May 2007

Hablamos Juntos demonstrations began by having to invent ways to assess and train interpreters. Their charge was to increase the number and quality of interpreters. The first and immediate challenge was the need to develop trained interpreters. Supported by the National Program Office and with Robert Wood Johnson Foundation grant funding, most demonstrations were able to develop local capacity to assess and train interpreters within a 2 year timeframe but their experience demonstrated how significant this challenge is for most health organizations.

This experience begs a larger question, why should every health care organization in America - on its own with their own resources - have to invent (literally from the experience of others) the capacity to meet federal mandates and clinical standards for millions of limited English patients? This is an important question that health leaders and policy makers need to further explore. This article briefly compares the developmental history of other forms of interpreting and reports on privately funded efforts now underway in health interpreting.

The establishment of the League of Nations, now known as the United Nations (UN) created the first distinct setting for employing interpreters to enable nations to formally communicate with one another. This impetus gave rise to the conference interpreter. Immigration trends after World War II increased demand for community interpreters in many countries. From the beginning, the ability to interpret from one language to another was seen as a natural gift. Early UN interpreters learned their trade through on-the-job training. It was assumed that knowing more than one language required an interpreter to have a broad culture générale; a notion that still prevails today. A critical factor to international development and professionalization of conference interpreters was the concentration around a single organization.

In the United States, the community interpreter has evolved to meet language communication needs that occur in public institutions such as hospitals and courts; Sign Language interpreters are also considered community interpreters. The formalization and development of different types of community interpreters has generally followed legislative action formally acknowledging the need to provide and assure the quality of interpreters. Court interpreting for example gained footing with the Federal Court Interpreter Act of 1978, which requires interpreters for the courts to demonstrate proficiency. Federal standards stimulated interpreter associations and universities to develop formal education programs. One example, the Monterey Institute of International Studies ( Monterey, California) offered its first certificate course in court interpreting in 1983 as an adjunct to the Masters Degree in conference interpreting (MIIS, 1999).

Section 504 of Rehabilitation Act of 1973, as amended, mandates interpreters are made available for people who are deaf or hard of hearing. Further, Congress funded “the establishment of training programs to grow the number of qualified deaf interpreters in the nation" through budget earmarks within the Department of Education, Office of Special Education and Rehabilitative Services (OSERS). Today, OSERS continues to fund the development of curriculum and standards for training Sign Language interpreters.

Unlike other forms of community interpreting, there are neither recognized standards for training nor benchmarks for assessing the quality of health interpreters. Although, Title VI of the Civil Rights Act makes clear an obligation to assure equal access to safe, quality health care for all residents in the country and requires all health care providers receiving Federal aid to provide language services to non-English speakers; hospitals, clinics and doctors are each, generally independently, are expending resources to create capacity to meet this obligation.

While other forms of community interpreting have advanced as a result of recognized national standards or sponsorship; the field of health interpreting has had to rely on philanthropic foundations and volunteer efforts. The largest investment on a national scale to develop solutions to language barriers to health care has been made by the Robert Wood Johnson Foundation. The National Council for Interpreters in Health Care are working to establish a framework that promotes culturally competent health care interpreting, develop and monitor policies and research and model practices, among other goals with foundation funding. As important as privately funded initiatives may be, they can not match the scale of the U.S. Department of Education nor lend the authority of Federal Court Interpreter Act of 1978.

Federal funding is needed to develop a trained workforce of interpreters and stimulate innovation to create population based solutions which would help all health organizations, large and small, meet their obligation to offer equitable, safe and quality health services. Until then doctors and hospitals will have few reasonable options beyond using family and friends to interpret; hiring bilingual employees from heritage language communities or investing in the development of interpreters with little to guide them. Health leaders and policy makers can learn from the experience of other forms of community interpreting to focus health dollars where they will do the most good.

Did you know that only 9.3% of Americans speak both English and another language fluently, compared with 56% of citizens living in European Union nations? So, why should the U.S. health care sector, which accounts for nearly one-sixth of the national economy, care about language capacity? Recent federal action provides insight.

We know that the face of America is changing. Future growth for the nation is expected to come primarily from immigration. In 2005, nearly 52 million persons over the age of 5 spoke a language other than English in the home. California, an early exemplar of this national trend, counts 27% of its residents as being foreign born while 20% of the state’s population report speaking English less than “very well,” according to the U.S. Census Bureau. As communities change, so do the patients seeking health care and the sources of prospective employees. Successful businesses are those that adapt to changing markets and customers’ needs. In contrast to other industries, the U.S. health care sector has been slow to respond to these changes.

Physicians often are among the first to witness such changes in their community. Nationally, physician organizations are working to implement organizational and clinical supports to facilitate such change. For example, entities such as the American Medical Association and the American College of Physicians are investing in research and awareness campaigns to help physicians be better equipped to deal with these societal changes.

Beyond demographic trends, hospitals have additional pressures drawing attention to a growing population with limited English proficiency. According to the latest evidence from Joint Commission on Accreditation of Healthcare Organizations communication barriers increase the risks to patient safety. If this weren’t enough, federal law, and increasingly state statutes, obligates health care organizations to provide limited English proficient patients equal access to health care services like English speakers.

Hiring employees from heritage communities to create interpretation and translation services is a natural first step. A workforce that reflects the community is more likely to understand how care organizations need to adapt to changing community demographics but may not be enough. One reason is a general lack of appreciation and interest, nationally, in promoting language development and supporting heritage communities to retain their native language proficiency. This includes a lack of investment in English development for those with limited English proficiency.

The nation’s lack of foreign language proficient individuals threatens the nation’s “national and economic security,” according to Sen. Daniel Akaka of Hawaii, the lead sponsor of the National Foreign Language Coordination Act. The bipartisan bill, introduced recently in Senate, would create a National Language Czar and a coordinating council to oversee the development of language skills and cultural competency in the United States.

The legislation, which was also introduced in the House, aims to serve the interests of security agencies and builds upon the National Security Language Initiative, a federal interagency effort announced last year by President Bush to “dramatically increase the number of Americans learning critical need foreign languages.” Both efforts are a response to a 2004 national call to action by leaders in government, industry and academia to increase the nation’s foreign language capabilities in the face of globalization and a post- 9/11 world. Leaders in government and the business community understand that low levels of U.S. foreign language capacity impedes our ability to keep our citizens safe; engage with people from other cultures; as well as promote domestic well being.

The scope and intended reach of this defense led initiative on language brings home clearly how the world is changing, and draws attention to current day fundamental demographic and societal changes. These types of industry level solutions are needed to facilitate equal access to health care services for persons with limited English proficiency. Meanwhile, hospitals essentially struggle on their own to adapt to changing demographics and increasing demand to offer access to health services for patients with limited English proficiency.

Local strategies are essential for innovation to occur and to test possible solutions for effectiveness. Hospitals are a key player in meeting the health care needs of patients around the country. But without national attention and investment, precious health resources will be lost to futile reinvention and misguided interventions. Health care leaders can learn from the security sector and their efforts to develop national capacity by creating a national authority to bring attention and coordinate broad reaching actions across sectors. A national presence is needed to guide efforts that ensure equal access to health care services. Perhaps the American Hospital Association can do more to help hospitals respond to changes of tsunami proportion.

Round 2: Finding Answers: Disparities Research for Change – Call for Proposals

Finding Answers: seeks to improve the quality of health care provided to patients from racial and ethnic backgrounds likely to experience disparities. Approximately, $6 million over three years will be awarded. Brief proposals are due May 17 , 2007. Innovations in the treatment of cardiovascular disease, depression, and diabetes are eligible for research funds. For more information click here.

National Committee for Quality Assurance (NCQA):
Recognizing Innovation in Multicultural Health Care Award Program

All health plans including managed care organizations (MCOs) and preferred provider organizations (PPOs) are encouraged to submit applications for consideration. Applications must be received by May 31, 2007. Award winners will be honored at an awards event and present posters at the NCQA conference on Culturally and Linguistically Appropriate Services (CLAS) in Washington, DC on November 12 th and 13 th. For more information click here.

New Resources for Languages

Medicare Prescription Drug Plans Fail Limited English Proficient Beneficiaries

A new report by the National Senior Citizens Law Center (NSCLC) and partner organizations indicates that companies that contract with the federal government to provide prescription drug coverage to Medicare beneficiaries in California are falling far short of their obligation to provide service in languages other than English.

Key results of the survey include:

• More than 60% of calls placed never reached an individual speaking the language of the caller.
• More than 50% of all calls ended without any attempt by the plan representative to connect the caller to someone speaking the caller's language.
• The rate of successful calls varied greatly by language: only Spanish calls exceeded a 50% success rate. Non-Spanish speaking limited English proficient individuals who call their Part D plan are able to speak with someone in their primary language less than 37% of the time.
• Customer service representatives lack appropriate training or resources to successfully connect non-English speaking callers with someone who can speak their language.
• Written materials were not made available to callers in their native languages despite the federal government's requirement that these materials be provided by the plan sponsors.

To learn more click here.

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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