Enhancing Cultural Competency: Working with Limited English Proficient Patients and Interpreters

1. Enhancing Cultural Competency: Working with Limited English Proficient Patients and Interpreters Leah S. Karliner, MD MCR Assistant Professor, Department of Medicine Graduate Medical Education Grand Rounds July 2007

2. Outline • Language Barriers • Interpreters • Definitions • What the data shows • Language Access at UCSF: Systems Change • Working With Interpreters • Professional • Non-interpreter staff • Family and Friends

3. Language Barriers

4. Limited English Proficiency • Unable to speak, read, write or understand English at a level to interact effectively with health care providers • Different from primary language spoken at home • U.S. 2000 Census: • 47 million non-English primary language at home • Half report speaking English less than very well

5. Language Barriers & Health Disparities • Less access to usual source of care • Fewer physician visits & preventive services • Poorer adherence to treatment & follow-up for chronic illnesses (e.g. asthma) • Lower comprehension of dx & treatment after ED visit • Less satisfaction with care • Increased medication complications • Increased admissions from the ED • Increased length of stay in hospital Language Barriers in Healthcare Settings: An Annotated Bibliography of the Research Literature; 2003. The California Endowment. http://www.calendow.org/reference/publications/cultural_competence.stm

6. Language Concordance • Patient and physician speak the same language • Associated with increased: • Patient satisfaction • Patient-reported health status • Adherence with medication • Adherence with follow-up

7. Language Concordance Why we cannot rely on language concordance alone • >100 languages spoken commonly in U.S. • At UCSF in our survey of primary care clinicians, 20 different languages reported • Patients maneuver through entire healthcare system • Registration • Lab • Radiology • ED • Hospitalization • Cashier

8. What does the law say? • Civil Rights Act of 1964 – Title VI • If providers receive Federal financial assistance, and • If language is a ‘threshold’ language (>=5% of patient population), then • Must offer language assistance

9. What actually happens in practice? • Bilingual clinicians • Bilingual staff – clinical and non-clinical • Family & friends • Telephone – e.g. Language Line • Video conferencing professional interpreters • In-person professional interpreters

10. Outline • Language Barriers • Interpreters • Definitions • What the data shows • Language Access at UCSF: Systems Change • Working With Interpreters • Professional • Non-interpreter staff • Family and Friends

12. Definitions • Interpreter: 3rd party present in clinical interaction whose role is to facilitate oral language interpretation • Ad Hoc Interpreter: Untrained person called upon to interpret • e.g. family member/friend, bilingual staff pulled away from other duties, self-declared bilingual who volunteers (other patients) • Professional Interpreter: Person paid & provided by hospital or health system to interpret • Training not standardized

13. Do Interpreters Make a Difference? • Systematic review of literature 1966-9/2005 • 28 published papers comparing at least 2 language groups & reported data about medical interpreters in following areas: • Communication (errors and comprehension) • Utilization • Clinical outcomes • Satisfaction • 21 assessed professional interpreters separately from ad hoc interpreters

14. Do Interpreters Make a Difference? • In all four areas • Use of professional interpreters was associated with improved clinical care approaching or equal to that of English-speakers • This improvement was more than with use of ad hoc interpreter • Karliner, et al. Health Services Research, April 2007

15. Outline • Language Barriers • Interpreters • Definitions • What the data shows • Language Access at UCSF: Systems Change • Working With Interpreters • Professional • Non-interpreter staff • Family and Friends

16. Interpreter Services Systems Changes at UCSF • Mulit-pronged approach to improvement with goals of: • Increasing access to professional interpretation • Maximum flexibility in meeting patient/clinician needs

17. Interpreter Services Systems Changes at UCSF • Increased hours of staff Spanish interpreters • Multiple modalities: • In-person (gold standard, but access an issue) • Telephonic • Dual-handset (inpatient in particular) • Speed Dial to interpreter services • Language line • Video-conferencing

18. Interpreter Services Systems Changes at UCSF Video Medical Interpretation (VMI) • Interpreters positioned at dedicated station • Available in real-time at a distance via video-conferencing • Dispatcher directs call • Interpreter can see and hear patient and clinician • Patient and clinician can see and hear interpreter

19. Interpreter Services Systems Changes at UCSF: Video Medical Interpretation (VMI) Advantages: -- reduces wait time: allowing patients to be seen when clinician is available -- reduces travel time for interpreter -- increases encounter capacity for interpreter -- potential for sharing across hospital systems & thus increasing language/interpreter capacity -- maintains visual and physical cues -- requires a dispatch system: improves effectiveness and efficiency of resource allocation

20. Interpreter Services Systems Changes at UCSF: Guidelines for Choosing Modality In-Person Professional Interpretation Cantonese/Mandarin, Russian, Spanish (UCSF Staff) • Psychiatric Patients • Patients with Impaired cognition • Patients with impaired hearing • Patients with impaired vision • Large family meetings • End of life conference/discussions • Delivery of bad news • Patient or family in emotional distress • Actively psychotic patients • American Sign Language (outside agency)

21. Interpreter Services Systems Changes at UCSF: Guidelines for Choosing Modality VMI or Telephonic: • If video is available, this will be default (pilot now in Children’s Hospital and Pediatric Specialty clinics) • Telephonic • Language not offered at UCSF • On-demand via Interpreter Services • After-hours / weekends • Non-clinical encounters (e.g. billing, registration, front-desk)

22. Outline • Language Barriers • Interpreters • Definitions • What the data shows • Language Access at UCSF: Systems Change • Working With Interpreters • Professional • Non-interpreter staff • Family and Friends

23. How to work with a professional interpreter: The Ideal • Allow extra time for an interpreted visit; • Select an interpreter keeping gender and confidentiality in mind; • The interpreter is part of your therapeutic team: hold a brief pre-meeting with the interpreter: • share relevant information about your patient and this visit; • Ask the interpreter to cover everything that is said, conveying the tone and meaning of the message, rather than paraphrasing or rephrasing

24. How to work with a professional interpreter • Position yourself in a therapeutic triad • Introduce yourself directly to the patient; • Introduce the interpreter to the patient; • Address the patient directly; • Watch the patient during the interpretation • Body language • Behavioral clues • Invite correction: “this is what I understand so far…let me know if I missed something...” Interpreter Clinician Patient

25. How to work with a professional interpreter • Speak in short units • Ask short questions • Explain medical terms in simple language • Ask the patient to repeat back any instructions

26. How to work with an untrained/ad hoc interpreter: • Untrained staff • Language abilities may not be equal in both English and the 2nd language • May not know medical terms in either English or the 2nd language • Ask if comfortable interpreting with this particular patient (gender / confidentiality)

27. How to work with an untrained/ad hoc interpreter • Be explicit before they come into the room about what you need / give them guidance • Word for word interpretation (preserving tone & meaning) • Avoid answering for the patient • Position them in triad (show them where) • Give permission to ask you to slow down or rephrase something in easier terms

28. How to work with an untrained/ad hoc interpreter • Family and friends • Avoid using minors!!! • May be uncomfortable interpreting personal/intimate information • May try to ‘protect’ parent/relative from information • Alters relationship between parent and child

29. How to work with an untrained/ad hoc interpreter • Same techniques as with staff, but need to emphasize certain points even more: • Ask them to avoid answering for the patient; • Give them permission to ask you to slow down or rephrase something in easier terms • Speak directly to the patient • Keep your spoken units and questions short

30. Summary • Like any other skills this takes practice • When you have a language barrier with a patient, use a professional/trained interpreter if possible • If you must use an ad hoc interpreter, give them guidance • Avoid using minors to interpret

31. Selected Online Resources • CLAS standards:http://www.omhrc.gov/assets/pdf/checked/Executive%20Summary.pdf • JCAHO: http://www.jointcommission.org/HLC/Resources_Standards.htm • Unequal Treatment: http://www.iom.edu/?id=16740 • Lewin Report: http://www.hrsa.gov/culturalcompetence/measures/default.htm • The Cultural Formulation http://www.med.uiuc.edu/m34/xcultopps/PDF/clinical%20cultural%20assessment.pdf

32. Selected Online Resources • U.S. DHHS on-line/DVD CME: https://cccm.thinkculturalhealth.org/ • The Network for Multicultural Health Resource Page: http://futurehealth.ucsf.edu/TheNetwork/Default.aspx?tabid=387 • Diversity Rx: Models and Practices (cultural and linguistic access): http://www.diversityrx.org/HTML/models.htm