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.
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.
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.
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
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
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 6 th 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.
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.
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