Post on 18-Jul-2015
Empowering Leaders: Building the Business Case for Language Access
IMIA Tri-Symposia
Oct. 3rd, 2014
Douglas E. Green
© International Medical Interpreters Association
Why Healthcare Reform• Historical Challenges• Comparison• The ACA and Reimbursement
The LEP Opportunity Under the ACA• Increasingly Diverse• Understanding the LEP patient experience• Ensuring Comprehensive Access
Best Practices Aligning to Organizational Goals
• Organizational Solutions• Community Solutions• Future Models
The Neurosurgeon and the sink basin1
•Dr. Guy Clifton, leading surgeon and chief of neurosurgery at a leading Texas Hospital.•Called upon administrators to address the safety concerns of his staff.•Not enough sink basins, drew up blue prints to fix 3x•Push to digitize x-rays to eliminate the need to perform duplicate x-rays, ‘No business case for’•Core issue, disjointed culture and high turnover leading to post surgical complication, developed plan to address and was refused. •Study: $10,000 per patient per surgical complication
1 ‘Unaccountable’, Marty Makary, MD, pg 30-33, 2013
An example of a systemic flaw
The Case for Healthcare Reform• The Case for Healthcare Reform
• Size of the healthcare industry• 17% of the Gross Domestic Product
• .17 cents of every dollar produced in the US• Number of deaths per year
• America's healthcare-system-induced deaths are the third leading cause of death in the U.S., after heart disease and cancer.
• 12,000 deaths per year due to unnecessary surgery• 7,000 deaths per year due to medication errors• 20,000 deaths per year due to other errors in hospitals• 80,000 deaths per year due to infections in hospitals• 106,000 dues to negative effects of drugs
• Global ranking(s)• The US Healthcare system is ranked 37th globally by the World Health
Organization• 14th in preventable deaths• 24th in life expectancy• 72nd in level of health• 2nd in Total Health Expenditures as a percent of GDP
The Case for Healthcare Reform
The Case for Healthcare Reform• Medical Errors
Medical errors kill enough Americans to fill over 390 Boeing 747 Airplanes every year.
• Poor communicationThe HC Industry loses 12B a year due to poor communication (about $1.2B for LEPs)
• TJC Sentinel Events3rd leading cause of all sentinel events is errors of poor communication, found as a root cause in 59% of all sentinel events
• Willie Ramirez caseThe $72M word
• Cost: The US HC system costs $8.2K a year per capita, 2.5Xs other developed nations
The Case for Healthcare Reform
The Case for Healthcare Reform• Waste of the US healthcare System
The US Healthcare system wastes over $750B a year, or 30% of all medical procedures on unnecessary and inefficient services.
* 2012 Institute of Medicine Study
0
10
20
30
40
50
60
$26 billion
$50 billion
$30 billion
$42 billion
Opportunity: Language access eliminates waste
Before Healthcare Reform Language Access Was Seen as an Expense
How does your organization view language access?
New Rules Under the ACA: Beyond Coverage
• Greater resources and commitment to primary and preventive care• Greater focus on community health centers• Formation of ACO’s
• 30-day readmission penalties• 2,217 Hospitals have been penalized $280 million in 20131
• Patient satisfaction and reimbursement bonuses• Focus on quality of care versus ‘amount’ of care
The ultimate goal of the Affordable Care Act is to reduce healthcare costs by increasing the health and wellness of the US Population.
1A Path Forward on Medicare ReadmissionsKaren E. Joynt, M.D., M.P.H., and Ashish K. Jha, M.D., M.P.H.N Engl J Med 2013; 368:1175-1177March 28, 2013
Readmissions Penalties Under the ACA
Under the ACA hospitals will be penalized up to a 2% reduction in Medicare payments for all procedures for high 30 day re-admissions for Congestive Heart Failure, Heart Attacks, and Pneumonia (chronic Pulmonary Disease, and Hip Replacement 2015).
In addition, CMS will not reimburse for the cost of the readmissions.1
169 Texas Hospitals penalized in 20132
1 Hospitals work to keep patients from being readmitted, USA Today, Shari Rudavsky, March 18 th,20132 Texas Tribune, Interactive: Hospitals Penalized for Readmission Rates, Becca Aaronson, August 16, 2013
Case Study: Readmissions at Memorial Healthcare
1 Hospitals work to keep patients from being readmitted, USA Today, Shari Rudavsky, March 18 th,2013
Example: Memorial Healthcare, Broward County, Florida
2011:•35% of patients spoke a language other than English in the home.•1,430 readmissions within 30 days•10,041 days of care that cost the system $114.8 million. •Average cost per episode was $80,279.•Readmissions ranked in the bottom quartile with a rate of 14%•Estimated penalty for 2014 at 2% would have been $3.8 million. •Total Loss: $118.6 million
Patient Satisfaction Penalties Under the ACA
What affects Patient Satisfaction?
1U.S. Ties Hospital Payments to Making Patients Happy, The Wall Street Journal, Janet Adamy, Oct. 14, 2012
Nearly $1 billion in payments to hospitals over the next year(2012) will be based in part on patient satisfaction, determined by a 27-question government survey administered to patients. Hospitals with high scores will get a bonus payment. Those with low ones will lose money.1
The HCAHPS Survey
Topic
Questions Involving
CommunicationTotal
Questions PercentNurse Care 2 4 50%Doctor Care 2 3 67%Hospital Environment 2 10 20%After You Left the Hospital 2 3 67%Overall Rating 0 2 0%Understanding Your Care 2 3 67%About You 3 7 43%
Total 13 32 41%
The intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care.1
1www.hcahpsonline.org
Readmissions, Patient Satisfaction and LEPs
1. Heart disease is the leading cause of death among minorities in the United States, according to the U.S. Department of Health and Human Services' Office of Minority Health.
Hispanics and Latinos are at greater risk. Due to: 1.High Blood Pressure2.Obesity3.Diabetes1
2. LEPs are going to have lower patient satisfaction scores than English speakers.
1The American Heart Association
English LEP
Satisfied 71% 52%Would not return 9.50% 14%
LEPs are 36% more likely to be dissatisfied with care and 47% more likely to not return. The study also showed that LEPs are more likely to report overall problems with care,
communication, and testing.2
Why Healthcare Reform• Historical Challenges• Comparison• The ACA and Reimbursement
The LEP Opportunity Under the ACA• Increasingly Diverse• Understanding the LEP patient experience• Ensuring Comprehensive Access
Best Practices Aligning to Organizational Goals
• Organizational Solutions• Community Solutions• Future Models
The Future of Healthcare: America in 2050
Increasing Diversity: The US in 2050*• 1 in 5 will be immigrants (1 in 12 2005)• Latino population will triple by 2050 and will be the largest ethnic
group comprising 29% of the population (14% in 2005)• The non-Hispanic white population will be a minority at 47% in 2050• Population growth will continue to occur in immigrant populations• The dependency ratio will increase from 59 children and adults per
100 adults of working age to 72
*Pew Research Projections: US Population Projections 2005 – 2050, February 11 th, 2008
"My great-grandfather did not travel across four thousand miles of the Atlantic Ocean to see this nation overrun by immigrants,"
The US is Historically Diverse
What happens when LEPs enter the US HC system?
What Happens When LEPs Enter the HC System?
Patient Safety, Quality, and Cost DriversQuality and cost drivers are emerging in support of work in this area:• Longer length of hospital stays for LEP patients when professional interpreters were not used at admissions and/or discharge.• Greater risk of line infections, surgical infections, falls, and pressure ulcers due to LEP patients’ longer hospital stays compared to English-speaking patients with the same clinical condition.• Greater risk of surgical delays and readmission due to LEP patients’ greater difficulty understanding instructions, including how to prepare for a procedure, manage their condition, and take their medications, as well as which symptoms should prompt a return to care or when to follow up.• Greater chance of readmissions for certain chronic conditions among racial and ethnic minorities compared to their white counterparts.
Improving Patient Safety Systems for Patients With Limited English Proficiency A Guide for Hospitals, AHRQ Publication No. 12-0041,September 2012
What Happens When LEPs Enter the HC System?
Risk ManagementRisk management remains a critical concern .• Patient comprehension of medical condition, treatment plan, discharge instructions, complications, and follow up• Inaccurate and incomplete medical history;• Ineffective or improper use of medications or serious medication errors;• Improper preparation for tests and procedures;
Improving Patient Safety Systems for Patients With Limited English Proficiency A Guide for Hospitals, AHRQ Publication No. 12-0041,September 2012
20
Triage Registration MD Tests DischargeED
Front Desk
RN MDRegular Appt
Triage RegistrationMD
SurgicalMD
Anesthesia DischargeProcedure
Technician Test
MD Rounds
RN 2 or 3XAdmin of
Medication Consults DischargeInpatient/Med/
1 day
Front Desk
Front Desk
Mapping the Patient Experience
Lulu Sanchez, Director Implementation Services, Languageline Solutions
21
Mapping Patient Encounters
UtilizationNumber of Encounters
LEP %
LEP Encounters
Avg. Hospital Stay
Avg. Encounters per day
Total Encounters
In-Patient 100,000 20% 20,000 5 4 400000
Out Patient 200,000 20% 40,000 1 4 160000Emergency Department 30,000 20% 6,000 1 5 30000
590,000
NOTE: It is estimated that even the most advanced language access programs only meet about 20-30% of LEP encounters.
Interpreter neededFor Patient Family
Use SBAVRIAvailable?
Use VRIUse Language Line
YesNo
SBAAvailable?
LASInterpreterNeeded?
LAS Interpreter Sent
Call Dispatcher
Language Line NotAvailable
YesNo
Interpreter needed for outpatient
*Edgardo Garcia, Manager Language Access Services, Childrens Medical Center Dallas
Out Patient
Type Modality Encounters
Front Desk SBA/VRI/OPI 40,000
RN SBA/VRI/OPI 40,000
MD SBA/VRI/OPI 40,000
Front Desk SBA/VRI/OPI 40,000
Interpreter NeededFor Patient Family
Call Dispatcher
LAS InterpreterAvailable?
Send LAS InterpreterVRIAvailable?
Use VRIIUse Language Line
Yes
Yes
No
No
Interpreter needed for inpatient
*Edgardo Garcia, Manager Language Access Services, Childrens Medical Center Dallas
In Patient
Type Modality Encounters
MD Rounds Staff/Video/OPI 100,000
RN SBA/VRI/OPI 100,000
Medication SBA/VRI/OPI 100,000
Consults Staff/Video/OPI 100,000
Interpreter Needed for Emergency/First Care/Arch ED Patient Family
Interpreter NeededFor Patient Family
Call Dispatcher
ER InterpreterAvailable?
Send ER InterpreterOther InterpreterAvailable?
Send Other InterpreterSBAAvailable?
Use SBAVRIAvailable?
Use VRIIUse Language Line
Yes
Yes
Yes
Yes
No
No
No
No *Edgardo Garcia, Manager Language Access Services, Childrens Medical Center Dallas
Emergency Department
Triage Modality Encounters
Registration SBA/Over the phone 6,000
MD Staff/Video/OPI 6,000
Tests Staff/Video/OPI 6,000
Front Desk SBA/Over the phone 6,000
Discharge Staff 6,000
Modalities by encounter type
OutpatientIn
PatientEmergency Department Total
SBA/Over the Phone 160,000 200,000 12,000 372,000
Staff/Video/OPI 0 200,000 12,000 212,000
Staff 0 0 6,000 6,000
Total 160,000 400,000 30,000 590,000
OutpatientIn
PatientEmergency Department Total
SBA/Over the Phone 27% 34% 2% 63%
Staff/Video/OPI 0% 34% 2% 36%
Staff 0% 0% 1% 1%
Total 27% 68% 5% 100%
Emergency Room Inpatient OutpatientTriage Typically no Paperwork
Admitting
Permission to Treat
Admitting
Permission to Treat
Admitting
Permission to Treat Insurance Insurance
Insurance Notice of Patient Rights Notice of Patient Rights
Notice of Patient Rights HIPAA Notification HIPAA Notification
HIPAA Notification Financial Documents Financial Documents
Financial Documents RoundsDisease
Education/Treatment Testing Informational Brochures
Testing
Informational Brochures Rounds Medication Education Specific Consents
Specific Consents Procedure Consent FormConsult
Informed consent
Consult Informed consent
Discharge
Discharge Instructions Referrals to aftercareReferrals to aftercare Medication Information
Discharge
Discharge Instructions
Discharge
Discharge Instructions Information for Transfer Medication Information
Medication Information Patient Education Information for transfer
Information for transfer Patient Education
Patient Education
Localized marketing and support content-Web-Education campaigns
Bilingual Staff-Fluency testing
-Training- Medical interpreter testing
- Call center monitoring
Inbound LEP calls
-Customized greeting-Call routing
Over the phone interpreting
-Language diversity-Data capture
-speed of answer-connect time
Video Remote Interpreting-Critical encounters-Quick connect-Smart phones, tablets, PC
Translation Solutions-Vital documents-Consent forms-Discharge InstructionsOnsite Interpretation-Extended critical encounters
Comprehensive Language Access Solutions
Why Healthcare Reform• Historical Challenges• Comparison• The ACA and Reimbursement
The LEP Opportunity Under the ACA• Increasingly Diverse• Understanding the LEP patient experience• Ensuring Comprehensive Access
Best Practices Aligning to Organizational Goals
• Organizational Solutions• Community Solutions• Future Models
© International Medical Interpreters Association
dherence
afety
roductivity
mage
evenue
xpense
Aligning to Organizational Goals
Organizational goals and priorities will shift based upon the environment in which we work.
It is important to identify the focus of your internal champions.
Position Area of concern
Risk Management Safety/Adherence
CNO Productivity/Safety
Patient/Guest Services Image/Safety
Manager/CFO Revenue/Expense
CEO ASPIRE
30
Organizational Initiative: Referral to primary care
Historic Metric: Significant non-critical care being treated in the ER
Resolution: During triage referred to primary care physician
New Metric: Significant reduction in re-admissions, uncompensated care, and increases in efficiency and wait times.
Organizational Solutions: Referral to Primary care
Productivity and Expense
31
Organizational Initiative: Reduce/eliminate no show appointments
Historic Metric: $250 loss per no show
Resolution: Proactive in language outbound campaign
New Metric: Significant reduction in no-Shows
Organizational solutions: Reduce/Eliminate no Show Appointments
LEPs are perceived to have a higher rate of no shows to appointments due to a
lack of understanding
Productivity, Revenue, Expense
Organizational Initiative: Reduce discharge time
Historic Metric: 1 hour 23 minutes
Resolution: Integration into EPIC
New Metric: 20 Minutes
Organizational Solutions: Reducing Discharge Time
NOTE: Translation of discharge materials seen as contributing to
reduced readmissions and treatment plan compliance, but most hospitals
only sight translate.Adherence, Safety, Productivity, Image, Revenue, Expense
Future Models of Healthcare: Texas Health Resources
What other innovations are Health Care providers utilizing?
Texas Health Resources: Meeting needs through education
Image, Productivity, Revenue, and Expense
Future Models of Healthcare: Kaiser Permanente
What other innovations are Health Care providers utilizing?
Kaiser Permanente: Communicating through culture
Image, Productivity, Revenue, and Expense
Representative Solution: St. Luke’s Episcopal Hospital
6 Hospitals (Acute + Specialty Acute) 5 Urgent Care or Freestanding ER3 Clinic/Physicians-Primary Care 2 Disease Mgmt/Health Mgmt2 Rehab/PT/sports Clinic
ASPIRE
© International Medical Interpreters Association
Questions?