Language Access Basics

Updated ACA, CLAS and Joint Commission standards have changed the game for hospitals

How to comply with updated language access standards

Contents

How to comply with updated language access standards. 2

The Federal government via the ADA.  2

The Federal government via Title VI.  2

ACA tightening standards and imposes progressively increasing fines. 4

FAQs. 5

Sourcing. 6

Scheduling: how do you arrange for service?. 7

Good metrics leads to better scheduling. 7

Languages of limited diffusion or LLD: How do I provide language access for LLD patients and their families?   7

According to the Joint Commission. 9

It’s my first time working with an interpreter, what do I need to know? 12

Working with an in-person interpreter.12

Working with a video interpreter for the first time, What should I do differently?12

To comply with the law, your facility needs to satisfy a four -factor analysis.13

Ask yourself on a regular basis, are you providing meaningful language access to those who need it? 13

Overall,  13

Patient safety.  13

Definition of Terms. 14

Certifying Bodies for Medical Interpreters. 15

Web Links for Additional Detailed Information. 16

A Language Access Plan is required by law. Entities enforcing penalties include:

The Federal government via the ADA

• Americans with Disabilities Act or ADA prohibits discrimination on the basis of disability in employment, State and local government, public accommodations, commercial facilities, transportation, and telecommunications. It also applies to the United States Congress.
• To be protected by the ADA, one must have a disability or have a relationship or association with an individual with a disability. An individual with a disability is defined by the ADA as a person who has a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment. The ADA does not specifically name all of the impairments that are covered
  • Deaf, Deaf-Blind, Blind, Disabled (physically and mentally) all fall under the ADA

The Federal government via Title VI

• 1964 Federal mandate signed by President Johnson, prohibiting discrimination based on race, religion, and country of origin. Title VI is part of the Civil Rights Act, which is administered by the Office of Civil Rights
  • Denial of language access (i.e., access to an interpreter) is a civil rights violation. Any judgments awarded on behalf of plaintiff are NOT covered by malpractice insurance
• The Joint Commission
  • Accreditation for hospitals hinges on following Joint Commission protocols. Increasingly, they have focused on LEP patients and their family’s experience of care, in the weighting of their onsite assessment, performed yearly at all major hospitals.

Recipients of Federal Funds are required, to take reasonable steps to ensure meaningful access to LEP persons. To comply with the law, you need to satisfy the 4 factor analysis.

What are the 4 Factors?

1. The number/proportion of LEP persons served or encountered in the eligible service population
2. The frequency with which LEP persons come into contact with the program
3. The nature and importance of the program, activity, or service provided by the program
4. The resources available and costs to the recipient

Are you providing MEANINGFUL language access, is the question you must ask at every step.

A Language Access Plan is good for LEP patients.

• Poor patient–provider communication due to limited English proficiency (LEP) costs healthcare providers; hospitals; healthcare facilities; payers and everyone with a health insurance policy; money.
• LEP patients traditionally exhibit
• Higher readmission rates
• Increased hospital and emergency room admissions
  • No primary care provider, which leads to
  • Overutilization of the Emergency Room for primary care
• More misdiagnoses,
• Increase in the number of diagnostic tests ordered
• Poor patient compliance,
  • Leads to higher risk of medication errors
  • Difficulty linking to and following up with referrals
• Longer LOS (length of stay)
  • Higher number of associated complications and higher fall rates
  • Higher rates of no-shows for appointments

Scarcity of bilingual healthcare professionals and interpretation costs have hindered full implementation of language services despite federal and state laws requiring their provision.

For organizations seeking to initiate or expand their language services, the Internet provides access to guidelines, promising practices as well as best practice, planning tools, and research briefs. Such recent technological advances make provision of language services—to respond to federal and state mandates and improve access and quality of care to LEP persons more feasible than is widely believed. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2992399

LEP patients tend to be at greater risk for negative health outcomes. Over time, LEP individuals will also represent a disproportionately large percentage of the remaining uninsured; patients who regularly access services through emergency departments.

Given the incentives and penalties associated with the ACA, serving both insured and uninsured LEP patients will become more expensive. The cumulative effect should be a major incentive for healthcare organizations to provide the most effective services possible for LEP patients before, during, and after treatment.
(Cyracom ACA 2013 white paper version 1, pg.2)

ACA tightening standards and imposes progressively increasing fines

The ACA will be reducing reimbursement rates for failure to meet specific goals. As of October 2012, the government started cutting Medicare reimbursement for hospitals with readmission rates considered excessive. In 2015, hospitals that still have high rates of hospital-acquired infections will see a further reimbursement rate cut. With nearly one in five Medicare patients returning to the hospital within a month — about two million people a year — readmissions cost the government more than $17 billion annually. (http://www.nytimes.com/2012/11/27/health/hospitals-face-pressure-from-medicare-to-avert-readmissions.html?_r=0)

• 3% decrease in pay-outs for higher readmission rates, (rates that are significantly higher among LEP patients)
  • This is the third year the industry faces these penalties, which were created by the Affordable Care Act. This year potential fines are the highest: up to 3 percent of Medicare bills.
  • The penalties aren’t just getting increasingly harsh; they’re also affecting more hospitals. Half of the hospitals in 29 states and the District of Columbia will be losing money. Those states include CA, FL, GA, IL, MA, NJ, NY, OH, PA, TN and TX, according to a Kaiser Health News analysis of the penalties.
  • One reason the punishments are expanding is that Medicare is tracking more conditions. In addition to patients suffering from heart failure, heart attacks and pneumonia, this year Medicare analyzed readmissions of patients with elective hip and knee replacements and lung ailments such as chronic bronchitis. As a result, some hospitals that never faced fines are now on Medicare’s list.
• Using an interpreter for conversations, and translations for written documents, helps organizations
  • Reduce risk
  • Reduce harm to patients
  • Improve patient satisfaction
  • Improve health outcomes
• Improved language access links directly to Patient Safety
• Other benefits include
  • Improved efficiency
  • Lower hospital costs
  • Better outcomes
  • Reduced health disparities

For detailed information and resources to assist you as you create your LAP, please see:

http://portal.hud.gov/hudportal/HUD?src=/program_offices/fair_housing_equal_opp/promotingfh/lep-faq

http://www.in.gov/ocra/files/Civil_Rights_Form_10_-_Community_Sample_LAP_for_LEP_2010-10-06.pdf

FAQs

What do I need to include in my LAP in order to build a successful language access program?

1. Language preference collection protocols
2. Provision of service to those spoken language populations in excess of 5% of the local demographic, in at least one of the following modalities
   1. In-person interpreter
   2. Video interpreter

• Telephonic interpreter

1. Provision of service to all Deaf, Hard of Hearing and Deaf-Blind clients without exception, at all times

What are common pitfalls when implementing a language access program?

The number one answer to that question is: NOT knowing your demographic!

Know the answers to the following two questions, right off the top of your head

• What are the top five languages needed for your service or location?
• How are you currently collecting these data?

If I don’t know the answer to the two questions above, how do I remedy that?

• At Registration, ASK patient for their preferred language
  • Do NOT ask, “Do you speak English?”
    • Many LEP will answer “yes” if you ask the question this way out of fear of being turned away if they don’t speak English
    • Sadly, many institutions are reluctant to provide language access as mandated by law. Although their numbers are fewer today, the impact has been to cause fear of disclosing their language limitations by LEP patient and their families
  • Ask instead, “What language would you prefer to use when discussing your medical concerns?”
• Update your languages list (no more Yugoslavia/Czechoslovakia please!)
  • Have a poster, notebook or reference where all languages are listed in English and in their native alphabet. Sometimes these lists also include a picture of the country’s flag. This helps the LEP patient point out which language they speak, which will assist you in locating an interpreter
• Make sure the preferred language a “stop field” in the software program! If it isn’t, ask I.T. for help
• Track your interpreter requests and
• Compare your interpreter request numbers to the Information Desk and/or Registration numbers
• Note any discrepancies because
  • Discrepancies often mean inappropriate use of friends and family members as interpreter
  • Discrepancies can point to patients going without language access which is a violation of the law
• Know the number of requests for your top languages and
  • Track daily/monthly requests
  • Track requests by location
    • In-patient
    • Clinics
    • Rehab
  • It is common for patterns of usage to show which will help you staff accordingly
    • For example, Mondays is traditionally a heavy interpreter use day
    • Fridays tend to be lighter in volume
  • Facilitate the documentation on the EMR (electronic medical record) so providers can accurately document the language and the fact that an interpreter was used for the encounter

Sourcing

• What is your plan to provide language access?
  • Assessed bi-lingual providers?
  • Medical interpreter staff?
  • Independently contracted interpreters?
  • Interpreter agency contracts?
  • Remote interpreting services?
• What is your fallback position?
  • What is the protocol if the agency interpreter fails to show up on time or at all?
  • What is the protocol if the staff interpreter or bilingual provider calls out sick that day?
  • What is the protocol for when you cannot source an available interpreter for a rarer language, (known as LLD, or language of limited diffusion)?
  • What is the protocol for when you can’t source a tactile interpreter for a Deaf-Blind patient?

Scheduling: how do you arrange for service?

• In advance, and for
• Same day requests

Good metrics leads to better scheduling

Having good language preference collection means better outcomes when pairing clients with interpreters. You want to avoid mismatches, e.g., wrong dialects, wrong language.

Consistently asking the question, “In what language would you prefer to discuss you medical concerns?” makes all the difference. The language field within your admitting form or registration software should be a “stop field”. A blank field should not lead to the assumption that the patient speaks English. A blank field indicates that the question was not asked, and it needs to be. Ask I.T. to make sure your language field is a “stop field”.

This way, you can ensure the question is asked of everyone regardless of appearance or the ability to say hello and state their name. Often, when asked a yes/no question, LEP will nod “yes”, because they want to show they are cooperative. It should not be inferred that the patient actually understood the question itself.

Matching preferred interpreters with patients and clients leads to better outcomes and clearer exchanges of information as it avoids issues, which can often escalate, surrounding

• Differences in dialects
• Gender preference
• Clan or religious affiliations

Matching preferred ASL interpreters with Deaf patients also leads to better outcomes and greater patient satisfaction. Can you answer this question? What the difference is between a Certified Deaf interpreters and a Certified ASL interpreter?

• Certified ASL interpreter is hearing and speaks English as well as sign language (ASL)
• Certified Deaf interpreters are Deaf, and assist Deaf patients who do not know ASL to communicate, in effect, forming a bridge between the Deaf client and the ASL interpreter

Languages of limited diffusion (LLD)- How do I provide language access for LLD patients and their families?

• For a Central American agricultural migrant worker, whose first language is Mixteco, providing a Spanish interpreter is not helpful. The same applies for other industries such as fishing, logging, fish processing plants, lumber mills, any and all agricultural jobs such as pickers and packers. All of these sectors attract a higher percentage of indigenous language speakers who are also LEP
• Do you know which indigenous languages come to your clinic or hospital in significant numbers?
  • Often when they come to your facility for the first time, it is via the Emergency room, due to an on the job accident
  • Are you ready for these patients?
• Sourcing interpreters for languages of limited diffusion is challenging but possible
  • Sometimes the solution is to find an indigenous Central American interpreter who speaks Spanish, sourced remotely, with your staff or agency interpreter who speaks English/Spanish available onsite to partner with the remote interpreter
  • ASL and Certified Deaf interpreters always partner to provide service

What are the must-haves for a language access plan?

The easiest and most cost effective way to source an interpreter, particularly at a moment’s notice, is via the telephone. However, the telephone will never be able to satisfy ADA requirements for the Deaf. Video remote interpreting can. Video remote interpreting can also help you locate interpreters for LLD patients with far greater ease than you can via your local pool of contractors.

If you have the budget to hire or contract in-person interpreters, video is an excellent back-up strategy. There are always times when demand exceeds capacity for a particular language. You can lose staff to illness or long-term leave, retirement and recruitment from another employer. Sometime budget cuts don’t allow you to backfill vacated positions.

Have your strategy in place. Most institutions require a process for approving vendors. You need to have completed this process prior to the appointment where the patient is LEP.

• Availability must be 24/7, 365 days of the year
• This is the most basic, most affordable way, to provide language access to your LEP and Deaf patients.

CLAS standards require provision of meaningful language access to services. What exactly does that mean? It means for example, that the telephone doesn’t work for these scenarios:

• Deaf patients
• Hard of hearing patients
• Patients in ICU
• Confused or elderly patients
• Mental health patients

For certain other scenarios, you will always want to use an onsite interpreter. Situations requiring complex cultural brokering often do best with an onsite interpreter such as:

• Giving the patient bad news, best practice is to do this in person
• End of life/ Last rites
• Spiritual counseling
• Conscious sedation procedures
• Mental health encounters
• Family conferences
• ICU
• First visit by the patient to the facility

Who is the Joint Commission and what do they do? Why do they matter?

An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

The onsite hospital inspection, undertaken yearly by the Joint Commission, has increasingly focused on the LEP patient experience. Successful accreditation depends on their scrutiny.

According to the Joint Commission

• Language barriers appear to increase the risks to patient safety
• It is important for patients with language barriers to have ready access to competent language services
• Providers need to collect reliable language data at the patient point of entry and
• Providers need to document the language services provided during the patient–provider encounter

Remember, one size does NOT fit all! Different scenarios require different approaches.

IF YOU DON’T MEASURE IT, YOU DON’T KNOW HOW BIG IT IS!

How do I know what kind of budget and resources I will need to comply with these language access requirements?

Have a SYSTEM for collecting language preference from clients and patients so you can adequately plan for your needs

What are your most frequently requested languages?

• You should plan for your top five at least, if not the top ten

What is the monthly frequency of interpreter requests for those languages?

• How can you budget if you don’t know what you need?

Most hospitals use EPIC at registration

• What does your organization use?

What are you doing about translated information for your patients? Many of our English-speaking patients are not getting good care because they cannot decode health care their information adequately, particularly discharge instructions and follow-up referrals. Health literacy is a problem for all of us. Our English-speaking patients share this problem with our LEP patients and with our Deaf and differently-abled patients.

Have a FALL BACK position for when your agency interpreter fails to show, or when an in-person interpreter for a particular language is not available such as

• Telephonic interpreter service
  • Less popular with clients due to lower customer satisfaction rates, but fulfills the Title VI requirement for basic language access provision.
  • Again, assess for meaningful access!
• Video interpreter service
  • Much higher user satisfaction rates than video for both patient and provider
  • Users can see each other
  • Provides body language cues to interpreter
  • Patients can display prescriptions bottles which are visible to both the interpreter and the provider, leading to less time wasted trying to pin down medications names, needed refills, etc.
  • Video works for both spoken language and ASL

Video trumps telephone in terms of both provider and patient satisfaction. Plan to use a MIX of services (in-person, video and telephone) to satisfy the variety of needs your LEP and disabled patients, and clients will have.

Once I have implemented my LAP, how do I ensure it’s working well?

Now that you’ve set up your language access plan, there are still steps you need to take to make sure it is well utilized by clients, providers, patients and their families.

• Train all staff on how to work with interpreters
  • Include in new employee orientation
  • Include in volunteer orientation
  • Include in spiritual care orientation
  • Include in resident/intern/nurse and critical care staff orientation
  • Require this training as part of the annual competencies for all staff
• Collect language preference data at ALL points of entry
  • Emergency Room
  • Out-patient Clinics
  • Referrals
  • Transfers from other hospitals
  • Transfers from one unit or floor to another unit or floor
• Collect LEP patient satisfaction via surveys
  • Interpreters can assist filling out short surveys together with your LEP patients
• Translate signage into your top languages instructing patients and families on how to request an interpreter
• Translate patient education materials and instructions into your top languages
  • Develop enterprise-wide standards such as requiring all patient education materials to be written at 6^th grade reading level and central archiving

Best Practice for Working with Interpreters

It’s my first time working with an interpreter, what do I need to know?

Shorten what you have to say, by pausing frequently and SPEAK IN FIRST PERSON. Don’t say, “Ask her, to tell you, how her pain level is today”. Say instead, “How is your pain today?”

working with an in-person interpreter

• Introduction, make sure everyone knows each other’s name, this is very important to most cultures, and shows respect to patients. It also helps build trust
• Review any time constraints upfront and inform the interpreter about the general nature of the visit. This is called the pre-session. One or two sentences will do, e.g.,
  • This is a first visit
  • This is a referral for _____ care
  • I need to give this patient a diagnosis
  • We’re going to review pre-procedural preparation, etc.
• Remember to document interpreter use in EMR
• During the encounter
  • Look at the patient while they speak or you will miss valuable body language indicators
  • Avoid asking questions that can be answered with a yes or no, use teach-back to confirm understanding
  • Speak plainly. Avoid idiomatic expressions like
    • ‘Feeling blue’ or ‘down in the dumps’ say “depressed” instead
    • ‘Acting up’ or ‘Acting out’ say “misbehaving”
    • In short, boring is better, plain direct language is best

working with a video interpreter for the first time, What should I do differently?

Not a thing!

Just make sure the volume and picture are satisfactory at the beginning of the interpreted session. Both end users have controls right on the screen, to increase or diminish their respective volumes, brightness and contrast.

Summary

To comply with the law, your facility needs to satisfy a four -factor analysis

1. The number or proportion of LEP persons served in the eligible service population
   1. usually once a demographic hits 5% of the local population, it qualifies as one of the languages you should plan to offer with the assistance of in-house or contracted staff
2. The frequency with which LEP persons come into contact with your program
   1. sometimes, due to the nature of the services offered, people will travel from outside local city limits to seek services, or,
   2. if they know they can access an interpreter at your facility, they will travel quite far in order to avail themselves of that service. So their numbers may not be reflected in local demographics based on residence
3. The nature and importance of the program, activity, or service provided
4. The resources available and costs to the recipient

ask yourself on a regular basis, are you providing meaningful language access to those who need it?

This is the question you will be asked by the Joint Commission. Meaningful access is one of the CLAS standards.

“The key to providing meaningful access for LEP persons is to ensure effective communication between the entity and the LEP person.” (For complete details on compliance with these requirements, consult the HHS guidance on Title VI with respect to services for LEP individuals (65 Fed. Reg. 52762-52774, August 30, 2000) http://www.hhs.gov/ocr/lep.

What is effective for an LEP patient, may not effective for a Deaf patient, e.g., using a telephonic interpreter. Deaf-Blind patients’ needs differ significantly from other patients requiring assistance with language access. Again, there is no one solution for everyone. One size does not fit all.

Overall,

• Video trumps telephone in terms of both provider and patient satisfaction.
• Meaningful access requires using a MIX of services

Patient safety

• Improved access leads to
  • Improved efficiency
  • Lower hospital costs
  • Better outcomes
  • Reduction in health disparities

Definition of Terms

1. ACA Affordable Care Act
2. ADA American with Disabilities Act
3. ASL American Sign Language
4. CLAS Culturally & Linguistically Appropriate Services
5. Deaf Needs ASL interpreter
6. Deaf-Blind Needs tactile interpreter
7. EMR Electronic Medical Record
8. Forms of access In-Person Interpreter
   1. Telephonic Interpreter
   2. Video Interpreter
   3. Translated Forms and Documents
9. Hard of Hearing Needs technological assistance, amplification
10. Joint Commission published findings
    Divi C, Koss RG, Schmaltz SP, Loeb JM. Language Proficiency and Adverse Events in U.S. Hospitals: A Pilot Study.  International Journal for Quality in Health Care 2007; 19: 60-67.
11. LAP Language Access Plan
12. LEP Limited English Proficient, needs spoken language interpreter
13. LLD Language of limited diffusion. Can be an indigenous language or a foreign language that is underrepresented in the local population. Examples include Mixteco and Zapoteco from Mexico, Tongan and Marshallese from the Pacific Islands.
14. Title VI Federal mandate signed into law by President Johnson as part of the Civil Rights Act, prohibiting discrimination on race, religion and country of origin (which is where language access and language barriers come into consideration)

Certifying Bodies for Medical Interpreters

• CCIE national accreditation (ASL)
  • RID
    • however, no medical specialization currently available for ASL
  • NCIHC national accreditation process (spoken language)
    • CCHI – Medical
  • IMIA national accreditation process (spoken language)
    • NBCMI – Medical
  • DSHS Washington state accreditation process (spoken language)
    • Medical
    • Social Service

Web Links for Additional Detailed Information

 

1. About Deaf Culture
   http://www.gallaudet.edu/clerc_center/information_and_resources/info_to_go/educate_children_%283_to_21%29/resources_for_mainstream_programs/effective_inclusion/including_deaf_culture/about_american_deaf_culture.html
2. ACA Affordable Care Act. Specifically, about the law.
   http://www.hhs.gov/healthcare/rights/index.html
3. ACA Penalties for higher readmission rates
   http://www.npr.org/blogs/health/2014/10/02/353306337/medicare-fines-record-number-of-hospitals-for-excessive-readmissions
4. ADA American with Disabilities Act
   http://www.ada.gov
5. ADA Guide to Disability Rights Law
   ada.gov/cguide.htm
6. ASL American Sign Language
   http://www.nidcd.nih.gov/health/hearing/pages/asl.aspx
7. CLAS Culturally & Linguistically Appropriate Services
   http://clas.uiuc.edu and
   http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf
8. Deaf-Blind FAQs
   http://www.aadb.org/FAQ/faq_DeafBlindness.html
9. Joint Commission
   1. Language Proficiency and Adverse Events in U.S. Hospitals
      http://www.jointcommission.org/limited_english_proficiency
   2. Language Access and the Law
      http://www.jointcommission.org/assets/1/6/Lang%20Access%20and%20Law%20Jan%202008%20%2817%29.pdf
   3. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care http://www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727.pdf
10. LEP FAQs
    http://portal.hud.gov/hudportal/HUD?src=/program_offices/fair_housing_equal_opp/promotingfh/lep-faq#q7

11. Medicare Fines Related to High Readmission Rates
    http://www.npr.org/blogs/health/2014/10/02/353306337/medicare-fines-record-number-of-hospitals-for-excessive-readmissions
12. Robert Wood Johnson – Interpreter Satisfaction Survey
    http://www.rwjf.org/en/research-publications/find-rwjf-research/2007/03/interpreter-satisfaction-survey.html
13. Tactile Interpreting
    http://rid.org/UserFiles/File/pdfs/Standard_Practice_Papers/Drafts_June_2006/Deaf-Blind_SPP%281%29.pdf