Expanding Language Access Strategies in Palm Beach County. A Project of the Palm Beach Medical Society. In Collaboration with the:

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1 Expanding Language Access Strategies in Palm Beach County A Project of the Palm Beach Medical Society In Collaboration with the: Issued November 2010

2 The Freimann Initiative: A joint funding venture of Palm Healthcare Foundation & Allegany Franciscan Ministries 2

3 The Palm Beach Medical Society contracted with Gail Price-Wise, President of the Florida Center for Cultural Competence, Inc. to develop an on-line survey and to conduct a focus group on the subject of language access for clients with limited English proficiency (LEP). There were 32 survey respondents and 9 focus group participants from a diverse range of health and social service agencies in Palm Beach County. This report summarizes the findings of the survey and the focus group. It is organized by issues addressed. The purpose of the survey was to gather information regarding the following: current and projected need for interpreter services how organizations identify clients who need these services how organizations monitor the provision of interpreter services how interpreter services are currently provided opportunities for inter-agency collaboration to provide services Similar information was obtained in the focus group, with much more detail about the challenges faced by the participating agencies in providing services to LEP clients. The challenge can be summarized in this quote: WHEN I TALK TO THEM VERY SLOWLY, I DO NOT KNOW IF THEY GOT THE MESSAGE RIGHT AND IF THEY WILL FOLLOW UP INSTRUCTIONS. The potential for miscommunication can be reduced only through effective language services. Please note that this is informal research. The agencies that participated in the survey and focus group may not be a representative sample of the larger group of agencies in Palm Beach County. The survey instrument was not formally validated. Nevertheless, the information gathered provides some important insights into how LEP clients are served. 3

4 Using Bilingual Family Members and Friends as Interpreters Focus group participants corroborated what was found in the survey, that bilingual family members and friends are often used as interpreters for LEP clients. The chart below shows that 12 of the 19 agencies who responded to this question reported that if a client comes in with a bilingual family member or friend, the staff with USUALLY have that person interpret. This somewhat contradicts the survey responses presented in the next chart, in which many agencies report that they will seek an interpreter EVEN if the client has brought a bilingual family member or friend. 4

5 Analysis: Respondents may not have understood the question or may be trying to provide the right answer. It appears that the survey respondents USUALLY rely on friends and family, but sometimes will call an unrelated interpreter instead. Studies show that untrained interpreters can make interpreting errors that alter the diagnostic or treatment plan, increasing the risk of a medical error. The Office of Civil Rights of the US Department of Health and Human Services and the CLAS standards mandate that recipients of federal funding offer interpreters, and must not require a client to use bilingual friends and family members to interpret. The frequent use of bilingual friends and family members as informal interpreters among survey respondents and focus group participants demonstrates that many agencies are unaware of or unable to meet these requirements. Minor Children as Interpreters The chart below shows a mixed response among survey respondents as to whether minor children act as interpreters. Some agencies never use minor children and others will do so under certain conditions: if the child is over 12 years old; if the child appears to be mature enough; the topic is not too personal, or the client prefers to have the child interpret. Several focus group participants stated that minor children are frequently used as interpreters. Parents may take them out of school to interpret for medical visits, meetings with a landlord, immigration, etc. This practice forces children into adult roles at a premature age. 5

6 Clients Who Speak English Reasonably Well Most survey respondents report that staff assume clients who appear to speak English well do NOT need an interpreter. Analysis: This is problematic because even clients who appear to speak English well may not understand medical terms and may not be able to communicate effectively about their medical condition. They may misunderstand medical instructions, putting them at risk for errors. Preferred Language for Discussing Medical Information Most agencies document the client s language, but the following three charts are somewhat inconsistent as to whether this is the patient s preferred language, as opposed to dominant language. 6

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8 Analysis: It s not clear from the survey answers whether respondents ask clients in which language do you prefer to speak about your medical care? When the question requires the respondent to differentiate between dominant and preferred language, fewer agencies report that they collect data about preferred language. Recommendation: Agencies need to be educated to ask clients about the language in which they PREFER to discuss health issues. This may be different from the client s dominant language. Quantifying the Need for Interpreters It is difficult to quantify the need for interpreters because the data is either not collected at all or not reliably collected. For example, many clients who bring a bilingual family member or friend may not be included in the number of clients who require an interpreter. 8

9 Analysis: A plan for meeting the needs of LEP clients must be based on accurate data. Considerable work is required to establish accurate and reliable data collection systems. Recommendation: A more in-depth analysis of data systems should be conducted, including opportunities for agencies to share systems. However this is ONLY worth doing, if there are resources to actually provide better services once the needs have been quantified. Use of Contract Interpreters or Telephonic Interpreter Services As noted in the chart below, survey respondents indicate that if they have not used a contract interpreter or telephonic interpreter service, it is most often because they were unaware of the service, believe the service is too expensive, or too difficult to schedule. 9

10 Some, but not all the focus group participants had experience using a telephonic interpreter, such as The Language Line. They noted it is difficult to use a telephonic interpreter if the client s language has not been identified. I-Speak Cards Most of the focus group participants were not aware of the I-Speak card that a client can use to point to his/her language. The card was shown to the group, with the caveat that it cannot be used if the client is not literate in his/her own language. Educating Managers, Providers and other Staff about Language Access Services Focus group participants discussed the importance of having support from the top of their organizations to adequately serve LEP clients. They reported that agency managers do not understand the importance of interpreting services and need to be educated. Management must set policies and allocate resources to support language access services. Similarly service providers need to be educated about the importance of interpreters and how to communicate with a client through an interpreter. As noted in the chart below, just over half of the survey respondents report that their staff receive training in meeting the language needs of LEP clients. Analysis: The content and effectiveness of the training cannot be determined from the survey. Most agencies provide some training, demonstrating that they recognize the need for training. 10

11 Recommendation: Provide a one-hour Introduction to Culturally and Linguistically Appropriate Services for health care managers, providers and staff. This program could be offered on-site at hospitals and service agencies, at professional meetings, and other settings where there is a critical mass of people. The program topics would include legal and regulatory requirements, the potential impact of culture and language on health outcomes, instruction in the use of I- Speak cards, how to access telephonic interpreters, and how to communicate effectively through an in-person or telephonic interpreter. Interpreter Training and Testing The focus group participants as well as the survey respondents, indicate that fewer than half the agencies test interpreters to ensure their competence. 11

12 In South Florida, interpreter training is provided by The Glades Initiative and by the Florida Center for Cultural Competence, Inc. Training includes interpreter ethics and HIPAA compliance. Focus group participants noted that it can be hard to find funding for training. Analysis: Studies show that untrained interpreters including family members and untrained bilingual staff often make errors that can negatively affect clinical outcome. Accordingly, The Joint Commission has mandated verification of interpreter skills in its new standards. The Florida Center for Cultural Competence, Inc. provides interpreter testing and certification. In addition, there are two competing national certification efforts for medical interpreters: The Certification Commission for Healthcare Interpreters; and The National Board of Certification for Medical Interpreters. Recommendation: Bilingual staff who act as interpreters should receive training and testing to verify that they are competent. Unfortunately, training and testing everyone who acts as an interpreter would require more funding than may EVER be available. As a second best, over time, only certified interpreters would be used for the most essential encounters between providers and clients those encounters in which interpreting errors could do the most harm. A committee could be formed to create a list of those essential encounters. (eg. for medical history, informed consent, psychological evaluations, discharge instructions) Untrained, informal interpreters would continue to be used non-clinical communication, such as for scheduling appointments. Indigenous Languages There is a lot of confusion around indigenous languages. For example, many people from Guatemala speak indigenous languages and are unable to speak Spanish, or may have limited 12

13 proficiency in Spanish. Agency staff often assume Spanish is the primary language, simply because the client originates from Latin America. Kai chi is a very rare Guatemalen dialect, making it particularly difficult for a client to be provided with an interpreter or bilingual staff. For rare languages, it is even more common for children to be pulled out of school to serve as the family interpreter. Recommendation: Agency staff need to be educated about indigenous languages and should be instructed in how to access competent interpreters either in other local agencies or through telephonic interpreting services. Case Managers Focus group participants discussed the importance of case managers. Families come to trust them and rely upon them to act as interpreters for various aspects of the family s life. Unfortunately, when the case is closed, the family loses the relationship with the case manager. The Cost of Interpreters Many organizations, particularly smaller agencies, cannot afford to pay contract or telephonic interpreters. Recommendation: Organizations in Palm Beach County who currently use commercial telephonic interpreter services will note that the cost is significant. It may therefore be less costly to train and test their own bilingual staff to act as interpreters. Perhaps local agencies could agree to allow their trained and tested interpreters to act as telephonic interpreters for one another, ie. Agencies could call an interpreter at another facility for interpreting services. The interpreter would log the amount of time spent on the call, and agencies could periodically reconcile payment. Local agencies would charge one another less than what they would pay a commercial telephonic interpreting service. Community Liaisons The participants spoke about the importance of individuals who can serve as liaisons between the specific cultural groups and service providers, in order to encourage people to access needed services. Faith-based and other community-based agencies often assume this role. It is also important to have cultural brokers who can educate providers about the traditional beliefs and practices of specific groups, so that services can be adapted to those beliefs and practices. Recommendation: Providers should receive training in cultural competence, focused on how culture and language can affect: the clinical encounter, patient adherence to medical advice, and health outcomes. As much as possible, the training should be brought to pre-existing provider meetings, rather than trying to get providers to come to a separate event. Community liaisons should be invited to participate. Compliance with CLAS standards The CLAS standards are useful guidelines. Only 4 of the 14 CLAS standards are legally mandated those that relate to the provision of interpreter services. 13

14 Recommendation: The CLAS standards are currently being revised. Organizations in Palm Beach County should receive training and technical assistance in complying with the new CLAS standards, as well as the new Joint Commission standards on patient-centered communication. Organizational Support Few agencies have a designated person or department who manages language interpretation and translation. 14

15 Written Translation Almost every survey respondent provides translated material to clients. As noted in the chart below, material is most often translated by bilingual staff. The survey respondents and the focus group participant noted the scarcity of written materials in Creole, and the fact that many medical terms do not exist at all in Creole. Analysis: Written language can be problematic. Simple instructions in English, such as take once a day, can be misunderstood (O-N-C-E means eleven in Spanish). Clients may not be literate in their own languages. Since written Haitian Creole is new, many Haitians cannot read it. Further many medical terms exist only in the French used by educated Haitian people. Effective communication about medical issues rests on careful oral communication, asking clients to repeat instructions in their own words, and clear pictures to relay medical information. Recommendation: Agencies should receive assistance in identifying and sharing translated materials. Services for the Hearing Impaired As noted in the chart below, most of the survey respondents do not use qualified interpreters for deaf and hearing impaired clients, but rather encourage them to bring someone who can interpret. Almost all the agencies report that their staff do not receive training in serving these clients. 15

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17 Interagency Collaboration A few of the survey respondents report that they share interpreters and materials. Many of them refer clients to other agencies that can accommodate their languages. If available, many agencies would use interpreter training for bilingual staff and assistance in identifying qualified interpreters. 17

18 Satisfaction with LEP Services Most survey respondents report that they are satisfied or very satisfied with how their agency serves LEP clients. 18

19 Analysis: Whether or not agency staff are satisfied with how they serve LEP clients, the quality of services provided to LEP clients cannot be determined without data, for example: client satisfaction; rate of discontinuing services in the LEP population compared to the general population; client adherence to treatment/service plan; medical errors associated with miscommunication; health/social outcomes in the LEP population compared to the general population. Recommendation: Conduct a study to evaluate the indicators listed above. 19

20 Who Responded to the Survey? Most of the survey respondents were non-profit, community-based organizations. As shown in the chart below, there was great variety in the size and geographic reach of the organizations. 20

21 Who Who attended the focus group? There were nine participants in the focus group, representing one university, several non-profit community-based agencies, and county government. 21

22 Acknowledgements The design of the survey was a joint effort of the Palm Beach County Medical Society and the Florida Center for Cultural Competence. The survey charts were produced by Jacobi Ford, intern for the Palm Beach County Medical Society. Funding for this project was generously provided by Allegany Franciscan Ministries and the Palm Healthcare Foundation. 22