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Section 2 - Behavioral Health Transformation [DRAFT for Public Comment]

C.  Statewide Vision for Behavioral Health Quality and Equity

C.4 Health Equity and Culturally Responsive and Linguistically Appropriate Care

DHCS considers health equity as a cross-cutting priority integrated into statewide goals and measures, community planning, workforce development, and culturally responsive and linguistically appropriate care requirements.  

C.4.1 Culturally Responsive and Linguistically Appropriate Care Requirements

The population health approach, statewide behavioral health goals, and associated performance measures described above establish a robust framework for improving outcomes and advancing equity across California’s behavioral health system. Achieving that framework in practice, however, also requires counties and providers to deliver care in ways that are responsive to the cultural, linguistic, and lived experiences of the communities they serve.   

This section describes these requirements using the term “culturally responsive and linguistically appropriate care” instead of the historically used term “cultural competence” to better reflect the department’s equity goals. It defines this type of care as “the ability to reach underserved cultural populations and address specific barriers related to racial, ethnic, cultural, language, gender, gender identity, sexual orientation, age, economic, or other disparities in mental health and substance use disorder treatment services access, quality, and outcomes” (WIC § 5840.6(g)(1)). 

The BHSA promotes culturally responsive and linguistically appropriate care in several ways, including the following: 

  • All county BHSA programs must include culturally responsive and linguistically appropriate interventions (WIC § 5840(b)(3)(C)); 

  • Counties are encouraged to implement community-defined evidence practices that reflect the values, histories, and lived experiences of the communities served (WIC § 5892(k)(6)); 

  • Counties may invest Workforce and Education (WET) funds to build and maintain a workforce that is culturally and linguistically representative of the populations served (WIC § 5892(k)(5));  

  • Each county Integrated Plan must describe how the county will provide high-quality, culturally responsive, and timely care across the full behavioral health continuum (WIC § 5963(a)(1)), address disparities, and include a workforce strategy that ensures a network of providers that are culturally and linguistically concordant with the communities served and robust enough to achieve the statewide and local behavioral health goals and measures. (WIC § 5963.02(c)(8)); 

  • Community planning processes must affirmatively reach out to culturally and linguistically diverse stakeholders (WIC § 5963.03). 

Historically, DHCS has required Medi-Cal Behavioral Health Plans (BHPs)—i.e., Specialty Mental Health Services (SMHS) and Drug Medi-Cal Organized Delivery System (DMC-ODS) programs—to submit cultural competence plan (CCP) reports and annual updates, as required under regulation (9 C.C.R. § 1810.410) and outlined in counties’ Medi-Cal contracts with DHCS and Information Notices 10‑02 and 10‑17 and their associated enclosures, issued in 2010. 

Since that time, California’s behavioral health landscape has evolved significantly. CCP related policy expectations—particularly those related to disparity identification, community engagement, workforce development, and language access—are now captured through Behavioral Health Act Service (BHSA) implementation and reporting mechanisms. In addition, certain MHSA based requirements, which sunset on June 30, 2026, were referenced in prior CCP guidance further necessitating an updated approach aligned with BHSA.  

DHCS has superseded Information Notices 10-02 and 10-17 with updated policies on culturally responsive and linguistically appropriate care, as set forth in a forthcoming BHIN and further described in this section of the BHSA County Policy Manual. Effective in 2026, BHPs are no longer required to submit standalone CCP reports. Instead, counties will satisfy CCP regulatory requirements under 9 C.C.R. § 1810.410 through existing BHSA reporting requirements and Medi-Cal reporting requirements including but not limited to provider directory requirements established under BHIN 25-026.  

Beginning in 2028, DHCS will add a limited number of questions and prompts related to culturally responsive and linguistically appropriate care to the IP/AU, and progress will be captured in the BHOATR.  

With these new updated reporting and planning requirements, DHCS has strengthened and streamlined its approach to culturally responsive and linguistically appropriate care by leveraging the BHSA implementation framework, bolstering quantitative metrics, consolidating county reporting requirements, and seeking alignment across NSMHS and SMHS delivery systems through contracting.   

This section describes updates to county requirements for culturally responsive and linguistically appropriate care, including the new reporting requirements, organized as follows: 

  • Strategies for reducing racial, ethnic, and linguistic disparities 

  • Workforce development and training; and 

  • Approach for ensuring language access.  

The updated requirements described below advance National CLAS standards, which were established by the U. S. Depart of Health and Human Services Office of Minority Health in 2010 (enhanced in 2013) to advance health equity, improve quality and reduce disparities. The focus of DHCS updated requirements is on CLAS standards related to measurement, workforce and language access. 

C.4.1.1 Strategies for Reducing Disparities

DHCS recognizes that identifying racial, ethnic, and linguistic disparities—and implementing culturally responsive strategies to address them—is essential to advancing equity in behavioral health outcomes and achieving the BHSA’s goals. This priority aligns closely with the National CLAS Principal Standard, which calls for effective, equitable, understandable, and respectful quality care and services, and with CLAS Standard 11, which emphasizes data-driven efforts to evaluate and improve service delivery and health equity. Without sustained, data-driven action, the BHSA’s expanded services and equity requirements will not fully reach the communities experiencing the greatest gaps in access, utilization, and outcomes. 

Beginning in 2028, counties must provide more details on their disparity reduction strategies in their IP/AU. To inform these strategies, counties will be expected to leverage core BHSA elements and take the following actions: 

  • Conduct Data-Driven Assessments of Local Need to Inform Planning. In the BHSA Integrated Plan, counties must use BHT performance measures and other relevant state and local data to identify disparities, workforce and training gaps, and language access needs. Counties must demonstrate in their IP how this data informed their disparities strategy.   

  • Meaningfully Engage Culturally and Linguistically Diverse Communities in Planning. In developing the culturally responsive and linguistically appropriate care strategy in their IPs, counties must convene and engage a committee that is focused on this work and includes representation from culturally and linguistically diverse communities to inform the development of the disparity reduction strategy articulated in their IP.  

    • To reduce duplication, counties may align this engagement with broader IP community planning where feasible. Counties may choose whether to maintain a standalone Cultural Competence Committee, which historically have been the primary stakeholder engagement forums for CCPs, to support this engagement, or incorporate this engagement in community planning forums established for the BHSA. Counties may also partner with community-based organizations, trusted messengers, and culturally and linguistically appropriate focus groups or town halls and ensure programs, services and stakeholder materials are culturally responsive and linguistically appropriate.  

    • Counties must at minimum engage stakeholders to understand how disparities appear in practice and to elicit input on community-based, culturally grounded interventions—including community-defined evidence practices (CDEPs)—that build trust and promote healing and stability.   

    • Counties must summarize recommendations from stakeholders and how they informed their disparity reduction strategy in the IP.  

C.4.1.2 Workforce Development and Training

The BHSA establishes workforce development as a core equity strategy and allows counties to invest in a culturally and linguistically concordant workforce, with BHSS funds available to support training, recruitment, retention, workforce diversity, and integration of individuals with lived experience. See Section A.4 of this Policy Manual for detail on allowable uses. In addition, county contracts with DHCS also outline specific obligations for counties to train their staff and contracted providers under the Medi-Cal Behavioral Health Delivery System. This priority aligns with National CLAS Standards 3 and 4, which emphasize recruiting, promoting and training a workforce to respond to the cultural and language needs of the population.

Beginning in 2028, counties must provide more details on their workforce development and training strategies in their IP/AU. To inform these strategies, counties will be expected to leverage core BHSA elements and take the following actions:

  • Assess Workforce and Training Capacity and Gaps. Through the IP, counties must analyze their capacity and gaps related to workforce and training, with attention to cultural and linguistic discordance and especially for threshold languages spoken in the county. "Threshold Language" means a language that has been identified as the primary language, as indicated on the Medi-Cal Eligibility Data System (MEDS) of 3,000 beneficiaries or five percent of the beneficiary population, whichever is lower, in an identified geographic area (Cal. Code Regs. tit. 9, § 1810.410(a)).

  • Meaningfully Engage Culturally and Linguistically Diverse Communities in Planning. In developing the workforce development and training strategy in their IPs, counties must convene and engage a committee that is focused on delivering culturally responsive and linguistically appropriate care and includes representation from culturally and linguistically diverse communities.

    • As noted in Section C.4.1.1, counties may align this engagement with broader IP community planning where feasible.

    • Counties must at minimum engage stakeholders to understand community workforce needs, training gaps, and provider-client concordance and to identify effective strategies for improvement. 

    • Counties must summarize recommendations from stakeholders and how they informed their workforce development and training strategy in the IP.

C.4.1.2 Approach to Ensuring Language Access

Language access includes ensuring that populations with limited English proficiency (LEP) have access to services and resources such as bilingual services, oral interpreter services, and written translation of materials. Counties are responsible for ensuring that their subcontractors and network providers comply with all applicable requirements related to language access under the Medi-Cal program, as well as those applicable to BHSA under state and federal laws and regulations, the counties’ contracts with DHCS, this Policy Manual, and other DHCS guidance.

Adequate language access is foundational to achieving the BHSA goal of reducing disparities and delivering culturally responsive and linguistically appropriate care. This priority aligns with National CLAS Standards 5 and 8, which emphasize providing no-cost language assistance to LEP individuals and easy-to-understand written materials that support timely access to care and services.

Beginning in 2028, the IP/AU will include more specific questions about counties’ language access strategies. To inform these strategies, counties will be expected to leverage core BHSA elements and take the following actions:

  • Conduct Data-Driven Assessments of Local Need to Inform Planning. Counties must review relevant BHT performance measures to identify language access gaps, specifically related to threshold languages spoken in the county, oral interpreter services, written translation of materials in threshold languages, and services in non-threshold languages.

  • Meaningfully Engage Culturally and Linguistically Diverse Communities to Inform Planning. In developing the language access strategy in their IPs, counties must convene and engage a committee that is focused on delivering culturally responsive and linguistically appropriate care and includes representation from culturally and linguistically diverse communities. As noted in Section C.4.1.1, counties may align this engagement with broader IP community planning where feasible.

    • Counties must at minimum engage stakeholders to understand language needs and effective strategies for meeting those needs. 

    • Counties must summarize recommendations from stakeholders and how they informed their language access strategy in the IP.

C.4.2 Statewide Disparity Reduction Targets

Recognizing the importance of taking action and having accountability around reducing disparities, DHCS will not only report stratifications of BHT performance measures, but will also establish statewide disparity reduction targets for the BHT cross-goal equity measures. These targets will focus statewide attention on reducing racial, ethnic, and language disparities in access to and engagement with behavioral health services and evidence-based treatment. By establishing statewide targets, DHCS will create a shared expectation that progress on behavioral health transformation must include measurable reductions in disparities, not only overall improvements in performance.

The statewide targets for the three cross-goal equity measures will complement the stratified reporting of all BHT performance measures by identifying where targeted action is needed to close gaps between population groups. DHCS will use these targets to support transparency, guide statewide and local planning, and inform technical assistance and quality improvement activities. Counties and Medi-Cal MCPs will be expected to review performance on the equity measures, assess the drivers of observed disparities, and incorporate strategies to reduce disparities into their planning and reporting processes, including the BHSA Integrated Plan.

While DHCS is committed to ensuring that the state collectively works to improve the identified disparities in our equity measures, the department recognizes that not all counties will have disparities for the target populations identified at the state level. For counties who do not have a disparity in the population targeted for state-wide improvement, DHCS will expect those counties to work on their county-specific disparities only.

DHCS recognizes that meaningful disparity reduction will require sustained, cross-system action and that baseline performance, data quality, and available interventions may vary across counties, MCPs, and populations. Accordingly, DHCS will establish and refine targets in a manner that accounts for measure maturity, data reliability, and opportunities for improvement over time. The department will publish targets on the DHCS website and revisit the targets periodically.