CHAPTER 2: METHODOLOGY FOR DEVELOPING ACLAS SELF-ASSESSMENT TOOLThis chapter describes the methodology which guided the redesign <strong>of</strong> the CLAS inMCOs study instruments to be appropriate for implementation in LPHAs. A review <strong>of</strong> theliterature, lessons learned from the CLAS in MCOs study, and recommendations <strong>of</strong> theproject’s two advisory groups are described.2.1 LITERATURE REVIEWThe CLAS in LPHAs project adopted the conceptualization <strong>of</strong> CLAS, along with theessential components identified in the CLAS in MCOs study (OMH 2003b). Thefollowing sections briefly revisit the literature which was reviewed to identify how CLASwas defined in the health care field to date and revisit the available definitions anddescriptive components <strong>of</strong> CLAS. The literature review provided a knowledge base fromwhich modifications to the MCO instruments were made to be more appropriate forLPHAs.2.1.1 Defining LPHAsIn 1977, C. Arden Miller and colleagues described an LPHA as “an administrativeand service unit <strong>of</strong> local or state government, concerned with health, employing at leastone full-time person, and carrying some responsibility for health <strong>of</strong> a jurisdiction smallerthan a state.” NACCHO later refined Miller’s definition by excluding the “one full-timeperson,” as this is not necessarily the case in all LPHAs (1990). LPHAs vary injurisdiction size, organization, composition, and services <strong>of</strong>fered, yet all are publiclyfunded and concerned with community health. Populations served can range from under25,000 to over a million people. Most LPHAs are county-based, while the remainingserve town, city, regional, or city-county jurisdictions (NACCHO 2001; Public HealthPractice Program <strong>Office</strong> 1991). While specific services vary by agency, services mostcommonly include immunizations, communicable disease testing and control, health andcommunity education, environmental health services, and food safety and restaurantinspection. Public health encompasses many disciplines and services, however the overallfocus <strong>of</strong> all public health is the welfare <strong>of</strong> populations or communities (Association <strong>of</strong>Schools <strong>of</strong> Public Health 1990, IOM 1988). For example, the Seattle health departmentprovides primary care, while Cleveland’s health department focuses more on populationbasedservices (McHugh et al. 2001).LPHAs serve as a safety net for the underserved, i.e., the uninsured, low-income,persons with LEP, immigrants, and racial and ethnic minorities (Felt-Lisk et al. 2001;COSMOS Corporation, December 2003 2-1
Public Health Practice Program <strong>Office</strong> 1991). This population faces significant barriers toaccessing quality health care, because studies have shown racial and ethnic minorities andpeople who are LEP are more likely to lack health insurance than English speakers (TheHenry J. Kaiser Family Foundation 2003; Smedley et al. 2002). Consequently, studieshave documented how the uninsured have greater difficulty accessing health care thanthose who have insurance (Felt-Lisk et al. 2001).2.1.2 Provision <strong>of</strong> CLAS in LPHAsTitle VI <strong>of</strong> the Civil Rights Act <strong>of</strong> 1964 prohibited discrimination based on race,color, and national origin in programs that receive federal funding, and Executive Order13166 <strong>of</strong> 2000 went further, to require that federally funded programs be made accessibleto those who are not pr<strong>of</strong>icient in English. This order includes LPHAs which receivefunding from the federal government. Based on these requirements and other research,OMH issued a set <strong>of</strong> recommended national CLAS standards developed under anotherproject (Federal Register 2000), which may guide LPHAs in developing their ownstandards.LPHAs are aware <strong>of</strong> the increasing need for CLAS provision and strive to ensure thattheir clients’ needs are met. Some LPHAs have formed committees to investigate theircommunities’ needs (Interpreter Standards Advisory Committee 1998). For instance, theWashington State Department <strong>of</strong> Health has produced a report describing a formalizedtraining process for cultural awareness, changes in federal and state systems, and currentefforts to promote CLAS (Washington State Department <strong>of</strong> Health 1995). The ArizonaDepartment <strong>of</strong> Health Services has developed a needs assessment tool to ascertain theknowledge and attitudes <strong>of</strong> health management and staff regarding different cultures(Arizona Center for <strong>Minority</strong> Health Service 1996). Such assessments will help identifyhow CLAS (and overall quality <strong>of</strong> care) can be improved.While there is increasing literature that discusses health disparities <strong>of</strong> the underservedand the need for greater CLAS provision in health care settings, little was found whichdiscussed CLAS in LPHAs. This suggests that this topic should be further researched,especially in terms <strong>of</strong> quality and effectiveness <strong>of</strong> services.2.1.3 The Importance <strong>of</strong> Culture and Language in Health CareThe term culture refers to “the thoughts, communications, actions, customs, beliefs,values, and institutions <strong>of</strong> racial, ethnic, religious, or social groups” (OMH 2001). Allindividuals have a culture, and some individuals are associated with multiple culturalgroups simultaneously. Cultural categories and groups <strong>of</strong>ten are thought <strong>of</strong> in terms <strong>of</strong>race, ethnicity, and/or country <strong>of</strong> national origin. Similarly, an individual’s “culturalidentity” <strong>of</strong>ten is associated with groups <strong>of</strong> individuals along racial and ethnic lines.COSMOS Corporation, December 2003 2-2
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- Page 35 and 36: References
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- Page 39 and 40: Frye, B., “Health Care Decision M
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3b. Which of the following are refl
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6. Does your agency have a formal p
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10. Which of the following describe
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Post-Interview Script for LPHA Dire
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Appendix DStaffing Questionnaire
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A. QUALITY MONITORING AND IMPROVEME
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B. MANAGEMENT INFORMATION SYSTEMS (
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7. Please indicate, if you know, th
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1c. Please indicate for which categ
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6. Please indicate for which catego
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10. Which of the following topical
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17. Which of the following benefits
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4. Which of the following strategie
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Appendix EClient Services Questionn
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A. QUALITY MONITORING AND IMPROVEME
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6b.Which of the following community
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3. Please report or estimate what p
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3. Which of the following practices
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Oral Interpretation Services10. Whi
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16. At which of the following key e
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3. Which of the following kinds of
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Appendix FPilot Test Response Form
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RESPONDENT EVALUATIONOF THE QUESTIO
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Appendix GCLAS in MCOs Study Data C
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position, as titles will likely var
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complex and uncertain at the time t
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1. Incorporate a confirmation pre-c
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Exhibit 2DATA COLLECTION PROCESSSen