Promising Practices in Healthcare

1. Promising Practices in Healthcare Language Access Advocacy Project California 2004

2. Promising Practices in Health Care • Purpose of Presentation: To provide highlights of existing promising practices in the provision and financing of language services in health care • Overview of Presentation • Policies and Procedures • Needs Assessment • Delivery System • Training and Competency • Workforce • Monitoring and Evaluation • Use of Technology • Financing and Reimbursement • Ongoing Challenges

3. Policies and Procedures • Promising policies and procedures include elements that: • Publicize patient rights and availability of services • Identify and assess language needs • Assure proper documentation • Provide timely telephone communication • Ensure systematic data collection

4. Promising Policies and Procedures:Sequoia Community Health Foundation • Community clinic serving primarily farmworkers in southern Fresno County • Has a written policy on access to interpretation services • Includes specific procedures on how to access language line services • Incorporates written instructions in the personnel policies manual • Includes training for staff on policy and procedures in orientation process

5. Needs Assessments • Promising needs assessments include: • An assessment of community language needs • An internal assessment of institutional needs

6. Promising Needs Assessment: La Clínica de la Raza • Community clinic serving primarily Latino patients in East Oakland • La Clínica de la Raza conducted a Cultural Competence Assessment Survey • Assessed staff views regarding cultural competency • Was included as a component of the organization’s quality assurance oversight plan • Yielded results that illustrate a strong recognition among staff of the importance of culture • Identified needs • Materials and signs in different languages & cultures • Training and information about non-Latino cultures

7. Promising Needs Assessment: L.A. Care • Health maintenance organization serving Medi-Cal, Healthy Families, and CaliforniaKids enrollees in Los Angeles County • As part of its assessment, LA Care conducted a survey of providers to identify needs and challenges • 92% felt language and cultural issues are important in delivering health care • Over three-quarters would use translated materials or interpreters if made available to them • 50% would like training on how to use interpreters • 49% would like staff trained as professional interpreters

8. Delivery Systems • Promising delivery systems include components such as: • Coordinator and administrative structure • Scheduling and tracking system • Models of oral language assistance • Guidelines for translation of written materials

9. Promising Delivery System: Asian Pacific Health Care Venture • Community clinic serving Asians & Pacific Islanders in Los Angeles • Components of its delivery system include: • Bilingual staff hiring flow chart • Job descriptions for bilingual staff • Hiring criteria • Application process • Oral interpretation test • Written translation test • Translations of vital documents • Trainings for Staff • Patient satisfaction surveys

10. Promising Delivery System: Asian Pacific Health Care Venture Source: “A Functional Manual for Providing Linguistically Competent Health Care Services as Developed by a Community Health Center”

11. Promising Delivery System: Golden Valley Health Center • Community clinic serving Latino and Southeast Asian communities in Merced • Cultural Mediators • Provide language interpretation for Latino, Hmong and Lao patients • Receive 40 hours of training and tests for proficiency • Serve as part of the clinical team to transmit cultural understandings and beliefs between clinicians and patients • Cultural Competence Training • Culture Clinic for residents • Training to work effectively with interpreters

12. Promising Delivery System: Alameda Alliance for Health • Nonprofit health plan serving Alameda County • Makes arrangements and coordinates interpreter services • Pays interpreters directly at both the plan and provider levels • Identifies qualified interpreter services

13. Training and Competency • Key elements of promising training and competency activities include: • Interpreter training • Staff/provider training • Competency assessment • Core skills • Core knowledge • Code of ethics

14. Promising Training and Competency: Asian Health Services • Community clinic primarily serving Asians & Pacific Islanders in Oakland • Interpretation and Translation Services • Conducted in multiple languages: Cambodian, Cantonese, Farsi, Korean, Mandarin, Spanish, Vietnamese • Translation by a primary translator, Editing by a second translator, Formatting of document, Proofreading, & Cultural adaptations of health materials • Health Care Interpreting Training • 40 hour, 5 week training • Covers interpreter skills, roles, and ethics • Cross-Cultural Health Care Training • Training for health care staff on serving multicultural patients

15. Promising Training and Competency: Family HealthCare Network • Community clinic serving low-income, underserved individuals in Tulare County • Efforts to promote training and competency include: • Establishing a strong commitment to hiring bilingual staff from the community • Evaluating language proficiency • Utilize standardized oral and written tests • Bilingual staff shadow bilingual physicians initially to ensure accurate language proficiency

16. Promising Training and Competency: SSG/PALS for Health Program • Community based language access program serving Los Angeles and Orange County. • PALS for Health conducts language proficiency assessment in 10 languages • 48-hour Health Care Interpreting Training • Language proficiency test is a prerequisite to enrollment • Skills and knowledge building, standards, role plays, language labs, medical terminology, continuing education and interpreter support. • Patient Education • Informing LEP patients about language rights • Distribution of “I Speak” cards

17. Workforce • Components of a promising language services program include: • Workforce Recruitment • Workforce Retention

18. Promising Workforce Program: CA Physician Corps Loan Repayment • Provides loan repayment scholarships for physicians who practice in underserved areas • Operated by the CA Office of Statewide Health Planning & Development • Focused on primary care physicians • Priority consideration given to those who: • Come from an economically disadvantaged background • Have significant training in cultural/linguistic issues • Speak a Medi-Cal threshold language • Companion program for dentists to be implemented.

19. Monitoring and Evaluation • Key elements of monitoring and evaluation include: • Patient satisfaction • Process variables • Outcome and quality measures

20. Promising Monitoring and Evaluation: Venice Family Clinic • Free clinic serving primarily Latino and low-income patients in Los Angeles • As part of its monitoring and evaluation efforts, Venice Family Clinic designed a quarterly patient satisfaction survey to obtain input from patients • Assists the clinic in monitoring quality of care provided to patients. • Includes questions regarding cultural and linguistic services

21. Promising Monitoring and Evaluation: National Health Services • Community clinic serving low-income and farmworker patients in Kern County • As part of its monitoring and evaluation activities, National Health Services has created a Language Barrier Log • Records Patient’s Name, Arrival Time, Time Seen, Native Language • Reviewed as part of the quality assessment program • Patients should not wait more than 15 minutes for an interpreter or bilingual staff member

22. Use of Technology • Pilot projects are currently exploring and testing the use of new technologies: • Remote simultaneous translation • Videoconferencing

23. Promising Use of Technology: Gouverneur Hospital • Public hospital primarily serving Chinese and Latino immigrants in New York City • Implemented a remote simultaneous medical interpretation pilot • Use trained medical interpreters who interpret for providers and patients through wireless headsets • Interpreter listens to what is said by one party and transmits an interpretation to the other • Provider and patient only hear their own languages

24. Promising Use of Technology: Alameda County Medical Center • A system of public health care in Alameda County with 3 hospitals and 4 clinics • Alameda County Medical Center is currently piloting a videoconferencing medical interpretation system • Provider and patient talk to one another in the exam room while an interpreter in another location interprets via videoconference

25. Medicaid/SCHIP Financing and Reimbursement • August 30, 2000 CMS Letter discusses how states can draw down federal matching funds for language assistance in Medicaid/SCHIP • Only 10 states have established direct reimbursement using federal matching funds to pay for language services • Four models of reimbursement – • contract with language service agencies • reimburse providers for hiring interpreters • certify interpreters as Medicaid providers • provide access to language line

26. Model 1 – Language Service Agencies • Hawaii, Washington, and Utah contract with interpreter organizations. Providers schedule interpreters who then bill the state. • Washington offers testing and certification of its interpreters. For seven prominent languages, the state administers a certification test, and for other languages, the state has a process for qualifying interpreters.

27. Model 2 – Provider Reimbursement • Maine and Minnesota require providers to pay for interpreters and then reimburse providers • Providers have discretion on who to hire • In Maine, interpreters must sign code of ethics; cannot use family members/friends • Considerations • state oversight • quality of interpreters • provider concerns

28. Model 3 – Payments to Interpreters • New Hampshire requires interpreters to become Medicaid providers • Interpreters submit bills directly to the state • Considerations • requirements of becoming a provider • low reimbursement rates

29. Model 4 – Language Line • As of October 10, 2003, Kansas started paying for a telephonic language line which managed care providers can access for Medicaid/SCHIP patients • The language line is coordinated through the state’s fiscal agent (EDS) and providers receive a code for access • Estimated budget – $275,000 for first year

30. Current State Financing * $30 for business hours; $40 non-business hours ** Or usual and customary fee, whichever is less. FFS: Fee-for-service Medicaid enrollees All: both managed care and fee-for-service Medicaid enrollees Source: “Language Services Action Kit: Interpreter Services in Health Care Settings for People with Limited English Proficiency”

31. Ongoing Challenges in Health Care • Financial Reimbursement • Medi-Cal and Healthy Families patients • Uninsured patients • Changing Demographics • Diversity of languages • Indigenous languages • Workforce - Bilingual Providers and Interpreters • Recruitment • Retention • Lack of technical assistance resources and tools to assist in changing operations

32. Ongoing Challenges in Health Care • Trainings for interpreters, providers, and support staff • Cost of training • Opportunity cost of time away from clinic • Access to technology for remote interpretation • Rural areas may lack adequate telecommunications infrastructure • Confidentiality • Especially for rare languages spoken by small communities

33. Resources • CPCA’s publication, “Providing Health Care to Limited English Proficient Patients: A Manual of Promising Practices” at www.cpca.org. • AAPCHO’s publication, “A Functional Manual for Providing Linguistically Competent Health Care Services as Developed by a Community Health Center” at www.aapcho.org. • NHeLP’s publication “Providing Language Interpretation Services in Health Care Settings: Examples from the Field” at www.cmwf.org. • NHeLP and Access Project publication “Language Services Action Kit: Interpreter Services in Health Care Settings for People with Limited English Proficiency” at www.nhelp.org.

34. Questions?

35. Language Access Advocacy Project Contact Information • Asian Pacific American Legal Center Hemi Kim 213-977-7500 x 215 213-977-7595 Fax hkim@apalc.org • Asian & Pacific Islander American Health Forum Alice Chen and Gem Daus 415-954-9988 415-954-9999 Fax achen@apiahf.org gdaus@apiahf.org

36. Language Access Advocacy Project Contact Information • California Pan-Ethnic Health Network Ellen Wu and Martin Martinez 510-832-1160 510-832-1175 Fax ewu@cpehn.org mmartinez@cpehn.org • California Primary Care Association Vivian Huang 916-440-8170 x 238 916-440-8172 Fax Vhuang@cpca.org

37. Language Access Advocacy Project Contact Information • Fresno Health Consumer Center Teresa Alvarado and Sengthiene Bosavanh 559-570-1205 559-570-1253 Fax talvarado@centralcallegal.org seng@centralcallegal.org • Latino Coalition for a Healthy California Lupe Alonzo-Diaz and Patty Diaz 916-448-3234 916-448-3248 Fax Lupe@lchc.org Pdiaz@lchc.org

38. Language Access Advocacy Project Contact Information • National Health Law Program Doreena Wong 310-204-6010 x3004 310-204-0891 Fax wong@healthlaw.org Supported by The California Endowment