Medical Interpreters and Patient Navigators

1. Medical Interpreters and Patient Navigators What role do they play in the quest to eliminate disparities in health care? Juan F. Gutierrez MD, MA, MPH South Central AHEC Western Kentucky University

2. Objectives • Give an overview of the roles of the Medical Interpreter and the Patient Navigator. • Draw a brief comparison of such roles. • Make the case for Patient Navigation as a valid function of the medical interpreter. • Outline the importance of cross training.

3. Definitions • LEP: Persons Limited in their English Proficiency who are unable to speak, read, write or understand English well enough to interact effectively with service providers. (OMH, CLAS Standards) • Health Literacy: The degree to which individuals have the capacity to understand basic health information and services needed to make appropriate health decisions. (Healthy People 2010) • Cultural Competence: A set of attitudes, skills, behaviors and policies that enable organizations and staff to work effectively in cross cultural situations. (OMH, CLAS Standards)

4. Rationale for Providing Effective Patient Assistance Services • Increasing Diversity. • Complexity of the System. • Patient Safety. • Increased Focus on Patient Centeredness. • Health / Healthcare disparities. • Quality of services and outcomes. • Effective allocation of resources. • Legal Liability.

5. Demographics • Us Census Bureau: In 2006 about 55 million Americans (20%) spoke a language different from English at Home. • Of these, 32 million (12%) are Spanish speakers. • The US holds the 5th largest Spanish Speaking population in the world, after Mexico, Spain, Argentina, and Colombia.

6. Demographics • About 21 million Americans speak English “less than very well”. • About 14 million Hispanic Americans speak English “less than very well”.

7. Demographics • 25% of the children under 5 years old in 2008 were Latinos. • The median age for Latinos is 27.7 years old, compared with 36.8 years for everyone else. • There are 107 Latino males for every 100 females, in contrast to the general population (97 males per 100 females).

8. Health Literacy US. Agency for Healthcare Research and Quality (2009): • Almost 90% of adults lack skills needed to manage their own healthcare decisions. • Latino adults 4 ½ times more likely to have marginal health literacy. • African Americans and Native Americans are 3 times more likely to have marginal health literacy. • Adults with lower health literacy have poorer outcomes.

9. Disparities • 1989 American Cancer Society Hearings: • Poor people lack access to quality care • More likely than other to die of cancer • Greater pain and suffering from cancer • Uninsured. • Unable to pay. • Cancer education and outreach insensitive and irrelevant to poor people • Fatalism prevents them from gaining quality care

10. Disparities • Who are the poor in America? (Census 2002) • A disproportionate share of African Americans (24%) and Latinos (22%). About 8% of Non-Hispanic White Americans. • 32% of Latinos, 20% of African Americans and 11% of White Americans are uninsured. • People living in counties with a 20% or larger population in poverty have a 13% in men and 3% higher death rate in women.

11. Disparities • Racial and Ethnic Determinants? • 1998 President’s Cancer Panel: • “The biological concept of race is untenable and has no legitimate place in biological science” • “Racial injustice is a determinant of negative health outcomes”

12. Disparities • Institutes of Medicine (IOM). • Unequal Treatment (2003): “African Americans at the same economic and health insurance status are less likely to receive the most curative treatment for cancer”.

13. Disparities • Prevalence of Diabetes is 50% higher for Hispanics (Healthy People 2010). • Vietnamese women's’ rates of cervical cancer are 5 times higher than for whites (OMH). • African Americans and Hispanic/Latinos account for 25% of the population, 75% of adult (81% of pediatric) AIDS cases (HHS).

14. The Role Of the Medical Interpreter “To facilitate understanding in communication between people who speak different languages” (CCHCP) • Active rather than passive • Focus on the conduit role • Focus on accuracy

15. Barriers to Communication • Linguistic: Different Languages • Register: Health Literacy • System: • Complexity of the health care system. Include Ethnic and racial stereotypes • Culture: Different worldviews

16. Incremental Intervention • Advocate • Cultural Broker • Clarifier • Conduit

17. The Patient Navigator • 1989 American Cancer Society Hearings: - Disparities. • Dr. Harold Freeman: -Created 1st Patient Navigation Program Harlem 1990.

18. The Patient Navigator • Navigators helped low income patients. • Patients received faster care • 2005 Patient Navigator, Outreach and Chronic Disease Prevention Act. $25 Million over 5 years. • Currently, most programs based on the Harlem Model • Almost unheard of outside the Cancer treatment scope.

19. The Patient Navigator Role • Not strictly defined. • No predefined set of services • Flexible Problem Solving • Overcome Barriers to Care.

20. The Patient Navigator Role • Not strictly defined. • No predefined set of services • Flexible Problem Solving • Overcome Barriers to Care.

21. The Patient Navigator Role • Services overlap with other roles Such as nurses, physicians, social Workers, lay health advisors, and Medical interpreters. • Focus on Perceived Barriers • Services rendered according to barriers encountered by individual patients.

22. The Patient Navigator Role • Services overlap with other roles Such as nurses, physicians, social Workers, lay health advisors, and Medical interpreters. • Focus on Perceived Barriers • Services rendered according to barriers encountered by individual patients.

23. The Patient Navigator Role • (Dohan & Schrag 2007) • Barrier focused approach = Broad range of tasks, from locating missing paperwork to interpreting for LEP patients and family members, to providing education.

24. The Patient Navigator Role • Barriers Addressed: • Socioeconomic Conditions: -i.e. lack of insurance or inability to pay • Logistic problems: Schedule conflicts, transportation, rural areas, child or elderly care, etc. • Linguistic and cultural barriers: LEP, Cultural beliefs, Mistrust or fear, Fatalism

25. The Patient Navigator Role • Systemic barriers: High co-pays, Health Literacy (what to do next),Lack of coordination between providers • Emotional Barriers: Pain, side effects from treatment, fear of death, loss of independence, financial burdens, stress, depression.

26. Impact • Wells et al (2008): Evidence of efficacy - 11 to 17% increase in screening - 21 to 29% increase in adherence to follow-up care - Evidence suggests lower clinical stage at presentation and patient satisfaction.

27. Impact • More research is needed to determine cost-effectiveness and outcomes during survivorship. • Te role of the navigator has not been extensively studied outside the realm of cancer treatment.

28. Navigators and Interpreters • Overlapping roles: Several programs use navigators as interpreters. • i.e. Sarfaty et al (2005) Maryland. Lay patient assistants who serve as navigators and interpreters. • University of Arizona, Avon breast cancer project (Mass General), University of San Francisco: Bilingual and bicultural navigators

29. Navigators and Interpreters • Consistently serve as cultural brokers and advocates. • Reactive role, based on barriers rather than specific services. • Programs respond to local barriers. Difficult to extrapolate. • Generally, broker patient / provider relationships.

30. Navigators and Interpreters • Navigation functions often times fall under the interpreter’s role as a clarifier, cultural broker, and advocate. • Also, often times, go beyond those roles to act as a “troubleshooter”. • General troubleshooting and support functions are often times included in the interpreters’ job description (i.e. Mass General)

31. Best Practices to Language Access • Use Bilingual Staff. • If not available or sparse use professionally trained interpreters. • Supplement with a telephonic or video-remote interpreter service (very useful in remote areas). • Create a language bank of volunteer interpreters in the community. Make sure they are professionally trained.

32. Trained Interpreters • Adhere to a Code of Ethics. • Highly Accurate. • Bound by Confidentiality Laws and Policies. • Have learned and apply professional skills. • Are effective cultural brokers and patient navigators (compliance). • Have clear roles. • Respect boundaries.

33. Untrained Interpreters • Not familiar with code of ethics. Violate regularly. • Gossip (Breach Confidentiality). • Biased • Often inaccurate. Change Message. • Don’t know professional skills. • Ineffective cultural brokers and patient navigators.

34. Cross Training • Interpreter / Navigator will interpret everything exactly. • Interpreter / Navigator will manage the flow of the session and choose unobtrusive positioning. • Interpreter / Navigator will use appropriate mode (consecutive, simultaneous, sight translation) • Interpreter / Navigator will be an effective conduit, clarifier, and cultural broker.

35. Cross Training • A more precise definition is needed. • Navigator role has great potential as a tool to address health literacy concerns. • The chicken or the egg dilemma?? • Ultimately Interpreters / Navigators are as good as Navigators / Interpreters depending upon local population and barriers. • Bundling the roles could increase cost-effectiveness.

36. Interpreters / Navigators at TJ Samson Community Hospital • Language Access Plan: • 5 Trained qualified interpreters 24/7 • Supplemented by Language Lines. • Contractors to the hospital. • Small community. • Direct knowledge of community members and their needs.

37. Interpreters / Navigators at TJ Samson Community Hospital • Effective troubleshooters. • In 1st year of operation demand ten-folded. • Active scheduling, facilitating follow-up compliance. • Transportation: Community bus, Sheriff’s Department. • Financial Counseling

38. Interpreters / Navigators at TJ Samson Community Hospital • Troubleshooter role needs better definition. • Navigator cross training. • Potential for crossing over linguistic and cultural barriers. • More savings for institution and system? • More stable source of income for contractors?

39. QUESTIONS?

40. THANK YOU