Fillable Printable Form 405
Fillable Printable Form 405
Form 405
AHCCCS CONTRACTOR OPERATIONS MANUAL
CHAPTER 400 - OPERATIONS
405 - 1 of 6
405 - CULTURAL COMPETENCY, LANGUAGE ACCESS PLAN AND FAMILY/PATIENT
CENTERED CARE
EFFECTIVE DATES: 03/02/00, 10/01/12, 05/01/14, 07/01/16, 10/01/17
REVISION DATES: 11/16/10, 01/01/11, 10/02/12, 04/17/14, 06/02/16, 02/22/17
I. PURPOSE
This Policy applies to Acute Care, ALTCS/EPD, CRS, DCS/CMDP (CMDP), DES/DDD
(DDD), and RBHA Contractors. The purpose of this Policy is to outline the requirement that
Contractors offer accessible and high quality services in a culturally competent manner to meet
the needs of members with diverse cultural and ethnic backgrounds, including those with limited
English Proficiency, disabilities, and regardless of gender, sexual orientation or gender identity
and provide family-/patient-centered care, as applicable.
II. DEFINITIONS
COMPETENT
Properly or well qualified and capable.
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-cultural situations. Culture refers to integrated
patterns of human behavior that include the language, thoughts,
communications, actions, customs beliefs , values, and institutions
of racial, ethnic, religious or social groups. Competence implies
having the capacity to function effectively as an individual and an
organization with the context of the cultural beliefs, behaviors and
needs presented by consumers and their communities.
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. Culture
defines the preferred ways for meeting needs, and may be
influenced by factors such as geographic location, lifestyle and
age.
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 inherent patterns of living, and ensures
family collaboration and choice in the provision of services to the
member.
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INTERPRETATION
The conversion of oral communication from English into the
member’s preferred language while maintaining the original intent.
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 can be limited English proficient, or “LEP”. These
individuals may be entitled language assistance with respect to a
particular type or service, benefit or encounter.
LINGUISTIC NEED
For the purposes of this policy, linguistic need is defined as the
necessity of providing services in the member’s primary language,
including sign language, and the provision of interpretive and
translation services.
NATIONAL STANDARDS
FOR CULTURALLY AND
LINGUISTICALLY
APPROPRIATE SERVICES
(CLAS)
National standards developed to advance health equity, improve
quality, and help eliminate health care disparities by establishing a
blueprint for health and health care organizations.
PREVALENT NON-
ENGLISH LANGUAGE
A language determined to be spoken by a significant number or
percentage of members who have a limited English proficiency.
TRANSLATION
The conversion of written communication from English into the
member’s preferred language while maintaining the original intent.
VITAL MATERIALS
Written materials that are critical to obtaining services which
include, at a minimum, the following:
1. Member Handbooks,
2. Provider Directories,
3. Consent Forms,
4. Appeal and Grievance Notices,
5. Denial and Termination Notices.
III. POLICY
A. CULTURAL COMPETENCY PLAN
The Contractor shall have a comprehensive cultural competency program that is inclusive of
those with limited English proficiency and diverse cultural and ethnic backgrounds,
disabilities, and regardless of gender, sexual orientation or gender identity [42 CFR
438.206(C)(2)]. The Contractor shall develop a written Cultural Competency Plan (CCP).
The CCP shall describe how care and services will be delivered in a culturally competent
manner and shall include all information provided in Attachment A.
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The Contractor shall identify a staff member responsible for implementation and oversight
of all requirements for the cultural competency program and plan. RBHAs shall employ a
Cultural Competency Administrator as a key staff position as described in RBHA Contract,
Scope of Work. If there is a change in the staff member responsible for the cultural
competency program and plan, the Contractor shall notify the Division of Health Care
Management (DHCM). The CCP shall address the following:
1. Education and Training
a. The education program consists of the methods the Contractor will use to train its
staff to ensure that services are provided in a culturally competent manner to
members of all cultures. Training shall be customized to fit the needs of staff based
on the nature of the contacts they have with providers and/or members,
b. The education program consists of methods the Contractor will use for providers and
other subcontractors with direct member contact. The education program shall be
designed to make providers and subcontractors aware of the importance of providing
services in a culturally competent manner and understanding of health literacy. The
Contractor shall also make additional efforts to train or assist providers and
subcontractors with how to provide culturally competent services. The Contractor
shall track provider participation in cultural competency trainings, and
c. The Contractor shall ensure all staff receives Cultural Competency training during
new employee orientation and annually thereafter.
2. Culturally Competent Services and Translation/Interpretation Services
The Contractor shall describe the method for evaluating the cultural diversity of its
membership to assess needs and priorities in order to provide culturally competent care
to its membership. Culturally competent care requires that the Contractor evaluate its
network, outreach services and other programs to improve accessibility and quality of
care for its membership. It should also describe the provision and coordination needed
for linguistic and disability-related services.
The availability and accessibility of translation/interpretation services should not be
predicated upon the non-availability of a friend or family member who is bilingual.
Members may elect to use a friend or relative for this purpose, but they should not be
encouraged to substitute a friend or relative for a translation/interpretation service. A
Contractor, at any point of contact, shall make members aware that translation/
interpretation services are available and provide written notice informing members of the
right to translation/interpretation services in their preferred language. Additionally, the
Contractor shall ensure access to oral interpretation, translation, sign language,
disability-related services, and provide auxiliary aids and alternative formats upon
request. The services offered shall be provided by an individual who is proficient and
skilled in translation/interpretation. Translation/interpretation services shall be provided
at no cost to members.
Translations shall be provided in the following manner:
a. Written materials that are critical to obtaining services (also known as vital
materials) shall be made available in the prevalent non-English language spoken for
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each LEP population in the Contractor’s service area. [42 CFR 438.3(d)(3)] Oral
interpretation services shall not substitute for written translation of vital materials,
b. All written materials for members shall be translated into Spanish regardless whether
or not they are vital, and
c. The Contractor shall make oral interpretation services available at no cost to the
member. This applies to sign language and all non-English languages, not just those
identified as prevalent. The Contractor shall also provide information on which
providers speak languages other than English.
3. The Contractor shall provide easy-to-understand print and member information materials
as well as signage in the languages commonly used by the populations in the service
area. This includes the production of materials with consideration of members with LEP
or limited reading skills, those with diverse cultural and ethnic backgrounds, and those
with visual or auditory limitations.
4. The Contractor and its subcontractors shall:
a. Utilize licensed interpreters for the Deaf and the Hard of Hearing, and
b. Provide auxiliary aids or licensed sign language interpreters that meet the needs of
the individual upon request. Auxiliary aids include 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.
5. 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.
B. CULTURAL COMPETENCY PLAN ASSESSMENT REPORTING
The Contractor shall assess its CCP for effectiveness at a minimum on an annual basis
including modifications based on the assessment. The assessment should consider:
linguistic need, comparative member satisfaction surveys, outcomes for certain cultural
groups, translator/interpretive services and utilization, member complaints, grievances,
provider feedback and/or Contractor employee surveys. Identified issues must be tracked
and trended, and actions taken to resolve the issue(s). The CCP should also address how the
Contractor communicates its progress in implementing and sustaining the CCP goals to all
stakeholders, members and the general public.
The Cultural Competency Plan Assessment shall be submitted with Attachment A, as
specified in the Contract.
C. LANGUAGE ACCESS PLAN
The Contractor shall submit a Language Access Plan annually that indicates how the needs
of members with Limited English Proficiency are met. The Plan shall be submitted with
Attachment A, as specified in the Contract. It shall address each of the following elements:
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1. Assessment: Needs and Capacity
Processes to regularly identify and assess the language assistance needs of its members,
as well as the processes to assess the Contractor’s capacity to meet these needs
according to the elements of this plan,
2. Oral Language Assistance Services
Processes for the provisions of oral language assistance (such as qualified interpreters or
staff whose proficiency in non-English languages has been documented), in both face-to-
face and telephone encounters, that addresses the needs as specified in assessment
above. The Contractor shall provide the established point of contact for members with
LEP, such as an office, official, or phone number. The Contractor shall include the
process used to ensure that the interpreters used are qualified to provide the service and
understand interpreter ethics and client confidentiality needs,
3. Written Translations
Processes to identify: translate and make accessible in various formats vital materials in
accordance with assessments of need and capacity conducted as specified in assessment,
ACOM Policy 404, and ACOM Policy 406,
4. Policies and Procedures
Written policies and procedures that ensure members with LEP have meaningful access
to programs and activities,
5. Notification of the Availability of Language Assistance at No Cost
Processes to inform members with LEP that language assistance is available at no cost.
The Contractor is responsible for taking steps to ensure meaningful access to their
programs, including notifying current and potential members with LEP about the
availability of language assistance at no cost. Notification methods may include
multilingual taglines in member materials, as well as statements on forms including
electronic forms such as agency websites. The results as specified in assessment above,
should be used to determine the languages in which the notifications should be
translated,
6. Staff Training
Description of employee training to ensure management and staff understand and can
implement the policies and procedures of this Plan,
7. Assessment: Access and Quality
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 customer need,
8. Stakeholder Consultation
Process for engaging stakeholder communities to identify language assistance needs of
members with LEP, implement appropriate language access strategies to ensure
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members with LEP have meaningful access in accordance with assessments of customer
need and evaluate progress on an ongoing basis, and
9. 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.
D. CRS FAMILY CENTERED AND CULTURALLY COMPETENT CARE
The CRS Contractor will provide family-centered care in all aspects of the service delivery
system (as specified in AMPM Policy 330). The additional responsibilities of the CRS
Contractor for support of family-centered care include but are not limited to:
1. Recognizing the family as the primary source of support for the member’s health care
decision-making process. Service systems and personnel should be made available to
support the family’s role as decision makers,
2. Facilitating collaboration among recipients, families, health care providers, and
policymakers at all levels for the:
a. Care of the member,
b. Development, implementation, evaluation of programs, and
c. Policy development.
3. Promoting a complete exchange of unbiased information between recipients, families,
and health care professionals in a supportive manner at all times,
4. Recognizing cultural, racial, ethnic, geographic, social, spiritual, and economic diversity
and individuality within and across all families,
5. Implementing practices and policies that support the needs of recipients and families,
including medical, developmental, educational, emotional, cultural, environmental, and
financial needs,
6. Participating in Family-Centered Cultural Competence Trainings,
7. Facilitating family-to-family support and networking,
8. Promoting available, accessible, and comprehensive community, home, and hospital
support systems to meet diverse, unique needs of the family,
9. Acknowledging that families are essential to the members’ health and well-being and are
crucial allies for quality within the service delivery system, and
10. Appreciating and recognizing the unique nature of each recipient and their family.
