Cultural Competence Standards in Managed Care Mental Health Services For Native American Populations | Quality Monitoring and Improvement


The Health Plan should have a regular quality monitoring and improvement program with defined indicators applicable to evaluating services to minority populations.


Implementation Guidelines

The Quality Improvement Plan for both urban/suburban and rural/reservation Native Americans should include:

1. Urban/Suburban and Rural/Reservation:

Sampling approaches of current and past utilization patterns, by modality (including pharmacotherapy), and level of care.

2. Urban/Suburban and Rural/Reservation:

Quality improvement teams including Native American consumers and Native American Mental Health Specialists which review data from quality indicators relating to Native American and other minority populations. If irregularities or deficiencies in care are found, special quality studies and corrective actions should be undertaken to identify causes and address root causes/processes.

3. Urban/Suburban and Rural/Reservation:

Consumer satisfaction surveys, translated orally and in written format into local languages and dialects, implemented by members of the community independent from the Health Plan. Surveys should be available in various formats to facilitate the participation of consumers at all socioeconomic and educational levels. Sampling should include involvement of Health Plan drop-outs. Evidence of discrimination on the basis of consumer complaints should be a reason for termination of contract.

4. Urban/Suburban and Rural/Reservation:

Periodic assessment of functional outcomes which are valid and applicable to Native American populations, for consumers and families receiving services, as well as the entire covered population. Outcomes should be quantifiable objectives, not just process variables.

5. Urban/Suburban:

Service provision, quality and outcome data for Native consumers and families identified by provider. Data should be reported on a regular basis to the governing entity and used as a basis for determining contract renewal.


Service provision, quality and outcome data for Native consumers and families identified by provider. Data should be reported on a regular basis to the governing entity, tribal sovereign nation(s), multiple state compact, and multiple state-federal compact, and used as a basis for determining contract renewal.

6. Urban/Suburban and Rural/Reservation:

Credentialing and privileging standards specific to different disciplines which include cultural and linguistic competence knowledge, skills, and attitudes relevant to the Native American population. These should include a continuing education requirement. It is important to note that in some cases there may be qualified personnel without formal credentials, i.e. traditional healers. Therefore, this must be handled in a culturally and community based manner.

7. Urban/Suburban and Rural/Reservation:

A record of, and regular reporting on, all appeals, grievances, and law suits differentiated by ethnicity of the complainant and the specific provider. Disproportionate trends by ethnicity should require measurable and timely corrective action. For reservations, in addition to checking with state and federal laws, tribal laws must be checked.

8. Urban/Suburban and Rural/Reservation:

De-listing criteria and tracking for providers and practitioners which are open for review, analyzed by ethnicity and gender of provider and able to account for differing service needs of diverse populations.

9. Urban/Suburban and Rural/Reservation:

Tracking of movement across levels of care and of unusual occurrences by age, ethnicity, and specific practitioner, with sanctions for desirable and unacceptable performances.

10. Urban/Suburban and Rural/Reservation:

Identification and tracking of high-cost consumers resulting in the review and adaptation of their treatment plans to better address their needs.


Recommended Performance Indicators

  1. Presence of a Quality Improvement Plan.
  2. Representativeness of Native American consumers, providers, and community members on the quality improvement team.
  3. Occurrence of special quality studies focusing on deficiencies in the care of Native American consumers.
  4. Linguistically and culturally factored consumer satisfaction surveys which are independently administered and include Health Plan drop-outs and short term recipients.
  5. Regular reporting of Native American-specific quality assurance data to the governing entity, including appeals and grievances.
  6. Systematic tracking of high-cost consumers with support to treatment teams to identify and implement successful interventions.
  7. Systematic tracking and open reporting of provider de-listing by ethnicity.


Recommended Outcomes

  1. Consumer and family satisfaction with services for Native Americans.
    Benchmark: Comparable to overall service population
  2. Rates of drop-out, grievances, restrictive care, unusual occurrences, and adverse events for Native Americans
    Benchmark: Comparable to overall service population
  3. Match between level of care/restrictiveness of modality and level of treatment need for Native Americans
    Benchmark: Level of match comparable to overall population
  4. Functional outcomes in domains of daily living (e.g., housing, access to primary health care, family role, vocational/education/employment, community tenure)
    Benchmark: Improvement over time, rates comparable to overall community
  5. Comparability of access and benefit from service
    Benchmark: Comparable rates of access, consumer satisfaction and clinical results across overall service population
  6. Rates of recidivism into restrictive level of care or other restrictive placements
    Benchmark: Comparable to overall population served and significant reductions where inequities exist.