Topical Conference Call 1

Language Access: Implications for State MCH/CSHN Programs

A Focus on California

This call was conducted on October 4, 2001, 3:00 – 4:30 PM, E.T.

The featured speakers was:

Gregory A. Franklin, M.H.A.,Presently:Deputy Director of Health Information and Strategic Planning Division, California Department of Health Services

At the time of the call: Chief, Office of Multicultural Health, California Department of Health Services

Tawara Goode: Mr. Franklin is currently a member, of the California Department of Health Services Executive Staff and Chief of the department’s Office of Multicultural Health. In this capacity, he’s responsible for the development an analysis of policy regarding multicultural health.

Before coming to this position, Mr. Franklin was the chief of the department’s managed care, education, and outreach and health plan contracting activities. In this role he created guidelines and standards that are currently in use to inform persons eligible for Medicare of their health plan choices. He was also instrumental in the implementation of the state’s two-plan model of MediCal Managed Care and the development of enrollment policies.

He has held positions in the state’s medically indigent services program, tuberculosis control, and also refugee health program. So without further ado, Mr. Greg Franklin.

Greg Franklin: Okay, great. First of all I want to thank the NCCC or the National center for highlighting California first, it’s certainly a great pleasure, and being first always means that you’re somewhere near the top in folks’ minds.

Wendy Jones: I’ve got the first question for you, Greg.

Greg Franklin: Okay, Wendy.

Wendy Jones: Can you briefly describe the responsibilities of your office and your role there?

Gregory Franklin: Okay, our office is essentially a policy office here in the state of California in the Department of Health Services. We report directly to our director, Dr. Diana Bonton by being positioned in the director’s office, that gives the Office of Multicultural Health some authority over the programs in our entire department, but not authority to the point to where we actually get out and punish people, but certainly we do have influence over some of their programs and some of their program policies, but we try to collaborate as much as possible.

The other thing in regards to my role, I function primarily internally as a consultant and externally, as a liaison, to a lot of the community groups, advocacy groups, physician’s organizations, nurse’s organizations, it’s more or less a catch-all position for dealing with issues related to multicultural health. We do a lot of policy and legislative work, a lot of marketing of our programs and a lot of ensuring that our programs are culturally competent.

Wendy Jones: Can you give us some idea of what the demographics of the area are and/or the population served?

Gregory Franklin: Well, California is very diverse, in fact in 1990, 57 percent of our population was Caucasian, around 26 percent Hispanic. But the 2000 Census indicates that we have experienced a decrease in the white population of 46 percent and our Hispanic population has risen to 32 percent. There’ve also been increases in our Asian population.

So that’s pretty much the diversity of our state, but within that, because again, I’m talking about the major ethnic groups, within that there are a significant numbers of language we serve including Arabic, Armenian, Cambodian, Cantonese, Samoan, Spanish, Tagalog, Thai, Turkish, Korean, Italian, and a host of others, so actually there’s like 29 different languages we serve in our public health programs.

Wendy Jones: Excellent. Can I ask you one more question and then I’ll turn it over to Diana. Why do you use the term multicultural health rather than minority health?

Gregory Franklin: Well it’s important that we understand that we’re not a minority, but more importantly, multicultural is more inclusive. Minority kind of revisits some of the past things that occurred in the sixties and some of the past terminology of the sixties. Multicultural has also been more palatable for our legislative folks, they tend to stay away or shy away from the word “minority” in many of the things that we may send up to them.

So I believe we made that decision in 1992, there was a report put out by Congress on black and minority health, I want to say in the early ‘90s, and there was a decision, or a discussion, regarding how we should term our office, and by and large, almost to a person, everyone said, well, multicultural health is more appropriate, it’s more futuristic, and certainly more palatable to those folks who are ultimately going to make decisions.

Diana Denoba: Thank you Greg, and by your telling us of the different languages of the people that you serve, I guess it may be obvious, but could you just tell us how language access became a priority in your program, was it your population only, was it the Title VI of the Civil Rights Act?

Gregory Franklin: Well you know I think the law had something to do with it, but I also believe that it’s beyond priority, it’s actually essential. The people we serve are very diverse. The people we serve who are eligible for our programs happen to be this very same diverse population and by making this essential, I mean essential to the business that you do, essential to your survival, thinking of it in those terms will ensure that you actually visit that each and every time you plan a program, each and every time you look at making adjustments to a program.

Up until ten years ago, our department was pretty much monolingual. All of our media spots, our radio, our television, were pretty much English only. Bilingual recruitment, it occurred, but I think it really occurred very rarely and on a limited basis. Today we have radio spots in Cantonese, in Spanish, in Hmong, and they’re also on ethnic networks like Univision, they’re also on public access television, so it’s absolutely essential to our survival that we think about language and, with that, that we think about translations. And by that I mean translating those vital documents into the languages that are going to reach the population that we want to serve. And thinking about translations, you also have to think about literacy as well.

Diana Denoba: Excellent. In your agency, are there some current policies or structures in place that specifically address the provision of language access services? And if so, can you please give us an example or two?

Gregory Franklin: We have two that I can talk to you about. One is within our MediCal program, which is our Medicaid program, and the other is a law that was passed, maybe, I want to say about six years ago, it’s the Dimely-Allatori Bilingual Services Act. And that requires all state agencies to survey the population they serve and if more than five percent of that population speaks a language other than English, you’re required to have a significant number of bilingual persons on staff.

Now that gets at the issue of state agencies and our ability to work with individuals who call us directly, or individuals with whom we may work in the community and who prefer to be communicated with in a certain language.

With that Act comes some requirements, of course, that we do our survey every other year, but there are also requirements that we do actively recruit for people.

With regards to the MediCal managed care policy letters, those have been fairly, I guess, taught throughout the United States so far, but when we embarked on moving MediCal beneficiaries into managed care arrangements, there was a sense, or a thinking that a lot of the commercial health plans we were going to be using really had no notion of what cultural competence was.

We convened a group of individuals, advocates, community folks, health plans, provider groups, other state agencies, and many more to help us craft these cultural and linguistic competency standard policy letters. And we wanted to address things like linguistic services, translation of written materials; we wanted our health plans to convene community advisory committees, so they could have their pulse on the community and understand some of the changes that needed to be made as time went on.

We wanted them to look at and also do group needs assessments, and that is, you start with their providers, take a sample of the community as well to memorialize some of their findings and hopefully look at it as each year passes. And then of course we did lay out a guideline on how to operationalize all of that. So those are, I think, two really good examples of policies that we have.

Diana Denoba: That’s great, and since you’ve had these policies or structures in place, Greg, have you seen an increase in access to services or utilization of services by people with limited English proficiency?

Gregory Franklin: I believe we have, I think any time you mandate, for lack of a better word, some activities, and where our health plans are concerned, tie it to some compliance issues and, maybe if things go correctly, some sanctions in regard to funding, I think we have.

I think also just by doing that we’ve seen an increase in education and awareness of the people we do business with contractually, because now they too are also more sensitive to the issue, they too, because of the increase of enrollment, the increase of beneficiary assignment, and I’m talking about our MediCal managed care program, they too are actively recruiting physicians who are bilingual, they too are actively recruiting nurses who are bilingual, they too are not asking for, quote, “compensation reimbursement,” but they understand that a significant number of the folks they do business with require these services, and if they want to stay in business they have to provide these services.

With regard to Dimely-Allatori, state agencies have to perform because every now and then we’re called before the legislature to be accountable for the things that they say we should do. So I have seen, even with our department, an increase in activities to hire and also retain bilingual staff.

Diana Denoba: Okay, thank you.

Wendy Jones: Greg, I think I heard you say something related to involvement of communities, I’d like you to expand upon that a little bit more? So is there a mechanism that ensures the involvement of family or community members in development and/or ongoing assessment of program policies and practices?

Gregory Franklin: Definitely. We have, I’d venture to say, well over 100 committees, advisory committees, that include community people, we have a Women’s Health Advisory Council, we have a Black Infant HHHHealth Advisory Council, we have my task force on multicultural health, we have a Refugee Health Advisory Council, Indian Health Advisory Council, Laotian Women’s Community Advisory Council, Cultural Linguistic Standards Advisory Council, I mean they all include folks in the community, it’s rotational, they’re appointed by the director, it is a very interactive process, the director attends these council meetings periodically, she’s interested in hearing from individuals personally.

With regards to what occurs at the health plan level with their community advisory committees, they bring in members from the community, actual people who are receiving services through the MediCal managed care program, and they get that input, and they bubble that input up to their executive staff. So there is an extensive network of community advisory type entities that pull in community input.

Wendy Jones: Thank you.

Diana Denboba: You were talking about a number of activities that you’ve been involved in and you talked about the mandate of your program, but how do your budgets support the cost that might be associated with the implementation of some of your language access services? First of all, can you just tell us what a few of them…you mentioned the media and working, training of your providers, what are some other language access services that you have and what about your budget for them?

Gregory Franklin: Pretty much each of our programs do something in regards to language, be that bilingual forms or translating forms into other languages, or developing other types of outreach campaigns, or having health fairs in given communities and enlisting the help of CBOs to pull in, to bring them in and work with some of our language issues.

For example, our WIC program, does a lot in the community and they also do a lot with regard to providing language access. Our Health Families Program, which is our SCHIP program, does quite a bit in terms of being on public access radio and conducting little talk shows or, again, putting on health fairs in communities that speak a language other than English.

As far as budgetary issues, it really depends on the program, and I’ll give you an example. When SCHIP was first rolled out, there was a lot of money and there was a sense, from the data, that over 70 percent of the individuals eligible in California were Latino or, in this case, Hispanic. So in order to be effective in reaching that population and getting them enrolled, we had to address their issues, therefore having our campaigns in that language, a lot of our outreach material in that language, a lot of the bus board materials in that language, that became appropriate.

Now another example where it may not be a budgeted situation but yet, still, there’s a community out there that needs to access our service, is our WIC program. The numbers in WIC are not as dramatic as those in SCHIP, so therefore WIC, who does not receive specific funding to do language activities, made a conscious decision on their own in terms of program management and program targeting, to target the impacted communities and that involved, again, translating materials into different languages, it involved recruiting bilingual staff, it involved working with community-based organizations, and a lot of our community-based organizations in California really do a lot of work for us without compensation, and that’s because of their own personal interest in seeing that folks have access to services.

Diana Denboba: I have another question, Greg. Have you see that this whole effort has helped to identify more children with special health care needs, or have you seen an increase in ongoing assessments of these kids?

Gregory Franklin: I think certainly this has helped to identify children with special health care needs, because each of the entities I talk about, and this is one of the positive things about, certainly, collaboration, each of the entities I talk about have made referrals into our CHDP program before, in fact they make many referrals into our CHDP program.

There has been a significant increase, I think in ’98, we had over two million kids referred to CHDP, children and adolescents, I’m sorry, and again, we wouldn’t have known or been able to communicate effectively without an effective approach to this language issue.

Diana Denboba: And I have one other question associated with cost. I know for some states there is an issue in terms of a reimbursement level, number one, of just spending additional time with children with special health care needs, above and beyond like the ten minutes that providers and managed care systems say that they can give. But if you’re asking for some of the language access services, do you feel that in the future you can legislate or implement something in terms of increased reimbursement for these providers?

Gregory Franklin: I would love to be able to say yes, but I don’t know if it would necessarily happen like that. And I sort of have a feeling that the issue might not be—and this is my own personal thought—so much as do we need to approach it from reimbursing for the language part of the visit, more so than looking at the base rate, are the rates that providers are being paid now, are they currently appropriate? And if they’re not, then maybe a partnership with those folks who have issue with the extended amount of time it takes to service a patient.

For example, in California, we know what the population is and we know that our population has a language need, and the child may have a special health care need. Well as part of you, the provider, taking on that responsibility, one is you have an obligation to provide quality service. The other is if the rate for that quality service is not inclusive of what you’re putting out, then you need to address it from a rate standpoint.

In California, this is going to be part and parcel of doing business, being able to provide effective communication and quality health care, and being able to do that and still adjust to language needs.

Diana Denboba: Great, thank you.

Wendy Jones: Greg, what do you see as the relationship between language access and the reduction of health disparity, do you see a connection there?

Gregory Franklin: Well there is a connection, again, like I was saying earlier, you need to be able to communicate effectively with the individuals who are coming to you for service or potentially eligible for services. I know Diana talked earlier about the goals and a ten-year action plan and all those things, and my understanding is that one of those goals happens to be that all children will be screened early and continuously for special health care needs. Well part of that is getting children in to be screened, and once they are screened, keeping them engaged in the system, and the best way to do that is to be able to make them comfortable, to put them in a situation to show, their parents and the children as well, they’re actually being heard and their needs are actually being addressed. Certainly the collaboration piece is important, because everyone up and down and throughout the network needs to be able to communicate effectively as well.