Increasing Access to Services for Limited English Proficient Persons

Abstract

Recent federal policy initiatives highlight requirements for all United States federal agencies and all recipients of federal funding to proactively accommodate the LEP populations they serve. However, many of the agencies and organizations that receive federal funds are unaware of this obligation or have not taken action to comply with it. Implementing these initiatives, especially in an era of fiscal constraints, poses significant management challenges for public agencies. Local government entities, advocates and community organizations share an obligation to ensure effective access to LEP populations, and can reap mutual benefits through coordinated efforts to do so.     

The CLAS Challenge: Promoting Culturally and Linguistically Appropriate Services in Health Care

Abstract

Vista Community Clinic's Cultural Awareness Program (CAP), funded by the US Office of Minority Health, aims to institutionalize culturally and linguistically appropriate services as outlined in the federal Culturally and Linguistically Appropriate Services (CLAS) Standards for the diverse San Diego County population through the promotion of organizational change at all levels of health care. The CAP program hopes to contribute to this end through offering educational sessions, aiding health care organizations in making changes to their structure in the areas of culture and language, as well as through the development of a website and a resource manual. Facilitating systems change in culturally and linguistically appropriate service delivery has proven to be the most challenging component of the CAP program. Based on seven years of experience in this area, CAP program staff proposes that the success of culturally and linguistically appropriate services depends on the degree to which organizational “buy-in” is achieved, the enforcement of the standards and the ability of health care organizations to work in collaboration with the community in which they serve.     

The Challenge of Providing Culturally and Linguistically Accessible Human Services in Rural and Increasingly Diverse Communities

Abstract

This paper uses a case study of one small rural community in New England to educate social workers, other human service professionals on linguistic, cultural accessibility issues with clients who have Limited English Proficiency (LEP). The relevant civil rights law, case law, federal guidelines, which form a framework of protection for persons with LEP are presented, used as a mirror to which human service efforts to meet linguistic, cultural accessibility are held. Finally, strategies for small rural communities with multiple small populations of persons with LEP are presented.     

Chapter 6. Psychosocial Stressors,Psychiatric Diagnoses and Utilization of Mental Health Services Among Undocumented Immigrant Latinos

Abstract

The combined effects of minority status, specific ethnic group experiences (political, economic, trauma and immigration history), poverty, and illegal status pose a set of unique psychiatric risks for undocumented Latinos in the United States. Restrictive legislation and policy measures have limited access to health care, and other basic human services to undocumented immigrants and their children throughout the nation. However, little is known about the patterns of mental health care use, psychiatric diagnoses and psychosocial problems prevalent among the undocumented who do succeed in presenting to clinical settings and to the mental health sector. To begin to address the need for further understanding in this area, we completed a clinical chart review of 197 outpatient adult psychiatric charts in a Latino mental health outpatient treatment program located in an urban hospital system.

We compared the diagnoses and mental health care use of undocumented Latino immigrants (15%) with that of documented (73%) and US born Latinos (12%) treated in this clinical setting. The undocumented Latinos in our study were more likely to have a diagnosis of anxiety, adjustment and alcohol abuse disorders. The undocumented also had a significantly greater mean number of concurrent psychosocial stressors (mean number = 5, p < .001) ascompared to documented immigrants and US born groups, which both had a mean number of 3 stressors identified at evaluation. The undocumented were more likely to have psychosocial problems related to occupation, access to healthcare and the legal system. However, the undocumented had a lower mean number of total mental health appointments attended (mean visits = 4.3, p < .001) in which to address these stressors as compared to documented immigrants (mean visits = 7.9) and US born (mean visits = 13.3). In terms of other previous mental health service use, the undocumented group had lower rates of lifetime inpatient and outpatient treatment use.

The results of this study suggest the importance of early assessment of psychosocial stressors, substance use and barriers to care when treating undocumented immigrants. Although all Latino groups included in this investigation demonstrated numerable concurrent stressors, our investigation highlights the particular importance of accessible social services and supports for addressing psychosocial stressors in the lives of undocumented patients. Our results stress the importance of reexamining policies, that restrict access to social services and healthcare for the undocumented. Our results also suggest the importance of culturally appropriate evaluation and treatment of substance abuse disorders as well as addressing other psychological and behavioral responses to multiple stressors among undocumented individuals.     

Planning,Budgeting, and Health Care Performance in Ukraine

Abstract

The Government of Ukraine has not pursued health care reforms now commonplace in the rest of Europe and Central/Eastern Europe that rely less upon centralized, state delivery of services and more on decentralized operational responsibilities and competition for services that increase patient choice. The Ukrainian health sector suffers from personnel overspecialization and facility overcapacity, resulting in high-cost, low productivity services. Budget funds are unavailable for operations and maintenance resulting in poor quality services. The state provides health care as a constitutionally-protected monopoly, relying on the traditional command and control model which ignores cost/quality competition options and responsibilities to patients. Overall, the system which produces these results is over-centralized, requiring achievement of physical service norms without providing sufficient funds. The centralized system does not monitor or evaluate services beyond narrow financial accountability and control requirements. The health care system is paradoxically over-centralized but unable to regulate or control local health care official decisions to ensure compliance with national standards. Needed are reforms in the health care policy and operational areas to produce the supply of services needed for national economic recovery. In the short-term, the budgetary framework can be improved as an operational/management guide through development of comparative information on results. Most of this information can be based on the economic classification consistent with the chart of accounts. Funding stability can be increased to improve expenditure control by implementing a new fiscal transfer formula that provides discretion (i.e., block grants) and performance criteria (i.e., outcome measures). In the medium-term, building on the technical foundation of physical norms and statistical reporting, the health care budgeting and financial management system should shift emphasis to: program planning, policy and management analysis, and public communications. The results of these reforms should lead to decentralized health care operations, service analysis, and delivery responsibilities. At the same time, the reforms should lead to proper centralization of responsibilities for strategic policy decisions, safety regulation, national standards, and program evaluation.     

THE PUBLIC MANAGEMENT CHALLENGES OF CONTRACTING WITH NONPROFITS for SOCIAL SERVICES

ABSTRACT

States and municipalities increasingly pursue privatization as a way to deliver public goods and services because of two expected outcomes, reduced costs and quality improvements. Several reasons are frequently cited for these anticipated benefits ranging from market competition to increased management flexibility and discretion to fewer rules and regulations. One policy area in which government has privatized many services through contracting with nonprofit organizations is social services. Contracted services are as diverse as providing shelters for the homeless, vocational education and job retraining, domestic violence services, refugee esettlement, child and elder abuse services, and food banks. A proliferation of public administration and nonprofit organizational scholarship has examined a range of issues associated with the government-nonprofit social service contracting relationship, not the least of which are topics related to management, measurement, and accountability. This article examines the public management challenges and implications of contracting with nonprofit organizations for the delivery of social services.     

Financing the health care of the aged.

The Medicare and Medicaid programs, which were enacted through the 1965 amendments to the Social Security Act, placed the federal government in the central role of assuring access of the aged and the poor to needed medical care. In this article the trends in the sources of financing medical care services for the aged are examined. The distinction in terms of insurance coverage between acute care services and long-term care services is highlighted. The effect of the programs in terms of reducing the aged's direct financial cost of medical care, increasing their access to medical services, and improving their health status is explored. The unanticipated increase in the cost of these programs has led to a change in emphasis in public policy, from assuring access to mainstream medical care to containing the cost of providing care. The direction of new federal policies is analyzed, and it is concluded that no longer will it follow the private sector's specifications of the conditions and arrangements under which health services are provided to program beneficiaries.     

Constructing Policy Networks: Social Assistance Reform in the Czech Republic

Abstract

Czech social insurance and family transfers experienced fundamental reform in 1995 but Czech social assistance benefits still lack comprehensive change. This article explains the delay in Czech social assistance reform by appling policy network studies in a postcommunist context. Although few organizations perticipate in the Czech social assistance policy network, they are divided: they lack the common interests and exchangable resources necessary to create dialogue and compromise. The organizations of disabled citizens are the only interest group active in the policy network, with the operators of state social care institutions their primary opponents. In the late 1990s, this already fragmented issue network suffered further division when the EU entered as a powerful network actor with another set of policy goals. Until the policy network structure facilitates more dialogue and consensus‐building, hopes for comprehensive social assistance reform will linger unfulfilled.     

Local Council Development Areas and Local Service Delivery: How a Fourth-tier Government Unit is Improving Access to Primary Health Care and Education Services in Lagos,Nigeria

ABSTRACT

Emerging accidentally from an array of political and legal contestations is a fourth-tier government unit in Lagos state – Local Council Development Areas (LCDAs). The LCDAs have survived almost two decades of existence without the ’traditional’ monthly federal allocation, which has been the mainstay of the existing 774 LGAs in Nigeria. This study attempts an explanation of this apparent survival by examining the institutional structure of the LCDAs vis-à-vis their service delivery performance. Different from earlier studies that have examined service delivery using final outcomes, the study examines accessibility as an intermediate output; dimensioned as availability, adequacy and affordability. Using a mixed-methods research design, the study shows that Lagos LCDAs’ inclusive operational structure is significantly improving access to primary health care and education services. Thus, the study finds evidence within the operational structure of Lagos LCDAs for Acemoglu and Robinson’s theory of inclusive and extractive institutions.     

Chapter 11. The Future of Culturally Competent Mental Health Care for Latino Immigrants

Abstract

This chapter underscores the importance of cultural competence in the provision of effective mental health services to Latino immigrants. Culturally competent mental health care must be understood within the context of a social-political-economic framework that is changing on a continual basis. Health and mental health care reform for Latino immigrants must be linked to both practice-based research efforts and timely diffusion of best practice innovations. Cultural competence must be integrated as a valued component of the organizational structure of mental health systems of care.     

The Need for Gender-Sensitive Medical Interpreters for Victims with Limited English Proficiency in Sexual Assault Examinations

Abstract

The difficulties and trauma associated with sexual violence are exacerbated by language difficulties. Language difficulties pose particular barriers in accessing legal, social, medical and support services. This presents additional challenges for sexual assault response teams (SART). The SART members serve critical functions in supporting a victim of sexual violence from trauma to trial.

This paper addresses the need for trained gender-sensitive medical interpreters for adult female victims with limited English proficiency (LEP) in sexual assault examination, and thus the need for inclusion of trained medical interpreters in SART. Such needs were articulated from interviews with advocates and medical interpreters in the US, from literature reviews and conversations with women with LEP in the US. The paper closes with a set of specific recommendations that will promote comfortable accessible service to female victims of sexual violence with LEP.     

Chapter 3. Mental Health Care of Hispanic Immigrant Children

Abstract

This chapter addresses the mental health care of Hispanic immigrant children within a school-based context. The school system is presented as a natural support agent that is psychologically, culturally and geographically accessible for the delivery of culturally competent mental health services. The development of a multifaceted New York City public school-based program created, by the first author of this chapter, in response to the psychosocial needs of Hispanic immigrant children is discussed as a viable approach that may be used in the provision of ethnic-sensitive mental health care.     

Health Care Versus Border Care: Justification and Hypocrisy in the Multilevel Negotiation of Irregular Migrants’ Access to Fundamental Rights and Services

Abstract

Providing—and also not providing—public services to unlawful residents implies a certain cost for host societies, and both inclusion and exclusion involve localized renegotiations of fundamental rights, legitimate needs, and social membership. Based on original qualitative research data, this article compares how, why, and under which conditions irregular migrants are granted or denied access to healthcare services provided in London and Barcelona. From a multi-level perspective and by drawing on organization theory, I highlight key differences in how the responsible governments deal with the underlying contradictions and thereby either help or hinder effective policy implementation.     

Health care for the poor.

In the 1980s the convergence of a number of factors is causing government at all levels, industry, and labor to plan or initiate major reductions in health spending. Important among these are rising health care costs, a troubled national economy, mounting federal deficits and state revenue shortfalls, and the philosophical course and domestic policy of the Reagan administration. In this context government has been rethinking its capacity to finance health services for the poor, and new and sometimes controversial arrangements for delivering these services are being developed. The dilemma government officials face now is how to cut costs while still assuring that quality medical services are available. This article focuses on what these new policy developments and arrangements are and whether the significant gains in access and in health achieved over the past 20 years will be sustained. Because truly sweeping reforms are unlikely, whether government will maintain earlier commitments and established arrangements for financing and delivering health services to the poor will be worked out piecemeal over the next several years.     

Public hospitals as competitors for medicaid revenue: the case study of St. Louis regional medical center

Medicaid revenues may determine whether public hospitals will survive. Public hospitals participate aggressively in the public market competition for their states’ Medicaid dollars. States must decide whether the survival of public hospitals, as providers of last resort to both Medicaid and uninsured patients, is of continuing importance to their Medicaid programs. Cities, if the states were willing, alternatively could voucher uninsured patients and direct Medicaid patients to the private hospitals that would outlive closed public hospitals. In fact, Medicaid's managed care programs already have heightened this competition, by organizing sufficiently large populations of prepaid Medicaid patients to attract networks of private providers to offer discounted prices, in competition with public hospitals for this market.

Although Medicaid has been a comparatively poor payer, nationally, almost half of public hospitals⁷ funding comes from this source of revenue. Urban public hospitals can barely live with Medicaid revenues, but the extent to which they can live without Medicaid revenues is being determined by surprising new turns in market competition for the revenue. A period of expansive and expensive new congressional mandates for the joint federal-state program was followed in the early 1990s by the introduction by the states of Medicaid revenue maximization strategies. The states’ funding levels, the bases for matching federal contributions, were artificially elevated by provider taxes, provider donations, and intergovernmental transfers. The revenue from all these sources was returned to these providers through the Disproportionate Share Hospital subsidy program for Medicaid-dependent hospitals, as soon as the federal revenue match was calculated, based upon the inflated figures. These practices currently are being stymied, and states simultaneously have escalated competitive bidding by private market managed care providers for Medicaid patients. Missouri has been in the forefront of states moving to maximize the federal Medicaid revenue match and to return Disproportionate Share Hospital funds to providers. St. Louis's public hospital, Regional Medical Center, has been weaned off its local government subsidies, as the intergovernmental transfer and DSH enticements compromised the stability of that hospital's revenue picture. Now, unprotected by an integrated healthcare system or other major role in a regional hospital network, this urban public hospital must struggle to survive within its Medicaid managed care competitive market. The question for the state of Missouri is whether perpetuating a future for Regional will ensure its Medicaid patients a traditional caring public medicine alternative as a fallback position, if Medicaid's present foray into the private market goes awry. For Regional and the city of St. Louis, the question is whether they can any longer count upon traditional state Medicaid revenue and financial support.     

Health care reform content and process:propositions from the states

Health care reform and cost containment have become central campaign and policy issues in the United States. Although focus now centers on federal health care reform policy, state governments have been actively introducing health care reform legislation. Some of the health care reform initiatives on the state level have influenced deliberations on the federal level and President Clinton's health care reform initiatives will spur further state experimentation regardless of legislative success in Congress, In 1992 nearly all 50 states had either legislation introduced, or special task forces assigned that addressed health care reform issues. This exploratory research compares the content and process of health reform in four states that attempted major reform in 1992—Florida, Washington, Michigan, and Wisconsin—and draws propositions for state reform based on comparisons of content and process. The four states chosen represent geographic diversity and a balance between legislation seeking partial change and legislation calling for universal health care reform. The principal reform bills in each state are compared and assessed on the degree to which they address eight reform elements; high tech medicine, administration, tort reform, long-term care, regulation, insurance mandates, small business insurance, and insurance portability. These initiatives are also compared on a series of reform process variables that relate to the political process for adopting reform: degree of health sector support, type of political strategy used, reform champion, degree of cooperation among policy stakeholders, and timing of initiative. Based on these four cases the phased/partial approach seems to have a greater chance for legislative success than immediate universal reform. Florida's partial, consensus-building approach resulted in the only signed bill of the four states. Washington's bill, which also took a partial approach, passed the state senate before ultimate defeat in 1992 and eventual passage in 1993. Neither of the more ambitious universal health care reform packages introduced in Wisconsin or Michigan got out of committee. Although some of the plans were thorough, none adequately addressed the tradeoff between increasing access to care and containing costs. In addition, this study will demonstrate that universal health care legislation, does not necessarily equate to comprehensive health care reform. The propositions derived from this research have implications for future state health care reform efforts, as well as for federal health care reform policy in terms of the substantive content of reform proposals and the political process by which they are advanced.     

Investing or Squandering Social Capital? Community-Based Organizations for Indigent Health Care

Abstract

Externally funded collaboratives are compared in a US–Mexico border location, focusing on the local commitments that are made in financial and social capital for long-term sustainability. The border offers special challenges to sustainable health care programs, given the substantial crossing that occurs among health care users in both North-to-South and South-to-North directions. Funding organizations that decentralize programs to community collaboratives, demanding considerable local leverage and in-kind contributions, create a pernicious tax on poor communities in the name of building community capacity. Despite good intentions, precious community social capital is squandered.     

Chapter 2. Mental Health in the Hispanic Immigrant Community

Abstract

This chapter addresses the mental health status of Hispanics in the United States. The prevalence and incidence of mental health disorders among different Hispanic ethnic subgroups is examined. Patterns of mental health services utilization and barriers to mental health care are also reviewed. Research specific to best mental health practices with Hispanics is stressed.     

The oregon plan: Toward a model for the future of health care financing

The State of Oregon has proposed a new method of financing health care services for its citizens. Oregon proposes to fund only the most cost-effective services. But in addition to narrowing the offering of health services funded by the State, Oregon proposes to fund all of the State's poor for services, no matter the family status. This broadened number of poor (everyone at the federal poverty level and below, single or married, children or not) will provide health care for more than 200,000 additional Oregonians. The supplementary legislation, SB 534 and SB 935, combined with broadened health care coverage for the poor (SB 27) will cover an additional 478,000 Oregonians. Nearly 95 % of its citizens will have some form of health insurance in Oregon.