Healthcare Disparities: Patients with Limited English Proficiency

Carmine Jabri

Foreign Born Population in the U.S.

In 2004, there were an estimated 34.2 million foreign-born people in the U.S.

In 2005, 1,122,373 people became legal permanent residents, 604,280 people became naturalized citizens, 53,813 people were admitted as refugees, and there were an estimated 175 million entries granted for temporary visitor status. Those numbers do not include people who enter the U.S. illegally.

Patients with Limited English Proficiency Many of this foreign-born population have

Limited English Proficiency (LEP). 52 million people in the U.S. speak a

language other than English at home. 95 million people have literacy levels below

that required to understand basic written health information, such as how to take a medication.

Encounters with LEP population

According to research, 63% of hospitals encountered LEP patients either daily or weekly.

17 % encountered LEP patients at least monthly.

Communication Errors

Errors in communication can be made with patients familiar with English.

The fact that some English words are being spoken should not give false sense of security that accurate information transfer has taken place.

Examples: Young Tamil couple, 18 month old son had ear

infection. Patient brought in with diabetic coma. Spanish-speaking woman asking her obstetrician

about a “planned abortion”.

Other Communication Errors

Different linguistic cultures Use different terminology High Context Communication: How

something is said and what is not said are just as important as what is actually said. Courtesy takes precedence over truthfulness.

Problems Resulting from Language Barriers Language barriers can result in:

miscommunication, misdiagnosis, inappropriate treatment, increased use of expensive diagnostic tests, increased use of emergency services and decreased use of primary care services, reduced comprehension and adherence to treatment, poor or no patient follow up when follow up is indicated, clinical inefficiency, malpractice injury and death.

Lawsuits

Hospitals and medical practices may be liable under federal requirements for language accessibility.

Each non-English speaking person who walks through the door represents a potential malpractice suit.

Example: Doctors and paramedics lost a $71-million judgment to a man left paralyzed when staff misinterpreted “intoxicado” to mean intoxicated rather than nausea; he was treated for a non-existent drug overdose when he was actually suffering from blood clots in his brain.

Challenges for Healthcare Providers

Difficult to find staff with desired cultural or linguistic competency.

Challenges created by having a diverse staff Cultural issues commonly cited as a

challenge Financial stresses in relation to serving

diverse populations. Inadequate funding for language services

Language Services

As a result of limited funding for language services, physicians offices and hospitals do not always offer interpretation services or translated documents.

Only 3% of hospitals indicated receiving direct reimbursement for providing language services, according to research.

According to JAMA, more than half of 2,000 medical residents surveyed had not been taught that patients with LEP have a legal right to professional interpreters.

In the JAMA survey: 77 % of medical residents said they

sometimes used professional interpreters 84% admitted to frequently using untrained

interpreters such as patient’s family members 20% admitted to sometimes or often relying

on children under age 12 to interpret.

Family Members as Interpreters

Problems: Children may speak English with no accent but

command of parent’s native language is often shaky and they have simplistic understanding of medical concepts.

Parents may be reluctant or embarrassed to disclose important symptoms and details to their child.

Stress for child: can fall behind in school because they are removed from school to go to appointments.

Bilingual Staff Members as Interpreters 82% of hospitals indicated that staff

interpreters were the most frequently used resource for providing language resources.

Could be a problem as most bilingual staff members are not actually tested on their bilingual medical terminology and interpreting skills.

Doing interpretation takes them away from their main job duties.

Telephonic Interpretation Services

Need to have a high-quality speakerphone in the exam room.

Most health insurers do not pay for interpretation services

92% of hospitals indicated that telephonic services were the most available resource for providing language services.

Efforts to Improve Quality and Reduce Disparities 9/13/06, New York expanded requirements

for all hospitals to provide skilled translators to patients with LEP or disablilities.

Hospitals are required to: Designate a language assistance coordinator Post signage regarding the availability of free

language assistance services Identify and document in the medical record

the language needs and preferences of patients upon their initial hospital visit.

Interpreters are required to be available in inpatient and outpatient settings within 20 minutes and in the Emergency Dept. w/in 10 minutes of being requested by a patient or a patient’s family.

Family members, friends, or non-hospital personnel may not act as interpreters unless that patient has agreed to their use and has refused interpreter services offered by the hospital.

Children under 16 may not be used except in emergencies.

Proactive Healthcare Providers

Woodhull Medical and Mental Health Center in Brooklyn, NY.

Created positions for 14 customer service coordinators to serve LEP patients

They walk patients through the center and stay with them until discharge.

Invested: $800,000 in salary expenses for the coordinators and medical interpreters, $864,000 in multilingual signs and plasma-screen kiosks, $150,000 in staff training for cultural competency and medical interpretation.

Resulting in: improved care and customer satisfaction w/ a dramatic drop in complaints. Gained insight into LEP population.

Another Proactive Healthcare Provider

Cambridge Health Alliance is a model for providing linguistic and culturally competent health care services.

Interpreting department staffed by people who can speak 35 languages and American Sign Language.

Have telephonic translation services available for over 100 other languages.

Interpreting services are provided at no cost to the patient. In 2004, they had more than 112,000 encounters w/ LEP

patients. They keep track of all languages used by their patients. They translate patient education materials and other documents

at or below a 6th grade reading level.

The Alliance’s Volunteer Health Advisor Program The Alliance developed a Community Outreach

program to target culturally diverse populations. Volunteer workforce that provides linguistically and

culturally appropriate health education to underserved and hard-to-reach people.

They have trained more than 200 volunteer health advisors (VHAs).

In 2001, VHAs organized and participated in 156 health events; screened more than 8100 people for high blood pressure, cholesterol and glucose levels.

In 2003-2004, these VHAs provided education and outreach activities equal to $150,000 worth of services by paid staff.

They also build awareness of the Alliance’s multicultural programs and services.

The Alliance doesn’t look at providing these services as a financial burden. They believe that it gives them a competitive advantage as their multicultural initiatives are attracting more and more patients from within and beyond their community.

38% of inpatient volume and 48% of primary care visits come from beyond the Alliance’s primary service area.

Solutions

One physician suggests the U.S. should have a national system of telephone interpreters modeled after the one the Australian government operates. Interpreting services are provided for medical practitioners across the country, 24 hours a day, 7 days a week, in one hundred languages for the cost of a local phone call.

Cultural competence training – to understand patient’s backgrounds and thought processes.

Solutions

Employ a diverse, multicultural, multilingual staff. While no healthcare provider can afford to hire in-

house linguistic experts to cover all languages, they should at least offer telephonic translation services.

Despite increased costs incurred as a result of providing language services, healthcare providers need to realize that LEP patients deserve to get quality healthcare services and should always be offered language services.

As a result, healthcare providers will help to protect themselves from lawsuits and they may discover that they actually gain a competitive advantage by providing language services