The Language of a Healthier Immigrant New York City

Transcription

1 The Language of a Healthier Immigrant New City Current Trends and Best Practices for Providing Language Assistance Services in New City Hospitals 2014

2 Acknowledgements The principal author or this report was NYIC s Director of Advocacy, Jackie Vimo, with contributions from Health Policy Fellow Erin Garcia. Research analysis was prepared by Paul Tainsh and the Center for New City Affairs, New School University. Surveys were conducted by Diana Araujo, Maha Attieh, Hyejung Choi, Debin Su, and Savana Hilaire. This report was made possible by a generous grant from the United Hospital Fund and the ongoing support of the New Community Trust. We are grateful to the following individuals from New City area hospitals for agreeing to participate in interviews for this research project: Elmhurst Hospital Center NYC Health and Hospitals Corporation Jacobi Medical Center Jamaica Hospital Medical Center Kings County Hospital Center Lincoln Medical and Mental Health Center Lutheran Medical Center New Hospital Queens Richmond University Medical Center SUNY Downstate Medical Center Jayne Maerker, Director of Volunteers; Glen Zuraw, Language Access Coordinator LaRay Brown, Senior Vice President, Corporate Planning, Community Health and Intergovernmental Relations; Caroline M. Jacobs Senior Vice President; Safety and Human Development; Matilde Roman, Senior Director, HHC Office of LEP/CLAS Joanne Grimes, Coordinating Manager, Patient Relations/Interpreter Services/Chaplaincy Relations/Interpreter Kelly Hoover, Language Assistance Program Coordinator; Alicia Martin, Administrator of Language Assistance Program; Bill Lynch, Chief Operating Officer Evgenia Lipkin, Assistant Director, LEP Services; Robert Berdin, Associate Executive Director, Regulatory Compliance/Risk Management Lucila Jimenez, Senior Associate Director, Network Language Assistance; Yvette Villanueva, Senior Associate Executive Director Virginia S. Tong, Vice President Cultural Competence; Husam K. Rimawi, MD; and Eiman Gheith, Patient Relations Representative Helen C. Lavas, MHA; Sr. Director & Chief Patient Experience Officer; Medina Kurtovic, Language Assistance/Patient Experience Coordinator Yolanda Jacobi, Language Coordinator Mary Ann Randazzo, Language Assistance Coordinator Finally, thanks to Moira Dolan (Assistant Director of DC 37's Research and Negotiations Department), Carol Pittman (Community Affairs Representative, New State Nurses Association), and Eric Candle (New State Chapter Chair, International Medical Interpreters Association) for providing labor perspectives for this study. i

3 CONTENTS I. Executive Summary a. Key Finding b. Best Practices c. Policy Recommendations II. Introduction III. Limited English Proficient Populations in New City IV. Study Methodology V. Analysis, Policy Recommendations and Best Practices VI. VII. Conclusion Appendix a. Observation/Walk- Through Scorecard b. Consumer Survey Tool c. Hospital Administrator Interview Questions d. Number of Surveys and Languages by Hospitals and Clinics e. Literature Review: Key Areas for Language Access Best Practices in Health Care Settings - Language Access Services and Health Outcomes for LEP Patients - Basic vs. Qualified Medical Interpreters - Dual Role Interpreters - Ad Hoc Interpreters, Family and Child Interpreters - Staff Diversity - Interpreter Certification and Training - The Role of the Physician: Language- concordance, Underutilization and False Fluency - Modalities of Interpretation - Medicaid Reimbursement for Language Assistance Services - Monitoring: Medical Records & Data Collection f. Legal Landscape of Hospital Language Access in New City - Legal Landscape: Federal, State, and City Hospital Language Access Laws - Joint Commission Accreditation Standards g. Medicaid/SCHIP Reimbursement for Language Assistance Services h. Examples of Successful Materials ii

4 I. Executive Summary Over 1.8 million residents of New City are limited English proficient (LEP), meaning they do not speak, read, write, or understand English well enough to communicate effectively with health care providers about sensitive information regarding their health and well- being, or to understand their diagnosis and treatment. 1 After more than a decade of advocacy by the New Immigration Coalition (NYIC) and partner groups such as the New Lawyers for the Public Interest (NYLPI) and Make the Road NY, in September of 2006 New State passed the Hospital Language Assistance Law, a new set of communication regulations for all private and public hospitals statewide. These regulations were intended to improve LEP patients access to health care and protect them from medical harm that can arise due to communication issues at area hospitals. We are well past the five- year mark of the passage of this important legislation. The good news is that this law has already led to a dramatic improvement in language access to health services citywide. 2 Unfortunately, NYIC s nearly 200 member groups statewide are finding that, despite these important regulations, LEP patients are often still left to rely on family members, untrained interpreters, or no interpretation at all. The lack of language assistance services can result in serious problems with diagnosis and treatment, in accessing health services, and in unwarranted medical bills. In the most severe cases, denial of language access services can result in tragic medical consequences, including the loss of life. As such, the provision of quality language assistance services is a vital necessity for complying with state, local and federal laws, for avoiding costly litigation, and for providing the best possible care for LEP patients. This project seeks to assess the status of implementation of language assistance laws and regulations in New City hospitals and to learn about best practices at exemplary hospitals. By conducting in- depth studies of a sampling of hospitals in different boroughs, we have developed a set of best existing practices for the provision of language access at hospitals and recommendations for state and local policies to improve LEP health care. These recommendations include: standardizing certification, testing and training for medical interpreters, developing qualified volunteer pools to provide medical interpretation, increasing public funding for hospital language access services, and utilizing a combination of modalities, including in- person/face- to- face interpreters and telephonic interpretation, in addition to considering new remote interpretation technologies. By adopting these policies and best practices, New can improve LEP access to city hospitals, thereby improving health outcomes for immigrant New ers and creating a healthier New. 1 U.S. Census Bureau, 2010 American Community Survey- Public Use Microdata Sample & Population Division- New City Department of City Planning 2 Hospital Communication Monitoring Report. Make the Road NY, NYIC and KC. April

5 Study Goals and Methodology The NYIC worked with the Center for New City Affairs at the New School University to design and execute a study that employed a combination of qualitative and quantitative methods observations and survey data. The survey examined 13 hospitals and clinics, both public and private, across the boroughs of New City. Surveys were conducted in five languages: Spanish, Korean, Mandarin, Haitian- Creole and Arabic. Surveys included the following components: Walk through/observation check- list: Survey takers conducted walk- throughs of the entrances, waiting areas, and emergency rooms at each facility and observed: visible signage and materials in languages other than English; notification of the availability of free language assistance services; and how reception and security staff responded to requests for interpretation. Consumer/patient survey instrument: Survey- takers conducted surveys in five languages at hospitals citywide as patients were exiting surveyed facilities after hospital and clinic visits. Survey participants were offered a $5 MetroCard as compensation for participating in the study. Structured Interviews: NYIC conducted in- depth, structured interviews with hospital administrators and staff responsible for overseeing language access at each facility. Interviews with Front- Line Staff: Front- line staff who interact directly with patients were also interviewed about their experiences with language services. 2

6 Key Findings Hospitals and clinics are doing a BETTER JOB of INFORMING PATIENTS ABOUT FREE LANGUAGE SERVICES and posting signage in languages other than English. Of patients surveyed, 65% were informed that free language assistance services were available, compared to 8% in 2004 and 33% in All but one hospital surveyed had visible signs in other languages than English at entrance of clinics, reception desks or waiting rooms. Patients are more informed about the availability of free language services, with 65.7% reporting that they were aware of free language services before they entered hospital/clinic. TELEPHONIC interpretation interpreting is the most common modality of interpretation, universally utilized by all hospitals. Only ONE hospital surveyed responded to request for interpretation by asking patient to BRING IN A FAMILY MEMBER. Most hospitals DO NOT employ FULL or PART- TIME MEDICAL INTERPRETERS. The three hospitals that did employ staff medical interpreters employed between 2 and 3 full- time interpreters, all of whom were qualified to interpret only in Spanish. Hospitals continue to utilize AD HOC (untrained individuals whose language skills had not been assessed - strangers, family members) or UNQUALIFIED DUAL- ROLE INTERPRETERS (bilingual staff whose primary job is not interpretation and who are not trained in medical interpretation, including medical terminology), despite the fact that they are not equipped to perform medical interpretation and that their errors can lead to negative health outcomes, civil rights violations and malpractice suits. DUAL- ROLE INTERPRETERS (even those who are qualified or trained as to be consistent with the point right above) are NOT COMPENSATED for the interpretation services they provide outside of their job descriptions, leading to frustration among bilingual hospital staff required to provide language assistance services. TRANSLATED MATERIALS and FORMS are NOT WIDELY ACCESSIBLE to patients, even if they are available to staff. Only half (51.5%) of those surveyed received forms in languages in their preferred language or had the forms translated for them. 3

7 Hospitals do NOT utilize CONSISTENT TRAINING, TESTING AND CERTIFICATION METHODS for interpreters; in some cases, individuals performing interpretation are only required to self- attest to their language abilities. All hospitals surveyed cited COST as the PRIMARY BARRIER to improving language assistance services and almost all hospitals in the study would hire full- time interpreters if they received additional financial support for language assistance services. While the recent state policy change allowing Medicaid reimbursement for the provision of language assistance services is a great step forward, the current reimbursement rates are insufficient to cover the costs of providing language services. Hospitals and clinics are adopting INNOVATIVE PRACTICES to provide language access, such as: Using VISUAL COMMUNICATION CUE CARDS with visual information such as images to represent key concepts that LEP and low- literacy patients can point to in order to communicate with non- medical hospital staff who do not speak their preferred language. Employing VOLUNTEERS to serve as interpreters by offering to train them or pay for their certification tests in exchange for a commitment to volunteer a certain amount of hours; Giving interpreters special COLORED T- SHIRTS MARKED INTERPRETER to designate qualified medical interpreters on hospital and clinic floors. Creating SPECIALTY CLINICS FOR TARGET POPULATIONS such as the Medina Clinic for West African patients and Lutheran s Chinese specialty clinic. Developing PUBLIC SERVICE ANNOUNCEMENTS in multiple languages to show in hospital waiting areas to inform patients about the availability of interpretation and other services. 4

8 BEST PRACTICES A. MODALITIES OF INTERPRETATION Hospitals should have access to a broad array of language assistance tools, ranging from in- person to telephonic and video interpretation to meet the diverse needs of their patient populations. Hospitals should explore using new technologies, such as remote video interpretation, which provide more flexible, mobile, and cost- effective solutions to interpretation and which capture visual information lost through telephonic communication. B. HUMAN RESOURCES Staff members who provide interpretation should be classified as such and provided with appropriate compensation. Dual- role interpreters should be given additional compensation for interpretation obligations. City employees who perform interpretation should be classified as interpreters according to the same system by which court interpreters are classified with corresponding salary and benefit requirements. Hospitals should hire full- time dedicated interpreters that speak the top patient languages spoken. If the language composition of the patient population fluctuates, these interpreters could be reassigned to other hospitals. Human resources departments should include language proficiency requirements in hiring staff that work directly with patients to ensure the staff composition reflects the demographics of the patient population. Hospitals should consider adopting existing models of a hospital interpreter cooperative hospital. Language proficiency testing should apply to all staff, including clinicians, who self declare fluency in a language and interact with patients in that language, even if not in a formal interpreting capacity. C. CERTIFICATION, TRAINING AND TESTING Hospitals should require that all staff members who conduct medical interpretation receive program certification through one of the two national processes available or have successfully completed a training program such as those offered by the Immigrant Health and Cancer Disparities Service for Memorial Sloan Kettering Cancer Center (formerly the Center for Immigrant Health at the New University School of Medicine) and CUNY Healthcare Interpreter Certificate Program. New should also follow California s example and establish a statewide certification for medical interpreters, as exists for court interpreters, and follow standards of practice for interpretation in a hospital setting, such as NCIHC National Standards of Practice for Interpreters in Health Care. 3 All interpreters should be tested for language proficiency upon hire with a recognized testing tool and should be retested every two years

9 Staff members who are nationally certified interpreters or interpreters who have successfully completed a training program should be clearly identified by wearing a particular color uniform or identifying badge that indicates their qualifications to provide interpretation and in what languages. D. IMMIGRANT- TARGETED CLINICS vs. NO WRONG DOOR Hospitals may consider creating specialty clinics targeting particular immigrant populations to address emerging community needs. Apart from specialized services, all health care facilities should adopt a No Wrong Door policy, whereby multiple agencies retain responsibility for their respective services while coordinating with each other to integrate access to those services through a single, standardized entry process that is administered and overseen by a coordinating entity. 4 Immigrants should be able to access care at any facility in New City. E. MATERIALS & SIGNAGE: Materials should be translated professionally and be targeted to low- literacy populations. Translations should also field tested by target communities. Facilities should be sure that translated signage and information about the availability of language assistance services are easily visible. Translated materials should be prominently displayed in waiting rooms and other high- traffic areas. Hospitals should create directories of providers who are qualified to provide services in languages other than English. Hospitals should consider running public service announcements in hospital waiting areas about patient rights to interpretation and financial assistance. F. DATA COLLECTION, MONITORING AND EVALUATION Hospitals should collect and note preferred language rather than primary language in patient records. Hospitals should craft intake questions carefully to accurately elicit preferred language for purposes of providing language assistance services. Hospitals should integrate their electronic information systems to ensure that records of preferred language are incorporated into scheduling programs to provide the proper coordination of interpretation services. Hospitals should not rely upon only one source of data to track and assess patient language needs. Hospitals should look to mixed data sources including interpretation services utilization (both in- person and telephonic records), Census and American Community Survey Data and feedback from patient surveys and community advisory boards. Hospitals should generate regular reports to assess the relationship between language spoken and a range of health outcomes to assess the provision of language services and the impact of language ability on outcomes and care. 4 Allison Armor- Garb, Point of Entry Systems for Long- Term Care: State Case Studies, prepared for the New City Department of Aging, Point_of_Entry_Systems_for_Long- Term_Care_State_Case_Studies.pdf 6

10 G. COMMUNITY AND PATIENT INPUT Hospitals should create specific community advisory boards that include particular immigrant populations/language groups or a general immigrant advisory board to solicit feedback about LEP/immigrant needs. 7

11 NYIC Hospital Language Access Recommendations and Best Practices to Improve Language Access in New City Hospitals POLICY RECOMMENDATIONS New should raise the Medicaid reimbursement rate for language assistance services from $11 (8-22 minutes) and $22 (flat rate for 23 or more minutes, with no maximum) to a reimbursement for interpretation services in line with national wage standards for interpreter services and should be reflective of salary differentials for New City. In addition, Medicaid should reimburse at higher rates for encounters over 23 minutes, since many face- to- face/in- person interpreting encounters are longer than 22 minutes in length. 5 Bureau of Labor Statistics (BLS) reports that nationwide the median annual salary is $43,300 for medical interpreters, or about $23/hour, without capping the fee after the first hour. 6 Nationally, other states reimburse at much higher rates, up to as high as $190/hour in the District of Columbia. 7 The State Legislature and the City Council should allocate funding to hire more full- time or part- time staff interpreters in New hospitals or to create a new pool of trained medical interpreters that could be deployed to different hospitals as needed; The state should develop a standard training curriculum or certify existing curricula for linguistic and cultural competency in a health care setting. Physicians should also be required to participate in cultural competency trainings, of which there are many modeled in cities across the US. The state and/or city should fund an interpreter training program, such as those offered at Memorial Sloan Kettering Cancer Center and CUNY, 8 which could assess and train a pool of interested existing staff members who could work as dual- role interpreters. Staff should be allowed to participate in these trainings at no cost and compensated for their time. Hospitals should identify potential staff interpreters and offer them incentives to be certified as medical interpreters to increase the pool of interpreters on staff. 5 Recommendation based on feedback from Wilma Alvarado Director, Community Engagement/Outreach, Center for the Elimination of Minority Health Disparities University at Albany, SUNY. correspondence, Tuesday, August 27, and- Communication/Interpreters- and- translators.htm 7 Youdelman, Mara. Medicaid and SCHIP Reimbursement Models for Language Services. NHeLP, March CUNY Healthcare Interpreter Certificate Program. interpreter/certificate- program.html. 8

12 II. Introduction For more than a decade, the New Immigration Coalition has been working with hospitals and health care providers providing training, consultation and feedback to help shape and implement language access policies. As such, the NYIC is in an excellent position to facilitate the sharing of best practices by hospitals and clinics for how they provide language access services, what challenges they face and how they have overcome these challenges and translated them into effective practices. The goal of the Language Assistance Best Practices project is to examine the language assistance services and practices of a sample of public and voluntary New City hospitals and community health care facilities serving Limited English Proficient (LEP) New ers across the boroughs. One year after the state s hospital language access regulation went into effect, the NYIC co- authored a study of language access services for Korean- and Spanish- speaking patients at ten New City hospitals. This 2008 study found that 78% of patients had received hospital- based interpretation, compared to 29% in the period between 2004 and However, only 31% of patients surveyed in 2008 were aware that they had a right to free language assistance services and not a single Korean- speaking patient signed a form in their native language. 10 Furthermore, there were great disparities between the language access provision at the city s public hospitals and voluntary hospital system, which lagged behind public hospitals in meeting LEP needs. One year after implementation, the 2008 report found that while great progress toward the equitable provision of health care for LEP New ers had been made, there was still room for improvement in city hospitals approaches to ensuring language access. 5 years after the implementation of the hospital assistance regulations is an opportune moment to evaluate the progress of implementation and the status of language assistance services for LEP patients in New City. Moreover, as services improve dramatically in some hospitals and clinics, NYIC hopes to share best practices from exemplary facilities so other facilities can replicate them. During 2012 and 2013, the Language Assistance Best Practices Project has collected information from hospitals and consumers in a sample of New City health care facilities on their efforts to meet the language assistance needs of LEP New ers. The goal of the project was to examine the language assistance services and practices of a sample of NYC hospitals and community health care facilities serving LEP immigrants and to document good language assistance practices for dissemination. To ensure a rigorous methodology, New Immigration Coalition partnered with the Center for New City Affairs to conduct field research and gather information from 9 Now We re Talking: A Study on Language Assistance Services at Ten New City Public and Private Hospitals. Korean Community Services, Make the Road NY, and the New Immigration Coalition. April Ibid 9

13 observations, surveys, and interviews on institutional compliance, policies, and practices, as well as consumer experiences with the health care system. This research has informed a set of best practices for language assistance to help city hospitals and clinics implement best practices/skills sharing and support changes in training and institutional policies. The New School s Center for New City Affairs worked with NYIC staff and the NYIC s Immigrant Health Access and Advocacy Collaborative (Health Collaborative), which brings together health advocates from NYIC s community- based member organizations (CBOs) and legal assistance partners to improve immigrants access to health care and health insurance through community education, capacity building and leadership development of CBOs and systemic advocacy. The Center, the NYIC Health Collaborative and NYIC staff collaborated to identify potential health care field sites, develop data collection instruments and protocols and support data collection activities. The Center developed a checklist and recording sheet for on- site assessments of language services provided by hospitals and structured interview questions and protocol for use in interviewing consumers, hospital administrators, physicians, and other key hospital staff. The fieldwork was performed by a combination of Collaborative members and graduate students fluent in five key language groups. The Center also provided training and support for the fieldwork to ensure the quality and consistency of the data that was collected. The results of the analysis indicate that many of the health care facilities have implemented effective practices, and that consumers are increasingly aware of their right to free language assistance while being generally positive about the language assistance they receive. Nonetheless, language assistance is not yet universal, nor is it uniformly available across or within facilities. This study points to some key areas for improvement. Ultimately, this report seeks to highlight some of the innovative and effective service provision at city hospitals and to offer recommendations for best practices for providing language access in a hospital or clinic setting. The task of providing quality language assistance services requires cooperation from both hospitals and policymakers. Hospitals should adopt the best practices recommended in this report. But in order for hospitals to be able to provide optimal language access services, the state and city must also do their part by overseeing certification of interpreters and providing adequate funding for training and full- time staff. The implementation of these best practices will provide a roadmap for the future of language assistance services statewide and a path toward a healthier state for all New ers, regardless of the languages they speak. 10

14 III. LEP Populations in New City In New City, nearly a quarter of the city s population (1.8 million) is Limited English Proficient (LEP). 11 Statewide, the number of LEP New ers has increased more than 40% since 1990, and the number has continued to rise over the last decade. 12 Nationally, New is the state with the third highest number of LEP residents. 13 Additionally, New City stands out nationally in terms of the diversity of languages spoken. In Texas, almost 90% of LEP residents speak Spanish, the top LEP state language. Meanwhile, only 50% of LEP New City residents speak Spanish, 14 and it has been estimated that New ers speak as many as 800 languages. 15 Citywide, the second most common language among LEP New ers is Chinese, spoken by 16% of the LEP population, with Russian next at 7%. 16 But the remaining 13% of LEP languages each represent 1% or less of the LEP language share. In other words, there are dozens of different languages spoken by at least 1000 New ers. This linguistic diversity adds another level of complexity to the already challenging task of meeting the language access needs of LEP New ers. In states like Texas, the 11 Selected Characteristics of the Native and Foreign- Born Populations American Community Survey 1- Year Estimates 12 Migration Policy Institute Fact Sheet, New : Language & Education. Accessed June Migration Policy Institute Fact Sheet, New : Language & Education. Accessed June Ibid 11

15 majority of the LEP population could be served by providing Spanish interpretation services; the magnitude of languages spoken in New means that there is no one- size- fits all approach to ensuring equal access to health care in New City. New s LEP health care landscape is further complicated by the regional linguistic diversity within New City. In the Bronx, 82% of LEPs speak Spanish; but Spanish- speakers represent only a third of Staten Island s LEPs. 17 Moreover, New City s linguistic terrain is constantly in flux, as changing migrant populations alter the city s vocabulary. For example, hospitals interviewed for this study reported emerging Bengali and Arabic patient populations at hospitals across the boroughs. Meanwhile, New s LEP population also faces challenges beyond English proficiency in the arena of health literacy. Inadequate health literacy and limited English proficiency are associated with poor health care access and outcomes, and the rate of inadequate health literacy is particularly high among LEP populations. 18 Accordingly, a comprehensive language access program for New s LEP population must also be sensitive to the needs of LEPs who face compounding literacy barriers. Finally, a recent analysis by the New City Health and Hospitals Corporation found the utilization of language assistance services increasing in New City. HHC s hospitals have witnessed a 22% increase in requests for over- the- phone interpreter services for LEP clients since In just two years, HHC s requests for telephonic interpretation increased from 563,000 to 700,000, with a corresponding increase in costs from $4.9 million to $6.7 million between 2010 and While an increase in access to hospital language assistance services for LEP New ers is a welcome development, we must ensure that facilities that provide appropriate care for LEP populations receive the financial support they require to meet the needs of their immigrant patient populations. 17 Ibid 18 Health literacy and the disenfranchised: the importance of collaboration between limited English proficiency and health literacy researchers. McKee MM, Paasche- Orlow MK. J Health Commun. 2012;17 Suppl 3:7-12. doi: / NYC Public Hospitals See Increased Demand for Language Services Among Non- English Speaking Patients: HHC responds to almost 700,000 requests for interpreter services; a 22 percent increase in two years. Press Release, NYC Health and Hospitals Corporation, June 14,

16 IV. STUDY METHODOLOGY This study of language assistance at New City Health care facilities employed a combination of qualitative and quantitative methods observations and survey data - - to better understand facility compliance with the law and to identify areas of promising practice. By using multiple data sources, the research project was able to gain perspective on the formal compliance with the minimal provisions of the New State law, as well as a basic understanding of the degree to which compliance has a positive impact on the consumers experience. Matching observed compliance with consumer comments provides an indication of the degree to which language access service provision permeates the institution and results in good practices. Site Selection The first research task was selection of the health care facilities participating in the research activities. The selection criterion included: 1) NYIC Health Collaborative member recommendation, 2) type of facility (hospital or community health center), 3) geographic representation, 4) public/ private affiliation, and, 5) participation in prior NYIC research on language assistance. At the May 25, 2012 meeting of the Health Collaborative, participants identified five hospitals serving Staten Island, Brooklyn, Queens and the Bronx with which they had relationships. The Center examined community and hospital demographic, geographic and utilization data to identify a diverse sample of hospital sites for the project, drawing from the collective knowledge of the member organizations of the Health Collaborative. A review of recent maps of New immigrant neighborhoods revealed a second set of hospitals and community health clinics that served these immigrant communities. A final group of hospitals was added to ensure broader geographic representation and to include facilities surveyed in earlier research, including Elmhurst Hospital and Jamaica Hospital Medical Center. 13

17 The chart below describes each of the facilities. a.) Research Site Characteristics Name of Facility Type of Facility Affiliation Communities Rationale New Hospital Queens Hospital Private Flushing, Queens Collaborative Member Jacobi Medical Center Hospital Public/HHC * Bronx Collaborative Member Richmond University Medical Center Hospital Private Staten Island Collaborative Member Lutheran Medical Center Hospital and Community Health Centers Private Bay Ridge, Sunset Park, Brooklyn Collaborative Member, types of facilities Kings County Hospital Center Hospital Public/HHC * Crown Heights, Flatbush, Brooklyn Collaborative Member Lincoln Medical Center Hospital Public/HHC * South Bronx Geographic representation SUNY Downstate Medical Center Hospital Public/SUNY Downstate Downtown Brooklyn Collaborative Member Jamaica Hospital Medical Center Hospital Private Jamaica, Queens Geographic representation Elmhurst Hospital Center * Health and Hospitals Corporation State University of New Hospital Public/HHC* Elmhurst, Queens Geographic representation, affiliation 14

18 Research Activities The research plan included three data collection activities: 1) A walk- through/ observation checklist; 2) A consumer/patient survey; and 3) an administrator interview. The Center developed the questions, instruments and protocol for these activities, directly referencing the provisions of the state law as well as tested questions and instruments from other surveys or research. The walk through/observation checklist was administered at each of the selected sites to collect easily observable or accessible information related to compliance with the state language assistance laws. Depending upon the type of facility, the walk through was conducted in up to four locations: the outpatient clinic, the emergency/urgent care waiting room, the billing/payment area and the main reception area (community health centers may consolidate all or most of these areas in one location in their facility). A total of 37 observations were conducted in thirteen facilities. The checklist operationalized these sections into five main components, asking observers to look for language assistance and general signage in multiple languages, the visibility of signage, presence of multilingual literature, and to ask a hospital staff person how language assistance is provided. A rubric was developed to provide a score for each observation/check list, with a potential score ranging from 0 to 5 (lowest to highest). A Consumer/patient survey instrument was developed to gather information about the access to language assistance and the quality of those services from the consumer s experience. The structured survey had series of questions that were designed to parallel the key areas of the state law, and asked about the presence of signage, the availability and types of language assistance offered, their availability in medical as well administrative areas of the hospital, and language assistance for written materials and instructions. Many of the questions were drawn from an earlier NYIC survey of language assistance services in local hospitals as well as suggested questions from members of the NYIC Health Collaborative. The survey was administered in five different languages Spanish, Chinese, Arabic, Haitian- Creole and Korean in 13 different hospitals and health clinics. The field workers placed themselves outside of the facility, proximate to either the emergency/urgent care, outpatient clinic, billing or main reception areas, with a dominant focus on the first two areas. They approached people emerging from the facility and, after introducing themselves, inquired about the purpose of their visit, whether the subject felt comfortable speaking English during their visit, and what was their primary language. If the individual indicated that they were not comfortable speaking English, and they spoke one of the five survey languages, the survey interview continued and the responses were included in the research analysis. Participants who completed the survey were offered a $5 MetroCard. 15

19 Surveys by Language Group Language Spanish Chinese Arabic Haitian- Creole Korean Number of Surveys The responses were coded, and entered into an Excel worksheet of analysis. Administrator interview questions were developed in consultation with the members of the Health Collaborative and NYIC staff. The purpose of the interview was to gather information about institutional policies and practices related to language assistance. The interviews were conducted by NYIC staff at selected sites. Two training sessions were held in the NYIC offices: one for members of the Health Collaborative and one for the graduate student field workers. The first two- hour training session was held in September 2012 and covered: using the observation score card and administering the consumer surveys, including administration of the different instruments, interviewing techniques, selecting participants and how to use the observation instrument and recording the information. A second training was held on February 13, 2013 for new field staff. In addition, a series of three check- in meetings were held every two weeks during the administration period to ensure consistency in administration, address issues that emerged from the field work and make adjustments in the protocol. 16

20 A. STUDY RESULTS a.) Walk Through Observation of Language Assistance (LA) Hospital Public/Private Location within hospital/clinic Signs in other languages Easily Visible LA signs Easily Visible Literature in multiple languages Lutheran Park Ridge Family Health Center Private Main Entrance Lutheran Chinese Private Main Entrance No No Family Health Center * Jacobi Medical Center Public/HHC Outpatient Billing Elmhurst Hospital Center Jamaica Hospital Medical Center Kings County Hospital Center SUNY Downstate Medical Center Richmond University Medical Center Lincoln Medical Center Public/HHC Private Main Outpatient Emergency Emergency Main Billing No No No No No No No No No No No Public/HHC Emergency No No No No No Public/SUNY Outpatient No Private Public/HHC Emergency Main Entrance Emergency Main Entrance No New Hospital Queens Brooklyn Hospital Center Lutheran Medical Center Private Emergency Outpatient Main No Public/HHC Emergency No Private Outpatient Main Entrance Billing No No No No No No * This clinic serves the local Chinese community and all of the signs are in Chinese and staff are bilingual, English/Chinese. Partially blocked by other signs. 17

21 Hospital b.) Outcome of inquiry regarding interpreter availability and wait time Location within hospital/clinic Interpreter would be made available immediately Use of telephonic interpreting service Bilingual staff Friend or family member to interpret? Lutheran Park Ridge Family Health Lutheran Chinese Family Health Center Jacobi Medical Center Elmhurst Hospital Center Jamaica Hospital Medical Center Kings County Medical Center SUNY Downstate Medical Center Richmond University Medical Center Main Entrance Main Entrance Outpatient Billing Main Entrance Outpatient Emergency Emergency Main Entrance Billing Emergency Outpatient Emergency Main Entrance * Lincoln Medical Center New Hospital Queens Emergency Main Entrance Emergency Outpatient Main Entrance Brooklyn Hospital Center Emergency Lutheran Medical Center Outpatient Main Entrance Billing * For secretarial purposes only. Book of translated information and frequently asked questions in many languages Staff said a family member could be brought in to interpret

22 RESPONSES TO CONSUMER SURVEY 93% did NOT feel comfortable speaking English during their visit. Did any hospital staff inform you that free language services are available here? 65% (60) No 34% (31) No Answer 1% (1) [N=92] Note: three of the No responses come from the Lutheran Chinese Family Health Clinic Informed of Availability of Free Language Services 1% 34% 65% No No answer Did you see any signs in your primary language informing you that language assistance services are available? 73% (72) No 19% (19) No Answer 7% (8) [N=99] Did you ask for a language interpreter? 65% (64) No 34% (34) No Response 1% (1) [N=92] At the time of your visit, did you know that you had a right to free language services provided by the hospital? 65.7% (65) No 32.3% (32) No Response 2% (2) [N=92] Did you have language assistance while you were seeing a doctor or nurse? 71% (70) No 23% (23) No Response 6% (6) [N=99] Was the doctor or nurse able to speak with you in your language? 53.5% (53) No 42.5% (42) No Response 4% (4) [N=92] Did the hospital give you any forms to read about your visit or your treatment? 55.5% (55) No 39.4% (39) No Response 5.1% (5) [N=99] 19

23 If you asked for language assistance what was the response: (N=69) 31.9% (22) A bilingual staff member would assist you 30.4% (21) Assistance would be provided over the telephone 23.2% (16) An interpreter would assist you 1.5% (1) Another patient or visitor would provide language assistance 0% (0) No language assistance is available in your language 13.0% (9) Multiple responses Responses to Request for Language Assistance No language assistance is available Mulxple Responses Another paxent or visitor would An interpreter would assist you Assistance would be provided over A bilingual staff member would Number of Responses Did you have to sign any forms regarding your visit, your treatment or your billing? 55.5% (55) No 33.3% (33) No Response 11.2% (11) [N= 99] Did you understand the written forms you read/signed? 48.5% (49) No 37.6% (38) No Response 12.9% (13) [N= 99] Did someone from the hospital translate the forms for you, or explain it in your language? 51.5% (51) No 31.3% (31) No Response 17.2% (17) [N=99] Are there questions about your health or your treatment that were not answered or you did not ask because of language? 30.3% (30) No 65.7% (65) No Response 3% (3) Other 1% (1) (Sometimes, interpreter helped) [N=99] Have you had any difficulty making appointments, getting follow up information or with hospital bills because of language issues? [N=99] 18.1% (18) No 77.7% (77) No response 4.2% (5) 20

24 c.) Comparing Survey Results with 2008 Survey, selected questions Survey Question 2008 Survey 2013 Survey Attended Hospital for Medical Visit 96% 95% Comfortable Speaking English 3% 7% Comfortable Reading English 4% 4.3% Informed of Free Language Assistance Services by Staff 27% 65% Saw signs about free Language Services 46% 73% Had Language Assistance During medical exam 71% Doctor or Nurse spoke primary language 53.5% Knew Had Right to Language Services 31% 65.7% Told Another Patient or Visitor Would Interpret 5% 1.5% Verbal Hospital Interpretation Bilingual Staff 38% 31.9% Interpreter 13% 23.2% Telephonic interpretation 23% 30.4% Written Communication Given forms to read 55.7% Hospital Forms in primary language 13% Given forms to sign 51% 58.7% Forms were translated by Hospital Staff 51.5% Forms translated by non- hospital staff 20.9% Understand written forms to read/sign 48.5% Other Issues Patient Wanted to Ask Questions But Couldn t 48% 30.3% Problems Making Appointments 23% 18.1% 21

25 d.) Hospital Administrator Responses to Interview Questions Health Administrator Interview Questions 1. Which communities does your hospital or health facility serve and which are the primary immigrant, non- English speaking populations to whom you provide health services? 2. How does serving large numbers of recent immigrants and non- English speaking patients impact on your health care facility and services? 3. What services, programs, staffing or accommodations does your hospital or health facility make available to patients who need language assistance or have particular cultural considerations in receiving health care? 4. Who is the designated Language Assistance Coordinator at your facility? 5. What is their main job title and what other job responsibilities do they have in addition to language assistance? 6. How often are your written policies and procedures for providing language assistance services for your patients reviewed and/or updated? Who conducts the review? 7. How often does your hospital or health care facility provide training or updated information on language access policies and procedures to your administrative or line staff? 8. Who generally conducts the training or review with your front line staff? Is it provided using internal staff or do you use outside resources for the trainings? 9. What printed materials do you provide that informs the public how to access free language assistance services? (Ask for copies of sample materials in a variety of languages) 10. Who provides direct language assistance services for patients at your hospital or facility? Do you employ trained interpreters or use bilingual hospital staff? 11. Do you use Language Line or another telephone service to provide language assistance? On average, 12. From your knowledge and experience, how long do patients wait to receive language assistance in their primary language either through staff services or telephone services? 22

26 13. What is the hospital or health facilities policy or process when a patient, even after being advised of their right to free language assistance, prefers to use a family member, friend or other non- hospital personnel to act as interpreter? 14. Which are the primary languages, other than English, that you provide your patients? 15. How have you identified these languages? 16. Who are the key front line hospital staff impacted by the need for effective language assistance to provide quality services? 17. Is language assistance available throughout your facility, including main reception, billing and other non- medical areas? 18. What would you say the biggest challenges are to providing a sufficient level of language assistance to ensure quality health care for all patients? How can they be best addressed? 23

27 Hospital Administrator Responses to Interview Questions Hospital/Clinic Elmhurst Jacobi Jamaica Kings County Lincoln Lutheran NYHQ RUMC SUNY Location Top Languages Elmhurst, Queens Spanish, Bengali, Mandarin, Arabic, Korean, Hindi Morris Park, Bronx Spanish, Arabic, Bengali Jamaica, Queens Spanish(80 %), Bengali, Punjabi, Mandarin, Haitian- Creole Flatbush, Crown Heights Brooklyn Spanish, Haitian- Creole, French- Creole, Arabic, Bengali, Russian, French (39 languages requested) Bronx (South Bronx, Mott Haven, Morrisania, Tremont) Spanish, French (34-39 languages requested in a given month) Bay Ridge, Brooklyn Spanish, Chinese, Arabic, Russian (also: Haitian- Creole, Italian, Polish) Downstate Flushing, Queens Staten Island Downtown Brooklyn Mandarin, Cantonese, Korean, Greek, Spanish, Russian Spanish (80% - most from Oaxaca/Mixteco dialect); Albanian, Russian, Mandarin, Polish, Italian, Haitian- Creole Haitian- Creole, Spanish, F/T Language Access Coordinator Telephonic F/T qualified Face- to- Face Interpreters (in- house - - official certification) External Qualified Face- to- Face Interpreters (Contract) (majority) 2 F/T Spanish, 1 ASL) (also oversees North- central Bronx) (majority) (oversees Harlem & Lincoln) (majority) No No No 3 F/T, 3 P/T (Spanish) 2 F/T in ambulatory care and 1 F/T in emergency; 3 P/T dispatched via cell phone No (except ASL) (only 2 in 2011 and 3 in 2012). (dedicated F/T) Speaker phones in patient rooms, cordless dual headset for physical therapy areas No. Used to have staff F/T medical interpreter, but no resources (occasionally, based on clinical need) (last resort) (majority) No No 2 F/T Trained by Hunter s 40- hour training certificate program. No (except ASL) (occasional) 24

28 Hospital/Clinic Elmhurst Jacobi Jamaica Kings County Lincoln Lutheran NYHQ RUMC SUNY Downstate Dual- Role Certified or Qualified Medical Interpreters Dual- role Qualified Non- Medical Interpreters (Not assessed for medical interpretation, but tested for conversational qualification) (10-12) 3 Mandarin, 1 Hindi, remaining Spanish (work within unit and can be deployed outside area as last resort) Can provide same- day face- to- face; dispatched by language access coordinator Existing dual- role staff have been tested. In process of working with CLAS on a way to re- certify existing staff and identify staff who are interested (1 NCB certified) Database of language capacity, but not connected to network for scheduling appointments (300) Qualified Medical Interpreters (QMIs) 70 employees did 40- hour training at NYU Staff fluent in language who want to serve as interpreters must have lived at least 5 years in region or have gone to school where the language is primary or fluency is assessed by outside agency Interpreters categorized as Non- medical Interpreter (NMI) [self- identified interpreters are not allowed to interpret] List of qualified interpreters (12) 2 Nationally certified Certificate training provided at Hostos Community College. If employed by HHC, HHC pays for training service (200) ~200 qualified medical interpreters. Voluntary external training. No No Staff, bilingual providers, security guards, housekeeping (must have star on Id to prove qualification) Some positions have language requirements NYHQ policy requires dual role staff only to serve as interpreters for telephonic interpreting services in their designated department, unless if he/she is needed for emergency use in a different unit. However, prior approval from the department is needed. Dual- role qualified medical interpreters wear a yellow badge. Are required to wear a different badge (blue) 4 categories: - Certified - Native - Qualified - Prequalified Qualified assessed by NYU Center for Immigrant Health Native speakers No 25

29 Hospital/Clinic Elmhurst Jacobi Jamaica Kings County Lincoln Lutheran NYHQ RUMC SUNY Downstate Volunteer Medical Interpreters (14) Elmhurst pays for language line test in exchange for 100 hours of volunteer time; staff works with LaGuardia college to identify students to volunteer No (4) Qualified through 120 hours of training; provide interpretati on in clinic areas and floors No No No (22 Spanish, Chinese, Korean) Tested at hospital's expense No No Identification for Interpreters ID marking No n/a No ID marking Star on ID Yellow badge: passed medical interpretation test; Blue badge: self- attestation/conversatio nal; Purple Polo Shirts: volunteer interpreters n/a ID badge Video Interpretation All psychiatric patients receive video interpretation instead of telephonic for safety reasons. Used for sign language interpretation NYHQ uses video interpreting services to streamline language interpretation for patients and has been proven a success according to Language Access staff 26

30 Hospital/Clinic Elmhurst Jacobi Jamaica Kings County Lincoln Lutheran NYHQ RUMC SUNY Downstate Testing Language line test is at own expense No 2 tests: proficiency & medical interpretati on test Fluency assessed by outside agency (NYU Center for Immigrant Affairs, Language Line, etc..); Assessed by outside vendor, NYU Center for Immigrant Health Medical translators must be medically certified from a credible program. Dual- role interpreters are tested once a year. If they do not pass, taken off the list. 5 minute in- house tool administered by staff; testing occurs at point of hire Screened 1,000 staff for Joint Commission Beginning to retest interpreters Tested for proficiency by language access coordinator Paid external services to test proficiency Piloting online test; Training (in- house/external) In- house Harvard University training 5 years ago In- house 101 Staff must seek additional training at own expense In- house External for certification Training conducted jointly by language access coordinator and CyraCom External trainings through SUNY, NYU (online program was conducted by NYU Center for Immigrant Health) In- house 101 Students can take CUNY national certification courses voluntarily at own expense In- house External: Pacific Interpreters + staff conducts training Hospital pays for testing for volunteer interpreters In- house External vendor and in- house 27

31 Hospital/Clinic Elmhurst Jacobi Jamaica Kings County Lincoln Lutheran NYHQ RUMC SUNY Downstate Training (frequency) New employee orientation Annual review Midyear review Conducted by language access coordinator Mandatory web- based test New employee orientation Each department conducts own trainings Leadership meetings every 3 weeks New employee orientation conducted by language access coordinator Annual reorientatio n Even though it is difficult for supervisors to allow supervisees to attend, annual workshop conducted for interpreters New employee orientation Annual training (web- based) When new services opened On demand New Employee Orientation - watch video/do's and don'ts of medical interpretation Cultural Competency Rounds once a month Orientation training; Annual education Orientation for new hire Staff retrains units as needed No annual training Piloting online interpretati on training program Metrics/Monitoring Telephonic usage and face- to- face interpretation usage Telephonic interpretatio n services usage reports Census Data. (Formerly used patient registration data, but switched to census data matched to zip codes served in primary catchment area) New City Department of Planning 2010 population data Monthly metrics by facility and network; Piloted a health data program to share patient data between Lincoln hospital and Puerto Rican health care systems in order to ensure that patient files are the same. Regulatory issues and patient consent legalities disrupted the pilot. No further action took place to re- launch the program Feedback from quarterly meetings w/cbos Developing quality measures for interpretation Clinic- specific data and system- wide data Telephonic usage of interpretation services tracked Patient satisfaction surveys Admissions records Track language through usage in internal systems Track language through telephonic usage reports 28

32 Hospital/Clinic Elmhurst Jacobi Jamaica Kings County Lincoln Lutheran NYHQ RUMC SUNY Downstate Materials Translated Policies Updated Materials are not currently evaluated by main office, but this is being explored Every 2 years by language access coordinator Leadership meetings every 3 weeks Every 2 years Signage sent to external agency for translation Every 2 years Materials translated into 3 languages: Spanish, Haitian- Creole, and French- Creole Discharge plans Materials translated by HHC available on intranet in 12 languages Official correspondence to patients translated through external vendor Every 2 years or as necessary HHC Intranet, Staff translations Written policies updated once a year (each network reviews own policy) Materials translated into 4 languages: Spanish, Chinese, Arabic and Russian (occasional Haitian- Creole, Intake/HIPAA/ Proxy forms Consent Forms Patient Guides Billing Treatment f/u Instructions Forms 5th grade reading level; Menus/diet into top 5 languages; Consent; Materials translated by external vendor and language access coordinator Pre- operation and discharge materials Nutrition information Financial assistance Materials translated into Spanish and Creole Every 2 years Every 2 years Annually Annually Emerging Populations Bengali- and Arabic- speaking populations increasing n/a Arabic, Mandarin, Haitian- Creole, Guyanese, Punjabi (Russian decreasing) n/a n/a n/a Bengali, Italian, Polish increasing Arabic n/a 29

33 Hospital/Clinic Elmhurst Jacobi Jamaica Kings County Lincoln Lutheran NYHQ RUMC SUNY Downstate Specialty Clinic? No Special outpatient clinic for Albanian patients Innovative Practices Challenge Elmhurst pays for language line test in exchange for 100 hours of volunteer time; works with LaGuardia college to identify students to volunteer Only reimbursed flat rate for any interpretation over 20 minutes, even if interpreter interprets for many more minutes or hours. Specialty in ASL/deaf communities Need medical interpretatio n training funded No No Medina Clinic for West African community/isla m Volunteer program Cost is largest challenge n/a Rare languages; patients frequently identify as English proficient when they are not, especially in ER Dedicated clinic serving Chinese- American populations Cultural Access Taskforce Cultural Competency Rounds once a month Meetings with Arab Community and NGOs Cost, low Medicaid reimbursement rate No No No Volunteer program, including purple polos in exchange for 120 hours of volunteer time trained at hospital's expense Patient services is looking to pilot a program where the implementation of ipad and laptop services for video ASL interpretation Free interpreter training, but hospital doesn't compensate for staff time while training n/a Physicians forget to document that they communicated with patients in preferred language Visual card for patients to point to images for low- literacy and LEP patients Lack of medical interpreter training for staff, lack of f/t interpreters If more resources Can provide free training, but need funding to compensate staff for training time; access to technology - - i.e. ipad or video for interpretation Centralized booking /scheduling for interpreters; also need to provide incentives for staff to become interpreters Would hire more f/t interpreters Would hire more p/t interpreters in order to accommodate diversity of language needs F/T interpreters; higher Medicaid reimbursement rate F/T interpreters Goal: to have 1-2 qualified dual- role Spanish speakers in each unit F/t staff for Spanish and Haitian- Creole; medical interpretati on training 30

34 V. ANALYSIS, RECOMMENDATIONS AND BEST PRACTICES Overall, the results of the survey demonstrate that the participating New City hospitals have made tremendous strides towards offering LEP New ers quality health care since the implementation of statewide language assistance requirements. In 2004, 8% of patients surveyed were informed of free language services by hospital staff. 20 By 2008, this number had risen to 33%. This 2013 survey found that 65% of respondents were informed of the availability of free language assistance services. In addition, patients are more educated in general about the availability of free language services, with 65.7% reporting that they were aware of free language services before they entered the hospital/clinic. Across the board, all measures of language access demonstrated improvement since the law was first implemented. At the same time, the study points to some persistent problems within language assistance service provision in New City, such as the use of unqualified interpreters; lack of standardized certification, testing, and training; and inconsistent availability of translated materials. These problem areas highlight challenges moving forward and key areas for improvement that will allow New City to build on the progress already made on improving health services for LEP New ers. Furthermore, all hospitals surveyed indicated that lack of resources was the single greatest barriers to enhancing language services. State and city governments could play a vital role in helping remove barriers to access by creating funding for interpreters, providing training programs for volunteer interpreters, and increasing the rate of Medicaid reimbursement for language services. Finally, this research has also uncovered innovative practices at city hospitals and in cities across the country that should be used as models for other facilities citywide to replicate. By focusing upon best practices, we hope to encourage other hospitals and health care facilities to emulate these examples and to collaborate to collectively develop better practices to meet the needs of immigrants citywide. 20 Now We re Talking: A Study on Language Assistance Services at Ten New City Public and Private Hospitals. Make the Road New, New Immigration Coalition, Korean Community Services of Metropolitan New. April

35 A. MODALITIES OF INTERPRETATION Surveyed hospitals are using a diverse array of modalities to provide language access, ranging from dual- role interpreters, to full- time professional staff interpreters and simultaneous video interpretation. Some hospitals depended more heavily on bilingual dual- role staff, whereas other facilities were almost entirely reliant upon telephonic interpretation. Externally contracted professional interpreters were rarely employed because of cost factors and time delay concerns. Telephonic interpretation was the most common modality, and was universally utilized by all hospitals. Administrators cited the convenience, cost, and immediate availability of an expansive list of languages as the reason for the greater usage for telephonic services. Time delays in connecting patients to interpreters were not reported to be greater than a few minutes, with the exception of the occasional uncommon language, such as rarely spoken indigenous dialects. If given the choice of interpretation modality, all but one administrator reported a preference for face- to- face interpretation services because of the visual cues lost in the process of telephonic interpretation and the human connection to the live interpreter. However, studies that have compared satisfaction with face- to- face modalities to telephonic and remote video interpretation have found while providers tend to favor face- to- face, patients do not necessarily share this preference. 21 However, this study found that in the New City hospitals, all administrators surveyed also stated that they preferred to have access to mixed modalities, including full- time interpreters, telephonic and video technologies. Administrators cited the cost of video services as prohibitive, but were hopeful about the possibilities of cost- effective video interpretation through the use of remote video interpretation as well as ipads or other portable interpretation technologies in the near future. Several municipalities across the country such as Cambridge, Massachusetts and Los Angeles, California have had success with implementing systems of remote video interpretation. 22 While in- person face- to- face interpretation communicates information that is lost in telephonic modalities, it also introduces another person in the room during the patient- provider encounter. This triadic structure has the capacity to distort patient- provider communication since the presence of the interpreter structures the communication as a three- way dialogue. 23 In Cambridge and Los Angeles, remote video interpretation systems have been implemented that remove the interpreter s physical presence while retaining visual information communicated at costs far lower than face- to- face modalities. New City should explore remote video interpretation and other technologies to lower costs while simultaneously improving the quality of interpretation in 21 Azarmina, Pejman et al. Remote Interpretation and Medical Encounters: a Systemic Review. Journal of Telemedicine and Telecare 11.3 (2005). Pp Paras and Associates. How New Technologies Address the Challenge of Health Care Interpretation. August Thanks to Dr. Francesca M. Gany from Memorial Sloan- Kettering Cancer Center for her insight into this challenge of in- person interpretation. 32

36 a hospital setting. Remote simultaneous Interpreting is another option: shown to be less prone to errors, more efficient/cheaper and with better patient satisfaction BEST PRACTICES: Hospitals should have access to a broad array of language assistance (strategies?), ranging from in- person to telephonic and video interpretation to meet the diverse needs of their patient populations. When possible, hospitals should utilize a range of interpretation modalities.. Although telephonic interpretation may be appropriate in many circumstances, in- person, face- to- face interpreters are preferable because remote telephonic interpretation fails to capture visual signs that may be communicated. Hospitals should explore using new technologies, such as remote video interpretation, which provide more flexible, mobile solutions to interpretation and which capture visual information lost through telephonic communication while lowering costs of interpretation to hospital networks. B. HUMAN SERVICES, STAFFING AND NON- STAFF INTERPRETERS All hospitals interviewed employed a Language Access Coordinator (LAC), and almost all of these LACs were full- time. Most hospitals do not employ full or part- time medical interpreters. The three surveyed hospitals that did employ professional medical interpreters had between 2 and 3 full- time interpreters on staff, all of whom were qualified to interpret only in Spanish. Unfortunately, hospitals continue to utilize ad hoc (strangers, family members) and unqualified dual- role interpreters (bilingual staff whose primary job is not interpretation and who are not trained in interpretation or medical terminology or tested for bilingual fluency) despite the fact that they are not equipped to perform medical interpretation and that their errors can lead to negative health outcomes, civil rights violations and malpractice suits. Family Interpreters Only one hospital surveyed responded to a request for interpretation by asking the patient to bring in a family member; some hospital administrators explained that the use of family members as interpreters was used on occasion. Hospitals surveyed generally understood the problems associated with using family interpreters (i.e. domestic violence, confidentiality, misinterpretation, projection, etc ) and have enacted policies to discourage their use unless the patient insists and signs a form waiving the right to free interpretation. It is clear, however, that hospitals must continue to educate staff about the dangers of using family members for medical interpretation and discourage their use in health care settings. On the other hand, in some cases it is important for the LEP family members to be engaged in the care of a bilingual patient who is proficient in English. If the patient consents under HIPAA, hospitals should provide interpretation services for LEP 33

37 family members who may need to be informed about the patient s health to make end- of- life or proxy decisions or to assist with treatment. The use of minors (younger than 16) as interpreters is against NYS Language Regulations Dual- Role Staff Meanwhile, the utilization of dual- role bilingual staff interpreters posed challenges for administrators interviewed from the vantage point of labor. Supervisors of dual- role staff were reported to be reluctant to give up their staff members to be diverted to provide interpretation elsewhere in the hospital, citing back- fill concerns. In some hospitals, dual- roles were confined to providing interpretation services only within their units. In other hospitals, dual- roles could be deployed outside their units only with the permission of the unit supervisor. Moreover, administrators noted that many dual- role staff felt that interpretation was beyond the scope of their job descriptions without further compensation. Some bilingual staff expressed interest in becoming trained as interpreters, but they could not find the time to participate in trainings during work hours even when the hospital paid for the cost of trainings. Jamaica Hospital sought to create incentives for bilingual staff to become interpreters by publishing a newsletter about language access in the hospital (see appendix) and featuring a different staff interpreter in each issue. This type of recognition offers a low- cost incentive to recruit more staff for interpretation. One of the greatest challenges reported with the utilization of dual- role interpreters was the difficulty of creating systems to match dual- role staff with patients who spoke their languages. Some hospitals maintain paper lists of dual- role staff by language capacity who can be deployed to units as requested by language access coordinators via telephone. Other hospitals use electronic patient records and scheduling systems to match dual- roles to patients. This patchwork approach seems ineffective and inefficient. Tthere should be a standard practice for deploying dual- role interpreters within hospitals across units. Again, anyone who interacts with patients in any given language, even if not in the interpreter capacity, should be tested in that language) Staff Diversity Language Access Coordinators and other staff responsible for overseeing language assistance programs recognized the benefit of hiring diverse staff that reflected the languages spoken by the patient population. Many human resources departments listed language capabilities as a requirement for positions that worked directly with patients as a means to increase staff diversity, recognizing that proficiency in common languages spoken was necessary for providers to do their jobs. Physicians Administrators interviewed reported several concerns about the role of physicians in the provision of language assistance services. First of all, some reported physicians to be reluctant to use language access services such as interpreters. Others exhibited false fluency and overestimated their proficiency in other languages. In general, physicians 34

38 were reported to show resistance to participating in cultural and linguistic competency trainings or other similar programs with language access program staff. However, some hospitals had effectively integrated their bilingual physicians as core features of their language assistance programs. For example, an Arabic- speaking physician at Lutheran Medical Center s clinic in Bay Ridge has become a major draw and trusted provider for the Arab- American immigrants in the area. Lutheran also offers directories of physicians with proficiency in top languages such as Arabic, Russian and Spanish. Volunteers At least one hospital we spoke with held the misconception that HIPAA prevents the use of volunteers for interpretation services. The use of volunteers is an acceptable practice under HIPAA and other applicable laws. New Hospital Queens employs volunteers to serve as interpreters by offering to train them or pay for their certification tests in exchange for a commitment to volunteer at least 120 hours. Similarly, Elmhurst hospital pays for volunteers to take the Language Line proficiency test in exchange for a commitment to volunteer for 100 hours. Jamaica Hospital also has a volunteer program. BEST PRACTICES Staff members who provide interpretation should be classified as such and provided with appropriate compensation. Dual- role interpreters should be given additional compensation for interpretation obligations. City employees who perform interpretation should be classified as interpreters according to the same system by which court interpreters are classified with corresponding salary and benefit requirements. Hospitals should hire full- time dedicated interpreters that speak the top patient languages spoken. If the language composition of the patient population fluctuates, these interpreters could be reassigned to other hospitals. Human resources departments should include language proficiency requirements (and testing) in hiring staff that work directly with patients to ensure the staff composition reflects the demographics of the patient population. C. MATERIALS & SIGNAGE: Signage Hospitals are doing a better job of posting signage in languages other than English spoken by the patient population. 73% of patients saw signs in their primary language, compared to ZERO in 2004 and 72% in However, approximately a quarter of areas surveyed lacked signs notifying patients of the availability of free language assistance services, or in some cases the signs were not easily visible. 24 Now We re Talking: A Study on Language Assistance Services at Ten New City Public and Private Hospitals. Korean Community Services, Make the Road NY, and the New Immigration Coalition. April

39 Materials and Forms Translated materials and forms are not widely accessible to patients, even if they are available to staff. Only half (51.5%) of those who were surveyed received forms in languages in their preferred language or had forms translated for them. In many cases, forms were available on hospital intranets, but they had not been printed and made available to patients. In some cases, materials were interpreted by hospital staff and included inaccuracies, were filled with jargon, or were otherwise inaccessible to low- literacy patients. Hospitals that used professional translation services through external contractors generated the highest quality translated materials. More positively, hospitals such as SUNY Downstate are using communication cards with visual information such as images to represent key concepts that LEP and low- literacy patients can point to in order to communicate with non- medical hospital staff who do not speak their preferred language. Public Service Announcements (PSAs) in Multiple Languages Patient Waiting Areas Finally, several administrators suggested producing and running short PSAs in different languages that could be shown in patient waiting areas. These PSAs could cover topics such as the right to interpretation and financial assistance. BEST PRACTICES: Materials should be translated professionally and targeted to low- literacy populations and field tested. Facilities should be sure that translated signage and information about the availability of language assistance services are more easily visible. Translated materials should be prominently displayed in waiting rooms and other high- traffic areas. Hospitals should create directories of providers who are qualified to provide services in languages other than English. Hospitals should consider producing and showing PSAs in multiple languages in hospital waiting areas. D. CERTIFICATION, TRAINING AND TESTING Certification, training and testing practices of the hospitals in this study varied across institution considerably. While some hospitals had one or two nationally certified interpreters on staff, certification requirements were not consistent for staff providing interpretation. Some hospitals surveyed had no certification requirements at all. Testing practices also ran the gamut from self- attestation to a requirement that staff take the Language Line medical interpretation test at their own expense. One hospital administered a five minute in- house tool. Another gauged language proficiency according 36

40 to the assessment of the Language Access Coordinator, regardless of language spoken, raising questions of whether the LAC could determine proficiency in other languages. The frequency of testing also varied, with some hospitals not testing at all and others testing on a yearly basis. All hospitals provided basic training on language assistance services at new employee orientation. About half of the hospitals conducted in- house trainings, and the other half utilized external trainers from telephonic interpretation services such as Language Line and Cyracom, sometimes in collaboration with hospital staff. Many hospitals used visual markers to designate qualified interpreters. Most hospitals designated interpreters on their identification badges, either through a colored dot indicating language ability or by a written annotation. At New Hospital Queens, volunteer interpreters were given special purple polo shirts with the words VOLUNTEER INTERPRETER printed on the back. BEST PRACTICES Hospitals should require that all staff members who conduct medical interpretation be certified through a national program or through certification programs such as those offered by NYU Center for Immigrant Health and CUNY Healthcare Interpreter Certificate Program (see above on first pages for clarification on these three bullets). New should follow California s example and establish a statewide certification for medical interpreters, as exists for court interpreters, and establish standards of practice for interpretation in a hospital setting. All interpreters should be tested for proficiency upon hire with a recognized testing tool and should be retested every two years. Staff members who are qualified interpreters should be clearly identified by wearing a particular color uniform or identifying badge that indicates their qualifications to provide interpretation and in what languages E. DATA COLLECTION, MONITORING AND EVALUATION Data collection practices also varied across facilities. While all facilities recorded patient language, not all hospitals recorded the patient s preferred language. Another issue that emerged was that that some electronic databases containing patient language did not connect with other hospital information systems, such as scheduling programs. This made it impossible to coordinate interpreters with the scheduled appointments of LEP patients. There were also problems with methods for soliciting patient language assistance needs. Frequently, patients reported being ashamed to admit that they were LEP and required language assistance. Some hospitals recognized this challenge and crafted intake questions that attempted to circumvent defensiveness about English language capacity. A related issue was that some hospitals asked intake questions only in English, so patients could not 37

41 respond to questions about language proficiency. In one hospital, a Spanish- speaking LEP patient had been an in- patient for three months, during which she had never received interpretation or been informed about her condition because when asked if she needed interpretation in English, she answered no because she did not understand the question. Practices for evaluation of language needs also varied. Some hospitals relied exclusively upon telephonic interpretation service utilization records or requests for interpretation to determine language needs. Others looked to Census or ACS data, which track demographic trends with varying levels of timeliness. Lutheran HealthCare also incorporated feedback from community advisory groups into its assessment of emerging language needs. On their own, each of these methods suffers from drawbacks. Utilization data alone may not reveal information about language groups in hospital catchment areas that are not utilizing the hospital services. On the other hand, the use of Census data may rely on demographics that have changed since the data were collected years before. BEST PRACTICES Hospitals should collect and note preferred language in patient records. Hospitals should craft also intake questions carefully to accurately elicit preferred language for purposes of providing language assistance services. Hospitals should integrate their electronic information systems to ensure that records of preferred language are incorporated into scheduling programs to ensure the proper coordination of interpretation services. Hospitals should not rely upon only one source of data to track and assess patient language needs. Hospitals should look to mixed data sources including interpretation services utilization (both in- person and telephonic records), Census and American Community Survey data and feedback from patient surveys and community advisory boards. Hospitals should generate regular reports to assess the relationship between language ability and a range of health outcomes to assess the provision of language services and the impact of language ability on outcomes and care. F. TARGETED CLINICS VERSUS NO WRONG DOOR One of the main topics of discussion during interviews was that of the benefits and limitations of targeting care to specific immigrant populations or language groups. Some hospitals have created special clinics. After identifying the growing population of West African immigrants in the city, HHC founded the Medina Clinic at Harlem Hospital Center to provide medical services tailored to their linguistic and cultural needs. The Medina Clinic provides health education, primary care services, and outreach screening with the West African community in mind, but all other cultures are welcome to use clinical services. 25 Similarly, Jacobi opened the Illyria Family Practice over a decade ago to cater to Albanian 25 medina- clinic.shtml 38

42 refugees fleeing Kosovo, and Lutheran has two specialty clinics that serve Chinese and Arab- American populations. While specialty clinics may play a helpful role in addressing emerging population needs and serving immigrant- specific enclaves, it is important that health care facilities also maintain a no wrong door framework for clinics and hospitals, whereby multiple agencies retain responsibility for their respective services while coordinating with each other to integrate access to those services through a single, standardized entry process that is administered and overseen by a coordinating entity. 26 Immigrants should be able to access care at any facility in New City. Immigrant groups may relocate from one neighborhood to another as the city s real estate market changes, so demographic- specific facilities may find themselves no longer able to serve their catchment population as demographics transform the surrounding neighborhoods. With a shrinking number of hospitals across the city, health care facilities designed for a single population may fail to serve the needs of all users. BEST PRACTICES Hospitals may consider creating specialty clinics targeting particular immigrant populations to address emerging community needs. Apart from specialized services, all health care facilities should adopt a No Wrong Door policy and be ready to serve all populations. G. COMMUNITY AND PATIENT ENGAGEMENT Several hospitals reported soliciting feedback about immigrant and LEP patient needs through community advisory boards. When Lutheran recognized the growing Arab- American presence in the community they served, they began convening a quarterly community advisory panel with the Arab- American community. Through this process, they became aware of special community needs that were not communicated through patient surveys. For example, they identified a large demand for information about dental care. In response, they brought in a dental provider to educate the Arab- American community about dental health and dental services. BEST PRACTICES Hospitals should create specific community advisory boards for particular immigrant populations/language groups or a general immigrant advisory board to solicit feedback about LEP/immigrant needs. 26 Allison Armor- Garb, Point of Entry Systems for Long- Term Care: State Case Studies, prepared for the New City Department of Aging, Point_of_Entry_Systems_for_Long- Term_Care_State_Case_Studies.pdf 39

43 H. FUNDING LANGUAGE ACCESS All hospitals surveyed cited cost as the primary barrier to improving language assistance services and almost all hospitals in the study would hire full- time interpreters if they received additional financial support for language assistance services. One hospital expressed concern about having hired a Haitian- Creole speaking interpreter who was underutilized when the Haitian- Creole patient population declined. These concerns could be addressed by reassigning interpreters to other facilities through union procedures or creating a citywide pool of interpreters that would be employed across hospitals. Furthermore, while all hospitals were thankful for the new Medicaid reimbursement policy for language assistance services, they described the $22 rate for 23 minutes or more as woefully inadequate. Most encounters last well over 23 minutes, so the hospital still has to cover the remaining interpreter time, resulting in substantial unreimbursed language assistance staffing costs. I. INTER- HOSPITAL COMMUNICATION In November 2013, Language Access Coordinators (LACs) from surveyed hospitals met at a roundtable to review the draft findings of this report. One of their primary responses to the findings was they felt that they benefited greatly from sharing experiences with other Language Access Coordinators from hospitals across the city. As a result, the NYIC has launched the Language Assistance Coordinator Taskforce, which brings together LACs on a quarterly basis to share experiences and best practices for providing language assistance services in a hospital setting. 40

44 POLICY RECOMMENDATIONS New should raise the Medicaid reimbursement rate for language assistance services from $11 (8-22 minutes) and $22 (flat rate for 23 or more minutes, with no maximum) to a reimbursement for interpretation services in line with national wage standards for interpreter services and should be reflective of salary differentials for New City. In addition, Medicaid should reimburse at higher rates for encounters over 23 minutes, since many face- to- face/in- person interpreting encounters are longer than 22 minutes in length. 27 Bureau of Labor Statistics (BLS) reports that nationwide the median annual salary is $43,300 for medical interpreters, or about $23/hour, without capping the fee after the first hour. 28 Nationally, other states reimburse at much higher rates, up to as high as $190/hour in the District of Columbia. 29 The State Legislature and the City Council should allocate funding to hire more full- time or part- time staff interpreters in New hospitals or to create a new pool of trained medical interpreters that could be deployed to different hospitals as needed. The state should develop a standard training curriculum or certify existing curricula for linguistic and cultural competency in a health care setting. Physicians should also be required to participate in trainings such as the physician cultural competency training developed in Oakland. The state or city should fund an interpreter training and certification program, such as those offered at MSKCC Center for Immigrant Health and CUNY Healthcare Interpreter Certificate program, which could train a pool of qualified interpreters to be available at city hospitals or to train interested staff. Staff should be allowed to participate in these training at no cost to them and should be compensated for their time. Newsletter and employee appreciation materials that profile staff interpreters may increase dual- role staff willing to participate in interpretation services. 27 Recommendation based on feedback from Wilma Alvarado Director, Community Engagement/Outreach, Center for the Elimination of Minority Health Disparities University at Albany, SUNY. correspondence, Tuesday, August 27, and- Communication/Interpreters- and- translators.htm 29 Youdelman, Mara. Medicaid and SCHIP Reimbursement Models for Language Services. NHeLP, March

45 APPENDIX A: OBSERVATION/WALK- THROUGH SCORE CARD TOOL 42

46 APPENDIX B: CONSUMER SURVEY TOOL Consumer/Patient Survey Interviewed By: Date: Hospital/Facility Name: Language Spoken: Location in Hospital/Facility: 1) Outpatient Clinic; 2) Emergency Room Waiting Area; 3) Billing; 4) Main Reception (write number here): Hello, my name is. I work with the New Immigration Coalition. We are learning how hospitals and clinics help patients whose primary language is not English. If you visited the hospital for health care, to make an appointment, or to ask about a bill or how to pay, I have a few questions to ask you. The questions will take about five minutes and the answers will be private no one will know your name or the answers you gave to the questions. What you tell us will help hospitals to serve patients who don t speak English better. If there is anything you don t understand, let me know and I will explain. I would like to ask you a few questions to see if you are eligible to complete the whole survey. If you complete the whole survey I will give you a $5 Metro card. 1. Are you here today for a Medical visit To schedule an appointment or for Billing or payment question 2. Do you feel comfortable speaking in English during your visit? No 3. If no, what is your primary language, the language you speak at home or feel most comfortable speaking? If they feel comfortable speaking English during a medical visit, please end the interview politely. The survey is intended for patients who rely on language assistance to get their health needs met. 43

47 4. Did any hospital staff inform you that free language services are available here? No Where did this occur? when you first arrived, in the reception area, in the waiting room, when you were seen by a doctor or nurse, Other 5. Did you see any signs in your primary language informing you that language assistance services are available? No. Where did you see them? When you entered the hospital or clinic In a waiting room By the reception area Other 6. Did you ask for a language interpreter? No If you asked for language assistance what was the response: An interpreter would assist you A bilingual staff member would assist you Assistance would be provided over the telephone Another patient or visitor would provide language assistance No language assistance is available in your language Other: 7. How long did you have to wait before someone came to offer language assistance? Less than five minutes Five to fifteen minutes More than fifteen minutes? 8. At the time of your visit, did you know that you had a right to free language services provided by the hospital? No 9. Did you come to this health facility because you knew they could speak to you in your primary language? No 10. Did you bring along someone with you to translate? No 44

48 If yes, who was it? A family member (relationship, age ) Other 11. Did you have language assistance while you were seeing a doctor or nurse? No Was the doctor or nurse able to speak with you in your language? No 12. How would you rate the language skills of the person who spoke to you in your language? Very limited/poor (I could not understand most of what they said) Fair (I could understand most of what was said) Fluent (I could understand everything) 13. How comfortable do you feel reading/writing English? Very comfortable Somewhat comfortable Not comfortable at all 14. Did the hospital give you any forms to read about your visit or your treatment? No Did you have to sign any forms regarding your visit, your treatment or your billing? No 15. Did you understand the written forms you read/signed? No 16. Did someone from the hospital translate the forms for you, or explain it in your language? No 17. Who translated the form(s) for you? Bilingual hospital staff, Interpreter provided by the hospital, Another patient, A family member or friend? 45

49 18. Did any of the forms ask you if you spoke a primary language other than English? No Don t know 19. Did you have to fill out any medical forms at home? No If yes, did someone help you complete the forms? No Who helped you? A family member A friend or neighbor Someone from a community organization Someone else: (who?) 20. Are there questions about your health or your treatment that were not answered or you did not asked because of language? No 21. Have you had any difficulty making appointments, getting follow up information or with hospital bills because of language issues? No 22. Did you get any printed information or booklets from the hospital translated into your primary language? No If yes, what materials did you get? (for example, information about your treatment, things to do when you get home, prescriptions, etc.) Thank you for your help. Please complete the following for each interviewee. Make additional notes on the reverse side of page. Male Female Age range (Give your best estimate) 20 to to to and over Accompanied Unaccompanied 46

50 47

51 APPENDIX C: Hospital Administrator Interview Questions 19. Which communities does your hospital or health facility serve and which are the primary immigrant, non- English speaking populations to whom you provide health services? 20. How does serving large numbers of recent immigrants and non- English speaking patients impact on your health care facility and services? 21. What services, programs, staffing or accommodations does your hospital or health facility make available to patients who need language assistance or have particular cultural considerations in receiving health care? 22. Who is the designated Language Assistance Coordinator at your facility? 23. What is their main job title and what other job responsibilities do they have in addition to language assistance? 24. How often are your written policies and procedures for providing language assistance services for your patients reviewed and/or updated? Who conducts the review? 25. How often does your hospital or health care facility provide training or updated information on language access policies and procedures to your administrative or line staff? 26. Who generally conducts the training or review with your front line staff? Is it provided using internal staff or do you use outside resources for the trainings? 27. What printed materials do you provide that informs the public how to access free language assistance services? (Ask for copies of sample materials in a variety of languages) 28. Who provides direct language assistance services for patients at your hospital or facility? Do you employ trained interpreters or use bilingual hospital staff? 29. Do you use Language Line or another telephone service to provide language assistance? On average, 48

52 30. From your knowledge and experience, how long do patients wait to receive language assistance in their primary language either through staff services or telephone services? 31. What is the hospital or health facilities policy or process when a patient, even after being advised of their right to free language assistance, prefers to use a family member, friend or other non- hospital personnel to act as interpreter? 32. Which are the primary languages, other than English, that you provide your patients? 33. How have you identified these languages? 34. Who are the key front line hospital staff impacted by the need for effective language assistance to provide quality services? 35. Is language assistance available throughout your facility, including main reception, billing and other non- medical areas? 36. What would you say the biggest challenges are to providing a sufficient level of language assistance to ensure quality health care for all patients? How can they be best addressed? 49

53 APPENDIX D: Number of Surveys and Languages by Hospitals and Clinics Hospital/Clinic Number of Surveys Administered (N=99) Languages Lutheran Park Ridge Family Health Center 2 Arabic Lutheran Chinese Family Health Center 3 Chinese Jacobi Medical Center 7 Spanish Elmhurst Hospital Center 25 Spanish, Korean, Chinese Jamaica Hospital Medical Center 8 Spanish, Haitian- Creole Kings County Medical Center 7 Haitian- Creole SUNY Downstate Medical Center 8 Haitian- Creole Richmond University Medical Center 7 Spanish Lincoln Medical Center 10 Spanish New Hospital Queens 16 Korean, Chinese Brooklyn Hospital Center 1 Arabic Lutheran Medical Center 5 Arabic Total 99 50

54 APPENDIX E: Hospital Language Access: Literature Review & Key Issues Providing language access for LEP individuals in a hospital setting is important for many reasons. Effective communication is the basis for the patient- provider relationship. Effective patient- provider communication is a critical element for a patient- centered approach to care. If providers and patients cannot communicate, there is little hope for an effective diagnostic process or successful treatment adherence. Health care organizations face an array of challenges in providing accurate, adequate and efficient on- site medical interpretation for Limited English Proficient (LEP) patients. Hospitals failure to provide adequate linguistic competency and tools 30 and use of untrained ad hoc interpreters, 31 results in poor patient outcomes for LEP patients. 32 As such, hospital language assistance services are crucial for: providing quality care for LEP patients; preventing medical misdiagnoses/errors; and avoiding liability and costly malpractice litigation and civil rights complaints or investigations. The experiences of members of NYIC s Health Collaborative illuminate the stakes of utilizing untrained interpreters in a hospital setting. During a recent Collaborative meeting, a member reported that one of his Punjabi- speaking clients lost custody of her child when an unqualified interpreter mistranslated information between the physician and his infant patient s mother. Due to errors in interpretation by the unqualified interpreter, the provider falsely accused a mother of abusing her child. As a result, the child s parents were forced to move out of their homes and relinquish custody of their infant child to his grandparents. Mistakes by untrained interpreters can lead to medical errors and other negative consequences for LEP patients in this case, an ad hoc interpreter cost these LEP parents their child and their home. In order to ensure quality care for LEP patients in US hospitals, it is crucial to establish criteria for training and certification to ensure the qualifications of medical interpreters. Beyond concerns of simple miscommunication, untrained interpreters run the risk of misinterpreting cultural meanings or imposing their own interpretations upon the patient s descriptions. 33 As such, establishing criteria for qualified medical interpretation is necessary for hospitals seeking to provide the best care for their LEP patients. 30 Flores, Glenn. Language Barriers to Health Care in the United States N Engl J Med; 355: July 20, and Scheckner, Yael, At El. "Her husband doesn't speak much English: conducting a family meeting with an interpreter. J Palliat Med. Apr;15(4): doi: /jpm Epub 2011 Nov 22, Flores Flores, Glenn, At El. Access to hospital interpreter services for Limited English Proficient Patients in New Jersey: A statewide evaluation (2008) and Scheckner, Yael, At El. "Her husband doesn't speak much English: conducting a family meeting with an interpreter. J Palliat Med. Apr;15(4): doi: /jpm Epub 2011 Nov 22,

55 Despite all these pressing concerns, language assistance practices in health care settings are poorly understood and under- examined in the scholarly literature. Participants in a 2004 OMH study identified various factors that impede the funding and publication of cultural competence research. According to study participants, funders and journal reviewers tended to lack familiarity with the impact of language and culture on health care delivery and viewed cultural competence research as marginal and/or high risk. 34 These factors have contributed to inadequate resources for this type of research and reluctance on the part of researchers to dedicate themselves to this field. Yet while language and cultural competence issues have not been studied as widely or rigorously as they should be, a review of the field of scholarly literature that has been published reveals a practically unanimous consensus about best practices for serving LEP populations in hospitals and other health care environments. a. Language Access and Health Outcomes for LEP Patients The literature on language access in US hospitals provides overwhelming support for the necessity of adequate language assistance services for protecting the health of LEP populations. Studies dating back to at least the early 1990s find that Limited English Proficiency is associated with adverse health outcomes. 35 According to a 2005 study, LEP patients are more likely to experience an adverse event, defined as any unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient. 36 In others words, failure to address language barriers can lead to real harm for LEP patients. 37 More specifically, LEP status is correlated with lower rates of access to preventive services, inconsistent access to health care, drug complications, poor compliance, and over- diagnosis. 38 Studies have also demonstrated that patients are less likely to receive crucial health education without language access in health care setting such as emergency departments. 39 Fortunately, qualified language assistance services have been found to mitigate the adverse health effects of LEP status and lead to increased satisfaction for patient populations. According to a systemic analysis of language assistance services, when LEP patients have access to services such as interpreters, they experience, optimal 34 Fortier J. P., Bishop, D Setting the agenda for research on cultural competence in health care: final report. Edited by C. Brach. Rockville, MD: U.S. Department of Health and Human Services Office of Minority Health and Agency for Healthcare Research and Quality Flores, Glenn. The Impact of Medical Interpreter Services on the Quality of Health Care: a Systematic Review. Med Care Res Rev : 255. May 13, Todd 1993, David 1998, Enguidanos 1997, Crane 1997, Baker 1998, Carrasquillo 1999, Derose Quoted in, Divi, Chandrika, Richard G. Koss, Stephen P. Schmaltz and Jerod M. Loeb, Language proficiency and adverse events in US hospitals: a pilot study. International Journal for Quality in Health Care. Volume 19, Number 2: pp: February Ibid, p Flores, p Baker DW, Parker RM, Williams MV, Coates WC, Pitkin K. Use and effectiveness of interpreters in an emergency department. JAMA ; 275 (10):

56 communication, the highest patient satisfaction, the best outcomes, and the fewest errors of potential clinical consequence. 40 Qualified interpreters lead to better health outcomes for LEP immigrants who have access to their services. Poor communication is also highly correlated with patient dissatisfaction and can pose a barrier to informed consent. 41 According to a 2001 study, almost one quarter of all patients who change physicians are motivated by dissatisfaction with physician- patient communication. 42 Quality language interpretation services thus lead to both healthier and happier patient populations. b. Basic vs. Qualified Medical Interpreters (these two whole paragraphs are not clear) Individuals claiming proficiency in the patient s language but lack the training to provide adequate medical interpretation services should not be confused with qualified medical interpreters. Many hospitals utilize basic interpreters, interpreters who speak conversationally and interpret information for patients. Many basic interpreters lack the necessary English skills to understand medical providers in hospital care meetings with a LEP patient. 43 Moreover, because they do not have training in medical terminology, they lack the vocabulary to properly translate medical terms, which results in frequent cases of misinterpretation and miscommunication of health information both to the provider and to the patient. 44 Some of the hospitals in this study made distinctions between basic interpreters (not qualified to provide medical interpretation) and qualified medical interpreters, allowing basic interpreters to provide simple information to patients such as directions within the hospital but prohibiting them from providing medical interpretation. Other hospitals deployed basic interpreters to provide medical interpretation when qualified interpreters were unavailable. Basic interpreters may serve a valuable role in a hospital setting to provide conversation and basic non- medical assistance to patients, but it is crucial that hospitals do not rely upon basic interpreters to provide medical interpretation between providers and patients except for in extreme emergencies. If one person speaks directly in the language without interpreting, they should not be called interpreters. A native Spanish speaker who went to medical school in Mexico (or a nurse trained in Venezuela or a nurse aid who grew up in Ecuador and finished high school there) may provide care, services, in Spanish but is NOT interpreting. A basic interpreter, from what I understand here, may be someone who interprets a conversation that has no 40 Flores, p Woolshin et. al 1995; Jackson, 2001; Hafflner, 1992l Fortier Jackson Moreno, Maria R et al. Assessing Dual- Role Staff- Interpreter Linguistic Competency in an Integrated Healthcare System. J Gen Intern Med 22(Suppl2): Moreno, Maria R et al. Assessing Dual- Role Staff- Interpreter Linguistic Competency in an Integrated Healthcare System. J Gen Intern Med 22(Suppl2): p

57 medical or any other clinical content, e.g., making an appointment, financial assistance, etc.) c. Dual- Role Interpreters Many hospitals also utilize dual- role interpreters, staff who perform other roles such as providers, administrative and medical assistants who are identified as bilingual for the purposes of providing interpretation services. In some cases, dual- role interpreters are tested by the hospital for language proficiency and for knowledge of medical terminology in the languages they are going to interpret. But in many hospitals, dual- role interpreters are self- identified and receive no formal training or testing. A 2007 study of dual- role interpreters found that, 1 in 5 dual- role staff interpreters at a large health organization had insufficient bilingual skills to serve as interpreters in a medical encounter. 45 The study found that some staff designated as dual- role interpreters were actually LEP themselves and lacked the basic language skills to understand provider communication in English. 46 The study looked at the efficacy of a language competence assessment exam that included written and oral components in English and the second language. Approximately 23% of the dual- role interpreters in the study did not qualify as medical interpreters. Thus, almost a quarter of the dual- role interpreters in the study should not have been providing medical interpretation. This evidence makes it clear that it is crucial for hospitals to make distinctions between basic and qualified medical interpreters and to test all dual- role interpreters for basic proficiency and ability to provide medical interpretation. Besides strictly medical concerns, the utilization of dual- role interpreters raises a host of complicated labor issues. Dual- role interpreters often complain of having additional duties imposed upon them without supplementary compensation, and some labor unions object to the provision of language assistance services as outside the scope of the job descriptions of their members contracts. To complicate matters, dual- role interpreters who provide interpretation outside of their assigned area may lead to staffing shortages when they are pulled away from their primary jobs to act as interpreters. d. Ad Hoc Interpreters, Family and Child Interpreters It is also a common practice for hospitals to rely upon ad hoc interpreters family members, friends, untrained medical and nonmedical staff, and strangers when formal interpretation is not available. 47 But ad hoc interpreters can do more harm than good for LEP patients and families in a hospital setting. 48 According to Schenker, et al., Many ad 45 Moreno, Maria R et al. Assessing Dual- Role Staff- Interpreter Linguistic Competency in an Integrated Healthcare System. J Gen Intern Med 22(Suppl2): Ibid, p Flores, p Flores, p

58 hoc interpreters do not have adequate skills in both languages to interpret complex medical discussion, and heightened emotions or personal beliefs may further threaten their ability to interpret accurately. 49 Ultimately, the use of ad hoc interpreters may disrupt patient outcomes. 50 The use of ad- hoc interpreters is common in US health care settings, and studies generally find that their use is harmful for LEP patients. An evaluation study of the New Jersey health care system found that 75% of hospitals that employ on- site medically qualified bilingual staff or volunteer interpreters actually used ad hoc interpreters to serve as translators, which compromised their primary job responsibilities. 51 Studies also have found that ad hoc interpreters most commonly commit errors of omission (52%), followed by false fluency (16%), substitution (13%), editorialization (10%), and addition (8%). 52 Moreover, many ad hoc interpreters are actually LEP themselves. 53 More specifically, the use of family members as ad hoc interpreters creates a host of linguistic and ethical problems. 54 Linguistically, the family members may not have the skills to provide accurate communication, and stress has been shown to affect interpretation by untrained interpreters. 55 The ethical challenges around family interpretation begin with concerns over confidentiality and privacy and attendant HIPAA compliance issues. 56 Furthermore, the presence of family members or a partner during a clinical encounter may deter a patient from sharing information during a medical diagnosis appointment, especially among those patients who are visiting due to sensitive issues, such as domestic violence, substance abuse, or psychiatric illness. 57 One of NYIC s Health Collaborative members recently reported a case of an Arabic- speaking father interpreting for a daughter who was alarmed when the provider informed him that the patient required a pregnancy test before receiving an X- ray, a routine procedure for all women of child- bearing age (regardless of sexual activity). The father, an observant Muslim, became enraged at the allegation that his unmarried daughter could be pregnant, thereby discouraging the daughter from continuing to seek treatment. In general, emotions from a family member may alter a patient s diagnosis, and cultural beliefs and religious views may discourage a patient from revealing vital health information. 58 With the exception of one scholar that argues for a positive role that family 49 Schenjer, Yael, Alexander K. Smith, Robert Arnold, and Alicia Fernandez. Her Husband Doesn t Speak Much English: Conducting a Family Meeting with an Interpreter. Journal of Paliative Medicine Volume 15, No. 4, Flores Flores, Glenn, Et Al. Access to hospital interpreter services for Limited English Proficient Patients in New Jersey: A statewide evaluation (2008) 52 Flores, et al. Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters Pediatrics 53 Ibid 54 Pauwels A Cross- cultural communication in the health sciences McMillan Education, Melbourne, Haffner L Translation is not Enough: Interpreting in a Medical Setting. Western Journal of Medicine Health Insurance Portability and Accountability Act of 1996 HIPAA; Pub.L , 110 Stat. 1936, 57 Flores, 2006; Flores, Scheckner, et al.,

59 members can play as cultural brokers in health care settings, 59 the resounding consensus in the literature is that it is medically inappropriate for family members to provide interpretation. 60 Meanwhile, the use of minors as ad hoc interpreters also represents a special case, which is all too common in US hospital settings. When minors perform interpretation for family members in difficult medical situations, they can experience Post Traumatic Stress Disorder (PTSD) as a consequence. 61 Often, providing interpretation in delicate medical situations may put minors in situations that they are not mature enough to process. The literature concludes that the use of minors interpreting should be avoided except for in cases of extreme emergency. e. Staff Diversity Another subfield of literature has found that patient outcomes are also linked to racial, ethnic and language concordance between providers and patients (where physicians and patients share race, ethnicity or language). 62 Concordance along racial/ethnic and linguistic lines has been associated with improved patient outcomes, longer visits, and greater patient satisfaction. 63 Across studies, there is strong support for increasing workforce diversity to reflect patient populations as a means of improving linguistic and cultural competence in clinical settings. In fact, HHS CLAS standards call for increasing workforce diversity across a range of staff roles, ranging from receptionist to providers to members of boards of directors of health care facilities. 64 Further, workforce diversity is also a stated goal of the Affordable Care Act. 65 As such, both the CLAS standards and the ACA make a strong case for hospitals to adopt workforce diversity measures as part of overall language access programs. 59 Using Family Members as Interpreters in the Clinical Setting. The Journal of Clinical Ethics 19(3), Ho, A. (2008). 60 G. Flores et ai., "Errors in MedicaL lnterpretation and Their Potential Clinical Consequences in Pediatric Encounlers," Pediatrics "111, no. 1 (2003): 6-14; E. Jacobs et al., "Impact oflnterpreter Sewices on Delivery of Health Care to Limited- English- Proficient Patients," Journal of General Internal Medicine16, no. 7 (2OO1.)t Z. G. Rollins, "Translation, Por Favor," - FIospitals and Health Networks 76, r\o. 72 (2002): 46-50; C. Blake, "Ethical Considerations in Working with Culturally Diverse Populations: The Essential Role of ProfessionaL lnterpreters," CPA Bulletin 35, no. 3 fiune 2003): 21-3; Floles et al. 61 Jacobs B The Hazards of Using a Child as an Interpreter. Journal of the Royal Society of Medicine, 88 8, Cooper, Lisa A. and Neil R. Powe. Disparities in Patient Experiences, Health Care Processes, and Outcomes: the Role of Patient- Provider Racial, Ethnic, and Language Concordance. Commonwealth Fund, July Ibid 64 Staff diversity at all levels of an organization can play an important role in considering the needs of patients/consumers from various cultural and linguistic backgrounds in the decisions and structures of the organization. Examples of the types of staff members whose backgrounds should reflect the community s diversity include clinical staff such as doctors, nurses, and allied health professionals; support staff such as receptionists; administrative staff such as individuals in the billing department; clergy and lay volunteers; and high- level decisionmakers such as senior managers, corporate executives, and governing bodies such as boards of directors How Will the Affordable Care Act Help Diversify the Health Care Workforce? Robert Wood Johnson Foundation publications/find- rwjf- research/2011/12/how- will- the- affordable- care- act- help- diversify- the- health- care-.html 56

60 f. Interpreter Certification and Testing There is currently no official government certification process for medical interpretation, and there are two healthcare interpreter certification programs in the US. Nationally, there are several independent bodies that establish standards for medical interpreters: the National Board of Certification for Medical Interpreters (NBCMI), the National Council on Interpreting in Health Care (NCIHC), 66 and the Certification Commission for Healthcare Interpreters (CCHI). 67 NCIHC provides both written and oral certifications in Spanish only and oral certification in Russian, Cantonese, Korean, Mandarin and Vietnamese. In New City, the Health and Hospitals Corporation (HHC) has partnered with the City University of New (CUNY) to create the CUNY Healthcare Interpreter Certificate program which, upon successful completion, allows students to serve as hospital interpreters. 68 In addition, private companies, such as Language Line Solutions and Cyracom also provide interpreter skill tests and language proficiency testing. Other states, such as California, have established statewide rules for certifying medical interpreters. As of 2009, all interpreters who provide service to limited- English- speaking enrollees and beneficiaries covered by commercial plans and insurance in California must get trained in the standards of practice of the California Healthcare Interpreting Association (CHIA). 69 In New, a statewide certification exists for court interpreters but there are no standards of practice for interpretation in a hospital setting and no official requirements for training or testing of medical interpreters. g. The Role of Physicians: Language- Concordance, Underutilization and False Fluency Other research has assessed to the role of physicians within overall systems of language assistance. The literature demonstrates that LEP patient needs tend to be better served by language- concordant providers, meaning the provider is able to communicate with the patient in his or her preferred language. 70 Studies of Spanish- speaking patients have found that patients were more likely to keep appointments, ask their provider more questions, and recall treatment instructions at a higher rate when their provider was Spanish- speaking/language- concordant. 71 While language- concordance may not always be possible, these findings lend weight to above- mentioned studies calling for greater workforce diversity so that staff better reflect patient populations. 66 National Council on Interpreting in Healthcare. National Standards of Practice for Intepreters in Health Care. September release shtml Fortier and Bishop, 71 Manson Seijo,

61 Meanwhile, other studies suggest that physicians underutilize language assistance services such as interpreters, even when they are available. 72 The causes for this are not well understood; however, this trend points to another provider- related challenge, that of false fluency, whereby physicians with inadequate language skills overestimate their capacity to communicate in the patient s preferred language. 73 While some physicians and other providers may not welcome initiatives to test their language capacities, it is crucial for hospitals and clinics to find ways to address this challenge to avoid medical errors. Physician- patient interactions between LEP patients and providers who do not speak their preferred language are both bilingual and bicultural, as language communicates cultural meanings as well. 74 As such, it is not sufficient for providers to simply learn the languages of their patients they must learn how to interact with interpreters and to be aware of the cultural dimensions of language in a clinical setting. The literature highlights successful provider training programs such as the Cross Cultural Health Care Program at Asian Health Services of Oakland, California. Programs such as this can serve as replicable models for improving care for LEP patients across the country. 75 h. Modalities of Interpretation When a language barrier exists between providers and patients, health care institutions can adopt a range of approaches to overcome this obstacle. On a national level, hospitals utilize a broad range of methods to provide medical interpretation. A 2009 survey conducted by the telephonic provider Cyracom defined four primary modalities of providing oral interpretation: telephonic; dedicated staff interpreters; contract interpreters; and bilingual staff (dual- role). 76 According to the survey, 75% of health care providers employ more than one modality for interpretation at their facilities % of facilities provide language services telephonically; over 50% hire staff interpreters; approximately 45% use dual- role bilingual staff; 19% rely upon family members; and over 10% utilize volunteer interpreters. When asked about largest obstacles to providing language services, respondents identified the following factors as most important (listed from most to least): too few interpreters; funding; lack of staff training; and staff/physician resistance 78 The choice of modalities may be largely determined by the public reimbursement streams available in each state (discussed below). For example, states like 72 Diamond, Lisa C, Yael Shenker, Leslie Curry, Elizabeth Bradley, and Elizabeth Fernadenz. Getting By: Underuse of Interpreters by Resident Physicians. J Gen Intern Med 24 (2): December Flores, Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters Pediatrics Vol. 111 No. 1 January 1, 2003 pp (doi: /peds ) 74 Scott, C.J. Enhancing patient outcomes through an understanding of intercultural medicine: guidelines for the practitioner. Maryland Medical Journal 46 (4) Teaching Cultural Competence in Health Care: A Review of Current Concepts, Policies and Practices. Office of Minority Health, US Department of Health and Human Services, March 12, language- services- are- provided- in- us- hospitals/ 77 Ibid 78 Ibid 58

62 Kansas that only offer Medicaid/SCHIP reimbursement for telephonic services may discourages other in- person modalities. However, the question remains: which modality is the most effective for providing quality health care? The shortcomings of using untrained and dual- role interpreters have been discussed at length above. Yet questions remain about the use of proximate- consecutive techniques such as in- person interpretation (which can introduce a time- lag between the words of the patient and the interpretation) versus new forms of remote and simultaneous interpretation made possible through telephonic and remote video- conferencing technologies whereby the interpreter simultaneously converts patient communication from one language to the other in the first person. 79 Recent studies have found that providers prefer in- person medical interpretation and video to telephonic services. 80 Visual cues are lost during telephonic interpretation encounters, thereby depriving all parties of crucial nonverbal information. However, new technology offers possibilities for remote communication of visual language. While interpreters across different studies consistently prefer face- to- face communication, clients and doctors seem to be satisfied with remote interpretation through methods such as videoconferencing. 81 Although remote video technologies still remain costly, they offer important possibilities for future provision of language access services. In the meantime, telephonic interpretation remains the least preferable method of providing language access and should be the last resort if face- to- face or video options are available. Also, further studies are needed to assess the efficacy of new technologies across larger sample sizes and longer periods of time. i. Medicaid Reimbursement for Language Assistance Services The availability of financial support for providing language assistance services remains a key factor in determining if and how hospitals across the country provide language services. There are currently 15 states, including New, that provide reimbursement for language assistance programs through Medicaid and SCHIP. Several other states (CA, TX, NC) are in the process of developing language access reimbursement mechanisms. 82 The majority of these states receive a 50% reimbursement from the federal government, with Hawaii, Idaho, Maine, and Utah receiving higher reimbursement rates up to 79.25%. 83 It is important to note that the majority of the states who reimburse providers for 79 Hornberger, John C. et al. Eliminating Language Barriers for Non- English- Speaking Patients. Medical Care, Vol. 34, No. 8 (Aug. 1996) pp Locatis, Craig et al. Comparing In- Person, Video and Telephonic Medical Interpretation, J Gen Intern Med 25 (4): 345:50. January 27, Azarmina, Pejman et al. Remote Interpretation and Medical Encounters: a Systemic Review. Journal of Telemedicine and Telecare 11.3 (2005). Pp Youdelman, Mara. Medicaid and SCHIP Reimbursement Models for Language Services. National Health Law Program. March Ibid, p.3 59

63 language assistance costs through Medicaid and SCHIP, with the exception of Hawaii, have relatively small LEP populations. 84 For states that do reimburse for language assistance services, there is a vast range of reimbursement rates and mechanisms. In Hawaii, for example, the state reimburses all fee- for- service providers $36/hour in 15 minute increments; the reimbursement is paid directly to the language agencies. Meanwhile, in Idaho, providers are directly reimbursed through a fee- for- service model at the rate of $12.16/hour. Meanwhile, Kansas Medicaid/SCHIP only reimburses for telephonic interpretation for Medicaid managed care at the rate of $1.10/minute for Spanish and $2.04/minute for all other languages. 85 New, which recently began Medicaid reimbursements for language assistance, reimburses at the rate of $11/hour for a minimum of 8 and a maximum of 12 minutes of medical language interpreter services and $22/hour for 23 or more minutes, with no maximum. 86 j. Data Collection and Patient Records Finally, the literature also highlights the issue of incomplete patient records and inadequate data collection as an obstacle to quality care for LEP patients. 87 Literature supports the finding that health care organizations should collect information on patients race, ethnicity and language in order to understand the needs of the population they serve, measure disparities in care within their institution, initiate programs to improve quality of care, and provide patient- centered care. 88 In addition to improving care for patients, complying with standards for collecting data on language and race/ethnicity is also mandated by the Center for Medicare and Medicaid Services (CMS) and required for accreditation by the Joint Commission. 89 However, compliance to standards of data collection has proven to be a challenge for hospitals. A 2004 Commonwealth Fund Report found that while 78% of hospitals collect patient information on race and ethnicity, the data is of poor quality. 90 Poor standards of data collection in hospitals undermine efforts to use data to improve quality of care. The literature on data collection points to several key ways to improve data: 1) hospitals should rely upon on self- reporting for race/ethnicity because it is more accurate than staff observation; 2) hospitals should collect preferred language for LEP patients; and 3) hospitals should address negative patient reactions upon solicitation of this information by 84 Chen, Alice M et al The Legal Framework for Language Access in Healthcare Settings: Title VI and Beyond. J Gen Intern Med November 22(Suppl 2): Ibid 86 New State Medicaid Update: Coverage of Medical Language Interpreter Services. Vol 28, No. 11. October Ver Ploeg, M. and E. Perrins. (eds). Eliminating Health Disparities: Measurement and Datea Needs. National Research Council. Washington, DC: National Academies Press, Hasnain- Wynia, Romana and David W. Baker. Obtaining Data on Patient Race, Ethnicity, and Primary Language in Health Care Organizations: Current Challenges and Proposed Solutions. Health Research and Educational Trust. 41:4 Part 4, August Pp Ibid, Ibid,

64 training staff to assure patients of the confidentiality of this data, alleviate fears about racial/ethnic profiling and immigration status concerns, and to address other barriers for patients to providing accurate information. 91 Moreover, hospitals should improve the use of data by stratifying data by relevant demographic categories and language ability and develop metrics to correlate this data to health care outcomes to measure disparities. 92 Training is key to the success of these data collection efforts. A study of Massachusetts LEP care found that greater staff comfort in asking questions about race/ethnicity led to decreased patient resistance to sharing information. 93 In addition, another study found that patients were less reluctant to share information of this nature when they were explicitly told it was to improve quality of care. 94 Finally, in order to collect accurate data on language assistance needs, patients should be assessed by being asked both: 1) to rate their ability to speak English (i.e. less than very well ); and 2) to identify their preferred language. 95 This contrasts with the practice at many hospitals of only collecting primary language, which may not necessarily reflect the language in which patients prefer to receive services. 91 Ibid 92 Wynia, Matthew, et al. Collecting and using race, ethnicity and language data in ambulatory settings: a white paper with recommendations from Commission to end Health Care disparities. American Medical Association, Weinic, RM et. al Measuring racial and ethnic disparities in Massachusetts. Health Affairs (5): Baker DW et. al Attitudes toward health care providers collecting information about patient s race, ethinicity, and language. Med Care : Report Brief: Race Ethnicity, and Language Data: Standardization for Health Care Quality Improvement. Institute of Medicine of the National Academies. August

65 APPENDIX F: The Legal/Policy Landscape of Hospital Language Access 1. The Legal Landscape The right to language access in a health care setting is guaranteed by laws on the federal, state, and local level. As such, providing language access in hospitals for LEP patients is crucial from both a medical and a legal perspective. Language access is important from a provider point of view because of the liability that providers could face and because it is required to comply with local, state and national laws and to receive accreditation from the Joint Commission. Below is an overview of relevant laws that regulate the provision of language assistance services in the city of New. Federal Law CIVIL RIGHTS ACT TITLE IV (1964) According to Title IV of the Civil Rights Act, No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance from the Department of Health and Human Services. 96 In 1974, the Supreme Court ruled in Lau v. Nichols that discrimination based on language is a proxy for nation of origin discrimination as covered under the Civil Rights Act (CRA). 97 As a result of this decision, federally- funded entities such as hospitals (most of which receive federal Medicaid, SCHIP and Medicare funds) cannot discriminate based on language spoken. The US Department of Health and Human Services (HHS) subsequently issued further guidance on language access under the CRA, stating No person may be subjected to discrimination on the basis of national origin in health and human services programs because they have a primary language other than English [emphasis added]. 98 Importantly, HHS also clarified through regulations that intent was not necessary to prove discrimination - - discriminatory effects were all that were required to establish discrimination. As such, organizations receiving federal funds may not, directly or through contractual or other arrangements, utilize criteria or methods of administration 96 Section 601, Civil Rights Act of U.S.C. 200d, et. seq..; 45 C.F.R et seq.; and 28 C.F.R Lau v. Nichols, 414 U.S. 563 (1974), 98 Fed. Reg (Dec. 17, 1980) cited in Chen, Alice, Mara Youdelman, and James Brooks The Legal Framework for Language Access in Healthcare Settings: Title VI and Beyond. J Gen Intern Med 2007, November; 22(Suppl 2):

66 which have the effect of subjecting individuals to discrimination because of their race, color, or national origin. 99 According to New Lawyers for the Public Interest, It is sufficient for an entity s actions to have a discriminatory impact in order for HHS to commence an enforcement action. Therefore, failure to provide language access [in and of itself] has a discriminatory impact on the basis of national origin. 100 This interpretation has important implications for the provision of language access in a hospital setting, as the failure to provide language access per se constitutes a form of discrimination. A 2001 Supreme Court case, Alexander v. Sandoval, weakened a key enforcement mechanism by ruling that individuals did not have a private writ of action under Title IV to sue for disparate ( indirect ) impact, but only in cases of intentional discrimination. 101 However, hospitals receiving federal funding still have an obligation to provide language assistance services under Title IV. Patients who are denied language assistance services may file a complaint with the Office of Civil Rights (OCR), which could trigger an OCR investigation. 102 Hospitals in states such as California, Illinois and New Mexico have had to modify their language access plans in response to OCR investigations. 103 Moreover, HHS may deny federal funds to hospitals deemed not to be in compliance with the language access requirements of Title IV. 104 EXECUTIVE ORDER (2000): In 2000, President Clinton issued Executive Order 13116, Improving Access to Services for Persons with Limited English Proficiency, 105 which was later reaffirmed by President George W. Bush. E.O importantly highlighted LEP language access issues on a national stage and directed federal agencies to develop plans for how to federal fund beneficiaries can provide LEPs language access to comply with Title IV. 106 Under this Executive Order, the Department of Justice (DOJ) was conferred the authority to provide agencies guidance on their obligation to provide language assistance. 107 To further clarify the extent of an organization s obligations to provide language access, OCR developed a four factor analysis C.F.R. 80.1, et. seq. cited in NYLPI Legal Access Legal Cheat Sheet, February Final%20- %20February% pdf 100 Ibid 101 Alexander v. Sandoval, 532 U.S. 275 (2001) areas/civil- rights/language- access/hospital- care- in- new- york.html 103 Ibid. 104 Ibid /pdf/ pdf 106 Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons Empire Justice Center,

67 These four factors are summarized by the Joint Commission as follows: 1. The number or proportion of LEP persons served or encountered in the eligible service population; 2. The frequency with which LEP individuals come in contact with the recipients program, activity, or service; 3. The nature and importance of the recipient s program, activity, or service; and 4. The resources available to the recipient and costs. 109 OCR also issued guidance that 1. LEP populations must be notified about the availability of free interpreting services; 2. Covered entities cannot require friends or family to provide interpretation; and 3. Interpreters must be competent in medical terminology, confidentiality and impartiality. 110 In addition, written (not oral) vital materials (i.e. consent, intake, notifications of rights, and complaint forms), must be translated according to the following requirements under a safe harbor clause that limits liability for federally funded providers: 1. Written vital documents must be translated for each LEP group that constitutes 5% or 1000 persons, whichever is less, of the population served; 2. For LEP populations totaling less than 50 or representing 5% of the population served, covered entities can fulfill their obligations by providing written notice in the primary language of the availability of free oral interpretation of written materials. Offering a more comprehensive guidance for the provision of language assistance services, the HHS Office of Minority Health (OMH) issued National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care that apply to all federal fund recipients. 111 The following are the most recent version of the CLAS standards: 112 National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care: Principle Standard 1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs Fed. Reg Ibid 111 National Standards for Culturally and Linguistically Appropriate Services in Health Care The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice. 64

68 Governance, Leadership, and Workforce: 2. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources. 3. Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area. 4. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. Communication and Language Assistance 5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. 6. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing. 7. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. 8. Provide easy- to- understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. Engagement, Continuous Improvement, and Accountability: 9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization s planning and operations. 10. Conduct ongoing assessments of the organization s CLAS- related activities and integrate CLAS- related measures into measurement and continuous quality improvement activities. 11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery. 12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area. 13. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness. 14. Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints. 15. Communicate the organization s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public Finally, the following federal laws and regulations also contain language access provisions applicable to hospital settings: 65

69 Americans with Disabilities Act: requires that public accommodations provide access for people with disabilities, including qualified interpretation; 113 and Rehabilitation Act: Includes requirements for effective communication with the deaf and hard of hearing; 114 Additional laws and regulations cover private insurance plans that interact with hospitals and health care facilities. 115 State Law After more than a decade of advocacy by the New Immigration Coalition and allies, New State issued regulations in 2006 that would define language assistance in a hospital setting. In the years prior to the issuance of regulations, the NYIC engaged in a range of advocacy, including conducting surveys at hospitals, filing civil rights complaints, and advocating with hospitals and state policymakers, to push for the implementation of a statewide mandate to provide language access. This victory was followed by an expansion of the state s language access laws beyond hospitals to cover all state agencies that provided services directly with individuals through a 2011 executive order issued by Governor Cuomo. The 2006 regulations amended New State s public health law to explicitly address language assistance for LEP New ers in the state s Patient s Bill of Rights. According to the Patient s Bill of Rights, 116 New hospitals must: 1. Develop a Language Assistance Program for LEP patients; 2. Designate a Language Assistance Coordinator who shall report to the hospital administration and who shall provide oversight for the provision of language assistance services; 3. Develop policies and procedures that assure timely identification and ongoing access for patients in need of language assistance services; 4. Create materials that explain how to access free language assistance services; 5. Provide ongoing education and training for administrative, clinical and other employees with direct patient care contact regarding the importance of culturally and linguistically competent service delivery and how to access the hospital s language assistance services on behalf of patients; 113 Americans with Disabilities Act of 1990 (ADA) [42 U.S.C et seq.] 114 Rehabilitation Act of U.S.C Medicare Regulations for Medicare Advantage Program (42 C.F.R & ): requirement of multilingual marketing materials when private plans serve large LEP populations and cultural and linguistic competence; Medicaid Managed Care (42 C.F.R ): States must identify major LEP populations both enrolled and potentially enrolled and make written information available in those languages. Participating Managed Care Organizations must provide oral interpretation and notify enrollees of the availability of services; and Patient Protection and Affordable Care Act ( 1557 (Pub.L ):): extends the civil rights protections of LEP individuals to language access by applying those standards to insurance companies that provide insurance within state exchanges within which individuals are eligible for federal assistance. 116 Public Health Law(PHL)2803 (1)(g)Patient s Rights, 10NYCRR, 405.7,405.7(a)(1),405.7(c)

70 6. Post signage regarding the availability of free language assistance services in public entry locations and other public locations; 7. Identify the language of preference and language needs of each patient upon initial visit to the hospital; 8. Document the patient s language of preference, language needs, and the acceptance or refusal of language assistance services in the patient s medical record; 9. Not rely upon family members, friends, or non- hospital personnel may not act as interpreters, unless: a. the patient agrees to their use; b. free interpreter services have been offered by the hospital and refused; and c. issues of age, competency, confidentiality, or conflicts of interest are taken into account. 10. Not rely upon minors younger than 16 years of age; individuals younger than 16 years of age should only be used in emergency circumstances and their use documented in the medical record. 11. Provide interpreters to vision and/or hearing impaired individuals in the inpatient and outpatient setting. The interpreters must be provided within 20 minutes and to patients in the emergency service within 10 minutes of a request to the hospital administration by the patient, the patient s family or representative or the provider of medical care. 12. Perform an annual needs assessment utilizing demographic information available from the United State Bureau of the Census, hospital administrative data, school system data, or other sources, that will identify limited English speaking groups comprising more than one percent of the total hospital service area population. 13. Translate of significant hospital forms and instructions into the languages identified by the needs assessment; and 14. Make a reasonable accommodation for a family member or patient s representative to be present to assist with the communication assistance needs for patients with mental and developmental disabilities. 117 In addition to the Patient s Bill of Rights, Executive Order 26 (2011) requires that: 1. All Executive State agencies that provide direct public services shall translate vital documents in the six most common non- English languages spoken by LEP individuals in the State of New ; 2. Each agency provide interpretation services; and 3. All covered state agencies publish a language access plan. 118 Furthermore, both the New State Office of Mental Health (OMH) and Office of Mental Retardation and Developmental Disabilities (OMRDD) have issued similar patients rights regulations requiring the timely provision of language assistance services and the creation

71 of language access plans. 119 Health care insurers and health maintenance organizations are obligated to provide language access under state insurance 120 and public health laws. 121 Local Law On the local level, the New Immigration Coalition was instrumental in passing the two laws in New City Local Law 73 and Executive Order 120 that collectively call for city government agencies to provide free translation, interpretation and other communication assistance services to limited- English- proficient (LEP) New ers. The following are local New City laws that cover language assistance in hospitals citywide: 1. New City Human Rights Law: Prohibits discrimination on the basis of race, creed, color, national origin, age, gender, disability, marital status, partnership status, sexual orientation or alienage or citizenship status in all places of public accommodation. Language access is guaranteed under this statute Equal Access to Human Services Act/Local Law 73 (2003): 123 Requires that all city social service departments, health departments and Workforce Investment Act offices and their subcontractors provide language assistance services including free interpretation and translated materials and notices. Local Law 73 also requires that covered city agencies keep records about LEP populations they serve and the language services they provide. 3. Executive Order 120 (2008): 124 EO 120 creates a centralized language access policy for New City. Under this Executive Order, all City agencies that provide direct public services must create a language access implantation plan in order to ensure meaningful language access to their services. This plan includes designating a Language Access Coordinator and developing strategies to provide services in at least the top six languages spoken in New City %20%20Final%20- % pdf 120 Insurance Law 3217a, 4324 and 4802; 121 Public Health Law 4403 and Administrative Code of the City of New pdf

72 2. Joint Commission Standards for Language Assistance Services In addition to federal, state and local laws, hospitals accredited by the Joint Commission must comply with their patient- centered communication standards, which began in January of The following is an overview of Joint Commission accreditation standards that pertain to language access: Provision of Care o The hospital effectively communicates with patients when providing care, treatment and services. 125 Patient s Rights o The hospital respects the patient s right to receive information in a manner he or she understands. 126 o The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression. 127 o The hospital provides language interpretation services, which may include hospital- employed interpreters, contract interpreting services, or trained bilingual staff and may be provided in- person or via telephone or video. 128 o The hospital communicates with the patient during the provision of care, treatment and services in a manner that meets the patient s oral and written communication needs. 129 Informed Consent o The hospital honors the patient s right to give or withhold consent (pertains to translation or interpretation of consent forms). 130 Identification and Documentation of Preferred Language o The hospital identifies the patient s oral and written communication needs, including the patient s preferred language for discussing health care. 131 o The medical record must contain information that reflects the patient s care, treatment and services, including the patient s communication needs, including preferred language for discussing health care 132 Human Resources o The hospital defines staff qualifications. 133 o Qualifications for language interpreters and translators may be met through language proficiency assessment, training and experience. o Training & orientation should be documented Joint Commission Standards, PC X 126 Ibid, R Ibid, RC Ep Ibid, R EP2, EP5; PC , EP2; HER EP1 129 Ibid, R EP Ibid, R , E Ibid, RC EP1 132 Ibid, RC EP1 and PC , EP1 133 Ibid, HR Ibid, HR

73 APPENDIX G: Medicaid Reimbursement for Language Assistance Services The NYIC achieved another major victory in securing Medicaid reimbursement for language assistance services through its role on the Medicaid Redesign Team (MRT) in As an official member of the MRT Health Disparities workgroup, the NYIC and its partners advocated for a series of recommendations to reduce disparities, including providing Medicaid reimbursement for language assistance services, a campaign that the NYIC had been working on for more than a decade. Medicaid fee- for- services reimbursement for language assistance services began effective October 1, This reimbursement applies to Article , 32 and 16 outpatient departments, hospital emergency rooms, diagnostic and treatment centers, federally qualified health centers and office- based practitioners to provide medical language interpreter services. Medicaid and Family Health Plus plans began reimbursing for language assistance services as per negotiated rates in December New recommends but does not require any particular national certification for interpreters under this reimbursement. As mentioned in the previous section, New reimburses at the rate of $11/hour for 8-22 minutes and $22/minutes for 23 minutes up to no maximum cap. Providers are only reimbursed for third- party interpreters, who are employed by or contracts with the Medicaid provider. Since most medical encounters often require much longer than 23 minutes, hospitals and other providers absorb the costs of any interpreting encounter provided over 23 minutes, leading to significant amounts of unreimbursed language assistance costs. 135 New State Medicaid Update: Coverage of Medical Language Interpreter Services. Vol. 28, No. 11. October

74 APPENDIX H: EXAMPLES OF SUCCESSFUL HOSPITAL MATERIALS The Language of a Healthier Immigrant New City 71

75 72

76 73

77 The Language of a Healthier Immigrant New City 74