CCHAP Home > Newsletter Articles > Newsletter Eleven, September2007

CCHAP Newsletter Eleven

September 2007

Improving Health Outcomes
Tips For Providers Using Bilingual Staff as Interpreters
Retaining Bilingual Staff

Performance Objectives for Bilingual Staff (Interpreters)

Language needs of your patients (Practice Self Assessment)

CCHAP Administrative Team Is Moving

Medical Spanish Training

 

Improving Health Outcomes
For Spanish Speaking Families
In Your Practice

Should your next new hire be bilingual?

 [This article is adapted from a New England Journal article by Glen Flores, MD and Pediatric Grand Rounds by Lou Hampers, MD, MBA]    

Nearly 50 million Americans (18.7 percent of U.S. residents) speak a language other than English at home; 22.3 million (8.4 percent) have limited English proficiency, according to self-ratings.  One out of six households in Colorado (over 600,000 people) speaks a language other than English at home.  Over one-third of newborns are born into a family in which a language other than English is spoken at home.  Between 1990 and 2000, the number of Americans who spoke a language other than English at home grew by 15.1 million (a 47 percent increase), and the number with limited English proficiency grew by 7.3 million (a 53 percent increase).

Adverse health outcomes
Research clearly shows that language barriers impede access to health care, compromise quality of care, and increase the risk of adverse health outcomes among patients with limited English proficiency (LEP). When a parent has LEP, the family is less likely to adhere to medication or treatment plans, is more likely to miss appointments, is more likely to defer needed medical care, is less likely to have a medical home, receives less preventive care, and is more likely to experience medication complications. Language barriers can lead to inefficient care because clinicians are unable to elicit LEP patients’ symptoms and, thus, use more diagnostic resources or invasive procedures. Children with asthma, whose families have LEP, are less likely than others to return for follow-up appointments, have higher rates of hospitalization and drug complications, have more expensive care for acute illness, have an increased risk of intubation, and have lower levels of patient/parent satisfaction. The risk of medical errors and malpractice suits is higher. Many studies document that trained professional interpreters and bilingual providers improve health outcomes, reduce the number of tests and hospitalizations improve parent and provider satisfaction and reduce malpractice risks.

Guidelines and laws
The Federal government has made it clear that “health care workers and institutions must provide linguistically appropriate services to LEP patients,” based on Title VI of the Civil Rights Act of 1964 and the CLAS standards (The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care) developed by the Office of Minority Health, US Department of Health and Human Services (2000). Malpractice case law is also evolving to where adequate interpretation services are required for large health care institutions. 

The Office for Civil Rights 2003 guidelines exempt a health care organization if they are relatively small, cannot reasonably afford to provide interpretation, or if the frequency of LEP encounters is relatively low.  This would seem to exempt private practices……for now.  But, private practices are expected to at least have one of the following for languages “often” spoken in their patient population: bilingual staff, staff interpreters, volunteer interpreters, contract interpreters, or telephonic interpretation.

Untrained interpreters
In a busy office practice, ad hoc interpreters, including family members, friends, untrained members of the support staff, and the patient are commonly used as interpreters. Unfortunately, these untrained interpreters are considerably more likely than professional interpreters to commit errors that may have adverse clinical consequences.   Untrained interpreters are also unlikely to have had training and knowledge about medical terminology, confidentiality, and the nuances of the role of the interpreter.   They also may not be very proficient in both English as well as the foreign language. Ad hoc interpreters also may have priorities that conflict with those of patients and their presence may inhibit discussions regarding sensitive issues such as domestic violence, substance abuse, psychiatric illness, and sexually transmitted diseases. It is especially risky to have children interpret, since they are unlikely to have a full command of two languages or of medical terminology; they frequently make errors of clinical consequence; and they are particularly likely to avoid sensitive issues.  In fact, California has enacted a law to make it illegal to have a child interpret for a health care visit. In some cultures (especially Asian cultures), the child is expected to “take care of” the parent who does not speak English well. So, be sure to reassure the child that it is not anything against them personally, but that Federal guidelines require an older person to translate.

Catch 22: “The Open Secret”
Unfortunately, in Colorado, commercial insurers do not reimburse primary care practices for interpretation services.  So, private practices face the difficult bind that many of the options for interpretation they can afford are not adequate and third party payers do not reimburse for the trained interpreters  (either professional, contracted interpreters or translation phone lines) their patients need. What are the options for the private pediatric practice?

• A professional, trained interpreter costs $20–$26 per hour. This, of course, is not a very good option, because the volume of Spanish speaking patients in a private practice is too low and the hourly rate too high.
• Commercial telephone interpretation services cost $125 per hour. Inadequate health care reimbursement, of course, rules this out as an option.
• Use of untrained interpreters is discouraged because of possible errors and deleterious effects.
• A good option is to engage the family in the search for a qualified interpreter. They may be aware of resources in the community, such as Promotoras (lay health workers), nurses at their church, or trained volunteers in their community.
• Two other good options are:
• Hire bilingual staff and obtain medical translation training for bilingual staff who speak Spanish.
• Train providers in medical Spanish
• KEEP TRACK OF ALL THE TIME SPENT BY THE PROVIDER IN THE EXAM ROOM AND BILL BASED ON TIME, IF REIMBURSEMENT WILL BE GREATER BASED ON TIME (See Newsletter #5 for details on billing, using time).

Competent trained interpreters
Qualified, trained interpreters will have:
          Language proficiency in both English and the non-English language
          A working knowledge of medical terminology
          An understanding of rules re: confidentiality, informed consent and impartiality
          Had training regarding professionalism and the role of the interpreter
          A commitment to respect the beliefs and values of the individual

Effectively Working With an Interpreter in Your Practice
The most cost-efficient method to address the LEP problem in Colorado is to have bilingual staff, who are trained in medical Spanish and who use the methods used by professional interpreters.   The following are tips for clinicians and interpreters who want to provide quality interpretation for their patients and their families
1. Permission and confidentiality - Be sure to ask for permission from the patient/family to use the interpreter you have selected and, when feasible, inquire about whether there may be things they would not want to discuss in front of this person. If in doubt, trust your instincts and choose to use a phone language line for sensitive issues.
2. Pre-interview - Prior to entering the exam room, briefly discuss with interpreter: the general reason for the visit, known issues, and the goals for the encounter without breaking confidentiality.
3. Role of the interpreter - In the pre-interview, discuss with the interpreter the roles you want her/him to take.  Do you want the interpreter to simply interpret the words or do you want the interpreter to assist in better understanding barriers or needs of a cultural nature.
4. Starting - Ask the interpreter how to say an appropriate, professional greeting in the family’s native language and use the greeting to begin the visit.  Most of us feel awkward about talking through an interpreter.  Feel free to say so and encourage the parent to let you know if it is not working well for any reason.
5. Etiquette - When possible, try to arrange for you to face the patient, with the interpreter on the side. Ask the interpreter about the family’s cultural preferences regarding eye contact, closeness of sitting proximity, touching, etc.  Talk directly to the patient and parent, in the first person, as you would normally do.
6. The Dialogue - Try to use single questions and short phrasing.  Attend to the interpreters need to interpret what you are saying, and break long statements and questions down to shorter segments.  Periodically check whether the parent/patient understands by asking them to repeat their understanding.  If you wonder about the meaning or length of response, ask the patient and interpreter to clarify. Be patient, some phrases in English may require longer sentences in other languages to have the same meaning.
7. The Story - In many cultures, there is a tradition of “telling the whole story.”  So, the parent may talk for several minutes and the translator may give you a much shorter interpretation.  But, it may well be that the parent will want you to know the whole story and the degree to which you hear the whole story may influence their level of trust and compliance later.  So, spend the time up-front.  Ask the translator to tell you the story, show interest.
8. Barriers - Be sure to ask the interpreter to explore whether there are barriers that might interfere with treatment: monetary, transportation, attitudes, concerns, beliefs or other cultural barriers, as you would with any patient.
9. Adequate understanding - In this setting, there is obviously greater chance that the parent will not have a complete understanding.  Allow ample time for questions and specifically ask whether they have gotten all of their questions answered.  It is particularly encouraging if you learn the word for “question” in the parent’s language.
10. Debriefing - Before leaving the room, ask the patient/parent to provide feedback through the translator.  Also ask the interpreter for any feedback the interpreter has regarding potential barriers or concerns about the parent’s understanding or ability/willingness to follow through. 

Using Untrained Interpreters  (family members or volunteers)
In some instances, you may not have a formal interpreter available or telephonic voice interpreting. In that case, you may have to use an untrained, “casual” or an “ad-hoc” interpreter. This might include a co-worker, a family member or community volunteer, but never a child.  Some states, like California, are already working on legislation to prohibit using a child as an interpreter.

Be aware that when using untrained interpreters, there is a higher risk for errors than when using trained interpreters.  But there are times when it cannot be avoided. You should be much more cautious and double check important issues.  Remember that, when using family or a friend, confidentiality may become an issue and/or embarrassment.  If you sense this may be an issue,  get a trained translator or use a phone language  line.

In some families, the child may be expected to “take care of” the parent who does not speak English well.  So, be sure to reassure the family that it is not anything against them personally, but that medical, as well as Federal, guidelines require an older person to translate.

Acknowledge the importance of the perspective of the ad hoc interpreter (family member or friend) and talk with him/her enough to understand that perspective.  And then emphasize the importance of getting information as directly and precisely as possible from the patient.

Trust your senses: if the responses seem inadequately translated, or the history is confusing, insist on getting a trained interpreter or use the AT&T translation line.

And, of course, in the context of domestic violence, spouses or partners should not be used as interpreters.

Retaining Bilingual Staff
A bilingual staff member, trained in interpretation, is an invaluable addition to any practice.    The following steps will ensure that this person will be best utilized and willing to stay. 

• Commit to developing a formal process and identifying someone to be in charge of that process.  The practice will benefit from having the practice manager, a provider and the interpreter discuss the issues and process described here.
• Require office interpreters to take a course in which they learn about:
       a.  HIPPA rules and confidentiality
       b.  Professionalism and etiquette
       c.  Medical terminology
       d.  Ethical issues
       e.  Cultural issues
       f.   Positioning
       g.  Professional boundaries
• Agree that the interpreter and the provider will talk for a few moments before seeing the patient to prepare for the visit.
• Discuss how the interpretation role will interface with other responsibilities.  Interpretation should not be just an add-on to an already full job. It produces stress to pull someone away from their full-time duties to interpret and then expect them to return and rush to complete their regular duties.
• Discuss how you will acknowledge the importance of this role in the practice.   How will this person be compensated for the extra training and responsibility?  [It is often taken for granted, but it deserves extra pay and status in the practice]
• Develop guidelines for schedulers to be sure all patients needing an interpreter are scheduled when the interpreter will be available. Also, develop guidelines for notifying the interpreter when families will be coming in (or are in and ready) for interpretation.
• Decide how you will handle errors in translation and how you will communicate it to the interpreter.  How will you make it a learning experience for all interpreters in the office in a non-punitive manner?
• Arrange periodically to set aside time to discuss how things are going and to discuss problems and issues.

    *Flores G. Language Barriers to Health Care in the United States. New England Journal of Medicine. Volume 355:229-231. July 20, 2006
   

Health Care Interpreter
Performance Objectives

[Source: This code is a combination of the Codes of Ethics from the Hospital Interpretation Program in Seattle, WA; Boston City Hospital in Boston, MA; and the American Medical Interpreters and Translators Association (AMITAS) in Stanford, CA.  Made available at Cross-cultural Health Care Program web site : http://www.xculture.org/interpreter/overview/ethics.html#Confidentiality]

Self Assessment for Practices
on their ability to handle language needs of their patients

https://hclsig.thinkculturalhealth.org/user/home.rails

CCHAP Administrative Team Is Moving To The New Children’s Hospital!

Our email addresses will remain the same, and our mailing address will become 13123 E. 16th Avenue B085, Aurora CO 80045.  Our fax number will change to 720-777-7280.

Contents:

Improving Health Outcomes
Tips For Providers Using Bilingual Staff as Interpreters
Retaining Bilingual Staff
Performance Objectives for Bilingual Staff (Interpreters)
Language needs of your patients (Practice Self Assessment)
CCHAP Administrative Team Is Moving
Medical Spanish Training