professionals, clinics, hospital outpatient departments, certified day treatment facilities, certified residential treatment facilities, skilled nursing facilities, psychiatric health facilities, general acute care hospitals, and acute psychiatric hospitals. The MHP is a provider when direct services are provided to beneficiaries by employees of the Mental Health Plan. PROCEDURE Responsible Party BHSD Action Required 1. BHSD will comply with the provisions of BHSD s Cultural Competence Plan, and will annually update and submit any changes to DHCS for review and approval. 2. BHSD will establish a functional/organizational structure and staffing to appropriately meet its service population s cultural and linguistic needs and health equity. BHSD supports and sustains an independent Cultural Competence Advisory Committee to oversee cultural competence activities. BHSD ensures allocation of sufficient funds to support cultural competence and health equity. BHSD provides staff support to the Cultural Competence Advisory Committee. Page 3 of 9
BHSD updates and refines its Cultural Competence Plan to assist the population it is meant to serve and in accordance to the State of California Cultural Competency Plan Requirements, national standards for CLAS and the County Behavioral Health Directors Association of California Framework for Advancing Cultural, Linguistic, Racial and Ethnic Behavioral Equity and the strictest standards set by the County. BHSD creates, revises, and enforces cultural competency relevant policies and procedures. BHSD enforces existing policies and procedures, which are: P&P BHSD # 7300 Non- Discrimination P&P BHSD # 11400 Beneficiary Rights P&P BHSD # 11300 Providing Language Services P&P BHSD # 12000 Beneficiary Problem Resolution P&P BHSD # 350 Bilingual Certification 3. BHSD will sustain transparent fiscal accountability, clinical and support services contracts management, human resources recruitment and management, and preserve access, delivery and high quality of culturally and linguistically appropriate services to the population it serves. Page 4 of 9
BHSD protects development of county and contracted services to meet its population s cultural and linguistic service needs and health equity. BHSD engages in continuous quality improvement to include data collection, needs assessments, research, monitoring and evaluation, and reporting of activities to address services access (outreach and engagement), quality, outcomes (wellness, wellbeing and recovery) and health equity. 4. BHSD ensures mandated trainings in cultural competency. BHSD makes sure that all staff of county and contracted agencies and Behavioral Health Board appointees of the County Board of Supervisors (BOS) attend the training in "Foundations in Cultural Competency" within the first six months of official service appointment. BHSD makes sure that all staff take the brief Cultural Competency refresher course (web-based) once every year. BHSD makes sure that all staff of county and contracted agencies receive annual training on Client Culture that includes a client s personal experiences inclusive of racial, ethnic, cultural, and linguistic communities. Topics may include: culturespecific expressions of distress, explanatory models and treatment pathways, relationship between client and mental health provider from a cultural perspective, trauma, economic impact, housing, diagnosis/labeling, medication, hospitalization, societal/familial/personal, discrimination/stigma, Page 5 of 9
effects of cultural and linguistically incompetent services, involuntary treatment, wellness, recovery, and; culture of being a mental health client, including the experience of having a mental illness and of the mental health system. BHSD makes sure that all direct/clinical service staff of county and its contracted agencies attend advanced level trainings in cultural competency within the first year of employment with BHSD or its contracted agencies (Examples of Training Areas: Cultural Sensitivity in Assessment, Diagnosis, and Engagement; Population Specific Sensitivity Training; Interpretation and Translation; and, Culture and Evidence-Based Practice Models). BHSD ensures continuous learning through provision to or attendance of staff in training meetings, workshops and conferences that are relevant to advancing the field of cultural competency and health equity. BHSD allocates funds (e.g., stipends and scholarships) for students in clinical and health related graduate and undergraduate programs in working towards health equity and protect cultural competence skills and knowledge capital. BHSD oversees training and use of appropriate system-wide assessment and diagnostic, outcomes, and service satisfaction tools to ensure cultural competence. BHSD Director Maintains collaboration with the Cultural Competence Advisory Committee. Page 6 of 9
Ensures there is a staff liaison for the BHSD and Cultural Competence Advisory Committee. Designs and leads an efficient and effective organization staffed for stable and long-term relevance and development. Ensures annual budget plans and expenditures reports are available for review and comments by the Cultural Competence Advisory Committee. Ensures annual cultural competence plans and progress reports are available for review and comments by Cultural Competence Advisory and Quality Improvement Committees. Ensures and approves sufficient funding for cultural competence and health equity. Reviews and approves clinical and support services and staffing plans submitted by BHSD Executive Directors and Division Directors. Reports to County Valley Medical Center Executive Director and Deputy Executive Director. Cultural Competence Advisory Committee Provides oversight function. Establishes and updates by-laws for Cultural Competence Advisory Committee (Include: membership qualifications, roles and responsibilities and terms of appointment). Reports to the County Board of Supervisors. Advises Behavioral Health Services Department Director. Page 7 of 9
Reviews and comments on cultural competence plans and progress reports. Ethnic Services Manager Executive Management and Division Directors Serves as liaison for the BHSD and the Cultural Competence Advisory Committee. Reports to the BHSD Director Submits respective services and staffing plans for review and comments by the Cultural Competence Advisory Committee and BHSD Director. Implements approved clinical and support services plans. Oversees respective county and contracted services for cultural competence and health equity. Quality Improvement: Decision Support and Research Administration: Compliance and Contracts Management; Quality Assurance and Management Collects data, performs needs assessments, research and evaluation. Ensures availability of data reports to inform the Behavioral Health Services Director, Cultural Competence Advisory and Quality Improvement Committees, and Clinical Services and Support Services Directors, and the general public. Enforces all U.S., State of California, Santa Clara County and BHSD cultural competency relevant rules, regulations, policies and procedures that have been enacted. Report to BHSD Director. Monitors respective county and contracted services performance agreement. Page 8 of 9
Services Contract Monitors Quality Improvement: Training Team Reports to respective Directors. Develops, provides and monitors system-wide cultural competency trainings. Ensures reports are available to BHSD Director and Cultural Competence Advisory Committee for comments and review. Develops training plans and agreements with contracted agencies to improve training attendance. Administration and Quality Improvement Creates/develops, reviews, and updates policies and procedures to support cultural competence and health equity. Reviews performance metrics for cultural competency and health equity. Facilitates review and recommendation of assessment and outcomes tools and evidence-based culturally competent practice models. Facilitates use of assessment tools and outcomes data collection. Reports to BHSD Director. Attachments: https://www.thinkculturalhealth.hhs.gov/assets/pdfs/classinfographic-what-why-how.pdf https://www.thinkculturalhealth.hhs.gov/assets/pdfs/enhanc ednationalclasstandards.pdf Page 9 of 9