The ASIAN & PACIFIC ISLANDER AMERICAN HEALTH FORUM was established in 1986 to advocate for improved health status, to reduce health disparities, and to promote equal access to care for Asians and Pacific Islanders.

Promising Practices in Healthcare

Language Access Advocacy Project California 2004

Promising Practices in Health Care

Purpose of Presentation: To provide highlights of existing promising practices in the provision and financing of language services in health care

Overview of Presentation

• Policies and Procedures

• Needs Assessment

• Delivery System

• Training and Competency

• Workforce

• Monitoring and Evaluation

• Use of Technology

• Financing and Reimbursement

• Ongoing Challenges

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Policies and Procedures

Promising policies and procedures include elements that:

• Publicize patient rights and availability of services

• Identify and assess language needs

• Assure proper documentation

• Provide timely telephone communication

• Ensure systematic data collection

Promising Policies and Procedures:
Sequoia Community Health Foundation

• Community clinic serving primarily farmworkers in southern Fresno County

• Has a written policy on access to interpretation services

• Includes specific procedures on how to access language line services

• Incorporates written instructions in the personnel policies manual

• Includes training for staff on policy and procedures in orientation process

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Needs Assessments

Promising needs assessments include:

• An assessment of community language needs

• An internal assessment of institutional needs

Promising Needs Assessment:
La Clínica de la Raza

Community clinic serving primarily Latino patients in East Oakland

La Clínica de la Raza conducted a Cultural Competence Assessment Survey

• Assessed staff views regarding cultural competency

• Was included as a component of the organization’s quality assurance oversight plan

• Yielded results that illustrate a strong recognition among staff of the importance of culture

• Identified needs

  • Materials and signs in different languages & cultures

  • Training and information about non-Latino cultures

Promising Needs Assessment: L.A. Care

Health maintenance organization serving Medi-Cal, Healthy Families, and CaliforniaKids enrollees in Los Angeles County

As part of its assessment, LA Care conducted a survey of providers to identify needs and challenges

• 92% felt language and cultural issues are important in delivering health care

• Over three-quarters would use translated materials or interpreters if made available to them

• 50% would like training on how to use interpreters

• 49% would like staff trained as professional interpreters

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Delivery Systems

Promising delivery systems include components such as:

• Coordinator and administrative structure

• Scheduling and tracking system

• Models of oral language assistance

• Guidelines for translation of written materials

Promising Delivery System:
Asian Pacific Health Care Venture

• Community clinic serving Asians & Pacific Islanders in Los Angeles

• Components of its delivery system include:

  • Bilingual staff hiring flow chart

    • Job descriptions for bilingual staff

    • Hiring criteria

    • Application process

    • Oral interpretation test

    • Written translation test

  • Translations of vital documents

  • Trainings for Staff

  • Patient satisfaction surveys

Promising Delivery System:
Asian Pacific Health Care Venture

Source: “A Functional Manual for Providing Linguistically Competent Health Care Services as Developed by a Community Health Center”

Promising Delivery System:
Golden Valley Health Center

Community clinic serving Latino and Southeast Asian communities in Merced

Cultural Mediators

• Provide language interpretation for Latino, Hmong and Lao patients

• Receive 40 hours of training and tests for proficiency

• Serve as part of the clinical team to transmit cultural understandings and beliefs between clinicians and patients

Cultural Competence Training

• Culture Clinic for residents

• Training to work effectively with interpreters

Promising Delivery System:
Alameda Alliance for Health

• Nonprofit health plan serving Alameda County

• Makes arrangements and coordinates interpreter services

• Pays interpreters directly at both the plan and provider levels

• Identifies qualified interpreter services

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Training and Competency

Key elements of promising training and competency activities include:

• Interpreter training

• Staff/provider training

• Competency assessment
  • Core skills
  • Core knowledge
  • Code of ethics

Promising Training and Competency:
Asian Health Services

• Community clinic primarily serving Asians & Pacific Islanders in Oakland

• Interpretation and Translation Services

  • Conducted in multiple languages: Cambodian, Cantonese, Farsi, Korean, Mandarin, Spanish, Vietnamese

  • Translation by a primary translator, Editing by a second translator, Formatting of document, Proofreading, & Cultural adaptations of health materials

• Health Care Interpreting Training

  • 40 hour, 5 week training

  • Covers interpreter skills, roles, and ethics

• Cross-Cultural Health Care Training

  • Training for health care staff on serving multicultural patients

Promising Training and Competency:
Family HealthCare Network

• Community clinic serving low-income, underserved individuals in Tulare County

• Efforts to promote training and competency include:

• Establishing a strong commitment to hiring bilingual staff from the community

• Evaluating language proficiency

  • Utilize standardized oral and written tests

  • Bilingual staff shadow bilingual physicians initially to ensure accurate language proficiency

Promising Training and Competency:
SSG/PALS for Health Program

• Community based language access program serving Los Angeles and Orange County.

• PALS for Health conducts language proficiency assessment in 10 languages

• 48-hour Health Care Interpreting Training

  • Language proficiency test is a prerequisite to enrollment

  • Skills and knowledge building, standards, role plays, language labs, medical terminology, continuing education and interpreter support.

• Patient Education

  • Informing LEP patients about language rights

  • Distribution of “I Speak” cards

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Workforce

• Components of a promising language services program include:

  • Workforce Recruitment

  • Workforce Retention

Promising Workforce Program: CA Physician Corps Loan Repayment

• Provides loan repayment scholarships for physicians who practice in underserved areas

• Operated by the CA Office of Statewide Health Planning & Development

• Focused on primary care physicians

• Priority consideration given to those who:

  • Come from an economically disadvantaged background

  • Have significant training in cultural/linguistic issues

  • Speak a Medi-Cal threshold language

• Companion program for dentists to be implemented.

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Monitoring and Evaluation

• Key elements of monitoring and evaluation include:

  • Patient satisfaction

  • Process variables

  • Outcome and quality measures

Promising Monitoring and Evaluation:
Venice Family Clinic

• Free clinic serving primarily Latino and low-income patients in Los Angeles

• As part of its monitoring and evaluation efforts, Venice Family Clinic designed a quarterly patient satisfaction survey to obtain input from patients

  • Assists the clinic in monitoring quality of care provided to patients.

  • Includes questions regarding cultural and linguistic services

Promising Monitoring and Evaluation:
National Health Services

Community clinic serving low-income and farmworker patients in Kern County

As part of its monitoring and evaluation activities, National Health Services has created a Language Barrier Log

• Records Patient’s Name, Arrival Time, Time Seen, Native Language

• Reviewed as part of the quality assessment program

• Patients should not wait more than 15 minutes for an interpreter or bilingual staff member

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Use of Technology

Pilot projects are currently exploring and testing the use of new technologies:

• Remote simultaneous translation

• Videoconferencing

Promising Use of Technology:
Gouverneur Hospital

• Public hospital primarily serving Chinese and Latino immigrants in New York City

• Implemented a remote simultaneous medical interpretation pilot

  • Use trained medical interpreters who interpret for providers and patients through wireless headsets

  • Interpreter listens to what is said by one party and transmits an interpretation to the other

  • Provider and patient only hear their own languages

Promising Use of Technology:
Alameda County Medical Center

• A system of public health care in Alameda County with 3 hospitals and 4 clinics

• Alameda County Medical Center is currently piloting a videoconferencing medical interpretation system

• Provider and patient talk to one another in the exam room while an interpreter in another location interprets via videoconference

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Medicaid/SCHIP Financing and Reimbursement

• August 30, 2000 CMS Letter discusses how states can draw down federal matching funds for language assistance in Medicaid/SCHIP

• Only 10 states have established direct reimbursement using federal matching funds to pay for language services

• Four models of reimbursement –

  • contract with language service agencies

  • reimburse providers for hiring interpreters

  • certify interpreters as Medicaid providers

  • provide access to language line

Model 1 – Language Service Agencies

• Hawaii, Washington, and Utah contract with interpreter organizations. Providers schedule interpreters who then bill the state.

• Washington offers testing and certification of its interpreters. For seven prominent languages, the state administers a certification test, and for other languages, the state has a process for qualifying interpreters.

Model 2 – Provider Reimbursement

• Maine and Minnesota require providers to pay for interpreters and then reimburse providers

• Providers have discretion on who to hire

• In Maine, interpreters must sign code of ethics; cannot use family members/friends

• Considerations
  • state oversight
  • quality of interpreters
  • provider concerns

Model 3 – Payments to Interpreters

• New Hampshire requires interpreters to become Medicaid providers

• Interpreters submit bills directly to the state

• Considerations

• requirements of becoming a provider

• low reimbursement rates

Model 4 – Language Line

• As of October 10, 2003, Kansas started paying for a telephonic language line which managed care providers can access for Medicaid/SCHIP patients

• The language line is coordinated through the state’s fiscal agent (EDS) and providers receive a code for access

• Estimated budget – $275,000 for first year

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Current State Financing

State	Enrollees Covered	Providers Covered	Who the State Pays	Reimbursement Rate	Admin or Service
HI	FFS	FFS	Lang. agencies	$36/hr	Service
ID	FFS	FFS	Providers	$7/hr	Service
MA	All	Hospitals	Hospitals	Varies	Admin
ME	FFS	FFS	Providers	$30-$40/hr*	Service
MN	FFS	FFS	Providers	$50/hr**	Admin
MT	All Medicaid	All	Interpreters	$6.25/15 minutes	Admin
NH	FFS	FFS	Interpreters	$15/hr	Admin
UT	FFS	FFS	Lang. agencies	$22 (phone) / $39 (in-person)	Service
WA	FFS	Public entities	Public entities	50% expenses	Admin
WA	FFS	FFS	Brokers	$28/hr	Admin

 

Ongoing Challenges in Health Care

• Financial Reimbursement

  • Medi-Cal and Healthy Families patients

  • Uninsured patients

• Changing Demographics

  • Diversity of languages

  • Indigenous languages

• Workforce - Bilingual Providers and Interpreters

  • Recruitment

  • Retention

• Lack of technical assistance resources and tools to assist in changing operations

Ongoing Challenges in Health Care

Trainings for interpreters, providers, and support staff

• Cost of training

• Opportunity cost of time away from clinic

Access to technology for remote interpretation

• Rural areas may lack adequate telecommunications infrastructure

Confidentiality

• Especially for rare languages spoken by small communities

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Resources

• CPCA’s publication, “Providing Health Care to Limited English Proficient Patients: A Manual of Promising Practices” at www.cpca.org.

• AAPCHO’s publication, “A Functional Manual for Providing Linguistically Competent Health Care Services as Developed by a Community Health Center” at www.aapcho.org.

• NHeLP’s publication “Providing Language Interpretation Services in Health Care Settings: Examples from the Field” at www.cmwf.org.

• NHeLP and Access Project publication “Language Services Action Kit: Interpreter Services in Health Care Settings for People with Limited English Proficiency” at www.nhelp.org.

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Questions?

Language Access Advocacy Project Contact Information

Asian Pacific American Legal Center
Hemi Kim
213-977-7500 x 215
213-977-7595 Fax
hkim@apalc.org

Asian & Pacific Islander American Health Forum
Alice Chen and Gem Daus
415-954-9988
415-954-9999 Fax
achen@apiahf.org
gdaus@apiahf.org

Language Access Advocacy Project Contact Information

California Pan-Ethnic Health Network
Ellen Wu and Martin Martinez
510-832-1160
510-832-1175 Fax
ewu@cpehn.org
mmartinez@cpehn.org

California Primary Care Association
Vivian Huang
916-440-8170 x 238
916-440-8172 Fax
Vhuang@cpca.org

Language Access Advocacy Project Contact Information

Fresno Health Consumer Center
Teresa Alvarado and Sengthiene Bosavanh
559-570-1205
559-570-1253 Fax
talvarado@centralcallegal.org
seng@centralcallegal.org

Latino Coalition for a Healthy California
Lupe Alonzo-Diaz and Patty Diaz
916-448-3234
916-448-3248 Fax
Lupe@lchc.org
Pdiaz@lchc.org

Language Access Advocacy Project Contact Information

National Health Law Program
Doreena Wong
310-204-6010 x3004
310-204-0891 Fax
wong@healthlaw.org

Supported by The California Endowment

For more information, contact the APIAHF Policy Division staff:
Gem Daus, Legislative and Government Affairs Coordinator, GDaus@apiahf.org
Dr. Alice Chen, Sorros Fellow

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