Medical Office Staff Training Language Access & Cultural Issues

1. Medical Office Staff Training Language Access & Cultural Issues Presenter: Rebecca J. Patchin, M.D. Presented by the Riverside County Medical Association and the San Bernardino County Medical Society Supported by an educational grant from the California Academy of Family Physicians and The California Endowment

2. Helping your Doctor Care for Patients with Limited English Proficiency Resources Available Ideas & Tools What Others Have Done

3. Background • In 1990, 8.6 million Californians spoke a language other than English at home and 4.4 million were considered “limited English proficient” (LEP). • By 2000, those number increased by 40%, with 12.4 million speaking a language other than English at home and 6.2 million being identified as LEP. • Figures released in late 2007 show that one in five people in the US speak a language other than English in the home.

4. Language Diversity • Many native & foreign-born Californians speak a primary language other than English at home. • Statewide, more than 12 million Californians speak languages in each of the 39 language categories reported by the U.S. Census Bureau. • Not surprisingly, Spanish is far & away the most prevalent language spoken at home, after English. • However, among the top ten languages spoken in CA, more than half are Asian languages, Chinese, Taglog, Vietnamese, Korean and Japanese.

5. Riverside County • Riverside County has a population of 1,545,387 • Race & Ethnicity • White: 65.5% Black 6.2% • Hispanic: 36.2% Asian: 3.5% • 14% of the total population (221,999) are limited English proficiency (LEP) • Languages spoken in homes in Riverside County include • Spanish Tagalog Vietnamese • Korean Chinese Japanese • Laotian Persian Hindi • Gujarathi Urdo Thai • Cambodian Miao, Hmong

6. San Bernardino County • San Bernardino County has a population of 1,709,434 • Race & Ethnicity • White: 58.7% Black 8.9% • Hispanic: 39.2% Asian: 4.6% • 14% of the total population (240,549) are limited English proficiency (LEP) • Languages spoken in homes in San Bernardino County include • Spanish Tagalog Vietnamese • Korean Chinese Japanese • Laotian Persian Hindi • Gujarathi Urdo Thai • Cambodian Miao, Hmong

7. Clear Communication between Doctor & Patient Results in: More accurate diagnoses Agreed and understood treatment plans Increased adherence to medication instructions. Improved health outcomes Reduction in frustration of doctors and office staff. Increased patient satisfaction

8. What can YOU do to provide/identify language access issues in your practice? • Assess Your Practice’s Language needs • Identify Existing Resources • Develop a Plan for Improving Your Practice’s Language Access Hint: Use the “Addressing Language & Culture: A Practice Assessment for Health Care Professionals” as your guide.

9. Health Care Interpreters • Health Care Interpreters • The fundamental purpose of health care interpreters is to facility communication between two parties who do not speak the same language and may not share the same culture.

10. Health Care Interpreters • With communication: • Doctors can gather the information needed for an accurate diagnosis. • Patients & Doctors can better understand each others views, concerns, values and priorities, and cultural practices and perspectives. • Patients & Doctors can negotiate treatment plans. • Patients can understand how to care for themselves. • Patients can understand their options and participate in decisions regarding their health. • Patients and Doctors are more likely to develop trusting and caring relationships with each other.

11. Key Terms • Interpret: Language being interpreted from • Translate: Untrained and untested interpreter • Source language: Orally expressing a message from one language to another • Target language: Language being interpreted to • Ad-Hoc Interpreter: Converting written text from one language to another • Register: Vocabulary, grammar, and pronunciation that usually reflects a speaker’s educational and social background.

12. Definition of Culture (one definition) • The thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious, or social groups. • Culture defines how health care information is received, how rights and protections are exercised, what is considered to be a health problem, how symptoms and concerns about the problem are expressed, who should provide treatment for the problem, and what type of treatment should be given. • In sum, because health care is a cultural construct, arising from beliefs about the nature of disease and the human body, cultural issues are actually central in the delivery of health services treatment and preventative interventions.

13. Culture … • By understanding, valuing, and incorporating the cultural differences of America’s diverse population and examining one’s own health-related values and beliefs, health care organizations, practitioners, and others can support a health care system that responds appropriately to, and directly serves the unique needs of populations whose cultures may be different from the prevailing culture.

14. What Happens When Qualified Interpreters Are Not Available? • Family members, children, friends, any bilingual person in the area, and untrained bilingual employees are asked to interpret. All have good intentions and do not intend to cause harm, but … • Patients are seen without an interpreter. • Patients are turned away unless they bring someone to interpret for them.

15. Risks of Ineffective Communication • Incomplete communication between practitioners and patients plays a major role in medical professional liability claims. • Numerous studies show that the majority of patients do not fully comprehend the health information that is presented to them and that Doctors often make incorrect assumptions about patients’ level of health literacy.

16. Scope of Low Health Literacy (Institute of Medicine Report) • Nearly half of all American adults – 90 million people – have difficulty understanding and acting upon health information. • Forty million Americans cannot read complex texts (e.g. informed consent forms) at all. • Even people with strong literacy skills may have trouble obtaining, understanding and using complex health information.

17. Health Literacy • It is not difficult to imagine how misunderstandings or gaps in communication can fuel patient anger over a poor outcome and spark subsequent litigation. • Health literacy is defined as “the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions.”

18. Key Findings in IOM Report • The readability levels of informed consent documents exceed the documented average reading levels of the majority of adults in the U.S. • Health professionals and staff have limited education, training, continuing education, and practice opportunities to develop skills for improving health literacy.

19. Key Findings … IOM Report • Even signage and directions posted for employees and visitors can often be inadequate. • This report also noted that “identifying the extent of limited health literacy is also problematic because individuals tend not to tell their Doctors about literacy problems that they encounter in the increasingly complex health system, including trouble understanding both printed materials and the meaning of discussions with Doctors.

20. An Example • A two-year-old is diagnosed with an inner ear infection and prescribed an antibiotic. Her mother understands that her daughter should take the prescribed medication twice a day. After carefully studying the label on the bottle and deciding that it doesn’t tell her how to take the medicine, she fills a teaspoon and pours the antibiotic into her daughter’s painful ear.

21. Example…..cont. • The doctor may very well have told the patient’s mother than the medication should be taken orally, but the mother may not have understood what this meant and may have been too intimidated to ask. • In fact, “oral” appears on the following list of medical terms that patients may not understand and their translations into plain language.

22. Medical Term Analgesic Anti-Inflammatory Benign Carcinoma Cardiac Problem Cellulites Contraception Enlarge Health Failure Hypertension Infertility Lateral Lipids Menopause Menses Monitor Oral Osteoporosis Terminal Toxic Translation into Plain English Pain Killer Lessens swelling & irritation Not cancer Cancer Heart problem Skin infection Birth Control Get bigger Heart isn’t pumping hard enough High blood pressure Can’t get pregnant Outside Fat in the blood Stopping periods, change of life Period Keep track of, keep an eye on By mouth Soft, brittle bones Going to die Poisonous List published by the AMA Foundation. This list is not comprehensive but can serve as a reminder that common medical terms can be confusing for the average American. Note: An English-Spanish Dictionary of Health Related Terms, 3rd Edition, July 2005, is available on the MLC website at www.medicalleadership.org

23. Health Literacy & Informed Consent • Lack of informed consent is a frequent secondary allegation in medical professional liability claims • A patient alleges that he or she was not aware of a particular risk or side effect • For example, a vaginal birth after cesarean (VBAC) patient may allege that she was not aware that her uterus could rupture (or that she didn’t know what the term VBAC means) • A patient on a long-term medication may allege that he was not aware he could develop liver toxicity from taking that medication. • From a risk management perspective, the informed consent discussion is crucial to defending a physician. The discussion, though, serves no purpose if patients cannot comprehend what is being said.

24. Identifying and Addressing Low Health Literacy • Test for health literacy when taking vital signs • Literacy test available in both English and Spanish that is designed to quickly assess literacy without disrupting patient scheduling. www.newestvitalsign.org • Can be administered by a medical assistant while taking other vital signs. • Test based on the patient reading an ice cream label. Patient is asked to determine total calorie count and whether or not a person with a peanut allergy could eat the ice cream based on ingredients. • Although simple, the test can identify whether or not the patient can read, do simple math (important for calculating doses for medicine) and use abstract reasoning.

25. 6 Steps to Improve Communication with Patients Whose Health Literacy is Limited • Speak slowly & spend a small amount of additional time with each patient. • Use plain, non-medical language. • Show or draw pictures, which can improve the patient’s recall of ideas. • Limit the amount of information provided to pertinent tasks at hand. Repeat the information to enhance recall. • Confirm the patient’s comprehension by asking them to repeat back your instructions. • Create an intimidation-free environment by making patients feel comfortable asking questions. Enlist the aid of others (interpreters, patient’s family, friends) to promote understanding.

26. Developing Plain-Language Educational Materials • Visual materials can support effective communications. • Experts have noted that “when reading messages, readers look at the visual first, the caption second, and the text last.” • Research has shown that for patient health care instructions, visuals can increase patient understanding, and compliance.

27. CA Standards for Healthcare Interpreters • Confidentiality: Interpreters treat all information learned during interpreting as confidential. • Impartiality: Interpreters are aware of the need to identify any potential or actual conflicts of interest, as well as any personal judgments, values, beliefs or opinions that may lead to preferential behavior or bias affecting the quality and accuracy of the interpreting performance.

28. Respect for Individuals and Their Communities: Interpreters strive to support mutually respectful relationships between all three parties in the interaction (patient, doctor, interpreter), while supporting the health and well-being of the patient as the highest priority of all health professionals. • Professionalism and Integrity: Interpreters conduct themselves in a manner consistent with the professional standards and ethical principles of the health care interpreting profession. • Accuracy & completeness: Interpreters transmit the content, spirit and cultural context of the original message into the target language, making it possible for patient and provider to communicate effectively.

29. Cultural Responsiveness: Interpreters seek to understand how diversity and cultural similarities and differences have a fundamental impact on the health care encounter. Interpreters play a critical role in identifying cultural issues and considering how and when to move to a cultural clarifier roles. Becoming culturally sensitive and culturally responsive is a life-long process that begins with an introspective look at oneself.

30. Three-Way Partnership • Recognizes the three unique relationships in an interpreting encounter and the expertise of each party. • Relationship 1: Patient-Doctor • Relationship 2: Doctor-Interpreter • Relationship 3: Interpreter-Patient • Primary Relationship: Patient-Doctor • In most situations, interpreters support and reinforce the primary relationship between the patient and the provider 2) Doctor 1) Patient 3) Interpreter

31. Patient Privacy • Interpreters treat all information learned during the interpreting as confidential. • Advise all parties that they will respect the confidentiality of the patient/doctor interaction • Advise all parties in the interpreting session to refrain from saying anything they do not wish to be interpreted • Decline to convey to Doctors any information about the patient gained in a community context (Note: in cases where the interpreters are privy to information regarding suicidal/homicidal intent, child/senior abuse, or domestic violence, interpreters act on the moral, if not legal, obligation to transmit such information to the provider, in keeping with institutional policies, interpreting standards of practice and code of ethics and the law. • Decline to convey to patient any personal information about the doctor

32. HIPAA • Protects health information in oral, written or electronic form. • Defines when patient information can and cannot be used and disclosed without patient authorization. • In general, patient authorization is required to released protected health information except for purposes of treatment, payment, and health care operations (e.g. quality improvement, audits, training of health care professionals) and when legally required to do so.

33. Protecting Patient Confidentiality for Interpreters in Your Day-to-Day Work • DO safeguard written logs, schedules, or activity sheets that contain protected health information • DO look for private space or lower your voice when discussing protected health information • DO be aware that just leaving out a patient’s name may not be enough to protect the patient’s confidentiality. Other information may make it possible to identify the individual, even without the name

34. DO refer requests for protected health information back to the patient, doctor or other health care professionals or staff when possible. Avoid providing protected health information when the patient or others involved with the patients care can do so. • DO destroy or shred any documents (such as notes taken during the medical visit) that contain protected health information before throwing them away • DON’T share protected health information with anyone unless it is needed to do your job or their job.

35. DON’T share more information than is necessary for you or others to do your jobs. • DON’T access patient information unless you need it to do you job. • DON’T send email containing protected health information unless it is encrypted.

36. Additional Resources • Medical Leadership Council Web site www.medicalleadership.org • Patient Education Materials in multiple languages • Language Access Database • CA County-specific contact information for interpreters and county-specific, statewide and national listings for organizations and web sites providing services in languages other than English • Educational Tools • English-Spanish Dictionary of Health Related Terms • “Practice Assessment for Health Care Professionals” – each participant receives a free copy

38. The Body (El Cuerpo)