April 1, 2005
Mara Youdelman, Jane Perkins
Providing Language Services in Small Health Care Provider Settings: Examples from the Field, Mara Youdelman, J.D., and Jane Perkins, J.D., The Commonwealth Fund, April 2005
Today, hundreds of languages are spoken in both urban and rural areas of the United States. These changing demographics, as well as heightened federal and state policies, have increased the need for effective and efficient models of providing language services to individuals who are limited English proficient (LEP). As noted by a private pediatric practitioner in rural North Carolina, the increasing commitment to the LEP population is "driven less by the necessity to follow federal law than by our realization that these children are part of our future."
Small group practices compose a sizeable portion of the U.S. health care delivery system. These practices have the potential to serve significant numbers of LEP patients, but only if language services are available. According to the American Medical Association (AMA), 59 percent of all physicians are in solo practice or are self-employed in group practices. Group practices are primarily small, with 46 percent having three or four physicians. Further, 50.3 percent of all single-specialty groups and 61.8 percent of all family/general practice groups have three or four physicians.
The Institute of Medicine reports that 51 percent of providers surveyed believe patients do not adhere to treatment because of culture or language. At the same time, 56 percent of these providers reported having received no language or cultural competency training. Unfortunately, many providers are challenged by a shortage of knowledge and resources, which can create barriers to care. Resource constraints include a deficiency of bilingual providers and trained professional interpreters and inadequate reimbursement for language services by insurers such as Medicaid and Medicare.
To assess current innovations in language service programs and activities, the National Health Law Program (NHeLP) conducted 11 site visits and seven phone interviews at small health care provider settings, defined as those with 10 or fewer clinicians. Promising, replicable activities were identified in the following areas:
- Language access planning. Most providers interviewed for this project have designated a staff member to coordinate language service activities. Small health care providers are also developing written language plans, as suggested by the U.S. Department of Health and Human Services' Office for Civil Rights. These plans identify language needs and propose strategies for meeting those needs.
- Determining language needs at first points of contact. Some small health care providers are taking steps to introduce language access at the first points of patient contact. For example, "I Speak . . ." posters and cards, which identify patients' language needs as soon as they walk through the door, are being used by front-desk staff.
- Bilingual mid-level practitioners. A limited supply of bilingual physicians, along with heavy competition to hire those physicians, has motivated some provider sites to focus on recruiting and hiring bilingual mid-level staff, like certified nurse practitioners.
- Dual role bilingual staff. Many of the small provider sites assessed are hiring bilingual office staff to perform multiple roles, including language assistance tasks. For example, individuals with conversational proficiency in a second language may provide limited services at the front desk (e.g., answering phones, scheduling appointments) while those with medical proficiency may interpret for patients during medical or clinical visits.
- Dedicated staff interpreters. Particularly in communities with heavy demand for services in a particular language, small provider sites may hire full- or part-time, on-site interpreters.
- Contract interpreters. Providers are also considering interpreters who are available to work on contract with small provider sites. Potential sources for hiring such interpreters include area hospitals, state or local agencies, refugee resettlement sites, community-based organizations, or commercial entities.
- Community resources. Small health care providers can work with entities or individuals in their communities to improve the provision of language services. These may include local hospitals, managed care organizations, community-based organizations, community colleges, and former patients and their family members.
- Interpreter competency. Small health care providers are increasingly taking steps to improve the competency of bilingual staff who serve as interpreters. On-the-job training is offered in some sites by bilingual, mid-level practitioners and office administrators, who are also used to assess language skills during the hiring process and to evaluate new staff in training. Community training resources, available through local hospitals and community colleges, are also being used to improve interpreter skills.
- Telephone language lines. Some small provider sites are developing ways to make telephone language lines (i.e., services that offers interpreters via telephone) accessible to both providers and patients. Some sites have placed speaker phones in examination rooms, while other providers carry cell phones with speakers that can be easily exchanged between provider and patient.
- Use of family and friends. A growing number of small providers are seeking to minimize their reliance on using family or friends of patients as interpreters. Where family members are still being used, some providers will attempt to have a trained interpreter sit in during the medical encounter or follow up with the family within 24 hours to verify the patient's condition.
- Language services throughout the patient encounter. Because LEP patients experience language barriers throughout the health care encounter, small health care providers are using interpreters to assist the individual throughout intake, clinical encounter, and follow-up.
- Written translations. When evaluating the need for translated materials, small health care providers are making extensive use of existing materials. Sites are using translated materials offered by various organizations, Web-based materials from federal and state governments, and materials downloaded from health departments in other countries such as Taiwan and Hong Kong. Small provider sites are also working with bilingual staff, contract interpreters, local hospitals, and faith-based organizations to translate documents.
- Patient satisfaction. Small providers are monitoring patient satisfaction as they continue to evaluate and expand their language services. This may be as simple as patient-charting notations or more formal patient surveys.
- Funding opportunities. Small health care providers are seeking funding from a variety of sources, including federal, state and local governments; foundations; and nonprofit organizations.
The results here represent one step in the task of identifying the many models of providing linguistic access and cultural competency in health care. The activities described clearly demonstrate that one size does not fit all when it comes to providing language services. Rather, the nature, scope, and delivery approach will vary from state to state, community to community, and from one provider site to another. However, by borrowing and tailoring the activities already under way, small health care providers can make great strides toward improving health care access. Small providers who are developing language services should follow the following eight-step process:
Step 1. Designate responsibility.
Step 2. Conduct an analysis of language needs.
Step 3. Identify resources in the community.
Step 4. Determine what language services will be provided.
Step 5. Determine how to respond to LEP patients.
Step 6. Train staff.
Step 7. Notify LEP patients of available language services.
Step 8. Update activities after periodic review.
While determining appropriate language services will depend on individual circumstances, small health care providers have an array of options that can be tailored to meet the needs of their LEP patients. Based on practice type, setting, size, and location, providers can choose from services, including hiring bilingual practitioners or staff, using in-person or telephone interpreters, coordinating with other providers to share resources and costs, and partnering with larger health care entities or systems.