October 2006

The nation’s population 300,000,000 has recently reached and the number of individuals who have limited English proficiency (LEP) continues to grow. The limited supply and growing demand for language expertise is an increasing imperative for the health care industry. Numerous studies have shown that language barriers in the delivery of health care services, particularly in hospitals can lead to misdiagnoses, poor medical care, inappropriate medications and unnecessary hospitalizations. We also know that the LEP population is more likely to be seen in the emergency room but less likely to receive appropriate and accurate information, including preventative services.

Despite these studies, there has been very little national investment in researching beneficial solutions to addressing language barriers in order to effectively deliver safe quality health care services. To date Hablamos Juntos has been the only national investment of its scale to help health organizations develop practical solutions to language barriers. From our efforts, we have learned that the field is still developing and rigorous research studies that show effective solutions are few and far between. As a result, we have looked outside of health care to get a sense of how language barriers are being addressed by other industries (e.g. federal government and education system).

Federal Efforts
A few years ago, the federal government convened a National Language Conference to discuss the importance of language capabilities to national security, global market leadership and domestic well-being. One of their goals was to identify actions that could move the US to becoming a “language-competent nation.” They have since presented a ‘call to action’ for comprehensive leadership in all sectors – government, industry and academia – and stressed that growing language capacity in America is “a key component to addressing these supply and demand issues.” Specifically, they have outlined where to potentially draw the supply of expertise and how organizations can build their language capacity.

For conference materials click here / here.

Supply of Language Expertise
The federal approach acknowledges the need to first understand current language resources and to utilize them within federal initiatives. They note that language expertise can be drawn from a variety of sources: ethnic heritage communities, education system, US government language programs, private language-services sector, and outsourcing/localization in foreign countries.

We know that there are a considerable number of individuals who speak a language other than English and according to the US Census the majority (63%) of heritage speakers self rate their ability to speak another language as “well” or “very well”. By accessing local and state Census data, health care organizations can get a sense of their communities’ language capacity and then work to tap those local resources. Another source of language capacity is within the academic sector. Unfortunately, learning another language tends to be pursued later in life beginning in high school through undergraduate study, however measurable impact on the proficiency level of students is not seen until graduate level study. Health care organizations could benefit from partnering with the education industry to grow and develop the language skills of children.For example, in Pinellas County, Florida, efforts are already being made in academia to promote and grow language capacity in the schools, from primary to collegiate levels. Research shows that the capacity for young children to learn languages is far above the average adult, so these elementary schools are meeting the challenge to maximize their resources by adding language programs to the elementary school curricula.

Understanding the national necessity for increased language education, these parents and teachers have implemented programs to introduce foreign languages as early as kindergarten. Additionally, the National Language Security Act outlines efforts to broaden the recruitment base that include: establishing partnerships to begin language study early, identifying heritage communities across the country, and providing a federal emphasis on the study of languages in schools and colleges.

Building Language Capacity
At the federal level, initiatives to build language capacity begin with strategic planning. This approach allows for development at higher levels of training and expertise as well as changing the way regional language expertise is rated, valued, and employed within federal departments. Improving current job performance at the national level by providing adequate resources to address advanced language skills is another federal initiative. Building strategic reservoirs of language capacity through properly identifying and utilizing individuals and resources with specific skills is also a method of developing language experts.

The federal government promotes testing for advanced proficiency language levels and focusing on the languages that are critical to the security interests of the country can strengthen the national language infrastructure. Finally, broadening the recruiting base for language skills by encouraging and implementing language courses at an earlier age while also reaching out to the heritage communities to recruit, train, and deploy individuals with linguistic and cultural proficiencies are efforts currently being discussed.

In health care, most organizations do not have a strategic plan in place for addressing the language needs of their patients – LEP patient communication occurs mostly on an ad-hoc/as-needed basis. Health care organizations can improve job performance of bilingual staff by developing their skills with access to learning and teaching resources while providing incentives and rewards to acquiring and maintaining language skills. Assessments of language proficiency levels must be strengthened along with research on effective and efficient solutions to patient language barriers.

National-level leadership is imperative to meeting the needs of LEP patients. We know that “the need for language capacity in the country is at an unprecedented level,” (National Language Conference, 2004)demanding appropriate organization and application of national resources to bring about effective solutions. This issue requires national attention to investments in formidable steps to identify proven and effective ways of ensuring patient safety and quality health care for LEP patients.

There are over 40 Poison Control Centers (PCC) around the country, which are federally funded by the Health Resources and Services Administration (HRSA) within the Human Health Services Department. They are required to provide language access to individuals with limited English proficiency (LEP). Like many organizations, the growing number of LEP prompted the question, “How are we responding to the communication needs of this population?” Their first step was to learn what PCC’s around the country were doing to bridge language barriers; to identify needs and resources and come up with a cost-effective broad-based national solution.

Local PCCs were using a variety of strategies to address language barriers. Ninety-three percent used telephonic interpreter services, each center contracting independently with a vendor for these services. The other 7% referred calls to the West Texas Regional Poison Control Center who employs bilingual staff trained in poison control. The top five languages served were Spanish (97%), Vietnamese, Russian Slavic, Chinese, and French and use of telephone interpreter services ranged from zero to 166 times a month. Costs ran as high as $18,000 a year for a single center.

Several approaches were considered, including replicating and expanding the model developed for the West Texas Regional collaborative; using bilingual staff trained in poison control. Although the majority of PCCs were interested in collaboration, the PCCs with bilingual staff were concerned about funding disparities that would arise as PCCs with bilingual staff inherited an increased volume of incoming calls from non-bilingual PCCs. The alternative selected provides non-bilingual PCCs with access to interpreter services through a national contract with a telephonic interpreter contractor reached directly by calling the main 800 number that connects callers to their appropriate (based on their residence) center and when needed language line interpreter services.

This approach, purchasing language line services in bulk for all PCCs to access through one main line was cost effective; leveraging economies of scale and allowed the PCCs to standardize operations for addressing the language barriers of their consumers. This approach also made their services uniformly available to all clients, regardless of their native language .

To contact your local Poison Control Center call: 1.800.222.1222 or http://www.aapcc.org

Various modes of communication may be used to deliver health care services to patients with limited English proficiency (LEP). These include face to face medical interpreting, telephonic medical interpreting and video medical interpreting (VMI) to name a few. Though in person interpreting has been the most common form of communication used by providers, it is not always the most efficient.

VMI is an emerging high-tech alternative with potential to make interpreter services more efficient and effective. Hablamos Juntos grantees explored the reaches of technology and Central Nebraska Area Health Education Center pilot tested this high-tech alternative solution to language barriers rather than relying solely on in-person interpreting. In Nebraska, this technology mainly allowed for health care interpreters located in Grand Island to be made available to seven hospitals across wide geographic distances. These hospitals paid a monthly subscription to access the interpreters.

With this technology, interpreters can communicate from a remote location within the hospital or an outside call center via cameras and a video monitor. Recently, on a larger scale, three California hospitals successfully launched the implementation of video medical interpreting. San Mateo Medical Center, San Joaquin General Hospital , and Contra Costa Regional Hospital have effectively resolved challenges such as the interpreter having to travel between hospital rooms and sometimes between various facilities to do their work. They have also been able to increase the number of LEP patients seen on a daily basis, thus reducing costly delays in health care delivery. The provider and LEP patient were able to be linked with an interpreter within just 37 seconds at these hospital sites.

In health care the challenge is to provide quality interpreting to all patients who need it quickly and affordably. With the development of new technologies that support different modes of interpreting, health care organizations may find that a high-tech solution is what they need. Organizations must weigh the advantages and disadvantages of the various new technologies for medical interpreting.

Benefits of VMI
VMI provides a solution to loss of productivity time with face-to-face interpreting (the interpreter is in the room) by alleviating the pressure for the interpreter to get from one patient-provider session to another, which can cause a backlog of patients. With VMI more LEP patients that can be seen in a day. This approach enables an interpreter to assist from remote locations similar to telephonic interpreting who can then observe important visual cues or cultural brokering that could be important to communication. VMI virtually puts the interpreter in the room to see and hear the interaction without having to run from one session to another.

Cautions for VMI
Important considerations to using VMI include: understanding how it compares to other modes of interpreting for your facility, how the technology is used, and how patients and providers may respond to it. There may be some adjustments required to learn how to use the equipment, navigate around it while in the session, and a possible need to physically transport equipment to another room. Also, some patients may be camera-shy or think they are being taped and interpreters may not have the items needed for a demonstration (i.e. an inhaler). Though this mode of communication may be unfamiliar to patients, providers and interpreters the overall response of the participants in the Central Nebraska AHEC and other locations where it has been used was satisfactory; using VMI maintained an ability to communicate that was similar to face-to-face interpreting.

Costs of VMI
Although, VMI does have a significant upfront cost for the video conferencing units, we know that failed communication between patients and providers can result in dangerously improper treatment and can lead to other costs associated with liability and malpractice. VMI is one form of high-tech innovation that may help develop multilingual health care facilities in remote areas as well as any health care facility with limited face to face interpreter resources. Cost savings with the use of this technology are also seen in fewer travel expenses for the interpreter (especially in geographically rural areas), as well as the costs associated with keeping patients waiting (in a waiting room or exam room) for an available interpreter.

New Resources For Language Services

Hablamos Juntos II – Language Policy and Practice in Health Care funded by the Robert Wood Johnson Foundation to disseminate lessons learned from ten demonstration sites around the country and to set standards and create practical tools for developing useful health materials in languages other than English.

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