Linguistic Access Study of Health Care Services in San Mateo County

1. Linguistic Access Study of Health Care Services in San Mateo County SUMMARY OF FINDINGS AND RECOMMENDATIONS 7/21/06 Presented by: Brightstar Ohlson Associate, Gibson & Associates

2. Background • The Linguistic Access Study emerged out of the Healthy Communities Summit of 2004 to eliminate health disparities. • The Health Department spearheaded the study and contracted with Gibson & Associates to conduct the research and evaluation efforts. A steering committee was also formed to guide this process. • Research activities were conducted by Gibson & Associates and Health Department staff from October, 2005 to June, 2006.

3. What is linguistic access to healthcare? • Linguistic access refers to the ability of clients who don’t speak English well or at all to receive adequate health care services. • Improving linguistic access is about improving the overall health of immigrant communities.

4. Key Terms in Linguistic Access • Limited English Proficient (LEP) • Limited English Proficient is a term used by the Census. • The Census asks residents if they speak a language other than English and how well they speak English. Residents can choose: • Very Well • Well • Not well • Not at all • The Census classifies those who speak English not well or not at all as Limited English Proficient or LEP

5. Key Terms in Linguistic Access • Language Assistance Services refers to translation services, interpreter services and services rendered by bilingual staff, as well as any other practice or policy that facilitates linguistic access to healthcare. • Translation refers to written materials only. • Interpretation refers to the oral process of converting a message in one language to another language. • Oral Language Services encompasses the use of resources such as bilingual employees and staff, as well as interpreter services.

6. Why does linguistic access matter? • Linguistic barriers can limit prevent clients from seeking care and result in preventable emergency room visits. As one Latino resident stated, • “This friend of my mother’s, she was very sick and did not have any family who was able to take her. They couldn’t get the time off. I finally ended up taking her to the emergency room and tried to interpret for her. But, I didn’t know what they were saying. She was hospitalized and finally after three days a nurse who spoke Spanish came and explained to her that she had all of these problems. It took three days.” • Linguistic barriers can also result in misdiagnosis and improper treatment for LEP clients.

7. Why does linguistic access matter? • Linguistic barriers can keep LEP clients from accessing services. As one Chinese resident commented, • “We really hope that we never get sick because at the hospital there is no one that speaks Chinese there. People go to San Francisco and buy herbs and see a Chinese doctor in Chinatown. Or, if you are very ill, you consider going back to China for treatment.”

8. Why does linguistic access matter? • Health care organizations with high levels of linguistic access have high patient satisfaction levels. • Health care organizations will need to adapt to the changing demographics and increases in immigrant populations in the County and across California. • Federal fund recipients are required to provide free language assistance services to LEP clients.

9. Goals of the Linguistic Access Study • Examine current services and determine the degree to which San Mateo County health care organizations render adequate language assistance services • Identify service gaps • Establish a baseline against which to measure future improvement efforts • Make recommendations to reduce linguistic barriers to care • The study focused on the overall level of linguistic access available to LEP clients across the County, not on the specific policies or practices of individual organizations or programs.

10. Best Practices in Linguistic Access to Health Care • Research on best practices in linguistic access to healthcare was one of the first steps in the Linguistic Access Study. • This research is summarized in the Summary of Model Programs and Promising Practices in Linguistic Access. • The best practice research summary informed the content of each of our data collection tools. • It also served as a rubric against which to measure the policies, practices, and procedures in place at health care organizations across the County.

11. Linguistic Access to Health Care: Best Practices • The review of best practices in linguistic access found that several key factors influence an organization’s level of linguistic access. • An expressed organizational commitment to improving the health of immigrant communities. • Positive relationships with immigrant communities, including relationships with community leaders and organizations and a client friendly organizational culture.

12. Linguistic Access to Health Care: Best Practices • Adequate level of language assistance services, including a sufficient number of bilingual staff and providers to meet client need. • Written policies and procedures on the provision of linguistically appropriate services. • Clear procedures for accessing and using language assistance services • Appropriate training and on-going program monitoring related to language assistance services. • Time and resources dedicated to quality improvement and planning around cultural and linguistic access

13. Methods • In this study, we sought to answer the following questions: • What are the linguistic barriers to care for LEP clients in the County? Does linguistic access to health care services vary significantly by ethnic group, organization type, or region? • What is the linguistic capacity of health care organizations across the County? What policies, procedures and practices are in place to promote linguistic access to healthcare? • What types of language assistance services are available, and to whom? What is the overall quality of language assistance services and how consistently are they used?

14. Data Collection • Managers, staff, and clients from over 50 county and community-based health care organizations and programs from all regions of the County participated in the Linguistic Access Study. • More than 150 clients, residents, and advocates from six LEP communities in the county also shared their perspectives. • Research included a program manager survey, staff survey, client focus groups, and interviews with community leaders.

15. Data Collection • The findings from each of these measures were analyzed by Gibson & Associates staff. At the end of July, the following reports will be available for your review at: http://www.smhealth.org/hppp • Linguistic Access Study: Summary of Findings and Recommendations • Summary of Promising Programs and Model Practices in Linguistic Access • Client and Community Input: Findings and Recommendations • Program Manager Survey: Findings and Recommendations • Staff Survey: Findings and Recommendations

16. Data Collection • The findings and recommendations are reported as follows: • LEP Residents in San Mateo County • Findings: Accessibility of Services • Findings: Policies • Findings: Language Assistance Services • Recommendations • Conclusion

17. Linguistic Access Study: Limited English Proficient (LEP) Residents in San Mateo County • More than 30 languages are spoken in communities across San Mateo County. • According to the Census: • 38% of the population speaks a language other than English. • A quarter of those who speak a language other than English are limited English proficient. • The predominant languages spoken by LEP residents in San Mateo County and included in the study are: • Spanish • Chinese • Tagalog • Russian and Tongan were identified by many program managers and community leaders as important languages to include in the study.

18. Linguistic Access Study: Limited English Proficient (LEP) Residents in San Mateo County • LEP Speakers by Language Group in San Mateo County • Source: U.S. Department of Labor. 2000 Census special tabulation on Limited English Proficient Adults • *Census reports information on Pacific Islander languages as one group.

19. Key Findings on Accessibility of Services 1. Among the LEP groups included in the study, linguistic access to healthcare services was highest for Latino and Filipino residents and lowest for Chinese, Tongan, and Russian residents. • “Everyone comes to this clinic. Here the staff is very helpful, they all speak Spanish. They are always willing to work with you, explain things, and get you the help you need.” • Latinos reported more systemic barriers to care such as lack of insurance, transportation, and long wait times than other groups.

20. Key Findings on Accessibility of Services • Chinese, Tongan, and Russian clients reported low levels of linguistic access. While many receive care from a primary care doctor fluent in their language, they experience language barriers at hospitals, specialty clinics, and pharmacies. As one Russian client noted, • “We Russians all see the same doctor, who speaks Russian. It is at the hospital that we have problems because there is no one who speaks Russian to help. We sometimes call our family member from the exam room so they can interpret for us.” • Some Chinese clients who are LEP seek care outside San Mateo County, in San Francisco or Santa Clara because of a lack of healthcare services in their language.

21. Key Findings on Accessibility of Services 2. Social and economic factors, as well as systemic barriers confound linguistic barriers to care in many communities. • Social and economic factors, as well as systemic barriers to care compound many linguistic barriers, especially for Latino and Tongan clients, as well as recent immigrants from all language groups. • Lack of insurance and the high cost of care deter many from seeking care. • The geographic accessibility of services, especially for those residing in the northern region of the County, and lack of transportation are additional barriers.

22. Key Findings on Accessibility of Services • Long wait-times, poor customer service, and alienating interactions with staff deter some LEP clients from returning for care. As one client noted, • “The Latina receptionist there can be rude- like they don’t want to help you and like you are a bother to them. So, you just don’t want to come in. But, they never answer the phones, so you have to come in, even to get an appointment.” • Cultural factors and lack of understanding of non-Western concepts of health, illness, and treatment on the part of providers and staff are also barriers.

23. Key Findings on Accessibility of Services 3. While some health care organizations in the County have high levels of linguistic access, many have insufficient levels. • Small to mid-size clinics, programs and individual provider offices that focus on the health care needs of a single ethnic group (primarily Latinos) have the highest levels of linguistic access. • Access is highest in primary care settings and lower in specialty clinics, hospitals, and urgent care settings.

24. Key Findings on Accessibility of Services • Many health care organizations have the linguistic capacity to meet the language needs of Spanish and Tagalog-speaking clients, but are not adequately equipped to handle the language needs of LEP clients from the Chinese, Tongan, and Russian communities. As one staff member noted, • “If we have a Spanish speaking client, we just pull the receptionist in. But, we sometimes get Chinese clients and we tell them that they need to bring their own translator.” • Several large health care organizations are actively engaged in efforts to improve linguistic access to health care.

25. Key Findings on Accessibility of Services • Key factors include: • Number of bilingual staff • Organizational commitment to serving immigrant communities • Diversity of clientele • Organizational culture • Size • Services offered

26. Policies on the Provision of Linguistically Appropriate Services: Best Practices • Policies can codify an organization’s commitment to serving LEP clients. • They ensure consistent provision of services over time. • Health care organizations should have written policies on the provision of linguistically appropriate services.

27. Policies on the Provision of Linguistically Appropriate Services: Best Practices • Model policies address the following areas: • Notification of right to free interpreter services for LEP clients • Data collection procedures on language backgrounds and abilities of all clients. • Acceptable and preferred methods to deliver oral language services, including guidelines for contracting and using an interpreter • Translation services, including procedures for arranging for and ensuring high quality translation. • Training and program monitoring requirements for language assistance services.

28. Key Findings: Policies 1. Most organizations in the County lack written policies on the provision of services to LEP clients. Others are incomplete or require updating. • Most programs and organizations that participated do not have written policies. • Several organizations have policies on the provision of linguistically appropriate services to LEP clients or are in the process of creating them. • Many staff and managers were unfamiliar with their organization’s policies. Policies were not consistently implemented at many organizations. • Among those lacking policies, many had informal and ad-hoc policies and procedures related to language assistance services.

29. Key Findings: Policies • At one large clinic, we spoke with staff about how they serve clients who don’t speak English. The manager informed us that bilingual staff or telephonic interpreter services were used. However, providers and administrative staff told us separately that they usually told clients to bring a family member or a friend to interpret. They also reported that they rarely called bilingual staff in because they were busy with other duties.

30. Language Assistance Services: Best Practices • Language assistance services include translation and oral language services, as well as any policy or practice that facilitates linguistic access to health care. • Model Practices in Translation • A formal process for completing translation, including guidelines for contracting with a translation service or a bilingual employee. • Training in grammatically correct, as well as culturally and literacy-level appropriate translation for bilingual staff. • Procedures for reviewing and revising translated documents

31. Language Assistance Services: Best Practices • Model Practices in Oral Language Services • Bilingual staffing in a range of positions, including administrative and support, providers, and managers • Interpreter services, including telephonic, remote video, in-house, contract, or an interpreter pool. • Clear procedures for securing an interpreter, including a list of situations requiring an interpreter. • On-going documentation and monitoring of the use of interpreter services • A formal role for bilingual staff members who are expected to provide interpretation, with appropriate training. • Minimal reliance on family and friends to provide interpretation

32. Key Findings: Language Assistance Services • Health care organizations across the county rely overwhelmingly on bilingual staff to deliver language assistance service. • Most organizations use bilingual staff and providers, instead of contractors, to provide oral language services and translation services. • There are shortages of bilingual pharmacists and licensed providers across the county in Spanish, Tagalog, Chinese, and Tongan. As one manager explained, “We are very committed to hiring bilingual staff here. It is the best way to serve our clients. However, we have had positions remain open for months because we wanted a bilingual candidate. This is especially so for dieticians and providers.”

33. Key Findings: Language Assistance Services • Most bilingual staff members speak Spanish and occupy administrative and support positions, followed by licensed provider positions. A few occupy management positions. • The role of bilingual staff is informal, with little training, monitoring, and time dedicated to translation and interpretation duties. • Bilingual administrative and support staff play an important role in facilitating linguistic access, as they are the first point of contact for LEP clients. As one provider noted, “The receptionist is the one who usually figures out if they don’t speak English when they call to make an appointment. If they speak a language that we can’t cover, she will tell them to bring a friend. If they don’t and come in, they may have to reschedule.”

34. Key Findings: Language Assistance Services • Training, program monitoring, planning, and evaluation activities related to language assistance services are not in place at many organizations. • Few organizations have a formal process for determining whether documents, programs, activities, or services need to be added, reduced, or modified to improve service to LEP clients. • Few organizations trouble-shoot internal barriers to using language assistance services.

35. Key Findings: Language Assistance Services • A wide range of translated materials is available to Spanish speakers, but less frequently to speakers of other languages. • Signs, medication instruction, benefit information, and health education materials are available in Spanish at most organizations. • Materials are less consistently available in Tongan, Tagalog, Chinese and Russian. • Some Latino clients preferred to receive information through radio, TV, classes, and workshops. • Written notification of a client’s right to an interpreter was not observed in any language at most sites.

36. Key Findings: Language Assistance Services • Many translated materials were not appropriate to the culture and literacy-level of LEP clients. However, some organizations have implemented procedures to address the needs of low-literacy clients. • Some materials reflected high quality translations, with correct grammar, large print, non-literal translations, and many visual images. • Many observed materials were literal translations, text heavy, and written in a small font in academic language. • Some contained images that may be deemed culturally inappropriate by some clients.

37. Key Findings: Language Assistance Services • Several organizations have implemented procedures to address the needs of low-literacy clients. Several large organizations use an oral, rather than written intake process. • As small clinics, front office staff routinely assists clients with the completion of forms. • In one clinic, managers have worked to obtain medication instructions in Spanish with drawings and symbols instead of extensive written instructions.

38. Key Findings: Language Assistance Services • At large health-care organizations, oral language services are not consistently available or used at enough points of service. • Several health care organizations, primarily those serving Spanish-speaking client, have 100% bilingual staffing. • While many organizations do an adequate job at meeting the oral language needs of Spanish-speaking clients in primary care settings, there are insufficient oral language services for speakers of Chinese, Tongan, and other less commonly served languages. As one Chinese client explained, “I will wait until my son can come down from Sacramento because there is no use in going to the clinic without him. There is no one who speaks Chinese there and it will be a waste of time.” • Oral language services are not consistently available or accessed at many health care organizations, especially in urgent care, specialty clinics, and hospital settings.

39. Key Findings: Language Assistance Services • Use of interpreter services is an informal arrangement in many settings. • Organizations often rely on family and friends to provide interpretation. • Most staff members were unfamiliar with the situations requiring an interpreter. • Clients were highly satisfied with formal interpreter services, such as telephonic, remote video, and in-person interpretation and less satisfied with interpretation performed by bilingual administrative and support staff.

40. Key Findings: Language Assistance Services • Several organizations have implemented new technologies, such as remote video conferencing, interpreter trainings, and interpreter poolsto improve the use and quality of interpreter services. • One organization formed an interpreter pool of all its bilingual employees, created an interpreter phone book, provided interpreter trainings to bilingual employees and posted notices throughout their building highlighting the availability of interpreter services in almost twenty languages. • Another large organization has recently adopted remote video conferencing technology and has noted a dramatic increase in the use of interpreter services in the few months the technology has been in use. One very satisfied client stated, “At the hospital I did use the interpreter where they come on the TV. It was very good. I liked it very much and was very grateful to be able to understand what the doctor was saying.”

41. Recommendations: Linguistic Access Study • Conduct a self-assessment of linguistic access at an organizational level and develop a plan to improve linguistic access for a wider range of LEP clients. • The assessment should determine the level and quality of language assistance services available to LEP clients from each language group. • Determine practices related to notification of the right to free interpreter services, the use of family and friends to provide interpretation, and provision of interpreter services, as outlined in the best practice summary.

42. Recommendations: Linguistic Access Study • Conduct an internal review of translated materials by bilingual employees and clients to assess for clarity and quality. • Review census and utilization data to identify service gaps and needs for expanded services. • A plan to improve access to care for a wider range of LEP communities and at more points of service should be developed by large health care organizations and programs.

43. Recommendations: Linguistic Access Study • Create or update policies on the provision of linguistically appropriate services, train staff on policies, and monitor their implementation. • Review key provisions outline in the best practice research summary. • Ensure that policies comply with legal guidelines from the Office of Civil Rights.

44. Recommendations: Linguistic Access Study • Implement and expand training and on-going monitoring at an organizational level. • Upon creating new policies, procedures, and programs, monitoring systems should be put in place. • Standards, performance measures, and evaluation activities to track progress and trouble shoot internal barriers to improving linguistic access should be implemented.

45. Recommendations: Linguistic Access Study • Staff needs trainings and workshops to increase knowledge of linguistic barriers and to learn organizational policies and procedures.

46. Recommendations: Linguistic Access Study • Expand interpreter services and availability of translated materials to a wider range of languages and settings. • Determine the extent to which oral language services and translated materials are available to LEP clients from diverse language groups. • Larger health care organizations, hospitals, and HMOs should ensure that telephonic, remote video conferencing, or in-person interpretation options are available and consistently used at all points of service.

47. Recommendations: Linguistic Access Study • Reduce reliance on family and friends to provide interpretation by educating staff about the complications associated with this practice. • Expand the availability of written materials in Tongan, Chinese, Tagalog, and Russian clients.

48. Recommendations: Linguistic Access Study • Formalize role of bilingual staff members who perform interpretation and translation and provide appropriate training in these activities. • Continue to train bilingual staff in interpretation and consider offering bilingual staff courses in culturally and literacy-level appropriate translation and/or language courses.

49. Recommendations: Linguistic Access Study • Update job descriptions of bilingual employees to include interpretation and translation responsibilities and evaluate performance of these activities annually. • Formalize interagency sharing of bilingual staff by forming an interpreter pool, creating a directory, and providing interpreter trainings.

50. Conclusion • Over 150 clients, residents and community leaders from immigrant communities and over 400 managers, providers and staff from county and community-based organizations and programs shared their perspectives and experiences in the Linguistic Access Study. • We found promising practices and models of excellence in linguistic access at several healthcare organizations in the county. • We also identified several key areas on which to focus improvement efforts: • the consistency with which language assistance services are provided • organizational capacity to serve the language groups which represent smaller, but nonetheless significant segments of the LEP populations.