1 Cultural and Linguistic Services Training: SFHP Provider Network
2 Training Goals Define terms related to language access Learn how to work with interpreters Define culture, cultural competence, and cultural humility Learn how to address LGBT (lesbian, gay, bisexual, and transgender) communities Reflect on strategies for working with seniors and persons with disability
3 Terminology: What and Whom are We Discussing? Limited English Proficient (LEP) The term Limited English Proficient means that an individual cannot speak, read, write, or understand the English language at a level that permits him or her to interact effectively with clinical or non clinical staff in a health care setting. Language Access Services Language access services is the collective name for any service that helps an LEP patient obtain the same access to and understanding of health care as an English speaker would have. Language access services can include the use of bilingual staff and interpreters, as well as the provision of translated documents.
4 Terminology Interpreting* The process of understanding and analyzing a spoken or signed message and re expressing that message faithfully, accurately and objectively in another language, taking the cultural and social context into account. Translation* The conversion of a written text into a corresponding written text in a different language. NOTE: Interpreting and translation, when done well, both accurately capture the meaning of the original message. One is not more accurate than the other, or more faithful to the message. The primary difference is the source of that original message. *Excerpted from The Terminology of Health Care Interpreting: A Glossary of Terms published by The National Council on Interpreting in Health Care, downloadable FREE from their website at
5 Why is Linguistic Access Important? Accurate communication between patient and health care provider/health plan is essential for proper diagnosis, treatment, and patient compliance Helps reduce health disparities Is a quality of care issue Makes business sense Federal and state requirements
6 Asking about Language Preference How you ask a patient about his or her language will affect the response you get. Poor: You (or the patient) won t need an interpreter, will you? Asking the question this way discourages the patient, or the person who is making the appointment, from asking for the language assistance that he or she may need. Basic: What language do you (or the patient) speak at home? This question will get you information about the patient s home language, but ignores the possibility that the patient may be bilingual in English as well.
7 Asking about Language Preference Better: Will an interpreter be needed? In what language? This question may generate some information. But, patients may reply in the negative, believing that they have to either bring their own interpreter or have a family member interpret. Thus, you will not get an accurate record of how many LEP patients you are treating and from what language groups. BEST: In what language do you (or the person for whom you are making the appointment) prefer to receive your health care? Asking the question this way will provide you information on the language the patient feels he or she needs to speak in a health related conversation. If the answer is a language other than English, you can plan to have language assistance available for the patient, and you should add this information to the record.
8 Linguistic Access Helps Reduce Health Disparities Patients with language barriers experience: More outpatient drug complications. An increase in other medical problems and lower medication compliance. More likelihood of serious side effects More likelihood of unnecessary and invasive tests Grant Makers Health Issue Brief No. 18, August San Francisco, CA
9 Linguistic Access: Business Value Reduce medical errors Increase patient satisfaction Increase compliance Decrease costs for diagnostic testing Reduce unnecessary admissions More efficient member interactions Better community relations
10 Using Family Members, Friends or Minors as Interpreters May withhold information from patient from embarrassment, protection, emotional involvement Have their own agenda Children: parent disempowerment, role reversal Can cause guilt & trauma Serious mistakes
11 Tracking Language Preference It is important to record information on interpreter needs and language preference. Basic: Add a color or letter code to the patient s chart, noting that he or she needs an interpreter. Designate a code or color for each language. Better: Add the information under Notes in a patient s entry in your patient database, so that when a receptionist calls up the patient s record to make an appointment, the information about the need for an interpreter and the language can be noted as well. BEST: Add a question on your patient registration form or in your practice management system. Not only will you know when a patient is scheduled that he or she will need an interpreter, you will also be able to track how many patients you have who speak a particular language and how often they are seen.
12 Regulations Mandating Use of Interpreters for LEP Patients Federal Title VI of the Civil Rights Act of 1964 EMTALA Hill Burton Act Executive Order CMS State DMHC, SB853 DHCS (MediCal) Healthy Families, AIM Others JCAHO Note: This is not just an SFHP requirement!
13 SFHP Oversight Requirements of Medical Groups Notify members of their rights: Interpreter services at no charge when accessing health care Not use friends, family members or minors as interpreters unless specifically requested by the member Request face to face or telephone interpreter services Receive informing documents translated into threshold languages File grievances or complaints if linguistic needs are not met Notify PCPs of language member speaks Provide qualified interpreters/bilingual staff Train providers and office staff about linguistic access and cultural awareness
14 Working with Trained Interpreters, On Site Greet the patient first, not the interpreter. Face and talk to the patient directly. Speak at an even pace in relatively short segments. Speak in standard English and avoid medical terminology and jargon Ask one question at a time. Avoid interrupting the interpretation. Don t make assumptions about the patient s education level. An inability to speak English does not necessarily indicate a lack of education.
15 Working with Trained Interpreters over the Phone When working with an interpreter over a speakerphone or with dual head/handsets, many of the principles of on site interpreting apply. The only additional thing to remember is that the interpreter is blind to the visual cues in the room. When the interpreter comes onto the line let the interpreter know who you are, who else is in the room, what sort of office practice this is, what sort of appointment this is. For example, Hello interpreter, this is Dr. Jameson. I have Mrs. Dominguez and her adult daughter here for Mrs. Dominguez annual exam. Give the interpreter the opportunity to quickly introduce him/herself to the patient. If you point to a chart, a drawing, a body part or a piece of equipment, verbalize what you are pointing to as you do it.
16 What is Culture? Culture consists of a body of learned beliefs, traditions, and guides for behaving and interpreting behavior that is shared among members of a particular group, and that group members use to interpret their experiences of the world.
17 Cultural Awareness versus Cultural Competence Cultural awareness is being cognizant, observant, and conscious of similarities and differences among and between cultural groups. (National Center for Cultural Competence, Goode, 2001, 2006) Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in crosscultural situations.
18 What is Cultural Competence in Health Care? Recognition that people of different cultures have different ways of communicating, behaving, interpreting, and problem solving. Recognition that cultural beliefs impact patient s health beliefs, help seeking activities, interactions with health care professionals, health care practices, and health care outcomes, including adherence to prescribed regimens.
19 Cultural Influences Influences can be above or below the surface, seen and unseen.
20 Cultural Humility: An Ongoing Process Cultural humility: A commitment and active engagement in a lifelong process that individuals enter into on an ongoing basis with patients, communities, colleagues, and with themselves A process that requires humility in how we bring into check the power imbalances that exist in the dynamics of communication (Drs. Melanie Tervalon and Vivian Chavez)
21 SFHP Membership by Language SFHP Member Demographics SFHP Membership by Race/Ethnicity
22 California: Demographic Trends (California Department of Social Services) 1% California % 9% 15% 1% California % 7% 31% Caucasian Black Hispanic Asian Pacific Islander Native American 47% 6%
23 Caring for LGBT Communities Identify your own LGBT perceptions and biases as a first step in providing the best quality care Many LGBT people do not disclose our sexual orientation or gender identity because we don t feel comfortable or we fear receiving substandard care. Practice some helpful phrases: Do you have sex with men, women, or both? What pronoun do you prefer I use when referring to you? I m glad you shared that with me. I know that might have been difficult to tell me. Is there anything else in connection with your health care that I should know about?
24 Caring for LGBT Communities The California Department of Public Health maintains a list of helpful LGBT related resources: Homelessness LGBT Curricula in Schools Mental Health Legal Issues Affordable Care Act Census and LGBT Demographic Studies Drug and Alcohol Abuse Gender Identity Health Disparities HIV/AIDS
25 Caring for Seniors and Persons with Disabilities (SPDs) Meeting the individual accommodation needs of SPDs to the extent possible ensures the following: The practice provides appropriate and effective care Compliance with the federal Americans with Disabilities Act (ADA) and Section 504 of the 1973 Rehabilitation Act. The ADA and Section 504 require that healthcare services provide certain accommodations that ensure equitable and non discriminatory access to care. 70% of SFHP members with disabilities live with 2+ chronic conditions and 16% of these members have diabetes (compared with 7% in gen. pop.) About 25% have 4+ chronic conditions 30% of beneficiaries with disabilities receive treatment for mental health conditions annually
26 Accommodations: What Patients May Need Physical accessibility Effective communication Sign language interpreters, assistive listening devices, print materials in accessible formats Policy modification (for example, to allow more time for an office visit) Accessible medical equipment
27 Dimensions of Disability Disease/ Multiple Medications Visual Impairment Hearing Impairment Seniors/Persons with Disability Caregiver Burden Physical Impairment Cognitive Impairment/ Mental Health Adapted from US Dept of Health and Human Services, 2007
28 Examples of Preferred Terms Acceptable He had polio A person who uses a wheelchair She has a disability A person with a spinal curvature Offensive He was stricken with or a victim of polio Confined to a wheelchair, wheelchair bound She is crippled Hunchback, humpback
29 Questions? Need more info? Contact: Anna Le Mon or (415) for more information or resources
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