Lois Wessel & Isabel Isschot - Providing care to linguistically diverse populations: The hows and whys of interpreter services
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Presented by Lois Wessel, RN, CFNP, and Isabel Van Isschot, MS, on September 26, 2013 at the fourth annual Center for Health Literacy Conference: Plain Talk in Complex Times.
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Lois Wessel & Isabel Isschot - Providing care to linguistically diverse populations: The hows and whys of interpreter services
- 1. Providing care to linguistically diverse populations: The how and whys of interpreter services Plain Talk in Complex Times 2013 Lois Wessel, CFNP, ACU, Georgetown University Isabel Van Isschott, MA, La Clínica del Pueblo www.clinicians.org
- 2. Lots to talk about today! • Understand changes in the US population • Be familiar with legal requirements on serving LEP Populations • Understand principles of providing language access services • Be familiar with developing a language access programs www.clinicians.org2
- 4. LEP in United States www.clinicians.org4
- 10. Title VI Civil Rights Act 1964 Executive Order 13166 No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance. 42 U.S.C. 2000d
- 11. Who Is Covered by Title VI?
- 12. Compliance With Title VI OCR looks at the “totality of the circumstances” balancing four factors: 1. Number or proportion of LEP persons eligible to be served or likely to be encountered; 2. Frequency with which LEP individuals come in contact with the program; 3. Nature and importance of the program, activity, or service provided by the program to people's lives; 4. Resources available and costs.
- 16. Developing Language Access Services Photo Credit: Beth Israel Deconess
- 17. LEP & Agency Identify & Assess LEP Communities Providing Services Train Staff Provide Notice of Services Monitor & Evaluate & Update Services Providing Services www.clinicians.org18 Effective Language Access Policy Directives and Implementation Plans
- 23. Roles of Interpreter: Cultural Broker www.clinicians.org
- 25. Why Can’t Family Members Help? www.clinicians.org26
- 26. Reimbursement for Interpreter Services • Via Medicaid and the Children’s Health Insurance Program (CHIP) • Via managed care organizations (MCO) • Via insurance companies • Via grants to primary care association (PCA) or government agencies • May require trained and certified interpreters
Editor's Notes
- With such a diversity of needs, how do healthcare and social service providers assess the competency of staff interpreters? What community and institutional resources are available to agencies? This session will evaluate the importance of trained medical interpreters, assess the value of using certified interpreters, and help professional evaluate how improved interpreter services would benefit their clients and staff. Use of appropriately trained interpreters has been shown to enhance therapeutic relationships between providers and patients.
- According to the US Census, more than 25 million people speak English “less than very well” and may be considered limited English proficient (LEP). Healthcare providers across the country are increasingly treating LEP patients. According to reports commissioned by the National Health Law Program:Define limited English ProficiencyUnderstand the benefits of using a trained medical interpreterExplain Title VI of the Civil Rights Act of 1964 which mandates compliance for language access in agencies receiving federal fundingRecall the difference between interpretation and translationExplain and apply each of the four main roles of the medical interpreter (conduit, message clarifier, cultural broker, patient advocate)Compare telephonic and in-person interpretationAssess interpreter training programs for qualified staffUnderstand interpreter certification programsUnderstand the implications of using untrained staff and family members for InterpretationEvaluate interpreter usage in specific facilitiesRecommend improvements to interpreter services at each facilityStrategize on reimbursement issues for use of interpretersOther Considerations:Difference between interpretation and translation Modes of Interpretation (Consecutive, Simultaneous, Sight…)Interpreter training programs for qualified staffRoles of the medical interpreter (conduit, message clarifier, cultural broker, patient advocate)Telephonic vs in-person interpretationCertification programs for Medical InterpretersImplications of using untrained staff and family members for InterpretationReimbursement issues for use of interpreters
- ALSO DEAF COMMUNITIES Migration Policy Institute has most up to date info
- 80% of hospitals encounter LEP patients frequently – 63% daily/weekly; 17% monthly81% of general internal physicians treat LEP patients frequently – 54% at least once a day or a few times a week; 27% a few times per month84% of FQHCs provide clinical services daily to LEP patients – 45% see more than ten patients a day; 39% see from one to 10 LEP patients a day. The foreign-born, limited English proficient (LEP) population age 5 and older in the United States increased by 30.7 percent between 2000 and 2011.
- About 2 to 4 of every 1,000 people in the United States are "functionally deaf," though more than half became deaf relatively late in life; fewer than 1 out of every 1,000 people in the United States became deaf before 18 years of age.However, if people with a severe hearing impairment are included with those who are deaf, then the number is 4 to 10 times higher. That is, anywhere from 9 to 22 out of every 1,000 people have a severe hearing impairment or are deaf. Again, at least half of these people reported their hearing loss after 64 years of age.Finally, if everyone who has any kind of "trouble" with their hearing is included then anywhere from 37 to 140 out of every 1,000 people in the United States have some kind of hearing loss, with a large share being at least 65 years old.
- ScaredWorried due to reading level—IOMCoping techniquesdenial
- "Your Lusts For The Future"In 1977 United States President Jimmy Carter traveled to Poland. The U.S. State Department hired an interpreter who did not have much professional experience. Through the interpreter, President Carter said things like, "when I abandoned the United States." What he actually said was, "When I left the United States." At another point the President used the phrase, "your desires for the future." Unfortunately, that phrase was interpreted as, "your lusts for the future."
- STATE LAWSJoint COMMISSIONNCQAOn April 21, 2004, the District of Columbia enacted a fundamental piece of civil rights legislation—the DC Language Access Act of 2004. The Act holds covered agencies accountable for providing the District’s limited and non-English proficient (LEP/NEP) residents with greater access to and participation in their programs, services and activities. The Act identifies the Office of Human Rights (OHR) as the agency designated to oversee and enforce the implementation of the law. OHR houses the District’s Language Access Program whose mission it is to provide oversight, central coordination, and technical assistance to covered agencies in their implementation of the law.Know your rights, compliance records, language surveys, file a complaint, interpreters oath document, data sourcesNCQAMCOFrom Joint Commission:Abstract: Language Proficiency and Adverse Events in U.S. Hospitals: A Pilot StudyDivi C, Koss RG, Schmaltz SP, Loeb JM. Language Proficiency and Adverse Events in U.S. Hospitals: A Pilot Study. International Journal for Quality in Health Care 2007; 19: 60-67.Objectives: Differences in the characteristics of adverse events between English speaking patients and patients with limited English proficiency in US hospitals were examined.Methods: Adverse event data on English speaking patients and patients with limited English proficiency were collected from six hospitals over 7 months in 2005 and classified using the National Quality Forum endorsed Patient Safety Event Taxonomy.Results: About 49.1% of limited English proficient patient adverse events involved some physical harm whereas only 29.5% of adverse events for patients who speak English resulted in physical harm. Of those adverse events resulting in physical harm, 46.8% of the limited English proficient patient adverse events had a level of harm ranging from moderate temporary harm to death, compared with 24.4% of English speaking patient adverse events. The adverse events that occurred to limited English proficient patients were also more likely to be the result of communication errors (52.4%) than adverse events for English speaking patients (35.9%).Conclusions: Language barriers appear to increase the risks to patient safety. It is important for patients with language barriers to have ready access to competent language services. Providers need to collect reliable language data at the patient point of entry and document the language services provided during the patient–provider encounter.
- OMH The CLAS standards are primarily directed at health care organizations; however, individual providers are also encouraged to use the standards to make their practices more culturally and linguistically accessible. The principles and activities of culturally and linguistically appropriate services should be integrated throughout an organization and undertaken in partnership with the communities being served. The 14 standards are organized by themes: Culturally Competent Care (Standards 1-3), Language Access Services (Standards 4-7), and Organizational Supports for Cultural Competence (Standards 8-14). Within this framework, there are three types of standards of varying stringency: mandates, guidelines, and recommendations as follows: CLAS mandates are current Federal requirements for all recipients of Federal funds (Standards 4, 5, 6, and 7). CLAS guidelines are activities recommended by OMH for adoption as mandates by Federal, State, and national accrediting agencies (Standards 1, 2, 3, 8, 9, 10, 11, 12, and 13). CLAS recommendations are suggested by OMH for voluntary adoption by health care organizations (Standard 14). Standard 1Health care organizations should ensure that patients/consumers receive from all staff member's effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. Standard 2Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area. Standard 3Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. Standard 4Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. Standard 5Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. Standard 6Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). Standard 7 Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. Standard 8Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services. Standard 9Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations. Standard 10Health care organizations should ensure that data on the individual patient's/consumer's race, ethnicity, and spoken and written language are collected in health records, integrated into the organization's management information systems, and periodically updated. Standard 11Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area. Standard 12Health care organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities. Standard 13Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers. Standard 14Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information. OMH issued Culturally and Linguistically Appropriate Services Standards (2001)Standards 4-7 address language accessHealth care organizations must:offer and provide language assistance services at no cost at all points of contact, in a timely manner during all hours of operationsprovide in patients’ preferred language both verbal offers and written notices of the right to receive language servicesassure the competence of language assistance; family and friends should not be used to provide interpretation services (except on request by the patient)make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.
- Conducting a self assessment to determine what types of contract your agency has with LEP populationsDeveloping a policy, plan and procedure
- How LEP individual interact with your agency (hotline, outreach, public meetings, in person, over the phone)ID and assessment of LEP communities---how many from each language group/ What are the characteristics? Data form Census, D of Ed, federal interagency working group on LEP, state and local gov, faith based groups, community groups LEP services in place—oral and writtenTrain staff on Policies and proceduresProvide notice of LEP services (I speak cards, bilingual on hold messagesSurvey staff on how often they use services, customer satisfaction surveys, observation, feedback from community groups, keep current on demographics, collaborate with other agencies, monitor agency’s response to complaints or suggestions, keep records.
- Department of Economic Security – database does not proceed past certain fields without noting the client’s language needsclients are asked their primary language at initial and renewal interviewsincludes 68 language choices plus an open-ended optionAS CLINICS MOVE TO OPEN ACCESS, YOU MAY NOT BE ABLE TO PLAN FOR SERVICES, TELEPHONIC IS KEY.Resources for demographic info---US census, brookings, migration polictyinstitue.
- English. MobileMed is committed to providing culturally-sensitive and language-appropriate care for each patient. High-quality interpretation services enhance the quality of clinical care provided by MobileMed. There are several ways in which interpretation services are provided at MobileMed. Guidelines and Procedures:The Clinical Team will make every effort to “match” a patient who speaks another language with a MobileMed provider who speaks that language when possible. This may be done by the telephone receptionist/scheduler when scheduling an appointment or by the nurse coordinator at the time of the visit. At many MobileMed clinical sites, the community partner organization will be responsible for providing interpretation services through their staff and/or volunteer corps.On-site interpreters for Spanish and French may be requested through CASA of Maryland (Telephone 202-431-4185)Family members may act as the interpreter if the patient insists. However, this is not to be encouraged as it may decrease the quality of the interpretation.The LLE-Link, a telephone-access interpreter service, may be used for languages that are not common and for those occasions on which an on-site interpreter is not available. Procedure for Using the LLE-Link Use a speaker cell phone or telephone. If you are working with a patient on the telephone, use “Conference Hold” to place the patient on hold while you connect with the LLE-Link.Dial 1 -866-794-3372 Enter/say the Montgomery Client Cares code: 153823Enter/say the MobileMed Client ID: 6405Enter the language code (see attached list)Briefly explain the purpose of the conversation to the interpreter and give him/her the telephone number you are calling from, so he/she can call you back if disconnected.If working with a patient over the telephone, add them to the call.
- Medical Assistance Administration worked with community advocates to develop its “I Speak” poster and cards and a “Know Your Rights” pamphlet
- SkillsPart of the teamNational accreditation standardsTraining bilingual staffQualifiying bilingual providers
- We see gender, approximate age, dress style, physical characteristics---on the surfaceWe don’t see what’s below the surfaceConduit, message clarifier, cultural broker, patient advocate
- Use of family membersNon-trained interpretersAsking patients to interpret for other patientsAsking patients to bring interpretersInappropriate use of bilingual staffIt is not recommended that family members serve as interpreters except in cases of emergency and when an interpreter is not available. Information needed could be of a sensitive nature and could compromise information that you might get from the patient. The patient may not want other family members knowing the history of what has occurred.Non-trained interpreters may not be familiar with medical terminology or know the correct process for sharing information.Asking patients to interpret for other patients raises questions around confidentiality and medical liability. In addition, patients may not be familiar with medical terminology or how to interpret what is being conveyed. This individual may summarize what they thought the clinician was asking.Patients may want to bring an interpreter. In addition, there are some community individuals who offer their services but have not been trained in medical interpreting. Although they may be well intentioned, they may not be able to adequately assist the patients. Patients need to know ahead of the appointment that the clinic can provide interpreter services.Often staff may be bilingual. However, if this job responsibility is not part of their job description, the individual and the clinic can be held liable if there is an adverse medical event that occurs as a result of the staff member providing translation services. If this person is going to be used as a interpreter, the individual should receive training and this job function should be listed in their job description.
- Payments for interpreters, translators – statewide Medicaid/SCHIP Programs – only a handful of states have set up programs to provide direct reimbursementExisting programs – DC, HI, ID, KS, ME, MN, MT, NH, UT, VA, VT, WA, WYComing attractionsCT passed legislation in JulyTX to start pilot programNC initiating credentialing prior to reimbursementCA – Medi-Cal Language Access TaskforcePayments for interpreters, translators – statewide Medicaid/SCHIP Programs – only a handful of states have set up programs to provide direct reimbursementExisting programs – DC, HI, ID, KS, ME, MN, MT, NH, UT, VA, VT, WA, WYComing attractionsCT passed legislation in JulyTX to start pilot programNC initiating credentialing prior to reimbursementCA – Medi-Cal Language Access TaskforceNHeLP’s Language Access webpagehttp://www.healthlaw.org/library/folder.56882“Medicaid and SCHIP Reimbursement Models for Language Services”50 state law survey on language access statutes/regulations related to healthcareLanguage Services Resource Guide for Healthcare Providers – helps identify external resources including interpreter/translator associations and providers; training programs; translated materials; symbols; etc.