Governance

Standard

Each health plan’s governing entity should incorporate a board, advisory committee, or policy making and influencing group representative of the consumer populations served and the community at large, including age and ethnicity. In this manner, the community served will guide policy formulation and decision making, including Request for Proposals development and vendor selection. The administrator responsible for the Health Plan should be accountable for its successful implementation, including its cultural competence provisions.

Implementation Guidelines

• The governing entity should have final authority over all appeals and grievances.

• The Health Plan should include a formal grievance procedure with minority community and professional input, participation, and involvement at all levels, including fair hearings. Consumers should be informed of this procedure in their own language at intake and at the time of any steps in the complaint and grievance process.

• The Health Plan should appoint Latino ombudspersons to be involved in all appeals and concerns from the community served. The ombudsperson should have independence from the Health Plan, and there should be formalized procedures for resolving differences of opinion between the ombudsperson and the Health Plan administration’s governance.

• The governing entity should determine for each Health Plan an equitable percentage of profit or savings to be reinvested in minority community-based services and preventive programs on an ongoing basis. A disproportionate percentage should be allocated when inequities to access and/or comparability of benefits exist.

• The Health Plan should develop interagency and cross-system agreements or pool funding to coordinate services with other agencies (e.g., public health, social services, corrections, youth services).

• Financial and liability risks for the Health Plan should be shared plan-wide rather than be provider or practitioner specific to ensure availability of specialized skills and continuity of care.

• Policies governing practitioner ethics and behavior (e.g., gift giving by consumers, interactions with consumers outside the service setting, confidentiality) should provide for differences relevant to the context of Latino cultural values such as "respeto" and "personalismo" (see glossary).

• Contract continuation and renewal should be contingent upon successful achievement with performance standards which demonstrate effective service, equitable access and comparability of benefits for Latino and other underserved populations.
  

Recommended Performance Indicators

• The governing entity’s board, advisory committee, and other policy making and influencing groups have composition reflective of the demographics of the service area.

• Latino consumer awareness of Health Plan benefits, appeals procedures and ombudsperson, as demonstrated by comparable rate of grievances and complaints.

• Percent of complaints and grievances of individual practitioners is tracked and factored into performance evaluations.

• Presence of culturally-informed policies of practitioner behavior and performance based demonstrations of implementation.
  

Recommended Outcomes

• Proportion of grievances and complaints by Latino consumers
  
  Benchmark: Comparable to overall service population

• Final disposition of grievances and appeals for Latino consumers
  
  Benchmark: Comparable to service population.

• Percent of Latino consumers receiving blended, coordinated, or wrap-around services
  
  Benchmark: Comparable to overall service population and increasing over time

• Percent of reports of practitioner unethical behavior for practitioners serving Latino populations
  
  Benchmark: Comparable to overall service population

• Sanctions and incentives reinforce movement toward cultural competence
  
  Benchmark: Decreased rates of sanction over time

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