Medical Office Staff Training Language Access

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Medical Office Staff Training Language Access
Cultural Issues

• Presenter Rebecca J. Patchin, M.D.
• Presented by the Riverside County Medical
  Association and the
• San Bernardino County Medical Society
• Supported by an educational grant from the
  California Academy of Family Physicians and The
  California Endowment

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Helping your Doctor Care for Patients with
Limited English Proficiency

• Resources Available
• Ideas Tools
• What Others Have Done

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Background

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

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Language Diversity

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

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Riverside County

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

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San Bernardino County

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

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Clear Communication between Doctor Patient

• Results in
• More accurate diagnoses
• Agreed and understood treatment plans
• Increased adherence to medication
  instructions.
• Improved health outcomes
• Reduction in frustration of doctors and office
  staff.
• Increased patient satisfaction

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What can YOU do to provide/identify language
access issues in your practice?

• Assess Your Practices Language needs
• Identify Existing Resources
• Develop a Plan for Improving Your Practices
  Language Access

Hint Use the Addressing Language Culture A
Practice Assessment for Health Care
Professionals as your guide.
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Health Care Interpreters

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

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Health Care Interpreters

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

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Key Terms

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

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Definition of Culture (one definition)

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

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Culture

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

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What Happens When Qualified Interpreters Are Not
Available?

• Family members, children, friends, any bilingual
  person in the area, and untrained bilingual
  employees are asked to interpret. All have good
  intentions and do not intend to cause harm, but
• Patients are seen without an interpreter.
• Patients are turned away unless they bring
  someone to interpret for them.

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Risks of Ineffective Communication

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

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Scope of Low Health Literacy (Institute of
Medicine Report)

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

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Health Literacy

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

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Key Findings in IOM Report

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

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Key Findings IOM Report

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

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An Example

• A two-year-old is diagnosed with an inner ear
  infection and prescribed an antibiotic. Her
  mother understands that her daughter should take
  the prescribed medication twice a day. After
  carefully studying the label on the bottle and
  deciding that it doesnt tell her how to take the
  medicine, she fills a teaspoon and pours the
  antibiotic into her daughters painful ear.

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Example..cont.

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

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List published by the AMA Foundation. This list
is not comprehensive but can serve as a reminder
that common medical terms can be confusing for
the average American.

• Medical Term
• Analgesic
• Anti-Inflammatory
• Benign
• Carcinoma
• Cardiac Problem
• Cellulites
• Contraception
• Enlarge
• Health Failure
• Hypertension
• Infertility
• Lateral
• Lipids
• Menopause
• Menses
• Monitor
• Oral

• Translation into Plain English
• Pain Killer
• Lessens swelling irritation
• Not cancer
• Cancer
• Heart problem
• Skin infection
• Birth Control
• Get bigger
• Heart isnt pumping hard enough
• High blood pressure
• Cant get pregnant
• Outside
• Fat in the blood
• Stopping periods, change of life
• Period
• Keep track of, keep an eye on
• By mouth

Note An English-Spanish Dictionary of Health
Related Terms, 3rd Edition, July 2005, is
available on the MLC website at
www.medicalleadership.org
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Health Literacy Informed Consent

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

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Identifying and Addressing Low Health Literacy

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

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6 Steps to Improve Communication with Patients
Whose Health Literacy is Limited

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

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Developing Plain-Language Educational Materials

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

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CA Standards for Healthcare Interpreters

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

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

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

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Three-Way Partnership

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

2) Doctor
1) Patient
3) Interpreter
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Patient Privacy

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

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HIPAA

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

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Protecting Patient Confidentiality for
Interpreters in Your Day-to-Day Work

• DO safeguard written logs, schedules, or activity
  sheets that contain protected health information
• DO look for private space or lower your voice
  when discussing protected health information
• DO be aware that just leaving out a patients
  name may not be enough to protect the patients
  confidentiality. Other information may make it
  possible to identify the individual, even without
  the name

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• DO refer requests for protected health
  information back to the patient, doctor or other
  health care professionals or staff when possible.
  Avoid providing protected health information
  when the patient or others involved with the
  patients care can do so.
• DO destroy or shred any documents (such as notes
  taken during the medical visit) that contain
  protected health information before throwing them
  away
• DONT share protected health information with
  anyone unless it is needed to do your job or
  their job.

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• DONT share more information than is necessary
  for you or others to do your jobs.
• DONT access patient information unless you need
  it to do you job.
• DONT send email containing protected health
  information unless it is encrypted.

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Additional Resources

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

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The Body (El Cuerpo)