Language Access and Health Disparities Mara Youdelman, youdelman@healthlaw

1. Language Access and Health Disparities Mara Youdelman, youdelman@healthlaw.org Farmworker Justice Webinar June 22, 2010 “Securing Health Rights for Those in Need”

2. NHeLP • National non-profit law firm committed to improving healthcare access and quality for low-income individuals • Coordinates the National Language Access Advocacy Project, funded by The California Endowment • Includes a national coalition of stakeholders on language access working to improve polices and resources at the federal level

3. Demographics • Over 55 million people speak a language other than English at home (an increase of 8 million since 2000) and 19.7% of the population. • Over 25 million (9 % of the population and an increase of 3 million from 2000) speak English less than “very well,” and may be considered LEP. American Community Survey, 2007, Table B16001. LANGUAGE SPOKEN AT HOME BY ABILITY TO SPEAK ENGLISH FOR THE POPULATION 5 YEARS AND OVER - Universe: POPULATION 5 YEARS AND OVER

4. Treating LEP Patients Source: Reports commissioned by NHeLP from AHA/HRET, ACP, NACHC; available at www.healthlaw.org 80% of hospitals encounter LEP patients frequently – 63% daily/weekly; 17% monthly 81% of general internal physicians treat LEP patients frequently – 54% at least once a day or a few times a week; 27% a few times per month 84% of FQHCs provide clinical services daily to LEP patients – 45% see more than ten patients a day; 39% see from one to 10 LEP patients a day.

5. Language Barriers & Medical Errors • $71 million settlement in FL case for young man rendered quadriplegic • A 6-week-old infant was admitted for a barbiturate overdose caused by a 10-fold medication dosing error by an LEP mother who did not understand the outpatient dosing instructions available only in English • NHeLP report, The High Costs of Language Barriers in Medical Malpractice

6. Title VI of the Civil Rights Act of 1964 • “No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” 42 U.S.C. § 2000d • “National origin” includes individuals with limited English proficiency (LEP)

7. Who Is Considered “Limited English Proficient” (LEP)? • A person who is unable to speak, read, write or understand the English language at a level that permits him/her to interact effectively with health and social service agencies and providers

8. All public and private entities receiving federal financial assistance, including: State, county, and local health and welfare agencies Hospitals, clinics, and clinicians’ offices Managed care organizations Nursing homes Mental Health Centers Senior Citizen Centers Other programs/activities receiving federal financial assistance inc. Title XX, AoA, Medicare, Medicaid & CHIP Who Is Covered by Title VI?

9. What does Title VI Require? • Longstanding expectation that LEP individuals must have meaningful access to federally funded programs & activities • 2003 – HHS Office for Civil Rights issued final guidance explaining expectations for its federal fund recipients

10. What Are “Covered Entities” Prohibited From Doing? • Providing services more limited in scope or lower in quality • Delaying the delivery of services unreasonably • Limiting participation in a program • Requiring LEP persons to provide their own interpreters or pay for interpreters

11. How Does OCR Determine Compliance With Title VI? • OCR looks at the “totality of the circumstances” – balancing 4 factors: • Number or proportion of LEP persons eligible to be served or likely to be encountered; • Frequency with which LEP individuals come in contact with the program; • Nature and importance of the program, activity, or service provided by the program to people's lives; • Resources available and costs • OCR LEP Guidance available at www.lep.gov

12. CLAS Standards • OMH issued Culturally and Linguistically Appropriate Services Standards (2001) • Standards 4-7 address language access • Health care organizations must: • offer and provide language assistance services at no cost at all points of contact, in a timely manner during all hours of operations • provide in patients’ preferred language both verbal offers and written notices of the right to receive language services • assure the competence of language assistance; family and friends should not be used to provide interpretation services (except on request by the patient) • make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

13. State Laws • NHeLP 50 state survey • All states have at least 2 language access laws • comprehensive • targeted (e.g. emergency room, hospital) • State trends • Health professionals education – NJ, CA, WA • Healthcare Interpreter Competency Standards • Requirements on private insurers – CA • Standardization of pharmacy labels – CA

14. Promising Practices Reports • Reports by NHeLP from The Commonwealth Fund • Small Providers (released 4/05) – examined how small providers (<10 clinicians) offered language services • State/Local Benefit Offices (forthcoming) – examined how state/local health-related benefit offices offered language services • NHeLP/ACU report on promising practices in clinics – included FQHCs, free clinics, etc.

15. Measuring Nature/Frequency of Contacts • Important to identify individuals being served and eligible to be served • Determining language needs at first points of contact –notations in schedule/patient records; language notification flyers; “I Speak” cards/posters • Recording language needs • L.A. Care Health Plan – color-coded stickers designate language needs • Women’s Health and Education Center – notes language needs in schedule and computer data system

16. Identifying Language Needs • Identification of language needs • “I Speak” cards/posters – patients can point to their language and office staff can note • Recording language needs • L.A. Care Health Plan – color-coded stickers designate language needs • WA Department of Social and Health Services – requires client’s primary language in its database • KY Cabinet for Health and Family Services collects language information and specifics on each encounter using language services

17. Arizona • Department of Economic Security – database does not proceed past certain fields without noting the client’s language needs • clients are asked their primary language at initial and renewal interviews • includes 68 language choices plus an open-ended option

18. Community Resources • DC Medical Assistance Administration worked with community advocates to develop its “I Speak” poster and cards and a “Know Your Rights” pamphlet

19. Translation of Written Materials • NE – uses designated translators with a degree from translation program • ID Department of Health and Welfare – works with the Idaho Migrant Council and the Hispanic Commission to review benefits forms for appropriate Spanish translation

20. Identifying Available Resources • Need to identify both internal and external resources • NHeLP’s Language Services Resource Guide for Healthcare Providers helps identify external resources including interpreter/translator associations and providers; training programs; translated materials; symbols; etc.

21. Collaborations • Cooley-Dickinson Hospital (MA) – allows its interpreters to interpret at physician offices • UCSF – video-conferencing • St. Joseph Health System (CA) – uses promotores de salud to train community members (inc. kids) as volunteer promotores to share health and community resource information

22. Assessing Competency • St. Joseph Health System Community Health Programs (CA) – requires assessment of staff providing services in non-English language or as interpreter • North DeKalb Health Center (GA) – requires all bilingual staff to attend training sessions and pass test

23. Competency of Language Services • Interpreting v. translations • NHeLP, NCIHC, ATA – What’s in a Word: A Guide to Understanding Interpreting and Translation in Health Care • Translators • ATA – general certification, not healthcare specific • Interpreters • CCHI – developing national certification for healthcare interpreters

24. Interpreter Certification • NCIHC has National Code of Ethics and Standards of Practice, developing National Standards for Practice • 13 working papers on variety of interpreting topics • Existing state requirements • WA – has had state-based certification since early 1990’s • State requirements – IA, IN, OK, OR

25. Benefits of Certification • Helps Fulfill Standards and Elements of Performance Critical in Accreditation Settings • Facilitates Management of Interpreter Services • Consistency of Practices and Procedures Among Healthcare Interpreters Across the Healthcare Field • Serving the Needs of Individual Interpreters

26. Benefits of Certification • Illustrates commitment to quality and competency • Offers consistency in assessment • Limits legal liability • Responds to clients’ need to document competency for accreditation

27. CCHI Participants • Commissioners – majority of interpreters plus others from healthcare arena • Advisors –healthcare providers, policymakers, and certification experts including: • Lois Wessel, ACU • Jeffrey Caballero, AAPCHO • Representatives from AMA, AHA, NAPH, OMH, ACP, APHA, NHMA, NCAPIP, NCSL • Certification experts – NCSC, RID, ATA, ICE • www.healthcareinterpretercertification.org

28. Conclusions • Providing language services is required by federal law • Many effective and cost-efficient ways to provide language services exist • Certification offers one method of ensuring competency • More needs to be done to improve the availability and effectiveness of language services