PROVIDING LANGUAGE SERVICES IN SMALL HEALTH CARE PROVIDER SETTINGS: EXAMPLES FROM THE FIELD Mara Youdelman and Jane Perkins National Health Law Program FIELD REPORT April 2005 ABSTRACT: Changing demographics, along with heightened federal and state policies, have increased the need for effective models of providing services to individuals who are limited English proficient (LEP). Unfortunately, many providers are challenged by a shortage of knowledge and resources, which can create barriers to care. To assess current innovations, the National Health Law Program conducted site visits and phone interviews at small health care provider settings. Certain services emerged as “promising practices”—creative, effective methods that are replicable by other small providers. These practices include recruiting bilingual staff for dual roles (e.g., front desk and interpreter positions); ongoing cultural and language competency training for interpreter staff; using community resources like hospitals, managed care organizations, students, and volunteers; and capitalizing on underutilized funding sources. The authors include an eight-step plan to help providers develop a strategy to meet the needs of their LEP patients and the community.
Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and should not be attributed to The Commonwealth Fund or its directors, officers, or staff. Additional copies of this Commonwealth Fund publication are available on the Fund’s Web site at www.cmwf.org and the National Health Law Program’s Web site at www.healthlaw.org. To learn about new Fund publications when they appear, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 810.
CONTENTS About the Authors.......................................................................................................... iv Acknowledgments .......................................................................................................... iv Executive Summary........................................................................................................ vi Introduction .................................................................................................................... 1 Promising Practices for Small Health Care Providers ........................................................ 3 Examples from the Field ................................................................................................ 12 Solo Practitioners and Small Group Settings ............................................................. 12 Community Clinics and Health Centers................................................................... 21 Family Planning Clinics ........................................................................................... 38 Assistance to Small Providers from Other Systems/Institutions ................................. 48 Appendix A
Summary of Surveyed Models for Providing Language Assistance Services in Small Health Care Provider Settings ...................... 62
Suggested Plan for Implementing Language Services ............................... 69
Project Methodology.............................................................................. 75
ABOUT THE AUTHORS Mara Youdelman, J.D., L.L.M., has been a staff attorney in the National Health Law Program’s (NHeLP’s) Washington, D.C., office for over four years. She works on issues such as language access, civil rights, Medicaid, and racial and ethnic disparities in health care. She received her J.D. from Boston University School of Law and her L.L.M. from Georgetown University Law Center. Jane Perkins, J.D., M.P.H., has been with the National Health Law Program for two decades. Currently NHeLP’s legal director, she is a nationally recognized expert in Medicaid, children’s health, and civil rights. She received her J.D. from the University of North Carolina at Chapel Hill School of Law and her M.P.H. from the University of California, Berkeley, School of Public Health.
ACKNOWLEDGMENTS This report could not have been written without the generous assistance of The Commonwealth Fund. We specifically would like to thank Anne Beal for her assistance. In addition, our thanks are due to all the individuals who completed the survey. Special thanks also go out to the individuals and their staff members who provided indepth information about the programs highlighted in this report. These individuals are: Javier Aceves (Young Children’s Health Center); Mika Aoki (Asian Pacific Health Care Venture); Sonia Bouvier (Hampshire Health Connect); Joan Brinkman (Family Health Services); Vida Day (El Puente); Ardith Ferguson (Kids Connection); Kathy Ficco (Saint Joseph Health System Community Health Programs); Stacie Hardie (Washoe County District Health Department); Alexandria Hurtado (North DeKalb Health Center); Jan Korytoski (Cooley-Dickinson Hospital); Dinny Nielsen (Women’s Health and Education Center); Julia Ostropolsky (Bilingual International Assistant Services); Nancy Sayers (Mount Olive Pediatrics); Philip Siu (Chinatown Pediatric Services); Beatriz Solis (L.A. Care Health Plan); Lillian Tamayo (Planned Parenthood of the Palm Beach and Treasure Coast Area); Peg Welch (Planned Parenthood of Pennsylvania); Mary Ellen Zapata (Neponset Health Center); and Vincent Zarro and Barbara Hogan (Chinatown Clinic of Drexel). Additional individuals and organizations assisted in disseminating the surveys. We wish to thank Alice Chen (Asian Pacific Islander American Health Forum); Vincent Eng (National Asian Pacific American Legal Consortium); Adey Fisseha and Essence Ward iv
(National Immigration Law Center); Laura Hessberg (National Family Planning and Reproductive Health Association); Norman Kahn and Sheri Porter (American Academy of Family Physicians); Graham Newson and Jennifer Michael (American Academy of Pediatrics); and Kathy Poulos-Minott (National Limited English Proficiency Task Force) and the National Council of Interpretation in Health Care. Finally, we would like to thank three volunteers/interns who provided assistance in gathering and assembling information and conducting telephone surveys: Tiffany Brown, Laureen Pak, and Kelly Trahan.
This report describes a variety of ongoing activities designed to improve language services in small health care settings. Inclusion in this report does not signify endorsement by the National Health Law Program (NHeLP). NHeLP offers this information to help interested persons understand the variety and complexity of language services.
EXECUTIVE SUMMARY Today, hundreds of languages are spoken in both urban and rural areas of the United States. These changing demographics, as well as heightened federal and state policies, have increased the need for effective and efficient models of providing language services to individuals who are limited English proficient (LEP). As noted by a private pediatric practitioner in rural North Carolina, the increasing commitment to the LEP population is “driven less by the necessity to follow federal law than by our realization that these children are part of our future.” Small group practices compose a sizeable portion of the U.S. health care delivery system. These practices have the potential to serve significant numbers of LEP patients, but only if language services are available. According to the American Medical Association (AMA), 59 percent of all physicians are in solo practice or are self-employed in group practices. Group practices are primarily small, with 46 percent having three or four physicians. Further, 50.3 percent of all single-specialty groups and 61.8 percent of all family/general practice groups have three or four physicians. The Institute of Medicine reports that 51 percent of providers surveyed believe patients do not adhere to treatment because of culture or language. At the same time, 56 percent of these providers reported having received no language or cultural competency training. Unfortunately, many providers are challenged by a shortage of knowledge and resources, which can create barriers to care. Resource constraints include a deficiency of bilingual providers and trained professional interpreters and inadequate reimbursement for language services by insurers such as Medicaid and Medicare. To assess current innovations in language service programs and activities, the National Health Law Program (NHeLP) conducted 11 site visits and seven phone interviews at small health care provider settings, defined as those with 10 or fewer clinicians. Promising, replicable activities were identified in the following areas: •
Language access planning. Most providers interviewed for this project have designated a staff member to coordinate language service activities. Small health care providers are also developing written language plans, as suggested by the U.S. Department of Health and Human Services’ Office for Civil Rights. These plans identify language needs and propose strategies for meeting those needs.
Determining language needs at first points of contact. Some small health care providers are taking steps to introduce language access at the first points of vi
patient contact. For example, “I Speak . . .” posters and cards, which identify patients’ language needs as soon as they walk through the door, are being used by front-desk staff. •
Bilingual mid-level practitioners. A limited supply of bilingual physicians, along with heavy competition to hire those physicians, has motivated some provider sites to focus on recruiting and hiring bilingual mid-level staff, like certified nurse practitioners.
Dual role bilingual staff. Many of the small provider sites assessed are hiring bilingual office staff to perform multiple roles, including language assistance tasks. For example, individuals with conversational proficiency in a second language may provide limited services at the front desk (e.g., answering phones, scheduling appointments) while those with medical proficiency may interpret for patients during medical or clinical visits.
Dedicated staff interpreters. Particularly in communities with heavy demand for services in a particular language, small provider sites may hire full- or part-time, on-site interpreters.
Contract interpreters. Providers are also considering interpreters who are available to work on contract with small provider sites. Potential sources for hiring such interpreters include area hospitals, state or local agencies, refugee resettlement sites, community-based organizations, or commercial entities.
Community resources. Small health care providers can work with entities or individuals in their communities to improve the provision of language services. These may include local hospitals, managed care organizations, community-based organizations, community colleges, and former patients and their family members.
Interpreter competency. Small health care providers are increasingly taking steps to improve the competency of bilingual staff who serve as interpreters. Onthe-job training is offered in some sites by bilingual, mid-level practitioners and office administrators, who are also used to assess language skills during the hiring process and to evaluate new staff in training. Community training resources, available through local hospitals and community colleges, are also being used to improve interpreter skills.
Telephone language lines. Some small provider sites are developing ways to make telephone language lines (i.e., services that offers interpreters via telephone) accessible to both providers and patients. Some sites have placed speaker phones in examination rooms, while other providers carry cell phones with speakers that can be easily exchanged between provider and patient. vii
Use of family and friends. A growing number of small providers are seeking to minimize their reliance on using family or friends of patients as interpreters. Where family members are still being used, some providers will attempt to have a trained interpreter sit in during the medical encounter or follow up with the family within 24 hours to verify the patient’s condition.
Language services throughout the patient encounter. Because LEP patients experience language barriers throughout the health care encounter, small health care providers are using interpreters to assist the individual throughout intake, clinical encounter, and follow-up.
Written translations. When evaluating the need for translated materials, small health care providers are making extensive use of existing materials. Sites are using translated materials offered by various organizations, Web-based materials from federal and state governments, and materials downloaded from health departments in other countries such as Taiwan and Hong Kong. Small provider sites are also working with bilingual staff, contract interpreters, local hospitals, and faith-based organizations to translate documents.
Patient satisfaction. Small providers are monitoring patient satisfaction as they continue to evaluate and expand their language services. This may be as simple as patient-charting notations or more formal patient surveys.
Funding opportunities. Small health care providers are seeking funding from a variety of sources, including federal, state and local governments; foundations; and nonprofit organizations.
The results here represent one step in the task of identifying the many models of providing linguistic access and cultural competency in health care. The activities described clearly demonstrate that one size does not fit all when it comes to providing language services. Rather, the nature, scope, and delivery approach will vary from state to state, community to community, and from one provider site to another. However, by borrowing and tailoring the activities already under way, small health care providers can make great strides toward improving health care access. Small providers who are developing language services should follow the following eight-step process: Step 1. Designate responsibility. Step 2. Conduct an analysis of language needs. Step 3. Identify resources in the community. Step 4. Determine what language services will be provided. viii
Step 5. Determine how to respond to LEP patients. Step 6. Train staff. Step 7. Notify LEP patients of available language services. Step 8. Update activities after periodic review. While determining appropriate language services will depend on individual circumstances, small health care providers have an array of options that can be tailored to meet the needs of their LEP patients. Based on practice type, setting, size, and location, providers can choose from services including hiring bilingual practitioners or staff, using in-person or telephone interpreters, coordinating with other providers to share resources and costs, and partnering with larger health care entities or systems.
PROVIDING LANGUAGE SERVICES IN SMALL HEALTH CARE PROVIDER SETTINGS: EXAMPLES FROM THE FIELD INTRODUCTION Hundreds of languages are spoken in both urban and rural areas of the United States. Estimates of the number of limited English proficient (LEP) individuals range from almost 11 million people who speak English “not well” or “not at all” (4.2% of the population) to over 21 million who speak English less than “very well” (8.1% of the population).1 In the health care arena, where the transfer of accurate and often complex information is critical, this latter group represents an important population segment. Between 1990 and 2000, the population of foreign-born residents surged by 57 percent, a wave of immigration unsurpassed by even that of the last century’s first decade. Some states’ LEP populations are significant: California (where 20% report speaking English less than “very well”), Texas (13.9%), New York (13%), Hawaii (12.7%), New Mexico (11.9%), Arizona (11.4%), Nevada (11.2%), New Jersey (11.1%), Florida (10.3%), and Illinois (9.1%). Notably, LEP populations are increasing most rapidly outside urban states, with the largest gains in North Carolina, Georgia, Nevada, Arkansas, and Nebraska.2 Language Services in Small Health Care Provider Settings Small group practices compose a sizeable portion of the U.S. health care delivery system. According to the American Medical Association, 59 percent of all physicians are in solo practice or are self-employed in group practices.3 Group practices are primarily small—46 percent have three or four physicians. In addition, 50.3 percent of all single-specialty groups and 61.8 percent of all family/general practice groups have only three or four physicians.4 According to the American Academy of Pediatrics, 64 percent of pediatricians practice in office-based settings, with 10.6 percent self-employed in solo practice, 5.9 percent in two-physician practice, and 28.5 percent in pediatric group practice. There is a critical need for efficient and effective language access services in small provider settings, as illustrated by the following stories (as told to NHeLP staff): •
An elderly Vietnamese man visited a dental clinic for treatment. Without an interpreter, the man was told to sign an English-language consent form authorizing the extraction of many teeth. The man put his mark in the signature space, was placed under anesthesia, and awoke to discover what had been done.
A Vietnamese man suffering from a skin condition requiring laser treatment underwent treatment at a county clinic for more than one year. The man endured days of pain after each treatment, but was unable to communicate this because there was no interpreter available. Only after a community organization intervened did the clinic understand the patient’s pain and adjust the treatment.
A Russian woman was told by an eye clinic that she needed surgery for glaucoma. No one explained the procedure to her in Russian and she refused it out of fear. When a local community organization provided an interpreter, the patient was able to understand the risks and benefits and immediately opted to have the procedure performed.
A Russian-speaking patient with potentially life-threatening high blood pressure was not provided with an interpreter. When a trained interpreter from a community organization talked to the man, he revealed he had been cutting his blood pressure pills in half so they would last longer. Through the interpreter, the patient was educated about the need to take the prescribed dosage.
Research verifies these anecdotal data. One study found that language barriers are as significant as the lack of insurance in predicting Latinos’ use of health services.5 It noted decreased use of physician services by Latinos who have difficulty speaking English and revealed that more than one-half of these patients rated their usual health care as fair or poor. The Commonwealth Fund’s 2001 Health Care Quality Survey reported similar conclusions. In Hispanic populations, the study found, adults who do not speak English fluently have greater difficulty communicating with their health care providers, which leads to inequities in access and compromised quality of care.6 Unfortunately, many providers are challenged by a shortage of resources and knowledge, which can create barriers to care. Logistical and resource constraints include a deficiency of trained interpreters and translators and inadequate reimbursement for language services by insurers like Medicaid and the State Children’s Health Insurance Program (SCHIP). Lack of knowledge is also significant. The Institute of Medicine reports that 51 percent of providers surveyed believe patients do not adhere to treatment because of culture or language. At the same time, 56 percent of these providers reported receiving no language or cultural competency training. In 2002, the Kaiser Family Foundation found most doctors believe that health care disparities “rarely” or “never” occur based on factors like fluency in English or racial or ethnic background.7
The Need for Promising Practices Promising practices and innovations can help small health care providers better understand the needs of their communities, meet the needs of their patients, and decrease the unnecessary use of hospital emergency rooms by immigrant populations. Identifying promising practices will also help providers meet their responsibilities under Title VI of the Civil Rights Act of 1964. Guidance developed by the U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) explains how Title VI applies to all federally funded providers, including small providers. Taking their size into account, OCR expects these providers to ensure meaningful access for LEP populations.8 PROMISING PRACTICES FOR SMALL HEALTH CARE PROVIDERS During the winter and spring of 2004, the National Health Law Program (NHeLP) conducted a survey to identify organizations working on language and LEP issues. From more than 50 completed surveys, NHeLP selected programs for more in-depth assessment, ultimately conducting 11 site visits and seven in-depth telephone interviews to explore the nature and extent of language services in small provider settings. (For a more detailed description, please see the project methodology in Appendix C.) The health care providers and staff who were interviewed for this project repeatedly noted that it takes time to develop language services and that it is important to think creatively to implement effective language services and keep costs manageable. Certain services—described below—emerged as “promising practices.” These practices were not necessarily grand or expensive. Instead, they represented creative and effective methods of providing language services in a way that is replicable by other small providers. To maximize resources and minimize costs, provider sites should look to share information and, if appropriate, pool resources. More details regarding how these practices are implemented at the survey sites are available in Appendix A. Language Access Planning Most small providers interviewed for this project have designated a staff member to coordinate language service activities. By placing responsibility with a single individual, there is a greater assurance that language needs will be assessed, potential activities and costs analyzed, and programs developed. A language services coordinator will quickly become familiar with the service needs of the LEP population, the resources available in the community, and potential partners and funding sources for meeting the identified needs.
Small health care providers can develop written language plans, as suggested by OCR. These plans should identify language needs and set forth the entity’s strategy for meeting those needs. Having such a plan also is evidence of a provider’s compliance with Title VI. One of the surveyed providers has developed a written compliance manual that is distributed to all staff and used for training purposes (Asian Pacific Health Care Venture). In addition to establishing the language service delivery plan, the manual includes copies of staff interpreter job descriptions, language service protocols, training modules for bilingual staff, and translations of vital documents. 9
Determining Language Needs at First Points of Contact Small health care providers should take steps to introduce language access at the first points of patient contact. For example, “I Speak . . .” posters and cards are used by front desk staff to identify patients’ language needs as soon as they walk through the door (North DeKalb Health Clinic; L.A. Care Health Plan). The signs, which are simple for both patient and staff to use, list the various languages spoken in the service area. The patient simply points to his or her language and the front desk staff see the name of the language written in English. “I Speak . . .” materials can be downloaded from the federal government’s language site.10 Addressing telephone reception issues can also help to ensure LEP patients can effectively communicate with office staff. At Planned Parenthood of Pennsylvania, bilingual staff members generally answer the telephone; if not, an English-speaking staff member will immediately request assistance from a bilingual staff person. Washoe County Family Planning Program (Reno, Nev.) hires only bilingual support staff to ensure consistent coverage. In addition, it is essential to ensure that answering services or telephone answering machines provide information to LEP individuals, particularly after-hours callers. In areas where language needs are emerging, some sites are beginning to deal with telephone reception by including statements in multiple languages that inform callers how to contact emergency services. For example, the answering machine at Chinatown Pediatric Services (Philadelphia, Pa.) has messages in English and Mandarin. At St. Joseph Health System Community Health Programs (Santa Rosa, Calif.), the answering service has Spanishspeaking staff. North DeKalb Health Center (Chamblee, Ga.) has a bilingual Spanishspeaking advice nurse available after hours. Patients who speak other languages are connected to a local hospital’s interpretation service, which connects patients to bilingual hospital employees or language lines for assistance.
Once language needs are identified, small providers can create an easily accessible record of the language spoken. Many providers have developed coding for their computer systems, while others make chart notations. For example, physicians and clinics participating in L.A. Care Health Plan receive small, brightly colored stickers that can be affixed to the patient’s medical record to identify language needs and document that interpreter services have been accepted or declined. These notices allow any provider working with the patient to swiftly identify needs and past interpreter preferences. The Women’s Health and Education Center (Marshalltown, Iowa) notes clients’ language needs in its schedule and computer data system to ensure interpreters are available for each visit. Bilingual Mid-Level Practitioners Small health care providers are focusing on recruiting and hiring bilingual physicians. To date, however, the limited number of bilingual physicians and heavy competition to hire them has made this strategy successful mainly in urban areas. Thus, other provider sites are focusing on recruiting and hiring bilingual mid-level staff. For example, Mt. Olive Pediatrics, a private pediatric practice in rural North Carolina, has worked to hire bilingual certified pediatric nurse practitioners and certified nurse practitioners. These mid-level practitioners provide services to LEP patients, review and assist with written translations, and offer on-the-job language and cultural competency training to the remaining staff. While primarily used to provide services, these staff members also interpret for Englishspeaking providers in the practice. Bilingual Staff Trained as Interpreters Many of the small provider sites assessed for this project are hiring bilingual, non-clinical office staff and using them to perform specific language assistance tasks. For example, individuals with conversational proficiency may provide limited services at the front desk (e.g., answering phones, scheduling appointments), while those with proficiency in medical terminology may interpret during medical or clinical visits. For example, the Women’s Health Education Center (Marshalltown, Iowa) has two staff members who serve as both interpreters and accounting assistants. St. Joseph Health System Community Health Programs (Santa Rosa, Calif.) and Planned Parenthood of Palm Beach and Treasure Coast in Florida use bilingual promotores de salud (health promoters) who serve as interpreters and also provide health information. When bilingual staff are used, it is important to define job responsibilities to include both interpreting and office staff activities, to ensure their competency, and to monitor the demands being placed on these employees.
Dedicated Staff Interpreters Particularly in communities with heavy demand for services in a particular language, small provider sites may hire dedicated on-site interpreters, either full- or part-time. For example, in Dorchester, Mass., which has many Vietnamese immigrants, Neponset Health Center employs native Vietnamese speakers trained as medical interpreters either through the Massachusetts Medical Interpreters Association or the Massachusetts Department of Public Health. Pursuant to a grant, the center placed established interpreters on a team with a psychotherapist, resulting in a tenfold increase in the number of Vietnamese clients using the center’s psychotherapy services. Contract Interpreters In some communities, there may be insufficient need in a particular language to require full-time staff interpreters. In these cases, small providers may consider interpreters who are available to work on contract. These interpreters may be hired from area hospitals, state or local agencies, refugee resettlement sites, community-based organizations, language agencies, or commercial entities. At least one provider site (Neponset Health Center) is working to establish a per-diem core of interpreters who can provide backup to staff interpreters, just as substitute teachers are used in the school system. Community Resources Small health care providers can work within their communities to improve the provision of language services. Some hospitals, such as Cooley-Dickinson Hospital in Northampton, Mass., are making language services available not only on-site but also in the offices of physicians and other health care professionals affiliated with the hospital. Johnson County Hospital (Tecumseh, Neb.), upon receiving a state minority health grant, paid for inperson and telephone language services at local clinics. Local hospitals can also agree to assess the competency of the bilingual staff at small provider sites. North DeKalb Health Center (Chamblee, Ga.), for example, requires all bilingual staff members to attend training sessions, including staff of one of its satellite clinics. Hospitals can provide interpreters to affiliated physicians with admitting privileges for assistance in making their hospital rounds. Similarly, managed care organizations can work with participating providers. For example, L.A. Care Health Plan in Los Angeles offers its participating providers translated medical glossaries that reflect the dialect spoken by Latinos in the area. It also offers medical interpreter training for bilingual staff of participating clinics and medical groups, as well as training for health care providers (for continuing medical education credit) on how to work with interpreters 6
Bilingual college and graduate students can work under the direct supervision of medical and other professional staff, providing language services for school credit or workstudy assistance. Bilingual volunteers, under the supervision of staff, can assist with frontdesk activities and depending on their language capabilities, experience, and training, with clinical encounters. Chinatown Clinic of Drexel in Philadelphia identifies former patients and family members of patients who can be trained as interpreters. These individuals are trained and assigned to shadow existing interpreters until they are experienced enough to interpret on their own. Other providers are training community members to become health promoters. These individuals assist with outreach and education throughout the community by visiting families in their homes, participating in health fairs and after-school programs, and making presentations at faith-based organizations (Saint Joseph Health System Community Health Programs; Planned Parenthood of the Palm Beach and Treasure Coast Area). Other community institutions may also offer language services to health care providers. For example, El Puente, a nonprofit organization (Jackson, Wyo.), provides medical interpretation services to all health care providers in its service area, free of charge. Interpreter Competency Small health care providers have taken steps to improve the competency of bilingual staff who serve as interpreters. Some small providers offer on-the-job training by bilingual midlevel practitioners and office administrators, who can also be used to evaluate language skills of potential hires and trainees. Small providers can make arrangements with local hospitals to assess the competency of interpreters, or they can contract with commercial services to provide this type of assessment (Saint Joseph Health System Community Health Programs). Additionally, some providers regulate the situations where staff members can interpret, based on languages and medical terminology competency. Language and cultural competency courses are increasingly available in both urban and rural communities—at colleges, state departments of public health or offices for minority health, state-based interpreter associations, and area health education centers. Home-based study is also being developed. For example, Yale University and the University of North Carolina are developing interactive, DVD-based Spanish language proficiency modules for health care professionals.11 Telephone Language Lines Small provider sites are developing ways to make telephone language lines (i.e., services that offer interpreters via telephone) more accessible to both providers and patients. Some sites have placed speaker phones in examination rooms while other providers carry cell 7
phones with speakers that can be easily exchanged between provider and patient (Family Health Services, Washoe County Family Planning Program). L.A. Care Health Plan makes telephone dual head/handsets and a medical language phone line available at no cost to participating providers and clinics. Small provider sites using these services should verify the competency of the telephone language lines being used. For example, before contracting, providers can determine whether the interpreters are trained in medical ethics, confidentiality, and terminology; whether the telephone service has the capacity to continue providing services in case of unusual events; and whether there are nearby hospitals and providers who may be interested in partnering to purchase volume, discounted packages of services. Use of Family and Friends By using the previously described oral interpretation methods, small provider sites are seeking to minimize their reliance on patients’ family or friends. Concerns about confidentiality, conflict of interest, and interpreting skills lead many providers to forgo using family members or friends as interpreters, except in emergencies. If an individual wants to use his or her own interpreter, providers will often attempt to have a trained interpreter sit in during the medical encounter (Neponset Health Center) or follow up with the family within 24 hours to verify the patient’s condition (Mt. Olive Pediatrics). When trained interpreters are available, some providers are requiring LEP patients to sign a waiver if they choose instead to use their own interpreters (Planned Parenthood of the Palm Beach and Treasure Coast Area, Planned Parenthood of Pennsylvania). Language Services Throughout the Patient Encounter Because LEP patients experience language barriers throughout the health care encounter, small health care providers are using interpreters to assist during intake, clinical encounter, and follow up. Some providers assign interpreters to patients during appointment scheduling or at the front desk. Other providers are developing systems in which interpreters are not assigned to particular patients; the interpreter, rather is given a “home base” in a particular clinical area and receives requests through walkie-talkie communication from medical assistants (Neponset Health Center). Another method is to have interpreters “block scheduled” to a clinical area for a morning or evening shift (East Boston Neighborhood Health Center). Interpreters sometimes also accompany patients to off-site treatments and tests, as needed, thus helping to maintain the patient’s medical home (Chinatown Pediatric Services).
Finally, small providers are offering portable bilingual health care services, through mobile health clinics (including mental health) and dental clinics staffed with bilingual clinicians and staff (Saint Joseph Health System Community Health Programs). Written Translations Small health care providers can make use of existing materials for translations of vital documents, as well as more general information. Trade associations and other nonprofit organizations have proven to be an excellent source of patient-education materials. Providers interviewed for this project are using translations from organizations such as the American Academy of Pediatrics, American Heart Association, March of Dimes, American Lung Association, American Diabetes Association, Planned Parenthood Federation of America, and the Susan G. Komen Breast Cancer Foundation. Some providers also use materials from pharmaceutical companies and other sources. For example, Saint Joseph Health System Community Health Programs purchases a Spanish version of the Healthwise Handbook, a self-care manual with information on more than 180 health conditions.12 Pediatric sites can stock examination rooms with English and Spanish versions of the American Academy of Pediatrics monthly magazine, Healthy Kids. Sites participating in Boston University School of Medicine’s Reach Out and Read program can offer Spanish versions of age-appropriate picture and story books to families at each well-child examination and employ bilingual staff to help parents learn to use the materials with their children (Mt. Olive Pediatrics). Software programs, such as CareNotes, are also used to provide information regarding medications, diets, and discharge instructions in Spanish (Cooley-Dickinson Hospital).13 The Internet is increasingly used as a source of translated materials. In addition to the sites mentioned, small providers are finding educational materials at Web sites operated by the federal government (http://www.lep.gov) and state departments of health and public health and offices of minority health. Web-based materials from health departments in other countries, such as Taiwan, Hong Kong, and Australia, can also be downloaded for bilingual staff to review and tailor. The accuracy of the information depends greatly on its source and providers should consider implementing a process for verifying information before it is used. Bilingual staff or interpreters should check materials to verify accuracy, dialect, and literacy levels. Small provider sites can also use competent bilingual staff and contract interpreters to translate vital documents, such as physician requests. Local hospitals are another source of translated documents, like HIPAA compliance forms. Chinatown Pediatric Services, for 9
example, obtains translated documents from the Thomas Jefferson University Hospital’s Chinese Health Information Center. Local faith-based organizations that work closely with immigrant populations may also be available to assist with translations. Patient Satisfaction Small providers are monitoring patient satisfaction as they continue to evaluate and expand their language services. This monitoring may be as simple as charting return visits of LEP patients or as complex as written patient satisfaction surveys (Saint Joseph Health System Community Health Programs). Monthly meetings of bilingual staff to share lessons learned are another practical way to monitor the quality of language services. Funding Opportunities Small health care providers are seeking funding from a variety of sources to underwrite language services. The most readily available yet underutilized federal funding comes from Medicaid and SCHIP. Only a handful of states are currently using these funds for language services: Hawaii, Idaho, Kansas, Maine, Massachusetts, Minnesota, Montana, New Hampshire, Utah, and Washington. In addition to directly paying for language services, states can use Medicaid administrative funds to support a variety of related activities, including training interpreters, translating forms and documents, and providing language services at state and local benefit eligibility offices. Activities to explore or implement Medicaid/SCHIP funding are occurring in Ohio, Pennsylvania, and Virginia. NHeLP and the Access Project have developed a Language Services Action Kit for maximizing Medicaid/SCHIP funding.14 Other sources of federal funding include the Office of Minority Health Bilingual/Bicultural Service Demonstration Grant Program, which awards funds to community-based organizations to provide assistance to LEP individuals seeking health care, and the Health Resources Services Administration (HRSA) Bureau of Primary Health Care. State and local funding may also be available. Many states provide funds for language services through their offices of minority health or departments of health or social services. For example, Nebraska’s Office of Minority Health provides grants to each county to address health disparities. Some state offices provide funds to refugee organizations for language assistance. In addition, certain county health departments, like the one in Fayette County, Ky., provide funding for language services, although assistance may be limited to those accessing benefits at the county office. Some cities, such as Boulder, Colo., have provided funding to health care providers for services. 10
Charitable foundations are increasingly interested in language services. For example, the New Hampshire Endowment for Health funded a local nonprofit to establish a language bank of trained interpreters who are on-call to provide services; the Mid-Iowa Health Foundation funded a collaboration between hospitals and advocates to examine Medicaid reimbursement. The Commonwealth Fund is supporting the investigation of promising, replicable practices like remote simultaneous medical interpreting (similar to the telephonic system used at the United Nations), as well as other research on providing and evaluating language services. The California Endowment has made cultural competence and linguistic access a major funding initiative. The Robert Wood Johnson Foundation’s Hablamos Juntos (We Speak Together) project provided grants to test systems of medical interpretation across delivery points within health care systems. Conclusion While determining appropriate language services will depend on individual circumstances, small health care providers have an array of options that can be tailored to meet the needs of LEP patients. Based on practice type, setting, size, and location, providers can select among services including hiring bilingual practitioners or staff, using in-person or telephone interpreters, coordinating with other providers to share resources and costs, and partnering with larger health care entities or systems. Small providers who are developing language services should begin by following the following eight-step process: Step 1. Designate responsibility. Step 2. Conduct an analysis of language needs. Step 3. Identify resources in the community. Step 4. Determine what language services will be provided. Step 5. Determine how to respond to LEP patients. Step 6. Train staff. Step 7. Notify LEP patients of available language services. Step 8. Update activities after periodic review.
EXAMPLES FROM THE FIELD The following document provides summaries of 11 site visits and seven phone interviews conducted with a variety of small health care provider practices and a select group of larger entities or health systems that are assisting small providers. Inclusion in this report does not signify endorsement by the National Health Law Program (NHeLP). NHeLP did not conduct scientific evaluations of these practices, but rather offers this information to help providers, advocates, and policymakers understand the variety and complexity of language services provision.
SOLO PRACTITIONERS AND SMALL GROUP SETTINGS Bilingual International Assistant Services, St. Louis, Missouri Background Bilingual International Assistant Services (BIAS),established in 2003, provides services to individuals who are elderly or have physical, mental, or developmental disabilities. The agency offers mental health counseling and case management, social services, pharmaceutical and psychiatry evaluations, and interpretation and translation services. The agency currently serves close to 200 clients. Most are Russian-speaking (57%) but approximately 35 percent to 40 percent are Bosnian-speaking. BIAS serves a limited number of Spanish- and Chinese-speaking clients. The agency also provides interpretation services for Somali, Ethiopian, and Kurdish clients. Promising Practice: Bilingual staff and subcontracts with additional interpreters The agency has full-time bilingual staff who are qualified to provide counseling and case management, as well as interpretation services. By offering both direct service to clients and fee-for-service interpretation and translation to other organizations and health care providers, BIAS has developed a hybrid model to meet the needs of its LEP clients, as well the needs of the community. Bilingual staff BIAS staff are all bilingual American-trained health professionals who can provide counseling and case management services in English and in a second language, as well as interpretation services. There are five full-time bilingual staff: the executive director who is also a Russian-speaking licensed social worker, two case managers with B.A. degrees in social work (one Russian-speaking and one Bosnian-speaking), a Bosnian-speaking licensed professional counselor, and a Russian-speaking office manager who also provides interpretation services. The agency is seeking to hire a full-time Mandarin-speaking case manager. They also have a volunteer who speaks both Spanish and Cantonese who has assisted with document translation and publicity. 12
The agency subcontracts with two specialists: a pharmacist for medical assessments, evaluations, and monitoring of prescription treatment plans, and a psychiatrist who conducts medical evaluations and assessments. These services, like all those directly offered by BIAS, are provided in clients’ homes, with a bilingual staffer interpreting for the pharmacist or psychiatrist. As needed, the bilingual staff members also serve as interpreters for clients when they visit other health care providers. In these situations, the agency charges the provider for the interpretation services. The agency also refers clients to mainstream service providers and provides interpreter services for those visits. BIAS also advocates to ensure continuity of care and provision of LEP services Scheduling The main telephone answering machine offers information in BIAS’s primary languages: Russian, Bosnian, English, Cantonese, and Spanish. When a language is selected, clients receive information about how to contact a bilingual staff person or how to leave a message. Since most services are provided in clients’ homes, the staff control their own schedules. Clients generally are given the cell phone number of their case manager and may call directly to schedule appointments. Interpreters To supplement the bilingual staff, the agency subcontracts with additional interpreters on an as-needed basis. They work with interpreters who speak Somali, Ethiopian, Kurdish, and Russian. These interpreters are hired out primarily to state agencies. The rate is $50/hour for state agencies and $60/hour for health care providers. The agency provides interpreters for the state and the Social Security Administration. Interpreter training All the bilingual staff and contract interpreters have undergone interpreter training. Individual interpreters are not currently assessed for competency, but the agency hopes to implement this shortly. For its staff, the agency conducts in-house training and pays for staff to attend classes at the International Institute of St. Louis. The agency also pays for ongoing staff development classes. For example, some staff are attending medical interpreting classes at a local community-based organization. Course fees are paid by the agency, and time spent in class is counted towards work hours. Interpreters and bilingual staff must all sign a code of ethics and undergo a state background check.
Translated materials The agency translates its own internal documents. Most client history forms are in English, since staff members complete these forms when interviewing new clients. Notice of privacy forms and agency procedural information is translated. The agency also provides fee-for-service translation to outside organizations. Cultural competency training The agency holds weekly staff meetings to discuss issues that arise with clients, as well as cultural issues or differences. The agency staff also provide cultural competency and diversity training for a variety of external organizations such as state agencies, not-forprofit, and for-profit organizations. Publicity The agency has begun publicizing its services to widen its client base. The executive director writes a monthly column in a local Russian newspaper that discusses issues pertinent to elderly or disabled individuals. Recent topics have included applying for citizenship, explanation of Social Security numbers, and memory issues. The agency plans to extend this monthly column to a Bosnian newspaper. Funding Most of the agency’s budget for direct services comes from Medicaid and Medicare reimbursement, as well as from state agencies. Missouri’s Medicaid program does not reimburse licensed or clinical social workers for counseling or case management. BIAS bills Medicaid for the psychiatrist’s services. The state Department of Mental Health and Department of Senior Services both subsidize counseling services provided to eligible clients. The rest of BIAS’s budget comes from state funds, grants, and donations. Contact: Julia Ostropolsky Executive Director Bilingual International Assistant Services 10950 Schuetz Road St. Louis, MO 63146 Phone: 314-812-9320 E-mail: [email protected]
Web site: N/A
Chinatown Pediatric Services, Philadelphia, Pennsylvania Background Chinatown Pediatric Service (CPS) opened in 1995 and offers the only pediatric services available in the Chinatown area of Philadelphia. CPS seeks to provide the highest quality primary health services to the children of Chinatown and its surrounding areas. CPS is committed to providing culturally sensitive and language-appropriate health care. Philadelphia’s Chinatown has approximately 5,000 residents. Thirty to fifty thousand Chinese individuals reside in the greater metropolitan area. Promising Practice: Bilingual staff and clinicians assist patients CPS is a fully bilingual clinic where staff speak English, Chinese (Cantonese and Mandarin), and Vietnamese. The clinic’s physician, Dr. Philip Siu, also serves as the director of Thomas Jefferson University Hospital’s Chinese Health Information Center. Approximately 95 percent of CPS’s patients are Chinese-speaking, of whom 60 percent speak Mandarin and 40 percent speak Cantonese. Many are from Vietnam and speak Cantonese. Approximately 5 percent are ethnic Japanese, Cambodian, and French who can communicate adequately in English. Bilingual staff The clinic operates with a bilingual staff of six: pediatrician, bilingual family physician, office nurse, nursing assistant, front desk manager, and front desk assistant. In addition, a bilingual obstetrician currently rents space at CPS. All the staff members speak Cantonese or Mandarin. Two staff members also speak Vietnamese. Referrals CPS generally refers patients to Thomas Jefferson University Hospital (TJUH) because of language services available there. TJUH’s Chinese Health Information Center (CHIC) provides language interpretation at both in- and out-patient settings. CHIC has two fulltime interpreters available during business hours. During evenings and weekends, the hospital utilizes a language line or in-house bilingual staff. When CPS patients are referred to the hospital, the CPS staff assist with making arrangements—scheduling appointments with specialists or for tests, arranging for the hospital’s interpreters to attend the appointments, issuing referrals, and preparing paperwork. CPS retains oversight of patients admitted to the hospital rather than transferring supervision to an attending physician.
Competency of bilingual staff The clinic director interviews all staff members and assesses their language competency before employment. The clinic director primarily hires native speakers and ensures that his staff are culturally sensitive. On-the-job training teaches relevant medical terms both in English and Chinese. Translation of materials CPS obtains many of its translated patient education materials from CHIC, as well as from health centers in Boston and New York that serve Chinese and Vietnamese patients. It also obtains materials from Web sites, including the Taiwan Department of Health site and others based in Hong Kong and Australia. Before using any materials, the clinic staff check for accuracy. CPS translates some clinic-specific information in-house. After-hours assistance CPS’s answering machine is in English and Mandarin. The current system is not capable of offering additional languages. Since many Cantonese-speaking individuals also understand Mandarin, CPS chose to use Mandarin on its system. In addition, patients’ phone calls are forwarded to the on-call physician’s beeper for emergencies. The physician speaks Cantonese and Mandarin, so he can provide direct assistance to patients after hours. Chinese Health Information Center CPS’s director is also the director of CHIC. CHIC has a grant from the federal Office of Minority Health to provide a variety of services including screenings and follow-up for osteoporosis, blood glucose and cholesterol levels, and Hepatitis B; social services and benefits counseling; and parenting lectures. This grant also provides funding for interpreters; when the grant terminates, CHIC will retain at least two interpreters who will be funded by the hospital. Funding To date, CPS has operated as a private clinic. It estimates that meeting the language needs of patients has resulted in minimal additional cost, since all the physicians and nurses are bilingual. Some costs have arisen from the need for additional front-office staff. CPS anticipates that this need, which consists primarily of scheduling referrals, completing paperwork, and addressing billing issues and insurance discrepancies, is equivalent to onefifth of a full-time position. Future activities CPS is merging with Greater Philadelphia Health Action, an organization that currently runs six federally qualified health centers, among other facilities. CPS will benefit from 16
increased resources, improved reimbursement, and the necessary resources to develop into a full-scale primary care community health center serving Chinese-speaking patients. The merger will allow CPS to hire a social worker to assist patients in applying for benefits and understanding the health system and other support staff. In addition, CPS will be able to provide health care to uninsured patients on a sliding-fee scale. Contact: For more information, contact Mara Youdelman at the National Health Law Program, 202-289-7661 or [email protected]
Kids Connections, Louisville, Colorado Background Kids Connections works with families of infants and toddlers with developmental delays or disabilities in Boulder and Broomfield Counties, Colo. A nonprofit, interagency, collaborative organization, Kids Connections provided early childhood services to more than 500 children in 2003. About 15 percent of the families served by Kids Connections are LEP Spanish speakers. The agency also serves a small number of Chinese, Vietnamese, Korean, and Arabic speakers. The organization addresses the needs of its LEP families by employing bilingual full-time staff and therapists and contract interpreters. Promising Practice: Bilingual service coordinators and cultural mediators Kids Connections employs eight service coordinators; of whom three are bilingual. All eligible families are assigned a service coordinator; the organization matches LEP families with bilingual coordinators. Kids Connections provides services through contracts with early intervention therapists and collaborates with health departments, hospitals, doctors, child-care providers, school districts, and other community services. The service coordinators work in partnership with other providers to ensure that children and families receive appropriate services. The organization employs two bilingual cultural mediators to explain available services to culturally diverse families, who often are not aware that services exist. Cultural mediators become advocates for the children, educate families about their children’s rights and the importance of developmental services, and teach parents to be more assertive in clinical settings. In cities where Kids Connections has funding to offer cultural mediation services, it serves substantially more Spanish-speaking families than cities with similar demographics where the services are not offered.
Bilingual therapists Kids Connections contracts with bilingual therapists to meet the needs of LEP families. Moreover, administrators attempt to refer their clients to bilingual providers whenever possible. The organization maintains a database to match families with very low English proficiency with the most skillful bilingual providers. Contract interpreters In the event that a bilingual therapist or provider is not available, the organization contracts with interpreters for sessions with English-speaking providers or therapists. Contract interpreters are found through word of mouth or by announcements in local newspapers. Scheduling The organization’s data system is managed by a contract with the Department of Education and tracks the families’ primary language, nationality, interpretation needs, and interpretation history. Competency Kids Connections ensures the competency of interpreters and bilingual staff through an interview process to assess language proficiency, client-specific language skills (i.e., the ability to speak “Mexican” Spanish), and the interpersonal skills necessary to help families navigate sensitive issues. All staff, including those who provide interpretation services, are required to sign a code of ethics and confidentiality clause. Translated materials Kids Connections provides LEP families with translated documents related to their children’s care. The organization obtains documents from the Department of Education and contracts with translators; bilingual staff members provide only minimal translation services. Kids Connections shares translated materials with other organizations through a listserv. Funding The organization is primarily funded by the Colorado Department of Education, through federal funds from the Individuals with Disabilities Education Act (IDEA) for services for children from birth to three years. Kids Connections covers the estimated $220 per client per year for cultural mediation services through grants from the cities of Longmont and Boulder. These grants require that funds be used for residents of the two cities. When bilingual clinicians are not available, Kids Connections estimates costs of at least $600 per 18
patient per year to provide interpretation services. The cost of interpretation is factored into the budget and covered by the Department of Education, the organization’s primary funding source. The organization estimates costs of $500 per year to provide all clients with translated materials. It relies on grants from the Greenlee Foundation and the Family Foundation to pay for contract translators. A grant from the Community Foundation for Boulder County allows Kids Connections to maintain its Web resources, some of which are bilingual. Contact: Ardith Ferguson Executive Director Kids Connections 1371 Hecla Drive, Suite B-III Louisville, CO 80027 Phone: 720-890-1618 Fax: 720-890-1619 E-mail: [email protected]
Web site: N/A Mount Olive Pediatrics, Mount Olive, North Carolina Background Mount Olive Pediatrics is a satellite office of Goldsboro Pediatrics, a private pediatric practice. The office serves a rural, agricultural community where cucumber, chicken, and cotton farms are common. In 1991, the community began to experience a significant influx of LEP families, particularly Latino families. Since then, Dr. David Tayloe, who established Goldsboro Pediatrics in 1977 as a solo practice, has worked to recruit the workforce and resources needed to provide health services for the growing number of LEP children. According to Dr. Tayloe, this commitment to the Latino population “has been driven less by the necessity to follow federal law than by our realization that these children are part of our future.” 15 Mount Olive Pediatrics provides well-child examinations, primary care, acute care, as well as evaluations and referrals for chronic physical and mental conditions. The office is staffed by one pediatrician, two certified pediatric nurse practitioners, two certified nurse assistants, and office support personnel. About one-half of office visits are made by Spanish-speaking families, with other visits made by Korean and Chinese families. Most LEP patients are eligible for Medicaid or the SCHIP. Language needs are determined at intake. 19
Promising Practice: Bilingual mid-level practitioners and written translations Mount Olive Pediatrics employs bilingual mid-level practitioners who conduct examinations and clinical visits in Spanish and also assist physicians and other office personnel during encounters with Spanish-speaking patients. Since 1995, the office has employed a bilingual certified pediatric nurse practitioner who is in the office three days per week and coordinates many of the language and cultural access activities. This practitioner lived in Puerto Rico during her high school and college years and is fluent in Spanish. She sees mainly Spanish-speaking patients in her clinical work. She also provides office staff with on-the-job training regarding Spanish terms, cultural beliefs, and alternative medicine. She has also translated educational materials, like instructions for parents with newborns. A bilingual certified nurse’s assistant also sees Spanish-speaking patients. She performs hearing and vision testing for Latino children and provides education on topics like taking a child’s temperature and using a nebulizer for children with asthma. If a patient needs an appointment at a time when an interpreter is not available, the practice employs a telephone interpreter or the family may choose to bring an interpreter. In situations where families bring their own interpreters, if there is any doubt of diagnosis or follow-up compliance, Mount Olive brings the patient in within 24 hours for a followup visit or schedules an appointment with the pediatric nurse practitioner. The telephone interpreter services are expensive, often slow, and inefficient—requiring many stops and starts during the encounter. If a Mount Olive/Goldsboro Pediatrics patient is hospitalized, the local hospital—Wayne Memorial Hospital—usually provides interpreter services during hospital rounds. Goldsboro Pediatrics employs a part-time bilingual pediatrician at its other offices. In addition, it employs a certified nurse assistant and two nurse practitioners who have attended community college courses designed to improve conversational Spanish skills. Mount Olive Pediatrics provides translated instructional handouts that explains well-child examinations, office procedures, illnesses, and conditions. The Spanish handouts are prepared by the American Academy of Pediatrics, McKesson Clinical Reference Systems (a private company that provides translated materials), and, in some cases, by the bilingual staff at Mount Olive. Other materials are obtained from drug companies’ representatives and from the Web site of the North Carolina Area Health Education Center.16 The materials discuss a large variety of topics including allergies, appetite, breastfeeding, chickenpox, head lice, flu, sunburn, tuberculosis, urinary tract infections, and warts. Translated handouts are updated and supplemented approximately 20
every two years. The bilingual certified pediatric nurse practitioner reviews all translated materials. Mount Olive Pediatrics receives the Spanish version of the American Academy of Pediatrics Healthy Kids monthly magazine. These are available to Spanish-speaking families in each examination room and in the waiting area. Since 2003, Mount Olive Pediatrics has participated in Reach Out and Read (ROR), a program from Boston University School of Medicine that makes ageappropriate picture and story books available to pediatricians for their patients. 17 Mount Olive Pediatrics obtains both English- and Spanish-language versions of the books. A nurse works with parents to help them use the picture books and learn how best to read to their children. Parents also receive a Spanish-language handout describing the benefits of reading to children. ROR has been funded through Scholastic, Smart Start, individual donors, and civic groups. Contact: Nancy Sayers, RN, BSN, CPNP Mount Olive Pediatrics 327 Highway 55 West Mount Olive, NC 28365 Phone: 910-658-6922 E-mail: [email protected]
Web site: N/A
COMMUNITY CLINICS AND HEALTH CENTERS Asian Pacific Health Care Venture, Los Angeles, California Background Asian Pacific Health Care Venture (APHCV) is a community health center that aims to provide accessible, affordable, and culturally competent health care services to underserved Asians and Pacific Islanders living in Hollywood, North Hollywood, and the greater Los Angeles downtown area. APHCV provides primary health care services, including prenatal, pediatric, adolescent, adult, and geriatric care, family planning, and HIV testing and counseling. APHCV offers health education and outreach services targeting all age groups; programs include cancer prevention, HIV/AIDS prevention, diabetes prevention, tobacco control, teen pregnancy, lead poisoning, low-cost health programs, parenting education, and immunizations. APHCV sees more than 2,000 patients each month. Approximately 50 percent of its patients are LEP. Linguistic and cultural support are 21
available in four Asian and Pacific Islander languages—Thai, Vietnamese, Khmer (Cambodian), Tagalog (Filipino)—and in Spanish. Six to eight physicians work at APHCS and the use of bilingual providers is emphasized. APHCV also uses 12 support service liaisons (SSLs) to provide bilingual and bicultural services throughout the health care encounter, from intake and appointment scheduling and reminders to clinical visits, health education, and follow up. The SSLs also translate important documents and evaluate the accuracy of translations. In addition to SSLs, APHCV employs bilingual staff in roles in which the primary function is not interpretation. Bilingual staff fall into two language proficiency levels. Level 1 staff have conversational proficiency and can provide interpretation at the front desk and for outreach encounters. Level 2 staff have medical proficiency and provide interpretation during medical and clinical visits if an SSL is not available. Promising Practice: Implementing a written language access plan As suggested by the U.S. Department of Health and Human Services Office for Civil Rights, APHCV has developed a written language access plan that serves as a manual. Partial funding for the manual was provided by the Department of Health and Human Services’ Bureau of Primary Health Care. It has been distributed to all APHCV employees and is periodically reviewed and revised. Manual The manual outlines practices that APHCV employees must follow to comply with Title VI of the Civil Rights Act and OCR guidance. Four key areas are discussed: assessment of needs, development of policies and procedures, training of staff, and vigilant monitoring. •
The assessment chapter identifies and reviews information regarding the languages spoken in the APHCV service area. Appendices include an “I Speak . . .” card, APHCV’s patient registration form (identifying language needs), and a language assistance request/refusal form.
The policy chapter describes APHCV’s use of support service liaisons (SSLs) and other staff. Appendices include sample job descriptions for SSLs and bilingual staff, testing protocols for language competency, and oral assessment scripts. Additional materials include a copy of the interpreter request form, a notice announcing the availability of no-cost interpreter services, and sample translations of vital documents (e.g., patient consent, reminder card).
The staff training procedure chapter includes samples of training materials, including explanation of language services available at APHCV and information regarding working effectively with SSLs and other interpreter services.
The manual sets forth a process for ongoing monitoring of language services. Appendices include a patient satisfaction survey and a cultural competency selfevaluation form for APHCV staff.
The manual is available and distributed to all staff at the clinic. As expected, implementation of the manual has led to ongoing reevaluation of the manner in which APHCV provides language services. For example, the assessment process has identified uncommon languages not routinely offered. APHCV is addressing this, in part, through participation in the L.A. Care Traditional Safety Net Telephonic Interpreting Project, which provides no-cost interpreter services using dual headsets and handsets. (For more information, see L.A. Care Health Plan description.) Support service liaisons SSLs are trained interpreters who meet patients at intake and track them through the health care encounter: intake, clinical visit, and follow up. The SSLs provide case management, patient counseling, and health education, and serve as comprehensive perinatal health workers. SSLs are also used to translate APHCV-specific documents, outreach information, and health education materials The recruiting standards and hiring criteria for SSLs and bilingual staff are set forth in the manual. Recruiting from the native community is stressed and the hiring process includes both oral interpretation and written translation tests. Cultural knowledge and sensitivity are also tested. As part of its comprehensive services, APHCV also uses SSLs to accompany patients to off-site specialty care visits—a valuable service that helps patients negotiate difficult systems. This project was funded through a grant from the Office for Minority Health/Department of Health and Human Services, which has now expired. SSLs meet monthly with the health education manager and receive periodic evaluations. The SSL self-evaluation tool is used to review performance annually in combination with a competency test and provider feedback form. In addition, the SSLs attend monthly meetings dedicated to training and study sessions and to review policies and identify needs. The SSLs also share lessons learned, which has proven to be an important aspect of quality assurance. The monitoring process has led APHCV to reconsider its use of SSLs. To better address patient flow issues, APHCV is considering ways that clinic staff in various site centers (e.g. intake, follow-up) can provide language services, rather than have SSLs track patients through the clinic. 23
Quality Improvement Committee and Quality Assurance APHCV uses a Quality Improvement Committee (QIC) to collect and review qualitative data and to implement LEP policy and procedure. The QIC comprises the management team and a SSL representative. The committee collects information related to clinic use and demographic changes in the community to identify gaps in services, patient satisfaction, and future needs. The QIC issues reports on a semi-annual basis. APHCV also uses a one-page patient satisfaction survey to routinely solicit opinions on staff performance. The survey asks patients to rate the language and cultural performance of various staffers, of written materials, and of telephone and waiting room encounters. Contact: Mika Aoki Health Education Manager Asian Pacific Health Care Venture, Inc. 1530 Hillhurst Avenue, #200 Los Angeles, CA 09927 Phone: 323-644-3880 x223 E-mail: [email protected]
Web site: http://www.aphcv.org Chinatown Clinic, Drexel University College of Medicine, Philadelphia, Pennsylvania Background The Chinatown Clinic began in 1998 as an outreach project of medical students and Drexel University College of Medicine faculty. The mission of the clinic is to provide caring, nonjudgmental, interdisciplinary health care to the medically underserved, regardless of ability to pay. According to its mission statement and manual, the clinic also strives “to create a respectful environment in which students, health care professionals, patients, and community members can learn ways to work together to address community factors, especially language barriers, that affect health and access to health care.” This volunteer clinic offers primary health care services to uninsured Asians, especially individuals whose primary language is Indonesian or Mandarin. The clinic conducts histories and physical examinations and develops a medical problem list and treatment plan for patients. Patients with certain chronic conditions within the clinic’s scope of services receive ongoing care. These include diabetes, hypertension, thyroid disease, and musculoskeletal diseases. Others are evaluated and treated at the clinic or given referrals to health care providers, such as city health district offices or local hospitals. 24
The clinic also offers screening and immunizations for hepatitis B, influenza vaccinations, limited laboratory testing, and pharmaceuticals. The clinic has a medical director, nurse manager/diabetes educator, physicians, nurses, nurse practitioners, and pharmacists. All are volunteers except the nurse manager whose position is funded by a state grant. On an average night, the clinic has four to eight medical students, two to three nurses or nurse practitioners, one pharmacist, and at least two physicians. Promising Practice: Bilingual staff and community volunteer interpreters While operating on an extremely limited budget as a free clinic, the clinic has made important strides in meeting the needs of its LEP patients. The clinic provides language services in the following ways: through bilingual health professionals and students; through community volunteer interpreters; and via telephone language line services. Bilingual health professionals and students Many of the health professionals who volunteer at the clinic are bilingual, primarily Mandarin speakers. The volunteer clinicians include physicians, nurse practitioners, nurses, physician assistants, and pharmacists. In addition to professional volunteers, the clinic staff include health profession students. Many of these students speak Mandarin, Cantonese, other Chinese dialects, and other Asian languages. The students are either volunteers or participate to fulfill curriculum requirements under the direct supervision of the medical director and other professional staff. In addition to the health profession students, the clinic utilizes students from other disciplines, as well as volunteers, some of whom are bilingual, to assist with front desk services, record keeping, and other clinic operations. Community volunteer interpreters Because the clinic cannot afford to provide professional interpreting services, it has recruited people from the community to serve as interpreters, primarily for Indonesianspeaking patients. Some are paid a nominal fee from the state grant. Generally, these volunteers are patients, former patients, or adult family members of patients. They are screened by the clinic staff, who often know them from past interactions. The interpreters are trained in patient confidentiality issues and shadow existing interpreters until they are experienced enough to interpret on their own. The clinic is currently developing a more formal training program for these volunteers
Scheduling The clinic is open three days per week. Because of increasing demand, the clinic has transitioned from a drop-in center model to scheduling appointments. Patients’ language needs are noted in their charts to ensure the availability of a bilingual clinician or community interpreter. Urgent walk-in patients are evaluated by a physician and treated or referred, as appropriate. Referrals For clinical conditions not covered by the clinic, patients are referred to other health care providers, such as the city health department and local hospitals. When possible, the clinic refers patients to providers with language services. The clinic also educates patients to ask for language services. Immigrant Health Project To address legal, language, and literacy barriers to health care, the clinic has initiated an Immigrant Health Project in association with Community Legal Services (CLS) and the Sisters of Saint Joseph Welcome Center. The clinic assists patients in obtaining emergency medical assistance. CLS staff members visit the clinic weekly and assist clients in completing applications and obtaining necessary supporting documentation. CLS uses clinic staff and volunteers or telephone services to provide interpretation. Clinical rotations for other health care profession students The clinic accepts medical and other health care profession students for senior clinical rotations. It acts as a teaching site for the Bridging the Gaps consortium, which includes all the medical schools in Philadelphia as well as other health profession schools. This rotation offers a multidisciplinary experience, in which students may participate in various aspects of the Immigrant Health Project. Funding In 2003, the clinic received a two-year grant from the Pennsylvania Department of Health’s Bureau of Health Planning. These funds have allowed the clinic to hire a nurse manager, pay rent and other costs, and expand the range of primary care services offered. The state funding was contingent on locating the clinic in a federally designated medically underserved area of South Philadelphia. The clinic’s space is adjacent to a church and was renovated with the assistance of many volunteers, including medical students and athletic department staff members from Villanova University.
The clinic partners with local resources to obtain free services. The Philadelphia Health Department provides vaccine supplies (including influenza, tuberculosis, and Hepatitis B vaccines), Hahnemann University Hospital offers free laboratory services, and Drexel University College of Medicine provides funding for prescription medications. The university’s malpractice insurance covers the medical director and other university faculty. Because the clinic is an official project of Drexel University College Medicine, students are covered by the medical student insurance. Contact: Vincent J. Zarro, M.D., Ph.D. Medical Director, Chinatown Clinic Assistant Dean, Student Services and Community Outreach Projects Drexel University College of Medicine 2900 Queen Lane Philadelphia, PA 19129 Phone: 215-991-8515 E-mail: [email protected]
Web site: N/A Chinatown Clinic: 1156 S. Broad Street Philadelphia, PA 19146 Phone: 215-732-6875 Neponset Health Center, Harbor Health Services, Inc., Dorchester, Massachusetts Background Neponset Health Center offers primary health care in Dorchester, Mass., an urban setting south of Boston. Its staff includes 10 physicians and 10 nurse practitioners as well as additional support staff. The center encounters LEP patients daily, primarily Vietnamese speakers but also individuals speaking Spanish, Portuguese, and Cape Verdean. Promising Practice: On-site interpreters and staff training Neponset Health Center began offering language services in 1991 to reach out to the growing immigrant community. The center offers language services including dedicated on-site interpreters, bilingual nurses, contract interpreters, and a telephone language line.
On-site interpreters The Center primarily uses dedicated interpreters and has the equivalent of 4.4 full-time interpreters. All are native Vietnamese speakers and have been trained as medical interpreters either through the Massachusetts Medical Interpreters Association18 or the Department of Public Health. Pursuant to a grant in 2003, the center was able to hire an additional interpreter and place one of its more established interpreters on a team with a psychotherapist to provide behavioral health services to its Vietnamese clients. As a result of this team approach, the center saw a tenfold increase in the number of Vietnamese clients using its psychotherapy services. In addition to dedicated interpreters, the center has bilingual, Vietnamese-speaking staff. These individuals work in a variety of departments. They are cross-trained as medical interpreters and are utilized as interpreters when dedicated interpreters are unavailable. The center also has a trilingual Spanish- and Portuguese-speaking medical assistant who can provide interpreting assistance when needed. The center is aggressively seeking to hire additional bilingual support staff to assist Vietnamese-speaking patients with ancillary activities, such as scheduling and billing, to allow dedicated interpreters time for clinical activities. Bilingual staff Currently the center does not employ a bilingual, Vietnamese-speaking physician— although it has in the past and is looking again to recruit one. In addition, the center has two bilingual native Vietnamese-speaking nurses. The center would like to hire additional bilingual staff and advertises for such employees in the local Asian papers, but is constrained by a limited pool of trained health professionals who speak Vietnamese. Contract interpreters The center is working to establish a per-diem core of interpreters who can provide backup for its staff interpreters, just as substitute teachers are used in the school system. This group will be subject to the same requirements as the staff interpreters, including medical interpreter training. To date, the center has agreements with three individuals to serve as per-diem interpreters, including one staff member from an affiliated center. The center also works with a local social service agency, the Vietnamese American Civic Association (VACA). VACA staff provide back-up coverage when interpreters are on sick leave or vacation. They are not, however, available for on-call assistance.
Telephone language line The center also contracts with a telephone language line for back-up assistance. The telephone line is not generally used, primarily because the examination rooms are not equipped with speakerphones and providers wishing to use the language line must move to an alternate space. Scheduling The center is open seven days per week, until 9:30 pm on weekdays. The center is committed to having staff interpreters available at all hours so that patients are never turned away because of language barriers. Generally, two interpreters are available during regular business hours and Saturday, one on Sunday and Friday nights, and three on Mondays due to heavy volume. When a patient schedules an appointment, the appointment staff link a physician or nurse practitioner with an interpreter in the schedule. But because interpreters are often needed for non-clinical assistance, such as making reminder phone calls, writing instructions, and accompanying patients to the lab, scheduling is not always an effective method to ensure interpreters are available at the same time the providers are. Thus, the center is moving toward a system in which interpreters will have walkie-talkies. Instead of scheduling them for particular appointments, the medical assistant in the clinical area will page interpreters to determine who is available to provide assistance. In addition, each interpreter will be given a “home base” in a particular clinical area, which the center hopes will make them more readily available than when they are all located in a central area. When interpreters have down time, they can call patients for follow-up visits or undertake additional, non-clinical activities. The center’s medical staff members are paid incentives based on productivity. The center does not schedule longer appointment times for visits where patients need interpreters to avoid either reduced productivity or decreased interest among staff members in working with interpreters. Competency The center requires interpreters to undergo basic medical interpreting training. Two types of training are accepted—courses offered by the Massachusetts Medical Interpreters Association or the Massachusetts Department of Public Health. These courses are either 15 or 60 hours. When hiring interpreters, the center assesses the applicant’s language abilities through an oral interview and tests written skills by requiring applicants to translate a passage from English to Vietnamese and one from Vietnamese to English. The center 29
requires its interpreters and bilingual staff to sign a code of ethics and confidentiality and is currently working on institutionalizing some of its interpreter-related policies and procedures. The center also provides yearly HIPAA training for all staff, including interpreters. Use of family members and friends The center strongly discourages patients to use family members or friends as interpreters. When a patient requests to use a family member or friend, the center will explain that he or she has a right to a no-cost interpreter and to see a provider without a family member or friend present. If a patient insists on using a family member or friend, the center attempts to have an interpreter sit in during the medical encounter to ensure accuracy. Training for clinical staff New staff undergo cultural competency training to learn about the cultural practices, norms, and health beliefs of the patient population. One of the center’s physicians also coordinates periodic trainings for staff. In addition, a trainer from the Massachusetts Department of Mental Health’s Office of Multicultural Affairs has provided training for the Center’s behavioral health and mental health staff on using interpreters in psychotherapy. Referrals When necessary, the center makes referrals to local hospitals known to have language services for Vietnamese speakers. The center will undertake activities to ensure a successful transition for the patient to the new provider, including writing out directions and reminders in Vietnamese. When a patient does not appear for an appointment or does not make an appointment for a recommended treatment, the center staff are notified. Interpreters then contact the patient for follow-up to determine what assistance is needed to ensure follow through. Outreach The Center produces brochures and advertisements for the Asian papers and television stations, to inform the Vietnamese community about its services. This outreach, as well as the general availability of language services, has increased its patient base. Translated materials Two staff members have sufficient language skills to translate materials. The center uses these staff to translate short or simple documents, with one member translating the document to Vietnamese and the other translating back into English to ensure that the 30
meaning of the document remains intact. As needed, the center will purchase materials from VACA or other sources. Funding The costs of providing language services are covered by the center’s operating budget. Occasionally, it obtains grants for particular language services, such as establishing the psychotherapy team for Vietnamese-speaking patients. The center estimates costs of approximately $60 per visit per LEP patient for language services. The total language services personnel budget is $258,139.00 (including salary, fringe, and allocated departmental overhead). Contact: Mary Ellen Zapata Director of Social Services Neponset Health Center Harbor Health Services, Inc. 398 Neponset Avenue Dorchester, MA 02122 Phone: 617-282-3200 E-mail: [email protected]
Web site: N/A Saint Joseph Health System Community Health Programs, Santa Rosa, California Background The Saint Joseph Health System is based in Santa Rosa, Calif., in Sonoma County, approximately 55 miles north of San Francisco. According to the 2000 Census, approximately 9 percent of the county is LEP. The health system is dedicated to improving the health and quality of life of all people in the county and, through its community health programs, has made significant efforts to serve Spanish-speaking community members. Promising Practices: Mobile health and dental clinics with bilingual clinicians and staff The system uses mobile clinics to offer health and dental services. The Saint Joseph Mobile Health Clinic, operating since 1990, offers health screenings and well-child exams, immunizations, treatment of minor medical problems, health and nutritional education, information, and referrals. The clinic serves low-income children and adults without regular primary care physicians and those who have difficulty obtaining affordable health 31
care. The clinic is in the field four days each week and rotates among six high-need sites throughout Sonoma County. The staff, which is almost entirely bilingual, includes 1.3 full-time-equivalent (FTE) nurse practitioners and 2 FTE medical assistants, including a working supervisor. Approximately 97 percent of the patients are Spanish-speaking. The Cultivando la Salud (Cultivating Health) Mobile Dental Clinic provides basic and preventive dental care for agricultural workers and their families along with mental health and wellness services. The clinic, which has been in operation since 2002, is in the field three to four days per week and rotates across high-need sites. When possible, the mobile health and dental clinics are located at the same site. The dental clinic employs a 0.8 FTE dentist, 1.6 FTE registered dental assistants, 1 FTE clerical worker, 1.2 FTE promotores de salud (described fully in section below), and a 0.5 FTE dental supervisor. Approximately 98 percent of the patients are Spanish-speaking. The office assistant and dental assistant are bilingual and interpret for the dentist if a bilingual dentist is unavailable. The system also operates a fixed-site dental clinic serving children ages 4 to 20 that provides basic, preventive, and emergency dental care. Approximately 85 percent of the patients speak Spanish. Promotores de salud The promotores de salud (health promoters) program has three part-time bilingual staff members who train community members as volunteer promotores to share health and community resource information. Recent trainings accommodated 93 adults and more than 60 children. The 12 hour training includes information on the U.S. health care system, resources, and available services. The children’s promotorita program focuses on nutrition; traffic, pedestrian, playground and bicycle safety; and the Think First curriculum.19 The staff hold monthly meetings with the volunteer promotores—both adults and children—to provide additional health information, as well as community discussions. The community members drive the agendas of these meetings. Recently, topics have included mental health, relaxation, stress relief, and the interplay between western and complementary medicine.20 In addition, the staff promotores offer cooking and nutrition classes, in conjunction with the mobile health and dental clinics. The program has coordinated with the city of Santa Rosa to invite city staff members to present at the monthly meetings, as requested by the promotores. The city presentations have included information on bus and train schedules, bicycle safety, and the parks and recreation programs.
Language assessments In the fall of 2004, Saint Joseph Health System initiated a new policy that requires all individuals who directly provide services in a non-English language or provide interpretation as part of their job (with the exception of full-time dedicated medical interpreters) to undergo a language assessment. The goal is to ensure the quality and safety of the care provided and initiate a standard of practice to ensure consistency and quality interpretation of medical information. In addition to evaluating hospital staff, the health system is now requiring assessments of all bilingual clinicians and dual-role non-dedicated interpreters. Pacific Interpreters,21 under a contract with the health system, will conduct the assessments. Full-time medical interpreters have been previously assessed and will receive specific medical interpreter training. If an individual does not meet the language fluency requirements, he or she will receive training and the opportunity to improve skills in order to pass the assessment. These individuals may continue to interpret while they improve their skills. Visitor Information Access and electronic personal health records Visitor Information Access (VIA)22 is a free Internet database that retains migrants’ medical records, offering individuals a portable platform to maintain health history. Patients receive an access code they can give to health care providers. Multiple providers can share information or add new information to the record. All information is confidential and can only be accessed with the patient’s permission. The VIA information categories include: personal data, health insurance, emergency contacts, conditions and procedures, medical office visits, dental office visits, health care providers, pain and symptom diary, medications, allergies, immunizations, and family medical history. Enrollees also receive emergency information cards that provide basic demographic information, as well as current physicians, emergency contacts, conditions, allergies, and current medications. The VIA card also serves as a photo identification for immigrants who may not have ID cards from their native countries and may be unable to obtain U.S. ID cards because of immigration status. The promotores offer information about the VIA system and encourage individuals and families to enroll. Telephone language line Most of the patients assisted by the community programs are Spanish-speaking. For other language needs, like Eritrean, Vietnamese, and Russian, the clinics can access Pacific Interpreters’ telephone language line.
Patient satisfaction surveys The clinics conduct an annual patient survey to assess satisfaction of interactions with clinic staff. It is conducted in collaboration with the Redwood Community Health Coalition, as part of the system’s Continuous Quality Initiative. While the survey does not specifically assess the skills or competency of interpreters, it does gather information about communication between providers and patients, patient care, and how patients’ needs are met. Patients surveyed are asked whether: •
The doctors and nurses listen to me.
I understand what the doctors and nurses tell me.
I wait more than 30 minutes for my doctor to see me.
When a family member or I am sick, and the clinic is not in the area, I still have access to health care.
I am satisfied with the medical care I receive at the health center.
When I call the health center phone line I understand the information given on the voicemail.
The front-office staff treat me with courtesy and respect.
The system is considering changing the survey to match one given nationally by the Bureau of Primary Health Care. The questions will be reviewed by the executive directors and their staff and would be implemented in 2005. Referrals When making a referral, the clinic generally refers patients to providers who can meet their language needs. For example, the hospitals of Sonoma County, Santa Rosa Memorial, and Petaluma Valley, as well as entities of the Saint Joseph Health System, have Spanish interpreters in the emergency department on a regular basis. After-hours assistance The answering machine for the community programs’ office has messages in English and Spanish. The after-hours answering service for the mobile health clinic is staffed with Spanish speakers. Translated materials The clinics obtain translated materials from a variety of sources, including state agencies such as the Child Health and Disability Prevention program and Maternal and Child 34
Health bureau. In addition, materials are obtained from organizations like the American Academy of Pediatrics, the American Lung Association, and the American Diabetes Association. If materials are unavailable, the staff will translate information including registration forms, consent forms, after-care instructions, and educational and outreach materials. The clinics have also purchased a Spanish version of the Healthwise Handbook, a self-care manual. The handbook offers information on health conditions, prevention, and home care, in addition to information on when to phone a doctor. Healthwise is a not-for-profit organization working to help people stay healthy and take care of their health problems.23 The community health program office has purchased copies for its patients, including mobile clinic patients, and can also excerpt materials for training and educational presentations. Funding The Saint Joseph Health System dedicates 10 percent of its bottom line to “care for the poor” funding. Most of the mobile health clinic’s funding, however, comes from grants (including the Redwood Community Health Coalition), donations, and limited billings based on a sliding fee scale. The mobile dental clinic is primarily grant-focused, although when those grants sunset in 2005, it expects to obtain “care for the poor” funding from Saint Joseph Health System.24 The promotores de salud program is funded through grants and “care for the poor” funding. For the fixed-site dental clinic, “care for the poor” funding covers the clinic’s uncompensated care—approximately $100,000 per year. The rest of the clinic’s funding is paid for by the public health programs in which the children are enrolled. These include Medi-Cal (California’s Medicaid program), Healthy Families (California’s SCHIP program), and CHDP (Children’s Health and Disability Prevention Program), a California-financed program for children ineligible for Medi-Cal or SCHIP). Contact: Kathy Ficco, R.N. Executive Director Medical Access Programs Saint Joseph Health System of Sonoma County 751 Lombardi Court, Suite A Santa Rosa, CA 95407 Phone: 707-546-5899 35
Fax: 707-524-2473 Email: [email protected]
Web site: http://www.stjosephhealth.org/services/commbenefit.htm Young Children’s Health Center, Albuquerque, New Mexico Background Young Children’s Health Center (YCHC) is a community-based, pediatric clinic that provides comprehensive health services to families with children from birth to young adulthood. The clinic is located in a relatively isolated, impoverished area populated by individuals of many different cultures and ethnicities.25 Services provided by YCHC include home visitation, behavioral health services, and case management. The center also provides outreach activities to schools and the local community center and offers other neighborhood activities. Networking and collaborating with other community programs is a priority at YCHC. The program takes a special interest in children with special health care needs, including a large proportion of deaf children and their families. Over 90 percent of families that YCHC treats are Hispanic, 50 percent of those families speak only Spanish. Promising Practices: Bilingual staff, interpreter competency assessment, and cultural competency training The clinic staff include five physicians, four masters-degree-level social workers, three bachelors degree-level case managers, plus administrative and support personnel. All clinic staff are required to be bilingual. The clinic’s five physicians are bilingual, but the child psychiatrist and some other therapists are not. When the child psychiatrist works with LEP patients, a bilingual social worker interprets, allowing for interpretation that is sensitive to the patient’s psychological needs. The social worker also receives extra training in interviewing, counseling, and follow-up. Staff members are sometimes required to interpret for other therapists. Four staff members have been certified for medical interpretation through the University of New Mexico Hospital and receive extra salary compensation. Because of additional financial compensation offered to those certified, priority for training is given to bilingual staff members based on the amount of time they spend or plan to spend interpreting in the clinical setting.
Referrals The clinic employs a bilingual patient care coordinator who makes referral arrangements for LEP patients. The physicians are familiar with bilingual specialists and try to arrange for LEP patients to see those providers. When a bilingual provider is not accessible, however, the patient care coordinator arranges for an interpreter from the hospital to accompany patients. Assistance for deaf patients In addition to Spanish-speaking LEP patients, the clinic sees patients with hearing impairments. YCHC has made serving the deaf community a priority by initiating and advertising the Deaf Access Program. Every physician and staff member has gone through the first level of training in American Sign Language. When hiring new staff, YCHC looks for candidates with a willingness to learn sign language. The clinic also has a teletype phone system so patients with hearing impairments can make appointments.26 Cultural competency training The clinic makes education in cultural issues a regular focus of staff meetings by inviting individuals from other agencies to make presentations. Moreover, staff have participated in “Medical Home” training sessions, offered by the American Academy of Pediatrics, with an emphasis in cultural competency.27 The clinic also invites members of the deaf community to educate staff members about deaf culture during regular staff meetings. Translated documents YCHC provides translated versions of all of the written materials it dispenses. The University Hospital and the American Academy of Pediatrics provide some documents, but the clinic gets most of its translated documents by using a computer program with an extensive index of topics in English and Spanish.28 Funding The clinic is under the organizational umbrella of Children’s Hospital of New Mexico, which is part of the University of New Mexico. However, YCHC is responsible for its own funding and garners its annual $1.1 million budget through clinical billings, private grants, state appropriations, contracts with state agencies, the city of Albuquerque, and donations. The clinic supports the patient care coordinator position, which is full time, with private grants. Additionally, the clinic pays for the deaf services program entirely with private grants. In 2001, the clinic received $50,000 in private gifts to help run the Deaf Access Program. The program also received a McCune Charitable Foundation grant that provides $70,000 for the next two years.29
Contact: Dr. Javier Aceves Medical Director Young Children’s Health Center 306 San Pablo Street Southeast Albuquerque, NM 87108 Phone: 505-272-4071 E-mail: [email protected]
Web site: N/A
FAMILY PLANNING CLINICS Planned Parenthood of the Palm Beach and Treasure Coast Area, West Palm Beach, Florida Background Planned Parenthood of the Palm Beach and Treasure Coast Area (PPPBTC) was incorporated as a nonprofit organization in 1971. Its mission is to provide comprehensive sexual health services and education through medical services, educational programs, and public affairs. PPPBTC operates health centers in four Florida counties, serving more than 13,000 individuals with more than 40,000 medical visits each year. Approximately 17 percent of the clinic’s clients are Latino. Among the medical services offered by PPPBTC are cancer screening; colposcopy, cryotherapy and LEEP; contraception; annual female examinations; diagnosis and treatment of vaginal and urinary tract infections; HIV/AIDS testing; testing and treatment of sexually transmitted infections; pregnancy testing and options counseling; and vasectomies. PPPBTC operates a variety of educational programs including adolescent life skills, breast health education, and teen time and teen pregnancy prevention programs. PPPBTC also has a series of “free Pap” days where individuals can obtain free Pap smears. Promising Practice: La Promesa (The Promise) and Los Promotoras (The Promoters) PPPBTC developed La Promesa in response to changing demographics in its region. Florida’s Latino population is the third-largest in the nation and Spanish speakers represent the largest language minority in Florida. Between the 1990 and 2000 censuses, the Palm Beach Latino community more than doubled. La Promesa has two goals: to offer culturally and linguistically sensitive medical services and to help build a pact between Planned Parenthood and area Latinos to shape children’s futures through parental support. 38
The La Promesa program operates in three of PPPBTC’s four sites, funded by local foundations. PPPBTC’s Lake Worth clinic has six staff members, three of whom are bilingual, including the La Promesa staff person who divides time between outreach activities and staffing the clinic. At the Lake Worth clinic, the La Promesa staff member spends a minimum of two full days in the clinic each week. Contact with Spanish-speaking clients often begins at an outreach event conducted by La Promesa. The clinic undertakes significant outreach activities in the Latino community including participating in health fairs and after-school programs, and making presentations at faith-based organizations. The clinic also held two “free Pap” days specifically for Spanish-speakers. Clients often schedule appointments at the clinic following an outreach activity or to follow-up after a free Pap test. When clients call to make appointments, the intake staff ask if clients are more comfortable receiving services in English or Spanish. For those requesting Spanish, the schedule is marked LP for La Promesa. When a Spanish-speaking client arrives at the clinic, the La Promesa staff person greets the client and assists with completing necessary forms. The staff member also updates the client’s information, obtains information about the reason for the visit, and provides information about various health issues. Four current areas of focus are breast health, cancer prevention and screening, sexually transmitted infections, and family planning. When the patient is seen by the clinician, the La Promesa staff person may accompany the patient, as requested. Since many clinicians are bilingual, the La Promesa staff are not required to interpret but serves in a support role for the patient. The job qualifications for La Promesa staff include a B.A. degree, bilingual fluency (with a preference for native speakers), a public-speaking background, and knowledge of the local community. Once hired, La Promesa staff members receive on-the-job training regarding medical issues, confidentiality, and other topics relevant to the work. The La Promesa program is funded by the Quantum Foundation and the Picower Foundations, both based in Florida.30 During 2001, PPPBTC staff members established a partnership with a Guatemalan family planning agency. After observing the Guatemalan program, PPPBTC initiated a similar model to offer culturally sensitive sexual health information specifically for the Mayan community. The program identifies and recruits leaders from the Mayan community to serve as promotoras. The promotoras participate in 32 hours of training covering a range of family-planning topics such as baby spacing, sexually transmitted 39
infections, nutrition, and communication skills. Once trained, the promotoras present the information in Mayan homes and their communities. This model seeks to create job opportunities (by providing stipends to the promotoras) and cultivate community leadership. The program is funded by the Quantum Foundation and Planned Parenthood Federation of America. Adult Role Models Adult Role Models (ARMs) is a program that brings increased awareness about sexual health and teen pregnancy to the community. The program trains parent volunteers to provide instruction and outreach to other parents. ARMs volunteers interact with their peers, create a parental support system in their neighborhoods, and serve as model parents. In 2003, over 1,600 parents received the training. PPPBTC has established partnerships with Haitian Family Services, the Urban League, Aspira (a Latino youth development organization), and the Glades Community Development Corporation to develop and deliver culturally relevant sexual health education. ARMs programs are provided in English, Spanish, and Creole. The entire curriculum has been translated into Spanish and Creole. This program is funded by the Children’s Services Council of Palm Beach County and Planned Parenthood Federation of America. Interpreter competency Individuals interpreting in the clinics or providing services in a non-English language are assessed during the interview for competency in both English and Spanish. There is no formal certification or assessment. PPPBTC is exploring the possibility of using a local language company to conduct more objective language assessments of job applicants. Translation of materials The clinics obtain a significant amount of translated materials from outside sources, including Planned Parenthood Federation of America, the Susan G. Komen Breast Cancer Foundation, and commercial sources. For clinic-specific materials, the La Promesa and bilingual outreach staff translate materials including outreach flyers, client information forms, medication instructions, and discount coupons. Contact: Lillian A. Tamayo President/CEO Planned Parenthood of the Palm Beach and Treasure Coast Area 40
2300 North Florida Mango Road West Palm Beach, FL 33409 Phone: 561-472-9960 E-mail: [email protected]
Web site: http://www.pppbtc.org Planned Parenthood of Pennsylvania, York, Pennsylvania Background Planned Parenthood of Pennsylvania in York, Pa., employs six nurse practitioners, one nurse mid-wife, and 18 support staff members. It runs five full-time clinics and one clinic that is open one day per week. Five percent of all patients the clinics encounter are LEP Spanish speakers. The clinics have also encountered some Vietnamese patients and patients with hearing impediments. Promising Practice: Scheduling of LEP patients Bilingual staff members generally answer the phone. If not, when an LEP person calls, the person answering the phone immediately asks for assistance from the bilingual staff person. LEP patients’ language needs are noted when their appointments are scheduled to ensure a bilingual staff member will be available to interpret. These needs are also noted because bilingual appointments take significantly longer than appointments with proficient English speakers. Bilingual staff The organization has four bilingual support staff members, each working at a different clinic site. As such, there is a full-time, bilingual Spanish speaker on site at four of the five clinics. The other clinic rarely encounters Spanish speakers, but one of the bilingual staff members drives to that clinic to assist, when needed. Telephone language line Planned Parenthood uses a telephone language line for LEP individuals who speak languages other than Spanish. Administrators estimate the clinics use a language line about once or twice per month. Because of the sensitive nature of many patient issues, calls to the language line tend to be lengthy and cost from $60 to $140 per call. Sign language interpretation When the clinics encounter patients with hearing impediments, they contract with an agency in a neighboring town that provides American Sign Language interpretation.
Planned Parenthood values professional sign language interpreters who are sensitive to the personal nature of family planning issues. This service costs about $200 per visit. Family members and friends The clinics very rarely use family members for interpretation. There is a waiver that LEP patients at Planned Parenthood must sign if they choose to use a family member for interpretation rather than the services the clinic provides. The waiver, however, is only available in limited languages. Referrals The clinics generally refer patients to providers who serve low-income populations as they have found these providers are more likely to provide language assistance. The clinics rely mainly on word-of-mouth to determine which providers have Spanish assistance available. When referring patients who speak other, less frequently encountered languages, they call ahead to ensure language assistance will be made available. The clinics also give their patients “I Speak . . .” language cards to take to referral appointments. Translated materials The clinics translate most patient materials on-site. When a request is made, one bilingual staff member will translate the document. Then the document will be circulated to other bilingual staff members to ensure accurate translation. Planned Parenthood also gets translated documents from the March of Dimes, the American Heart Association, the American Lung Association, and Planned Parenthood Federation of America. Funding Most language service costs are incurred due to the occasional use of the language line and professional interpreters. The organization does not pay bilingual staff at a higher scale. Translations are provided by bilingual staff members during working hours, so the cost is built into the salaries. There is no separate budget or line item for language assistance costs. All clinic services are paid for by a combination of government funding, grants, patient fees (assessed on a sliding scale), and the Pennsylvania Department of Health. Contact: Peg Welch Director of Client Services Planned Parenthood of Pennsylvania 728 S. Beaver Street York, PA 17403 42
Phone: 717-843-9683 x207 Fax: 717-843-2698 E-mail: [email protected]
Web site: N/A Washoe County Family Planning Program, Reno, Nevada Background Located in urban Reno, Nev., the Washoe County Family Planning Program (FPP) provides family planning and gynecological services to women of childbearing age. The program employs six nurse practitioners, mostly on a part-time basis. The program also has two collaborating physicians on site once per month. Services are provided at the Washoe County District Health Department. The program has provided Spanish interpretation services for 17 years and is well known in the Hispanic community for assisting LEP patients. Up to 50 percent of the patients treated at the program are LEP Spanish speakers. Approximately once per quarter, practitioners encounter patients who speak other languages, such as Tagalong, Chinese, and Hindi. Promising Practice: Bilingual staff FPP meets its clients’ language needs by employing only bilingual Spanish-speaking support staff and by using a telephone language line. Every day, there are between four and six bilingual staff members on site. One of the nurse practitioners at the clinic speaks limited Spanish but occasionally requires assistance communicating with patients. Most of that practitioner’s schedule is filled with LEP patients. Competency There is no formal process for assessing bilingual staff members who provide interpretation services, but employees are hired only if their Spanish skills are deemed sufficient for clinical interpretation. The lead office assistant, who is bilingual, evaluates the applicants’ language skills prior to hiring and evaluates all new staff during training. She must approve of new hires’ skills in various clinical settings before they can provide independent interpretation services. Moreover, all new staff members receive informal training on cultural issues from the program manager. The lead office assistant evaluates existing staff members’ language skills on a yearly basis. If she detects an employee’s Spanish skills are not strong enough to interpret during exams, that interpreter will be limited to working outside the exam room.
Telephone language line The program keeps speakerphones in many of its exam rooms so practitioners can access a language line if the clinic is shorthanded or if it encounters patients who speak languages other than Spanish. Administrators at FPP estimate they use telephone language lines between five and 10 times per month. Scheduling Patients’ language needs are recorded in the schedule. Staff space LEP appointments so that there is always a bilingual staff member available to answer urgent phone calls. While the program never restricts the number of LEP appointments, LEP patients who are new to the clinic may wait up to two weeks longer to get an initial appointment than their English-proficient counterparts because the initial appointments are more time consuming. Patients’ language needs are also recorded in the clinic’s computer system. Referrals If patients need services not provided by the program, FPP tries to refer patients to bilingual physicians. Because most patients are low-income, they are mainly referred to other low-income agencies with interpretation services. FPP also refers patients to Nevada Hispanic Services for language assistance. FPP has a vasectomy program that provides service through private contracts with doctors in the community. The clinic does the initial informed consent and vasectomy counseling and then refers the patient to a doctor’s office. If a patient needs an interpreter for this service, the clinic provides one. Translated materials FPP provides its LEP patients with Spanish copies of every form required by the clinic. Two members of the support staff, supervised by a physician and the medical director at the County Health Department, translate all materials for the clinic. FPP also provides basic forms, such as birth control information sheets, in 12 other languages. They obtain these forms from the California Family Health Council.31 Funding FPP, which is managed by Washoe County, is a grantee of the Federal Title X Program and receives some local and state funding. Patients pay for services on a sliding scale. The program estimates that the costs of using a telephone language line and providing longer appointments for LEP patients average between $5 and $9 per visit. These costs are built into the program’s fees. Grants and local tax dollars supplement the services.
Ongoing quality improvement The Washoe County Health Department has initiated a Continuing Quality Improvement project to address interpretation, translation, and scheduling issues. FPP administrators and other County Health Department division heads will conduct sessions to determine the most effective and equitable means of funding and providing language services. Contact: Stacey Hardie Family Planning Program Washoe County District Health Department 1001 E. Ninth Street, Building B Reno, NV 89512 Phone: 775-328-2444 E-mail: [email protected]
Web site: N/A Women’s Health and Education Center, Marshalltown, Iowa Background The Women’s Health and Education Center is located in Marshalltown, Iowa, a rural area located about one hour from Des Moines. Marshalltown has a population of approximately 25,000. Of the clinic’s patient population, approximately 20 percent are Spanish-speaking; the clinic also occasionally encounters Chinese-, Laotian-, and Vietnamese-speaking clients. In addition to its central office site in Marshalltown, the clinic operates satellite sites in Grinnell and Toledo. The clinic provides family planning, reproductive health, and STD/HIV testing and treatment services. The clinic has 11 staff members: three nurse practitioners, three registered nurses (who also serve as executive director, director of patient services, and safety director), a licensed practical nurse, a fiscal manager, a health educator, and two accounting assistants who also serve as interpreters. The clinic has been providing language services to its Spanish-speaking clients for more than 10 years. Initially, the clinic had a bilingual nurse practitioner. After she left, the clinic began examining how to continue providing services to Spanish-speaking clients. The clinic employed interpreters from Iowa State University’s language department for a short time, but this proved difficult due to scheduling reasons and because the students spoke Castilian Spanish, not the clients’ dialect. The clinic then began
hiring bilingual staff who could serve as interpreters while also undertaking other responsibilities. Promising Practices: Bilingual staff Most of the clinic’s staff have some knowledge of Spanish and can assist with routine scheduling and front-office work. Two staff members serve in dual roles as interpreters and accounting assistants. This arrangement allows the clinic to have at least one person available for interpreting at all times. The interpreters initially meet with clients to obtain a health history and then accompany the client through the clinical exam with the nurse practitioner. Hiring and training The clinic does not require specific certification or training for interpreters. The interview process requires the applicant to write in both English and Spanish to check literacy level. Other clinic bilingual staff assess spoken language competency. The clinic’s director and other staff members train the interpreters on issues specific to the clinic, including medical terms, forms, HIPPA requirements, and confidentiality. Most of the training is conducted on-the-job as staff often assist in a variety of roles. New staff—both interpreters and general staff—undergo a clinic orientation and sign a code of confidentiality. Scheduling The interpreters rotate locations among the three clinic locations. Interpreters are available on-site four days per week in Marshalltown, one day per week in Toledo, and four days per week in Grinnell. Because the number of LEP patients varies, interpreters are available on-site when needed. In limited situations when this is not possible (e.g., during staff vacations), one interpreter is available by phone, as needed. When a Spanish-speaking client calls the clinic, the client’s language needs are noted in the schedule to ensure an interpreter will be available. Clients’ language needs are also noted in the clinic’s computer data system. The clinic has found that the length of the appointment does not differ for English- and Spanish-speaking patients and uses the same time blocks for all patients. Often the clinic must call a client to report lab results. An interpreter or one of the clinic’s bilingual staff members phones the client and schedules future appointments to discuss results or receive treatment. Because of confidentiality concerns and the sensitive nature of the services, the clinic does not disclose most test results over the telephone.
Referrals and after-hours assistance For clients who need services not offered by the clinic, staff members try to refer clients to bilingual providers, relying on their knowledge of local providers. Most clients are referred to the University of Iowa or a local primary health clinic because both sites have interpreters. The clinic’s answering machine offers information in both English and Spanish for after-hours assistance. The clinic also works with disease prevention specialists at the Iowa Department of Public Health. These specialists may meet clients at the clinic and use the clinic’s interpreters to conduct follow-up regarding reportable sexually transmitted diseases. Outreach The clinic conducts outreach at schools, churches, Women, Infants, and Children (WIC) clinics, and other facilities. When conducting outreach in the Hispanic community, the clinic’s interpreters accompany the health educator. Translated materials The clinic has a variety of information translated into Spanish. It obtains brochures and information from a range of sources, including the Family Planning Council of Iowa. The interpreters translate clinic-specific forms in a straightforward and basic way to reduce the need for continuous revisions. Some brochures are purchased, using the clinic’s general operating funds. Cost does preclude the clinic from purchasing numerous brochures. Family members and friends Because of the sensitive nature of the services provided, the clinic has a strict policy discouraging the use of family members or friends as interpreters. Only in true emergencies would the clinic rely on family members or friends. In rare circumstances when interpreters are not available, and the situation is not an emergency, the clinic may reschedule the client. Cultural competency The clinic’s entire staff participated in a language and cultural training when the clinic first began seeing Spanish-speaking clients. The trainer was a local professional health individual who had worked with clients in a Spanish-speaking country. Classes covered the basics of language, culture, and medical terminology. Many materials from the classes are still used to train new employees. The state Family Planning Council has also provided some cultural competency training. Staff have also used video resources for training on working with interpreters.
Funding The costs of providing language services are built into the clinic’s budget. Because the two interpreters fulfill dual roles by assisting with the clinic’s accounting and data entry, the cost has not been prohibitive. If the clinic did not need interpreters, it might instead employ one full-time accounting person rather than the 1.8 FTE it currently employs. For the occasions when the clinic needs Chinese interpreters, it uses a telephone language line. If the clinic begins seeing Chinese or other language speakers on a more regular basis, it will examine other methods of obtaining language services for these clients Contact: Dinny Nielsen Women’s Health and Education Clinic 704 May Street Marshalltown, IA 50158 Phone: 641-752-7177 E-mail: [email protected]
Web site: N/A
ASSISTANCE TO SMALL PROVIDERS FROM OTHER SYSTEMS/INSTITUTIONS Cooley-Dickinson Hospital, Northampton, Massachusetts Background Cooley-Dickinson Hospital (CDH), based in Northampton, Mass., is a 125-bed community hospital. It offers a range of services, including emergency, pediatrics, obstetrics and gynecology, radiology, and pharmacy. Cooley-Dickinson’s Hampshire Health Connect program helps eligible community members enroll in public health, pharmacy, and other programs. Promising Practice: Hospital pays for language services at affiliated medical offices In 1995, CDH applied to the Massachusetts Department of Health for permission to add a magnetic resonance imaging unit. As a condition of approval, the state required the hospital to provide on-site interpreter services 24 hours per day, seven days per week. The hospital implemented this policy not only on-site but also at the offices of physicians affiliated with the hospital. During fiscal year 2003, the hospital provided interpreters for over 1,000 sessions, 47 percent of which were off-site. The primary language need is Spanish, which comprises over 90 percent of the interpreting sessions. The next most requested languages are Polish, Cambodian, and Portuguese. Any health care provider on the medical staff may access interpreter services. These providers are not employed by the 48
hospital but do have admitting privileges. They include primary and specialty providers. The providers do not pay for these services. In-person interpreters The hospital uses two local organizations to provide interpreters. The primary contract is with Casa Latina, a local community-based organization that provides interpreters for Spanish, Polish, Khmer, Russian, and Vietnamese. The hospital pays Casa Latina a monthly administrative fee and a per-appointment usage fee. The administrative fee covers phone and beeper service and administrative staff. Interpreters are paid $30 per hour with a two hour minimum, plus mileage. Casa Latina interpreters are trained as medical interpreters and also undergo annual retraining. The hospital’s contract with the agency requires interpreters to sign a code of ethics and confidentiality and abide by HIPAA. The hospital also uses the University of Massachusetts (UMass) Translation Center to provide interpreters when Casa Latina does not have interpreters available or when there are additional needs. UMass Translation Center interpreters are paid $40 per hour. Scheduling All requests for interpreters—at the hospital and off-site medical staff offices—are made through the hospital’s case management department during regular business hours. One office assistant in the case management department has been trained specifically to handle interpreter requests. An office assistant in the education department offers backup support when this staff person is unavailable. After hours, the hospital’s switchboard responds to requests for interpreters. Some patients call Casa Latina directly to request an interpreter. If this occurs, Casa Latina staff confirm the appointment with the health care provider and notifies the case management department of the appointment. After-hours assistance As an additional backup, hospital staff may use the AT&T Language Line for patients in the hospital when Casa Latina or the UMass Translation Center are unavailable. This contract costs $50 to $100 per month, which includes approximately two hours of usage. Currently, this service is not provided to the CDH Medical staff offices. Bilingual staff The hospital has hired a few bilingual staff members but generally does not use them for interpreting in patient-care settings. Two to three individuals in the billing department speak Spanish and another Spanish-speaking person works in the administration department.
Training for hospital staff and medical offices Hospital staff members are trained to access interpreters and each department has information at its main desk regarding obtaining services. The hospital also conducts educational sessions at physicians’ offices and provides information and brochures about the language services. Translated materials The hospital translates materials on an as-needed basis and by request from hospitals or CDH medical staff offices. The hospital utilizes the UMass Translation Center to provide translations. Most requests are for translating documents into Spanish. Documents include HIPAA privacy notices, information on blood transfusions, lab instructions, pain management information, patient’s rights and Emergency Medical Treatment and Labor Act notifications, rehabilitation instructions, and HIV test consent forms. The hospital also uses CareNotes, a computer software program that provides English and Spanish information regarding pharmacy and medications, diseases and diets, discharge instructions, and other information. Funding The hospital pays for the interpreter services from its operating budget. The total budget for these services was approximately $90,000 in 2003, including foreign language and sign language interpreters and translation services. Hampshire Health Connect In addition, CDH houses Hampshire Health Connect (HHC), a nonprofit program that helps low-income, uninsured, and underinsured residents of Hampshire and surrounding counties access health coverage and health care services. HHC helps individuals by screening for eligibility in a range of public programs and assisting these individuals in completing applications. The public programs include free and reduced-fee hospital care, Medicaid, SCHIP, welfare and food stamps, and a variety of pharmacy-assistance programs. HHC also advocates on behalf of patients who have trouble accessing care or who are incorrectly terminated from benefits. All uninsured patients in the hospital’s emergency room are given a flyer about HHC, although any community member may request assistance. The hospital’s case managers can only provide assistance to patients when they are in the hospital while HHC can assist patients post-discharge. Consequently, the case managers also refer patients to HHC. HHC recently hired a bilingual, Spanish-speaking case manager to assist LEP 50
individuals. In addition to working at the hospital, this person works from the county department of health office two afternoons per week to assist clients in filing applications. HHC operates on a budget of approximately $200,000 per year. The hospital is HHC’s largest funder and also provides in-kind donation of office space and equipment. The program helps hospital patients to enroll in public health programs that can pay for the care provided. Other funding comes from local foundations and fund-raising efforts, including an annual dinner. Contact: Jan Korytoski Manager, Patient Access Cooley-Dickinson Hospital 30 Locust Street Northampton, MA 01061-5001 Phone: 413-582-2020 E-mail: [email protected]
Web site: http://www.cooley-dickinson.org/ Sonia Bouvier Director Hampshire Health Connect 30 Locust Street Northampton, MA 01061-5001 Phone: 413-582-2848 E-mail: [email protected]
El Puente, Jackson, Wyoming Background El Puente (the Bridge) offers medical interpretation services primarily in Teton County, Wyo. It started providing services in October 2003 after a local study revealed that disparities in access to care were due, in part, to language barriers. Approximately 2,500 Latinos live in Teton County, which includes Jackson Hole. Most are from Mexico (95%), although some are from Central and South America. Sixty percent have no English proficiency and 30 percent have limited English proficiency. Very few health care providers in the area speak sufficient Spanish to assist these individuals without interpreters.
Promising Practice: Providing trained medical interpreters free of charge to providers El Puente offers medical interpreting services at hospitals and health care provider offices in Teton County, Wyo., and on a limited basis in Teton County, Idaho. In its first year of operation, El Puente provided interpretation services at approximately 700 clinical encounters. During an average month, this includes 10 to 20 medical appointments daily, 5 to 10 labor/deliveries, 5 to 10 surgeries, and 30 to 40 calls from health professionals. Medical interpreters El Puente employs four interpreters, hired as part-time employees (from 15 to 30 hours per week) but authorized to work additional hours as needed. Additionally, El Puente has a director and part-time office assistant who also provides interpretation services on a limited basis. Telephone interpretation El Puente provides limited telephone interpretation, generally when a doctor at the hospital is conducting rounds and wants an interpreter to communicate with a patient. Since the time with the patient during rounds is minimal, an in-person interpreter is not provided. Competency of interpreters Before hiring a new employee, El Puente conducts an assessment of the individual’s language skills and knowledge of medical terminology. Upon employment, the staff member is trained as a medical interpreter using the Bridging the Gap32 curriculum. As part of this training, the interpreter must pass an evaluation by Pacific Interpreters, with whom El Puente contracts for the assessment. El Puente also uses the competency evaluation for determining which employees may interpret in certain situations. It only allows its native Spanish-speaking interpreters to work in complex situations, such as neurology, genetics, and mental health counseling. After-hours assistance El Puente’s medical interpreters answer their cell phones 24 hours per day, seven days per week. During regular business hours, one interpreter is on-call for labor and deliveries— this interpreter is cross-trained as a doula.33 The Jackson hospital recently hired four medical interpreters to staff its emergency department on nights and weekends. While these interpreters provide needed assistance in the emergency department, they do not assist patients in other departments or follow-up with emergency patients to assist in posthospital care. The hospital tries to use its two bilingual staff members (who work in the admitting and billing departments) as interpreters in the ICU, pediatric ICU, radiology, 52
and other departments. When these staff members are unavailable, El Puente interpreters are utilized. The El Puente interpreters are also on-call for after-hours assistance to the obstetrics department. Cultural competency training The director of El Puente traveled to Tlaxcala, Mexico, the state of origin of 80 percent of Teton County’s Mexican residents, to study the health services available there. The staff now offer a training module to health professionals that explains the health services available in Tlaxcala, which helps providers understand their patient’s expectations of care in the United States. Plans for expansion El Puente primarily provides services in Teton County, Wyo., although it offers limited services in one neighboring Idaho county. The long-term plan is to expand its services in the primary Teton County, Idaho, hospital. El Puente will first work with the hospital to inform staff about the need for medical interpreters and how staff will work with them. El Puente will also work to train the hospital’s volunteer interpreters and bilingual staff as medical interpreters. Over the next few years, the organization hopes the hospital will establish its own El Puente team of medical interpreters built on the Jackson, Wyo., model. Funding El Puente’s first-year budget was approximately $120,000. El Puente is supported by a number of different sources. Three local foundations and individual donors underwrite the budget. In addition, the Jackson hospital donates office space for the organization, an inkind donation worth approximately $12,000 to $15,000 per year. The organization solicits donations from the medical community and from its clients, who are asked to donate $25 per year per family for unlimited interpreter services. Clients are not, however, denied services if they choose not to donate. El Puente has found that most clients do wish to contribute, although these donations compose a small percentage of the total budget. El Puente is embarking on a long-term strategy to develop a for-profit social enterprise to support its nonprofit medical interpreting work. It is establishing Teton Gourmet Tamales and expects operations to begin in 2005. In the first three years, the organization plans to distribute locally and via the Internet, with a goal of opening a retail store. This venture will donate all profits to El Puente.
El Puente has also been approached by the Wyoming Department of Health to establish a medical translation business to translate department forms. Currently, El Puente does not have sufficient staff or expertise to undertake medical translation but will continue to explore this possibility as an additional revenue stream. Contact: Vida Day Director El Puente 536 East Broadway Jackson, WY 83001 Phone: 307-739-4544 E-mail: [email protected]
Web site: N/A Johnson County Hospital and Family Health Services, Tecumseh, Nebraska Background Family Health Services (FHS) is located in rural Tecumseh, Neb., approximately 50 miles from Lincoln. Operating since 1973, the clinic provides a range of public health services including medical examinations, family planning services, diabetes education (funded by a Health Resources and Services Administration rural health grant) and HIV prevention case management (funded through the Centers for Disease Control and Prevention). FHS operates in three sites, holding clinic hours at each site one to three times per month. FHS does not have any physicians on-site but has three medical directors overseeing its services. Two nurse practitioners provide all services and two office managers provide administrative support. The LEP population of Tecumseh and its surrounding areas are primarily Spanish speakers, although some patients are Laotian. Promising Practice: Hospital pays for in-person and telephone interpreters To meet the needs of its LEP clients, FHS initially utilized family members and friends to interpret, although it never relied on patients’ children because of the sensitive nature of the services provided. It then began utilizing a telephone language line and interpreters, paid for by Johnson County Hospital with state grant funding. Initially, FHS had one speakerphone operating on a 40-foot phone cord that was moved among the examination rooms. Recently, FHS purchased cell phones with speaker capabilities. The organization has considered hiring bilingual staff but has found it difficult to recruit qualified individuals. 54
On-site interpreters FHS has been providing language services for the past 18 months. The initiation of formal language services, rather than the ad hoc use of family members or friends, arose when grant funds were allocated to Johnson County Hospital to coordinate language services throughout Tecumseh. In the main FHS Tecumseh office, on-site interpreters are available during certain clinic hours. One is primarily utilized for clinic services and one for WIC outreach and counseling. Language line At the two satellite sites, staff members use a language line to communicate with LEP clients. The language line, also paid for by the hospital, is utilized for non-clinic appointments and when clients call FHS for assistance. Referrals At times, FHS refers clients to other health care providers for services that it does not offer. One local physician has language services that are funded by the hospital. When possible, FHS will refer clients to this provider. Translated materials The state family planning agency has assembled an LEP manual of resources, fact sheets, and brochures available in English, Spanish, and other languages. This has allowed FHS access to a range of translated materials that it can duplicate or order. Funding The state Office of Minority Health allocates each Nebraska county specific funding for minority health issues. The funding is based on a per capita amount using census numbers. The Office of Minority Health grants are available by application to any entity in the county that has a governing board composed of 50 percent ethnic minority members or has a significant number of ethnic minority individuals in key positions (including management, administrative, and service positions) who reflect the racial or ethnic community served or who have an established record of service to and involvement with the targeted community. The state is funding two language interpretation projects. In the past two years, Johnson County Hospital was the only entity submitting a grant for the Tecumseh area that focused on communication with LEP individuals. The hospital received $11,000 over two years and has used this money to pay for the interpreters and language line services for the hospital, FHS, a WIC clinic, the health department’s immunization clinic, and one local doctor’s office. Unfortunately, the funds 55
are running out halfway into the grant cycle and the providers may have to begin subsidizing the costs. Contact: Jean Brinkman Family Health Services 1179 Webster Street Tecumseh, NE 68450 Phone: 402-335-3988 E-mail: [email protected]
Web site: http://www.fhsi.org North DeKalb Health Center, Chamblee, Georgia Background The North DeKalb Health Center is a satellite clinic of Grady Hospital that offers general medicine, pediatric, and prenatal services in urban Atlanta. North DeKalb employs 13 physicians and 18 staff members; its patient population is 85 percent LEP, primarily Spanish speaking. Promising Practice: Staff interpreters and bilingual staff North DeKalb employs one full-time interpreter, two bilingual physicians, and a bilingual support staff member. The full-time interpreter provides most of the interpretation services. In her absence, physicians occasionally use bilingual medical staff, mainly nurses, for interpretation. Competency The full-time interpreter was required to undertake training before she could interpret at North DeKalb. Grady paid for her to take a course offered by Language Line Services34 that focused on language skills specific to medical interpreting, including a rigorous terminology test and ethical concerns for interpreters. After completing the course, she had four months to study for a certification test. Passing the test was a condition of her continued employment. Likewise, North DeKalb bilingual staff members and all bilingual hires must attend training sessions at Grady Hospital. Although there is no requirement to do so, many English-speaking providers also attend these sessions, which educate employees on medical Spanish, working with a medical interpreter in a clinical setting, and cultural competency.
Ongoing training The full-time interpreter at North DeKalb attends quarterly meetings at Medical Interpreters Network of Georgia to stay apprised of developments in the industry. Some interpreters in the Grady Health System attend yearly meetings of the Massachusetts Medical Interpretation Association, which draws participants from all over the country, and the American Translator Association Conference. Based on information they gather at these conferences, they provide a yearly training session for interpreters in the health system, including the full-time interpreter at North DeKalb, and a separate session for physicians and bilingual staff members. Telephone language line All providers at North DeKalb have access to an in-house telephone language line at Grady Hospital and to a commercial telephone service. Generally, doctors avoid using telephone interpretation services because they find in-person interpretation more useful. However, nurses must use telephone services occasionally as the volume of LEP patients is high and the full-time interpreter cannot fulfill all the clinic’s needs. Both telephone services are paid for as part of the Grady customer service budget. Referrals When arranging referrals to other providers, clinicians at North DeKalb make an effort to refer LEP patients to bilingual physicians. When that is not possible, they alert the physician that the patient will need language services. Additionally, the clinic gives its LEP patients “I Speak . . .” cards from the Medical Interpreters Network of Georgia. After-hours assistance At North DeKalb, a bilingual Spanish-speaking advice nurse is available to patients afterhours. When patients who speak a language other than Spanish call after-hours, they are put through to Grady Hospital’s interpretation services. An operator either transfers the call to an appropriate bilingual hospital employee or uses telephone language services. Translated materials North DeKalb provides several manuals, instructions, and other materials in Spanish. A full-time translator at Grady Hospital does all the translating for the clinic. When the clinic requests that a document be translated to a language other than Spanish, Grady contracts with a translation service in the community. All the translated materials the clinic provides must be approved by the Grady Hospital Interpreter Services Department.
Funding Grady Health System, a publicly funded organization, pays the full-time interpreter at North DeKalb. Out of 20 full-time interpreters in Grady Health System, six are paid for by the Indigent Care Trust Fund, a federal grant. The salaries for the other interpreters come out of the general Grady budget as customer service expenses. Contact: Alexandria Hurtado North DeKalb Health Center 3807 Clairmont Road, N.E. Chamblee, GA 30341 Phone: 404-616-0700 E-mail: [email protected]
Web site: N/A L.A. Care Health Plan, Los Angeles, California Background L.A. Care Health Plan (L.A. Care) is a public health maintenance organization that serves more than 750,000 people living in Los Angeles County, particularly those enrolled in Medi-Cal (California’s Medicaid program), Healthy Families (SCHIP), and Healthy Kids (a program for low-income children ineligible for Medi-Cal or Healthy Families, funded by foundation grants and L.A. Care). L.A. Care is one of the state’s largest health plans and the nation’s largest public health plan. L.A. Care contracts with more than 10,000 health care providers, including clinics and small provider offices. The cultural and linguistic services department of L.A. Care, established in January 2000, provides support to these providers. The health plan encourages hiring bilingual providers, as the language needs of the enrolled population exceed the availability of bilingual providers. L.A. Care’s enrollees include many LEP individuals—over 55 percent prefer a language other than English— including Spanish (45% of enrollees), Cantonese, Korean, and Mandarin, as well as 33 other languages. Promising Practice: Making resources available to participating providers The cultural and linguistic services department periodically surveys participating providers. The department also monitors developments and innovations nationally and in research literature. Using this information, as well as conducting its own research studies and reports, L.A. Care is constantly developing language services and information for its participating providers.
Traditional Safety Net Telephonic Interpreting Project The Traditional Safety Net Telephonic Interpreting Project has been operating since February 2004. The project targets county and community clinics and provider groups within L.A. Care’s network. The purpose of the project is to assist providers in communicating directly with LEP patients, while reducing the administrative time required to obtain interpreting services. Through the use of telephonic dual headsets or handsets, providers and patients can access language services when a bilingual health care provider or on-site interpreter is not available. The hand/headsets come in a toolkit and can connect to any kind of telephone system. Using this system, providers and patients do not need to pass a telephone or headset back and forth or use a speaker phone. L.A. Care makes the equipment, training, and technical support available to its participating providers at no cost; the toolkits cost L.A. Care about $9 for each handset and connector and $175 for the headset. L.A. Care also covers the costs for utilizing interpreter service for L.A. Care members enrolled in the Medi-Cal, Healthy Families, and Healthy Kids programs; providers use a coding system to designate usage for these patients. L.A. Care has negotiated a contract with Pacific Interpreters to provide interpreter services to all L.A. Care providers in the telephonic interpreting project. Pacific Interpreters’ specialty is health care. They are HIPAA compliant, have a quality monitoring process, and operate a disaster recovery center in England if delivery of services is disrupted in the United States. L.A. Care launched this project following pilot testing at three sites—a comprehensive care center with multiple clinics within the main facility, a safety net clinic, and a family care provider group. The test showed that the dual hand-sets reduced reliance on inappropriate use of friends and family members to interpret, as well as a decreased use of gesturing and other ineffective communication methods.35 Most calls were for services in Spanish and Korean. Total cost of telephone interpreter services for all three sites during the pilot period (June–August 2003) was $939.75. Language identification materials for providers L.A. Care is distributing language identification materials for participating providers. The goal is to allow patients to identify their preferred language efficiently and early and for the patients’ choices to be clearly noted and recorded for all providers and office staff. Providers are given “I Speak . . .” cards identifying 28 languages. Providers are asked to post the language identification cards in visible places at all key points of contact. L.A. Care also provides neon-colored medical record stickers to providers. Yellow stickers show patients’ preferred written and spoken languages, while green interpreter request 59
sheets show the date that interpreter services were offered, the names of interpreters used, and whether patients accepted or refused services. L.A. Care also provides an information card, in nine languages, that informs members of the free interpretation services available and provides telephone contact information of participating plans, as well as the main L.A. Care Health Plan contact numbers. Provider training As noted in a previous report, L.A. Care has been developing provider training programs.36 Two major types of training are currently offered and both programs offer continuing education credits to participants, including nurses and physicians. They may receive up to 40 hours for the first training and up to four hours toward their continuing medical education requirements for the second training. The 40-hour medical interpreter training program is offered at no cost to bilingual clinic, medical group, and hospital staff who also function as interpreters within L.A. Care Health Plan’s provider network. Participants must be fluent in English and a language other than English and must complete an assessment questionnaire prior to participating to ensure appropriate proficiency level. The training is divided into five sessions of eight hours each. The sessions are used to explain the role of interpreters, the standards of practice and protocols of health care interpreting, ethical principles (based on the California Standards for Health Care Interpreters developed by the California Healthcare Interpreters Association),37 appropriate techniques for effective interpreting, medical terminology in English and another language, and the impact of culture on communication. The training is offered at clinic, hospital, and provider sites. The four-hour training on how to work with interpreters is offered at no cost, targeting health care providers who use bilingual hospital and clinic staff to interpret for LEP patients. Participants include physicians, physician assistants, nurse practitioners, registered nurses, medical assistants, pharmacists, and health educators. The training uses lectures, demonstrations, videos, and small group practice exercises. Training topics include the impact of language and culture on the health encounter, ethical principles for health care interpreters, benefits of working with trained interpreters, and tips for health care providers and staff on working effectively with interpreters and on using telephonic interpreters. The training is offered at clinic, hospital, and provider sites during weekdays and weekends.
Texts and Web-based resources L.A. Care makes language access materials available to participating providers in hard copy and via the Internet. For example, in early 2004, L.A. Care began providing its participating providers with a 100-page English/Spanish Managed Care Glossary of Terms, at no cost. This volume offers English to Spanish translations of medical and health care terms. In developing the glossary, the cultural and linguistic services department gleaned terms from many sources, including members, participating providers, member letters, marketing materials, and health education brochures. The glossary reflects the Spanish dialect spoken by Latinos residing in the greater Los Angeles area. Bilingual managed care glossaries of terms are also available in Armenian, Chinese, Farsi, Khmer, Korean, Russian, Tagalog, and Vietnamese. L.A. Care also makes certain health member information materials (e.g. member handbooks, grievance forms, and resolution letters), vital documents, and health education materials available in Los Angeles County’s nine threshold languages (i.e., English, Spanish, Armenian, Chinese, Farsi, Khmer, Korean, Russian, Tagalog, and Vietnamese) through a library of translated documents and in the provider section of its Web site. Individuals can also access translated materials that focus on how to navigate the health care system and health information. The cultural and linguistic services department is currently expanding the availability of these resources in additional languages. Contact: Beatriz M. Solís, M.P.H. Director, Cultural and Linguistic Services Department L.A. Care Health Plan 555 W. 5th Street, 18th Floor Los Angeles, CA 90013 Phone: 213-438-5699 E-mail: [email protected]
Web site: http://www.lacare.org
APPENDIX A. SUMMARY OF SURVEYED MODELS FOR PROVIDING LANGUAGE ASSISTANCE SERVICES IN SMALL HEALTH CARE PROVIDER SETTINGS
Bilingual physicians, nurses, and support staff, and a language line provide oral interpretation and written translation in Spanish. For lab test results and scheduling appointments, clinic asks for the patient’s language of preference. The clinic has turned down English-only speaking job applicants in favor of bilingual applicants.
Bertha HerreraOchoa (Orange Co.)
General medicine, dental, and eye care clinic. Bilingual physicians, nurses, and support staff provide oral interpretation. The clinic is affiliated with a hospital that assesses the competency of the clinic’s interpreters. Written translations of education materials are obtained through a private company.
California Family Health Council (Los Angeles)
Spanish, Chinese, Vietnamese, Korean, Tagalog, Cambodian, Laotian, Hmong, Hindi, Punjabi, Russian, Armenian, Arabic
Acacia Family Medical Group (Monterey Co.)
Marybeth Ruiz (Contra Costa Co.) Saint Joseph Health System Community Health Programs (Santa Rosa)
The Council is a Title X grantee that develops and translates plain-language health education materials in 13 languages. Translation of materials involves preparation of source documents, professional review, field testing, and adaptation of illustrations.
Spanish, Mandarin, Chinese
Mental health practice operating as part of Contra Costa County Hospital and Clinics. The practice uses contract interpreters, telephone language line, and bilingual physicians and nurses to provide interpretation. Interpreters must pass written and oral tests that measure competency level. Contra Costa County Hospital and Clinics have a special committee developing expanded language services.
The system uses mobile clinics to offer health and dental services. The staff, including nurse practitioners, dentists, dental assistants, and clerical workers, are almost entirely bilingual. Three part-time bilingual staff members train community members as volunteer promotores to share health and community resource information. Most of the patients are Spanish-speaking. For other language needs, the clinics can access telephone language lines.
Colorado Spanish, Chinese, Vietnamese, Korean, Arabic
The program employs bilingual service coordinators, as well as bilingual cultural mediators who explain available services to culturally diverse families. It contracts with bilingual therapists to meet the needs of LEP families. When these providers are not available, the program uses contract interpreters.
Planned Parenthood of Palm Beach and Treasure Coast Area (West Palm Beach)
The organization’s La Promesa program employs bilingual staff to work both in clinic sites and in community outreach capacities. Under the Las Promotoras program, community leaders receive special training on culturally sensitive sexual health information and then help promote that information in their communities. Additionally, the Adult Role Models program, available in Spanish and Creole, trains parent volunteers to reach out to other parents about sexual health and teen pregnancy.
Duval County Health Department (Jacksonville)
Spanish, Bosnian, Russian, Filipino
Women’s health and pediatrics practice. Utilizes full- and part-time staff interpreters, contract interpreters, telephone language line, and bilingual physicians, nurses, and support staff to provide oral interpretation services. Participates in Interpreters Program Training, sponsored by McNeil Technology, to assess the competency of interpreters.
Kids Connection (Louisville) Florida
Chinese, Vietnamese, Spanish & others
Family planning, dental, WIC, and OB/GYN clinic. Uses full- and part-time staff interpreters, contract interpreters, telephone line, volunteers, and bilingual nurses and support staff to provide oral interpretation and some written translation. The cost of providing language services is $150,000, which is covered by federal and state grants.
Most of the clinic’s staff have some knowledge of Spanish and can assist with routine scheduling and front-office work. Two staff members serve in dual roles as interpreters and accounting assistants. The entire staff participated in a language and cultural training when the clinic first began seeing Spanishspeaking clients. Materials from that training are used to educate new employees.
Spanish, Polish, Khmer, Russian, Vietnamese & others
The hospital offers interpreter services 24 hours per day, seven days per week, not only on-site but also at the offices of physicians affiliated with the hospital. Interpreters are employed under contract with two local organizations. As an additional backup, hospital staff may use the AT&T Language Line. Bilingual hospital staff generally do not provide interpreter services in patient care settings.
Iowa Women’s Health and Education Center (Marshalltown) Massachusetts CooleyDickinson Hospital (Northampton)
Massachusetts (cont.) Spanish, Portuguese, Arabic, Italian, East Boston French, Neighborhood Haitian Health Center Creole, (East Boston) Vietnamese, Khmer, Chinese
Mental health clinic that uses full- and part-time staff interpreters, contract interpreters, telephone language line, trained volunteers, and bilingual physicians, nurses, and support staff to provide oral interpretation. The Interpreter Services Department provides professional translation of written materials. The budget for the Interpreter Services Department is approximately $600,000. The cost of providing language services is covered by grants from state, federal, and private foundations. Currently, the MA Medical Interpreters Association in partnership with the Dept. of Public Health is developing training and certification programs for medical interpreters.
Vietnamese, Spanish, Portuguese, Cape Verdean
The center offers language services including dedicated on-site interpreters, bilingual nurses, contract interpreters, and a telephone language line. The center requires interpreters to undergo basic medical interpreting training. When hiring interpreters, the center assesses the applicant’s oral and written skills. New staff members undergo cultural competency training to learn about the cultural practices, norms, and health beliefs of the patient population.
Spanish, Vietnamese, Cantonese Chinese
The Office of Disease Control addresses sexually transmitted diseases, HIV, tuberculosis, and other communicable diseases. Local certified interpreters provide oral interpretation. Translated materials are obtained from the federal Centers for Disease Control and Prevention and the Michigan Department of Community Health. The estimated cost of providing language services is $45– $95 per patient. Local clinics use a translated questionnaire to determine the need for interpreter services.
Planned Parenthood of the St. Louis Region (St. Louis)
Family planning and reproductive health services clinic with full-time staff interpreters, contract interpreters, and telephone language line to provide oral interpretation. Volunteers and staff translate written materials and Web site. The cost of contract interpreters is $40–$60 per hour.
Bilingual International Assistant Services
Russian, Bosnian, Chinese, Spanish
The agency has full-time bilingual staff who are qualified to provide counseling and case management, as well as interpretation services. To supplement the bilingual staff, the agency subcontracts with additional interpreters on an as-needed basis. All the bilingual staff and contract interpreters have undergone interpreter training, and the agency also pays for ongoing staff development classes.
Neponset Health Center (Dorchester) Michigan Genesee County Health Department (Flint) Missouri
Nebraska Johnson County Hospital & Family Health Services (Tecumseh)
In the main office, on-site interpreters are available during certain clinic hours. At the two satellite sites, staff members use a language line to communicate with LEP clients. The organization receives some funding from a local hospital that received a two-year grant focusing on communication with LEP individuals.
Rachel Stahr (Lincoln County)
Family planning and WIC clinic that uses contract interpreters to provide oral interpretation in Spanish. Providing language services costs approximately $1,000 per year, which is funded through a minority health grant partnership.
Family planning clinic that uses contract interpreters, and bilingual physicians, nurses, and support staff to provide oral interpretation in Spanish. The clinic pays for some staff to take Spanish classes at community colleges and universities. The clinic targets Spanish-speaking job applicants when making hiring decisions. The cost of providing language services is approximately $5 per patient, covered as a cost of business.
Spanish, Tagalog, Chinese, Hindi
FPP meets its clients’ language needs by employing only bilingual Spanishspeaking support staff and by using a telephone language line. There is no formal process for assessing bilingual staff members who provide interpretation services, but employees are hired only if their Spanish skills are deemed sufficient for clinical interpretation. Employees’ language skills are evaluated on a yearly basis.
Spanish, Vietnamese, French, Arabic, Somalian
Women’s health clinic that uses two full-time Spanish interpreters, two bilingual nurses, two bilingual management support persons, and telephone language line to provide oral interpretation. Translated materials are obtained from the state, community volunteers, and pharmaceutical companies. For a fee, Local Lutheran Family Services agency provides interpreter services for Vietnamese clients.
The office employs bilingual mid-level practitioners who conduct examinations and clinical visits in Spanish and also assist physicians and other office personnel during encounters with Spanish-speaking patients. It also uses telephone interpreters. The office participates in a program that makes ageappropriate picture and story books available to pediatricians for their patients, as well as information for parents regarding the benefits of reading to children. Mount Olive makes these materials available in English and Spanish.
Pediatric clinic where chief administrator, an immigrant from Panama, and a nurse practitioner, who is fluent is Spanish, interpret. When off-site, the administrator wears a beeper so that physicians can contact him to interpret, if needed. Administrator has completed a 40-hour medical interpreting course sponsored by the Charlotte Area Health Education Center.
New York Planned Parenthood (Poughkeepsie) Nevada Washoe County Family Planning Program (Reno) North Carolina Guilford County Health Department (Greensboro)
Mount Olive Pediatrics (Mt. Olive)
Shelby Children’s Clinic (Shelby)
Ohio Family Planning Assoc. of Northeast Ohio (Painesville & Ashtabula Co.) Planned Parenthood (Stark County)
Family planning clinic that uses full-time staff interpreters, contract interpreters, telephone language line, bilingual support staff, and college interns to provide oral interpretation. Oral interviews and certification are used to assess interpreter competency. The practice conducts patient satisfaction surveys to evaluate the effectiveness of the language services. The annual cost of $40,000 covers the staff and materials. Title X funds pay for the interpreters.
Family planning clinic that uses two Spanish native speakers who volunteer as outreach workers to provide language services. Written translations are obtained from Planned Parenthood Federation of America (PPFA), professional translators, and other sources.
Pennsylvania Chinatown Clinic of Drexel (Philadelphia)
Indonesian, Mandarin Chinese
The clinic provides the following language services: bilingual health professionals and students, community volunteer interpreters, and telephone language line services. Students are either volunteer or participate to fulfill curriculum requirements. To address legal, language, and literacy barriers to health care, the clinic has initiated a project to work on health literacy and education issues, and assistance for patients in obtaining emergency medical assistance.
Chinatown Pediatric Services (Philadelphia)
Cantonese & Mandarin Chinese, Vietnamese
The clinic operates with a bilingual staff; all staff members speak Cantonese or Mandarin and two staff members also speak Vietnamese. The clinic generally refers patients to a local hospital with a Chinese Health Information Center that provides language interpretation at both in- and out-patient settings.
Family Health Council, Inc. (Pittsburgh)
Family planning clinic that uses contract interpreters and telephone language line to provide oral interpretation. The cost of providing language services is approximately $6,000 per year.
Planned Parenthood of Pennsylvania (York)
The organization has four bilingual support staff members, each working at a different clinic site. For languages other than Spanish, the clinics use a telephone language line. The organization also employs professional sign language interpreters on an as-needed basis.
This primary care clinic provides language services with bilingual staff. Bilingual outreach workers provide transportation to clients, conduct home assessments for obstetrics patients and provide some prenatal teaching and counseling. If language needs will not be addressed by the specialist, an outreach worker accompanies the patient as an interpreter.
Family planning clinic that uses full-time staff interpreters, bilingual physicians and nurses, telephone language line, and Interfaith Ministries to provide oral interpretation. Providing language services cost $75 per year for language line.
Tennessee Rural Medical Services (Cocke & Jefferson Co.) Texas Wilson Family Planning Clinic (Wichita Falls)
Utah Holly Balken (Salt Lake City)
Pediatric subspecialty/multidisciplinary clinic uses full- and part-time staff interpreters, contract interpreters, telephone language line, volunteers, and bilingual physicians, nurses, and support staff to provide oral interpretation. Direct translation service costs $500, language line costs $600–$700, and salary for two bilingual staff costs $150,000–$200,000 per year.
Richard Black Health Sci. Center, Univ. of Utah (Salt Lake City)
Pediatric surgery practice affiliated with Health Sciences Center employs interpreters who provide oral interpretation and written translation.
Department of pediatrics that uses two full-time staff interpreters, telephone language line, volunteers, and bilingual physicians, nurses, and support staff to provide oral interpretation. Interpreters have state certification, and volunteer translators are screened for fluency. The two full-time interpreters cost $65,000 per year. The clinic employs bilingual/bicultural health educators from the medical school and health department to supplement patient education.
Nicole Frei Health Sci. Center, Univ. of Utah (Salt Lake City)
Pediatric practice at Health Sciences Center uses two full-time staff interpreters, as well as bilingual physicians, nurses, and support staff to provide oral interpretation. Translated materials are obtained via the Internet. County health department employees provide language services.
Prafulla Garg (Logan)
Pediatric practice that uses bilingual physicians, nurses, support staff, and volunteers to provide oral interpretation. The clinic obtains translated materials from the Internet.
Douglas W. Hacking, M.D. (Orem)
Pediatric practice that uses bilingual physicians or nurses to provide oral interpretation services. Written translated materials are obtained from other sources (i.e., American Academy of Pediatrics, Clinical Reference System).
Vicki Judd Student Health Svcs, Univ. of Utah (Salt Lake City)
Chinese, Japanese, Korean
Pediatric practice that provides oral interpretation through contract interpreters and telephone language line. Student fees cover the cost of providing language services.
Neonatology practice that uses full- and part-time staff interpreters, contract interpreters, telephone language line, volunteers, and bilingual physicians, nurses, and support staff to provide oral interpretation. The Health Sciences Center provides translated materials and covers the cost of providing language services.
Karen Buchi, M.D. Dept. of Pediatrics, Univ. of Utah (Salt Lake City)
J. Ross Milley Health Sci. Center, Univ. of Utah (Salt Lake City)
Utah (cont.) Kathy Ostler, M.D. (Park City)
Pediatric practice that uses bilingual physicians and contract interpreters to provide oral interpretation. Patients pay for the cost of language services.
Jerry Twiggs (Saint George)
Pediatric practice that uses bilingual physician, nurses, and support staff to provide oral interpretation and written translation. The practice covers the cost of providing language services.
Mark Valentine, M.D. (Sandy)
Pediatric practice with physician who speaks Spanish and writes instructions in Spanish for patients.
Willow Creek Pediatrics (Salt Lake City)
Pediatric practice with one bilingual physician and 15 nurses fluent in Spanish to provide oral interpretation.
Pediatric practice where bilingual physicians, nurses, and support staff provide oral interpretation services. To ensure the availability of language assistance services, the practice supports funding for a statewide Area Health Education Centers (AHEC), which is currently devising a language services program.
Virginia William C. Rees, M.D., M.B.A., F.A.A.P. (Burke) Wisconsin Reproductive Health Care Center (Platteville)
Family planning and reproductive health services clinic uses contract interpreters to provide oral interpretation. Grant funding pays the cost of providing language services, currently $500 per year.
Janet G. Cain (La Crosse)
Family planning clinic that uses telephone language line to provide oral interpretation. With a cost of 57 cents per minute, the language line is more cost-effective than hiring an interpreter.
Spanish, Hmong, Russian
Family medicine health center that utilizes bilingual physicians and nurses, as well as a telephone language line, to assist patients. The clinic obtains basic materials from the Milwaukee Health Department, other government sources and private agencies like the March of Dimes and La Causa, Inc., a bilingual, multicultural childcare agency. St. Luke’s Hospital also translates materials for the clinic.
El Puente offers medical interpreting services at hospitals and health care provider offices in its area. El Puente employs four interpreters and also has a director and part-time office assistant who provide interpretation services on a limited basis. Before hiring a new employee, El Puente assesses language skills and knowledge of medical terminology. Staff members are trained as medical interpreters and must pass an evaluation.
Johnston Community Primary Care Clinic (Milwaukee) Wyoming
El Puente (Jackson)
APPENDIX B. SUGGESTED PLAN FOR IMPLEMENTING LANGUAGE SERVICES Small health care practices can take the following steps to examine the language service needs of their practices and develop a strategy to meet them. Other resources are also available to help providers supplement their plan. For example, the California Academy of Family Physicians has published a guide for providing language services in small health care provider settings.38 Additionally, the Industry Collaborative Effort has developed a toolkit entitled, Better Communication, Better Care: Provider Tools to Care for Diverse Populations.39 Step 1. Designate responsibility. Deciding how to respond to the community’s and patient’s language needs involves gathering information and investigating and harnessing resources. Health care practices may want to designate a staff member who has the responsibility for the practice’s language activities. Many practices highlighted in this report have made such a designation, finding that it increases organization, efficiency, and ready access to community resources and funding. Step 2. Conduct an analysis of language needs. According to guidance issued by the Department of Health and Human Services’ Office for Civil Rights, the assessment of language services should balance four factors: •
The number or proportion of LEP persons eligible or likely to be encountered;
The frequency with which LEP individuals come into contact with the program;
The nature and importance of the program to people’s lives; and
The resources available and costs.
Most of the small provider sites studied for this report decided it was not necessary to hire an outside consultant to assess language needs. Rather, they engaged in a selfassessment of the languages spoken in the practice and in the community. Self-assessment tools are available at no cost. For example, the federal government provides such a tool at http://www.lep.gov. Some sites highlighted in this report have developed their own selfassessment tools. Those tools can be obtained from the site’s contact person. It is important to note that collecting patient base data may not always provide a complete picture. If a provider has a small number of LEP patients, it may be because 69
there are few LEP patients in the service area or it could be because LEP patients do not use the provider due to a lack of language services. Thus, it is important to assess not only the patients currently being served but also those eligible to be served. To fully understand the community’s language needs, the provider should consider other data. Easily accessible sources can provide additional information and include the latest census data for the area served (available at http://www.census.gov), as well as information from school systems, community organizations, and state and local governments. In addition, community agencies, school systems, religious organizations, legal aid entities, larger health care providers like hospitals, and other local resources can often assist in identifying populations that may be medically underserved because of existing language barriers. Step 2a. Ask patients about their language needs. The first step in determining which patients need language services is to ask them. If the practice serves children or incapacitated adults, it should also ask for the language needs of the patients’ parents or guardians. The practice should not only ask whether the patient needs language services in an oral encounter (such as the clinical visit) but also determine in which language the patient prefers to receive written materials and communications. Depending on the language and literacy level, the choice for language services may differ for oral and written communications. Staff members who answer the telephone should request patients’ preferred spoken and written language and document the information in the patient’s record and appointment schedule. This will allow the practice to plan in advance for the language needs and maximize appropriate language services during appointments. Practices may want to consider using an “I Speak . . .” poster or card, which can help identify the language spoken.40 The practice can provide patients with “Language ID” cards that can be used in subsequent health care encounters.41 Step 2b. Maintain data on patients’ language needs in medical records and management information systems. Providers should document patients’ language needs in charts and in the practice’s management information system. Having this information not only will assist providers in assessing patients’ needs but also in arranging for services during appointments. Some provider sites are using color-coded chart stickers to record patients’ written and spoken languages and the dates when languages services were offered and whether those services were accepted or declined. 70
Step 3. Identify resources in the community. As illustrated by the site visit reports, there are a variety of ways to provide language services. Establishing what resources are available in community will help determine what language services to provide and how to provide them. Practices should examine whether there are local language agencies that can provide in-person or telephone interpretation or written translations. Providers can also contact local immigrant organizations, refugee resettlement programs, or court systems. These organizations are likely sources of information about language services in the community. National organizations may also be of assistance. The National Council on Interpretation in Health Care offers a variety of resources and also lists local interpreting organizations (http://www.ncihc.org). Other resources include the Society of American Interpreters, the Translators and Interpreters Guild, the American Translators Association, and the state-based health care interpreters associations located in Alabama, Arizona, California, Colorado, Georgia, Idaho, Kentucky, Massachusetts, Minnesota, Nebraska, New York, Ohio, Pennsylvania, Tennessee, Texas, Virginia, and Washington. Step 4. Determine what language services will be provided. Depending on patients’ needs, available community resources, and the practice’s resources, a variety of language services may be implemented. Activities will depend heavily on the information uncovered from the self-assessment and there is no one-size-fits-all solution. As a rough guide: •
In-person, face-to-face interpreters provide the best communication for sensitive, legal, or lengthy communications.
Trained bilingual staff—either dedicated full-time interpreters or staff who serve in a dual role (e.g., part-time interpreter and part-time receptionist or billing clerk)— can provide consistent patient interactions for patients.
Contract interpreters can assist practices with less frequently encountered languages or when the LEP patient base is relatively small.
Telephone interpreter services can often provide an interpreter within a few minutes and are most cost-effective for short conversations or unusual language requests.
Step 4a. Ensuring competency of individuals providing language service. The practice should seek to provide the highest possible level of competency. Competent interpreters can ensure confidentiality, prevent conflicts of interest, and ensure that medical terms are interpreted correctly, thus reducing potential errors. 71
Bilingual individuals may not necessarily have sufficient command of both English and the target language to serve as medical interpreters. Further, oral interpretation and written translation each require specific skill sets that bilingual individuals may not possess. As stated by the Office for Civil Rights: [Health care providers] should be aware that competency requires more than self-identification as bilingual. Some bilingual staff and community volunteers, for instance, may be able to communicate effectively in a different language when communicating information directly in that language, but not be competent to interpret in and out of English. Likewise, they may not be able to perform written translations.42 While there are no national health care interpreter or translator standards, there are assessments that can be used to evaluate language skills. For example, Pacific Interpreters conducts language competency assessments for external clients and the Industry Collaborative Effort has an Employee Skills Self-Assessment Test on its Web site. Moreover, if a practice contracts with outside language agencies or interpreters, it should ensure the competency of those interpreters, either by requiring a certain level of training or conducting a language skills assessment. Similar precautions should be taken with telephone interpreter services. The practice should determine what sort of education and training the interpreters have received, whether the interpreters are trained in medical terminology and ethics, and whether the company has contracted for alternative site availability in the event their service is unexpectedly interrupted. Step 4b. Consider ways to minimize use of family members or friends. Significant problems can arise from the use of untrained family members and friends as interpreters. One study noted that interpreting errors by ad hoc interpreters are significantly more likely to have potential clinical consequences than would services provided by trained interpreters.43 Family members, particularly minors, or friends often do not interpret accurately. Untrained interpreters are prone to omissions, additions, substitutions, and volunteered answers. For example, family members and friends often do not understand the need to interpret everything the patient says and may summarize information instead. In some clinical encounters, patients may not disclose sensitive or private information. For example, if a battered woman is brought to the practice by her batterer, and the batterer is then asked to interpret, the woman is not likely to reveal the scope and cause of her injuries.
A practice can adopt a range of language services that minimize the use of family members and friends as interpreters. As the study sites show, resource and cost issues can often be reduced by making use of technological advances (such as the on-line availability of printed translated materials) and the sharing of language assistance materials and services among local providers. When family members and friends are used to interpret, there can be a follow-up visit or telephone contact in the target language to confirm the important aspects of the clinical visit. Step 5. Determine how to respond to LEP patients. Practices must determine how to respond to LEP patients, not only when patients visit the office but also when individuals call, both during and after normal business hours. Step 5a. Responding in the office setting. The first question to ask is how office staff will respond when an LEP patient walks in the front door. Do front-office staff speak the languages most frequently encountered in the practice? If not, how will they initially communicate with patients? The “I Speak . . .” posters and cards discussed in this report are an excellent first step in responding to patients’ needs. Once the front-office staff ascertain the language needs of the patient, the staff can make appropriate arrangements for language services. This might include calling a telephone language line so that an interpreter is available during the clinical visit or other interactions. It could also include requesting the appropriate bilingual staff to assist the patient. Step 5b. Responding over the telephone. The office should also have a plan for assisting patients over the phone during normal business hours. Some questions that should be addressed are: •
Does the practice have bilingual office staff who can assist LEP patients over the phone?
Does the “hold” message offer information in the practice’s prevalent languages?
If the staff person answering the phone is not bilingual, does this person ask a bilingual staff person for assistance?
Does the staff person call a telephone language line to assist in communicating with the patient?
Step 5c. Responding after-hours. After-hours communication with patients is critical to ensure patients can contact clinicians when necessary, regardless of their language needs. Some of the questions must be addressed include: •
If the office has an answering machine, does it include messages in the languages of the patient population?
If the office uses an answering service, does the service have bilingual employees or a plan to use a telephone language line when an LEP patient calls?
If a patient reaches a clinician after-hours, what is the plan for that clinician to access language services to ensure effective communication with the patient?
Step 6. Train staff. The practice should train staff to understand the language plan and policies. At minimum, staff in direct patient contact positions should be trained. Orientation for new employees should include information about language services. Staff members can also attend periodic in-service trainings, staff meetings, or brown bag lunches that reiterate the practice’s language services, access to services, and effectiveness of services. Sometimes, local community-based organizations or interpreter agencies and associations offer training programs focusing on working with an interpreter and other relevant topics. Step 7. Notify LEP patients of the available language services. It is also important to communicate to the practice’s LEP patients that language services are available and accessible. The practice should post information about its language services, translated into the prevalent languages, in the office, in newsletters, and in introductory materials for new patients. The practice can also provide information about its services in the local foreign language media. The practice can also disseminate information about its language services through local community-based organizations that work with LEP individuals. Step 8. Update activities after periodic review. After developing a language services plan, the practice should continually evaluate and update it, as needed. The demographics of a community can shift over a relatively short period of time, necessitating different or additional language services.
APPENDIX C. PROJECT METHODOLOGY The National Health Law Program (NHeLP), with funding from The Commonwealth Fund, undertook an assessment of current activities and programs that improve access to interpreter services in small health care provider settings. For this project, small provider settings were defined as those with fewer than 10 clinicians, including solo and small group provider offices (primary and specialty care), community clinics (primary care, dental, family planning), and rural clinics. NHeLP developed a survey instrument and distributed it electronically during the winter and spring of 2004. The surveys were distributed to NHeLP’s listservs (health, immigration, language, California advocates), as well as to the listservs of the National Immigration Law Center, National Asian Pacific American Legal Consortium, National Council of Interpretation in Health Care, the National Limited English Proficiency Task Force, Volunteers in Health Care, and CLAS-TALK. The survey was posted on NHeLP’s Web site and interested persons were invited to complete it. We also asked representatives of state-based interpreter associations and other state-based entities to distribute the survey. While we were unable to track each distribution of the survey by these entities, we have confirmed that health advocates throughout Oregon, Ohio, and New York distributed it. The survey was also distributed by the Austin Area Translators and Interpreters Association, Northern Virginia Area Health Education Center (AHEC), Medical Interpreters Network of Georgia, Massachusetts Medical Interpreters Association, Washington D.C.-area language access and legal services listservs, Colorado Association of Professional Interpreters, and the Illinois Primary Health Care Association. We also contacted health care provider associations to seek assistance in distributing the survey. The American Academy of Pediatrics distributed the survey to the members of its section on community pediatrics. The National Family Planning and Reproductive Health Association distributed the survey to its members. The American Academy of Family Physicians (AAFP) electronically linked the survey to an article in the AAFP Direct newsletter. Information about the survey was distributed to the Medicaid Coalition (convened by Families USA and composed of national organizations advocating on Medicaid issues), the Child Health Coalition (convened by the American Academy of Pediatrics and composed of national organizations advocating on child health issues), and the North Carolina Chapter of the American Academy of Pediatrics. The survey was not intended to elicit a complete picture of all available programs, but to estimate the range of current models. From the completed surveys, 40 programs 75
were selected for more in-depth assessment. Programs were selected to reflect a range of language services. Programs included solo and small group practices, community and family planning clinics, and assistance offered to small providers by larger health systems. Project staff conducted key interviews and research to learn more about these programs. Site visits were conducted at 11 settings. In addition, comprehensive phone interviews were conducted with seven organizations.
See U.S. Bureau of Census, Ability to Speak English: 2000 (Table QT-P17). Available at http://factfinder.census.gov/servlet/QTTable?_bm=y&-geo_id=D&-qr_name=DEC_2000_ SF4_U_QTP17&-ds_name=D&-_lang=en&-redoLog=false. 2
See U.S. Bureau of the Census, Profile of Selected Social Characteristics: 2000 (Table DP-2). Available at http://factfinder.census.gov/servlet/QTTable?_bm=y&-geo_id=D&-qr_name= DEC_2000_SF4_U_DP2&-ds_name=D&-_lang=en&-redoLog=false. According to the 1990 census, 13.8 percent of the population spoke a language other than English at home. See Language Spoken at Home: 1990 (Table PO31). For discussion of the 1990 census information, see “Why Language and Culture Are Important,” http://www.diversityrx.org, August 14, 1997. 3
Physician Socioeconomic Statistics, American Medical Association, 2001.
Medical Group Practices in the U.S., American Medical Association, 1999.
K. P. DeRose and D. W. Baker, “Limited English Proficiency and Latinos’ Use of Physician Services,” Medical Care Research and Review 57 (March 2000): 76–91. 6
K. S. Collins, D. L. Hughes, M. M. Doty et al., Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans (New York: Commonwealth Fund, March 2002). 7
National Survey of Physicians Part I: Doctors on Disparities in Medical Care (Menlo Park, Calif.: Henry J. Kaiser Family Foundation, March 2002). 8
See 68 Fed. Reg. 47311, U.S. Department of Health and Human Services Office for Civil Rights, August 8, 2003. To review previous versions of this guidance, see 65 Fed. Reg. 52762, August 30, 2000. 9
Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons, U.S. Department of Health and Human Services Office for Civil Rights, August 4, 2003. Available at http://www.hhs.gov/ocr/lep/revisedlep.html. 10
Materials available at http://www.lep.gov.
Materials available at http://yalepress.yale.edu/yupbooks/salud/ or http://salud.unc.edu.
Information on Healthwise available at http://www.healthwise.org/p_selfcare.aspx.
Information on CareNotes available at http://www.micromedex.com/products/carenotes/.
Materials available at http://www.healthlaw.org/langaccess/resources.html#nhelp.
D. Tayloe Jr., “Rising to the Challenge of Multilingual Healthcare: The View from an Eastern NC Pediatric Practice,” North Carolina Medical Journal 64 (May/June 2003): 125–26. 16
For a list of translations and more information about the Area Health Education Centers, see http://www.hhcc.arealahec.dst.nc.us/. 17
The Think First curriculum is a brain and spinal cord injury prevention program intended for use by primary school children to promote key safety messages. 20
Complementary medicine includes folk medicine and other homeopathic remedies.
More information on this handbook is available from Healthwise, at 800-706-9646 or http://www.healthwise.org. 24
Care-for-the-poor funding is funding set aside by Saint Joseph Health System to assist the low-income individuals it serves. 25
Teletype phones allow persons with hearing and/or speech loss to make or receive telephone calls by typing their conversations via two-way text. 27
Medical Home is a program by the American Academy of Pediatrics that teaches an approach to providing health services in a high quality, cost-effective manner. Parents and pediatric health care professionals work in partnership to identify all the medical and non-medical resources needed to help children reach their full potential. For more information, see http://www.medicalhomeinfo.org/. 28
For Clinical Reference Systems, available from McKesson Health Solutions, see http://www.Patienteducation.com. 29
J. K. Roberts, “Signing for Health,” Developments, The University of New Mexico Foundation, Inc. 30
The Quantum Foundation can be reached at 561-832-7497. Picower Foundation can be reached at 561-835-1332. 31
Bridging the Gap is a 40-hour medical interpreter training curriculum developed by Cross Cultural Health Care Program in Washington state. The program offers training for interpreters and a “train-the-trainer” module. See http://www.xculture.org/index.cfm. 33
A doula is a birth coach who provides emotional, physical, and educational support to women and their families during and after childbirth. 34
For information on Language Line Services, see http://www.languageline.com/.
“Summary Report on Pilot Study Using a Dual Hand-Set Phone Adaptor,” L.A. Care Health Plan, November 2003 (document on file with authors). 36
M. Youdelman and J. Perkins, Providing Language Interpretation Services in Health Care Settings: Examples from the Field (New York: Commonwealth Fund: May 2002). 37
Materials available at http://www.familydocs.org/mlc.
Materials available at http://www.healthlaw.org/pubs/nlaap/ICECulturalCompetencies.pdf.
For examples of “I Speak . . .” posters, see http://www.dol.gov/oasam/programs/crc/ ISpeakCards.pdf and http://www.dhfs.state.wi.us/civilrights/LEPposter.pdf. 41
For examples of “I Speak . . .” cards, see http://www.palsforhealth.org/, http://www.dss.cahwnet.gov/civilrights/ISpeakCard_1304.htm, and http://www.dhfs.state.wi.us/civilrights/ISPEAKCARDS.pdf. 42
Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons, U.S. Department of Health and Human Services Office for Civil Rights, August 4, 2003. Available at http://www.hhs.gov/ocr/lep/revisedlep.html. 43
G. Flores, M. B. Laws, S. J. Mayo et al., “Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters,” Pediatrics 111 (June 2003, Pt. 1): 1495–97.