Quality Health Care for Limited English Proficiency Patients

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There are 19 million people in the United States that speak English with limited proficiency (LEP). Over 80% of hospitals and federally qualified health centers provide care to these LEP patients regularly. Yet there is a lack of access to qualified interpretation in medical settings. Studies have shown that hospitals and health centers do not adequately meet the needs of LEP patients, one conducted in emergency rooms found that 50% of these patients do not receive interpretation services.

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JEANNA DUERSCHERL | The Roanoke Times 02/10/09

Providers often employ ad hoc interpreters such as staff, friends or family members, even the patient’s own children. This violates their right to confidentiality and risks hindering their ability to communicate symptoms or questions, make informed health decisions, and follow treatment guidelines. These kinds of ad hoc interpreters have been shown to frequently make clinically significant mistakes. One study in pediatrics found an average of 31 errors per interpretation. In psychiatric settings this leads to misevaluations of a patient’s mental state. In the case of using family members, they may experience discomfort or distress in communicating diagnoses. For Asian and Pacific Islanders, the use of their children or younger family members to interpret may alter power dynamics and cause discomfort.

Making qualified interpreters available to patients is critical to providing quality health care. Federal regulations exist, including the Civil Rights act of 1964, protecting individuals from discrimination on the basis of their national origin and requiring providers to maintain access to culturally and linguistically appropriate language services. The Affordable Care Act has broadened the scope of health care coverage meaning that more LEP individuals will have medical insurance, increasing the need for more language services. It also extends existing provisions requiring the use of “plain language” terminology in foreign languages, as well as written translation of important documents and free and timely oral interpretation in all health care settings. LEP patients face serious barriers to comprehension at every stage of health care, from decreased access to primary and prevention services, to confusion about insurance enrollment or payment options. They often suffer adverse health problems from a lack of comprehension of medicine labels, dosage and associated side effects.

While it is clear that increasing the availability of multilingual staff and qualified medical interpreters is necessary for LEP patients to obtain safe and confidential medical care, there are serious constraints to meeting this need. The increasing diversity of languages spoken makes it costly for smaller health centers to provide on-site personnel. Few states provide reimbursement for the use of interpreters through the Medicaid program. This challenge is exacerbated by a shortage of interpreters and multilingual health professionals. Once hired, retaining staff and certifying their language proficiency is difficult. In addition, some patients may prefer gender-concordant interpreters. Remote interpretation services such as through telephones may be more cost-effective and cover a wider breadth of languages. But these language lines are often not used and can be inadequate for elderly patients that have hearing problems.

These problems can be mitigated through teleconferencing with language-concordant physicians, providing linguistic and cultural competence training to health professionals, and increasing funding for interpretation services. Larger facilities should have professional medical interpreters available on-site and incentivize the hiring of multilingual staff. This will ensure that patients can communicate with health professionals at every stage of their care and increase trust and treatment adherence. In addition, materials should be linguistically and culturally sensitive for patients as they often contain medical jargon or convoluted phrasing that is difficult to understand. The same plain language considerations made for English materials should be applied to those in other languages. Even with interpretation, considerations need to be made that there will still be issues of comprehension and health literacy as LEP patients must learn how to navigate the U.S. health system, often very different from the structure and functioning of health care in their native countries. With over 60 million people in the U.S. speaking a language other than English at home, health care should adapt to provide safe, effective and quality care for all.

Further reading: Best Practices for Using an Interpreter

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2 Responses to “Quality Health Care for Limited English Proficiency Patients”

  1. jodetunde Says:

    This is a great blog . . . very informative. Important points were made; however, it would be great to have bulleted some of this points. Some of the points specifically target organizations (guidelines to providing proper interpreters); also perhaps provider-interpreter interactions are important. At times, providers may not show any form of respect to the interpreter or the process of the interaction between the patient and the interpreter. Also, i think it is important to highlight the importance of ‘self-advocacy’ as well as “community advocacy” concerning this matter. Even if you are being provided “free services”, this should not undermine the importance of the the quality of the service.

    Other things to consider: interactions with deaf and/or blind person. As well as conscious and unconscious bias to care.

  2. sloboda2016 Says:

    I think this is a really important issue in America, which healthcare professionals and health systems don’t take seriously enough. Speaking from personal experience in Philadelphia with significant immigrant populations, my hospital system is incredibly reliant on the phone interpreters, which are an absolute mess honestly. I’ve never felt comfortable walking away from one thinking that everything was understood properly. They take a long time to set up and translate everything, so you end up getting a very short and incomplete history. I think the care of the patient really suffers from this. I’ve never even seen a medical interpreter in person at a hospital during medical school because the hospitals immigrant or LEP patients usually go to that often serve uninsured/medicare/medicaid patients can’t afford them.

    I think medical and nursing schools should really invest and emphasize foreign language training in Medical School or at least more quality opportunities for students. Especially in Spanish as well as French, Creole, Arabic, Chinese, Korean, or whatever is most common in that city or area. I think just knowing some common interaction phrases and important history questions can go a long way in just making the patient-provider connection, but actual and full comprehension needs to ensured as well through proper translation eventually as it is their right and best for the patient. I don’t think med schools or residency programs should hold it against applicants for not speaking certain languages, but I think they should do more to support their education in learning those languages.

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