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The Centers for Medicare & Medicaid Services (CMS) commissioned this guide as well as a companion guide, Planning Culturally and Linguistically Appropriate Services (select for summary). Both were developed by a contractor of the Agency for Healthcare Research and Quality (AHRQ).

Disparities and Improvement of Cultural and Linguistic Competence

In recent decades, there has been increasing recognition of the prevalence of racial and ethnic disparities in health care delivery and outcomes in the United States. Culturally and linguistically diverse groups and individuals of limited English proficiency typically experience less adequate access to care, lower quality of care, and poorer health status and outcomes. This was shown in recent reports by the   and the .

Select for Definitions of Cultural and Linguistic Competence.

2003 CMS Project for M+COs

Each year, CMS identifies a topic for a national quality assessment and performance improvement (QAPI) project that Medicare+Choice Organizations (M+COs) must conduct to comply with program requirements. In 2003, M+COs have a choice of conducting a QAPI project that addresses either clinical health care disparities or the provision of culturally and linguistically appropriate services (CLAS). M+COs may seek assistance in developing and conducting projects that focus on clinical health care disparities from their State Quality Improvement Organizations.

To assist M+COs in conducting projects that address CLAS, CMS arranged for one of the contractors from AHRQ's to develop two guides for managed care plans. (Select to access a summary of the other guide, Planning Culturally and Linguistically Appropriate Services.)

Why Should M+COs Provide Oral Linguistic Services?

M+COs and their providers are subject to major cost constraints, which lead to concerns about costs associated with a new initiative. In addition, plans may feel that their current approach to providing oral linguistic services is adequate and meets the needs of their members. Further, M+COs may not recognize the serious adverse health impact that inadequate linguistic services may have on their LEP members.

Research indicates that linguistic barriers have numerous negative impacts on LEP members and that appropriate linguistic assistance addresses the following issues.

Patients with linguistic barriers:

• Are less satisfied.
• Make fewer visits and receive fewer preventive services.
• Are less likely to use or return to clinics.
• Score lower on health knowledge, and understanding of diagnosis and treatment.
• Have longer hospital stays.

Linguistic assistance:

• Increases satisfaction.
• Decreases reported problems with patient-clinician encounters.
• Increases primary care utilization.
• Increases health knowledge.
• Decreases costs for diagnostic testing.

The Business Case for CLAS in Managed Care

There is a plausible business case for plans to begin CLAS quality improvement programs to improve their cultural and linguistic competence. The changing racial/ethnic demographics of the Nation and managed care as well as regulatory and legal incentives drive this business case. Although managed care was confined at first primarily to the private and commercial sector, it has expanded recently into large public programs such as Medicare and Medicaid, which serve much more diverse and vulnerable populations. There has also been a marked increase in plan enrollment by racial and ethnic minorities, reflecting a similar trend in the Nation's demographics.

In the year 2000, racial and ethnic minorities comprised approximately 25 percent of the U.S. population, and the proportion of "minorities" will approach 50 percent by 2050. Culturally and linguistically diverse group members currently comprise 50 percent of managed Medicaid plan membership and 15 percent of M+CO membership.

What Does This Mean for Plans and CLAS?

It is good business for managed care to market effectively to potential members from LEP and minority groups, since they represent such a rapidly increasing share of the managed care market. In turn, a plan that institutes linguistic and other programs will be more likely to attract and retain LEP members, since it will be easier for LEP members to navigate and use plan services appropriately. As increasing numbers of LEP members join plans, it will become important to assist them in using cost-effective preventive services that reduce costly managed care utilization and are important to managed care accreditation performance (e.g., HEDIS).

In sum, there are multiple reasons for plans to undertake improvements in linguistic competence.

• To improve services, care, and health outcomes for current members (improved understanding leads to better adherence and satisfaction).
• To increase market penetration by appealing to potential culturally and linguistically diverse members.
• To enhance the cost-effectiveness of service provision.
• To reduce potential liability from medical errors and Title VI (Civil Rights Act) violations.

Purpose of This Guide

This guide helps plans address shifting demographic trends by:

• Offering an approach to defining the oral linguistic needs of LEP members.
• Developing strategies to meet their communication needs.

In particular, guidance is offered to M+COs that choose to improve oral linguistic services for their 2003 QAPI project.

This guide presents the journey toward oral linguistic competency as six steps for developing an Oral Linguistic Services Plan. The steps are as follows:

• Step 1: Identify Oral Linguistic Needs of Membership. The preferred spoken languages of current and prospective LEP members are assessed.
• Step 2: Assess the Capabilities of the Managed Care Plan. The infrastructure that supports the provision of linguistically appropriate services and the actual services provided by the plan and the provider network are evaluated.
• Step 3: Identify Points of Contact for Members of Managed Care Plans. The places and situations where the member and the managed care plan communicate are identified to determine where oral linguistic services are needed.
• Step 4: Consider Different Oral Linguistic Strategies. Five oral linguistic service strategies are discussed, including advantages and disadvantages of each strategy, where a strategy might fit in to an overall Oral Linguistic Services Plan, and ways to ensure quality.
• Step 5: Assemble an Oral Linguistic Services Plan. Factors to consider when assembling the final Oral Linguistic Services Plan are presented.
• Step 6: Monitor Oral Linguistic Services Strategies. Methods to evaluate the quality of the Oral Linguistic Services Plan at the individual interpreter/bilingual speaker level and the program level are presented.

In reality, the evolution toward linguistic competency is not clear cut, and the planning steps are not necessarily distinct. The assessment and monitoring steps are often intertwined. Some plans will have experience in developing and monitoring linguistic services and will have completed parts of the planning process, while other plans will be new to linguistic competency and may choose to start in a small way. Organizations are encouraged to start somewhere with small and achievable goals that will begin the journey rather than waiting until all the desired resources, information, and support are in place.

A number of quality improvement projects are introduced in the guide. For those interested in pursuing a specific area of oral linguistic competency, more detailed information can be found by investigating the citations in the guide's resource list and in the reference section. Many citations can be downloaded from the Internet. Case scenarios from plans that were interviewed for the guide are presented as real-life examples to consider. Background information describing each plan is in Appendix J of the guide.

The pursuit of oral linguistic competency is an ongoing process that begins with an awareness of the increasing diversity among a plan's membership. Plans that wish to meet financial and quality goals will recognize that not all members can speak English proficiently. For LEP members, the health care system presents formidable barriers to both accessing and receiving care. Proactive plans will develop and continuously improve services and processes that meet the language needs of all members.

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