Transforming the Face of Health Professions Through Cultural & Linguistic Competence Education:
The Role of the HRSA Centers of Excellence

Chapter 9: Next Steps

This curriculum guide was developed for the use of HRSA Centers of Excellence grantees and other educational programs that may find it helpful. The purpose of the guide is to provide the COEs with material that will assist them in meeting the mandated program requirements related to cultural and linguistic competence and to enhance the training programs for students to better prepare them for meeting the health care needs of diverse populations. For these reasons, it may be best to publish this curriculum guide on the Web so that it will be available to a wide audience, and so that the materials cited in this guide will be easily accessible.

This chapter will provide a brief summary of the curriculum guide and discuss potential challenges and issues COEs may face in implementing the contents of the guide. While this guide provides a starting point for COEs to address cultural and linguistic competence education, much can be done to build on this foundation. The Expert Team has identified and will share in this chapter a number of recommendations for next steps, both in using this curriculum guide and in encouraging wide recognition of the importance of cultural and linguistic competence training.

I. Summary of the Project and the Curriculum Guide

This curriculum guide was the result of a diligent effort over 18 months by members of an Expert Team who participated in numerous conference calls and face-to-face meetings, and debated the benefits of using various approaches to arrive at a collective consensus on the content of the curriculum guide. The guide took several turns in its development from the beginning of the process to its completion as a final document. The initial plan was to involve an Expert Team with significant expertise in the field of cultural and linguistic competency. However, one of the first principles the group unanimously agreed upon was to involve representatives of the COEs as much as possible throughout this process. Although the Expert Team is fortunate to include two COE grantee directors and several members who have worked closely with COEs, numerous COE directors have contributed significantly by participating in focus groups and in meetings. Their opinions were invaluable in directing the project to improve its focus to benefit COE grantees and students.

In its present form, the outline of chapters for the curriculum guide has been designed to inform readers systematically. Chapters 1 through 3 provide an overview of the history of COE cultural and linguistic competency issues and clearly identify a case for cultural and linguistic competence education in COEs. Models of cultural and linguistic competence are presented along with principles and goals. Chapters 4 through 6 address designing a cultural and linguistic competence curriculum, provides guidance on its content, and strategies to incorporate content into curricula. Chapters 7 and 8 focus on assessment and evaluation of cultural and linguistic competency education activities and dissemination strategies that can be used when sharing lessons learned in the community. Chapter 10 summarizes an extensive amount of resources available for COEs in fields related to cultural and linguistic competence education. The appendices contain examples of implementation strategies, a glossary of terms related to cultural and linguistic competency, and the Centers of Excellence Assessment and Promising Practices Report, which includes descriptions of cultural and linguistic competence activities of HRSA COE grantees.

II. The Need for Collaboration and Potential Challenges

When using this curriculum guide, COEs will find that as they add to or develop a curriculum in cultural and linguistic competency, it will be advantageous to work together with other COEs so that they can share information and ideas about strategies that have worked and those that have failed. There are, however, barriers to such collaboration in four specific areas:

a.) Collaboration. Among the constraints is the competitiveness among COEs, which tends to inhibit collaboration, the sharing of ideas, and assisting each other in developing programs in cultural and linguistic competency. Ways of fostering collegial collaboration should be seriously considered by HRSA including funding specific pilot programs.

b.) Funding Cycle. A three-year COE funding cycle is too short for institutions seeking to implement long-term changes such as the addition of cultural and linguistic competency elements to their curricula and subsequent assessment and evaluation of the curricular model. The directors said that they found it to be a challenge to address all the expectations of HRSA in terms of institutionalizing cultural competency, addressing appropriate outcomes, and conducting assessments and evaluations, while facing the risk of not having COE funding continued. In addition, pressure for support of activities that promote cultural and linguistic competence is increasing from the public, practice associations, and accrediting bodies, but implementation of curricula is labor-intensive and COE staff need time to make such changes.

c.) Communication: There is a need for more structured and dedicated communication on the topic of cultural and linguistic competence between the HRSA’s Bureau of Health Professions and the individuals COEs. This approach would allow both the COE grantee and HRSA to benefit from an exchange of ideas, strategies, and promising or best practices. Furthermore, it allows both to understand and set realistic expectations.

d.) Need for institutional support. For a curriculum in cultural and linguistic competency to be successful, there is a great need for understanding and support from the larger university institutions and their leaders. Each institution has its own culture, and therefore various approaches are needed to match the various institutional cultures. Also, changes in the curriculum will need support from a critical mass of faculty who can be instrumental in obtaining the buy-in from the institution to support the effort.

III. Recommendations and Next Steps

There is still much work to be accomplished in the area of developing cultural and linguistic competency in health care. Due to their unique positions, COEs have the opportunity to provide leadership among their institutions, community partners, and in the larger society in the movement of cultural and linguistic competence education. The following are some recommendations the Expert Team identified as possible next steps for the COEs to consider:

• Designing very specific pilot cultural competence elements in the curriculum and evaluating them empirically to assess the degree of change in knowledge, skills, and attitudes relevant to diversity, cultural competence, and health care disparities. These results should be shared with colleagues and other institutions though publications and presentations
  
• Working collaboratively with one another whenever possible to implement the curriculum. Doing so would particularly benefit COEs focused on specific ethnic minority groups or particular disciplines
  
• Fostering faculty and student efforts to conduct cross-cultural research and share findings
  
• Developing public-private partnerships to fund and develop cultural and linguistic competency curricula and educational materials related to specific health and illness conditions (both physical and mental health issues) in diverse populations
  
• Availing themselves of opportunities to develop transnational partnerships with health professions educational institutions in other countries that are developing cultural and linguistic competency curricula, programs, and materials
  
• Expending resources to explore methods of increasing the diversity of the workforce and ways to take advantage of a diverse workforce
  
• Encouraging projects and funding opportunities from agencies such as Federal Office of Mental Health and the National Institutes of Health
  
• Partnering with communities and community-based organizations to support efforts to address cultural competence

Other suggestions for COEs and HRSA to consider include:

• Conducting practical workshops and training for COE faculty on such topics as how to select a video and do a debriefing on it; how to integrate cultural and linguistic competency into lectures, case management, history-taking, and patient assessment; and how to insert just-in-time training on various aspects of cultural and linguistic competency into a curriculum
  
• Facilitating Web-based training
  
• Initiating efforts to promote sharing best practices and resources among COEs by developing a Website, for example, and a moderated listserve. The Website would include such resources as this curriculum guide and links to other useful publications and Websites, provide updates on resources that are available to COEs, and showcase successful models developed by COEs
  
• Collaborating closely with other Federal agencies on COE requirements and progress
  
• Providing feedback on next steps that would be helpful to COEs by making the sharing of resources and best practices among COEs a grant review criteria, for example

Cultural and linguistic competence is not an end point, but a process. As suggested earlier, this curriculum guide was written as a starting point for COEs to fulfill the mandate for teaching cultural and linguistic competency. It is a foundation on which they can build by engaging in a collaborative process within their communities and with other institutions. It is, however, just a beginning, and the COEs and other readers have the opportunity to use the content of this curriculum to educate future leaders in providing culturally and linguistically competent, and ultimately better quality, health care for all.