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Talking the Talk ~ Obtaining Culturally and Linguistically Competent Health Care in the United States

Tuesday, August 04, 2009

Countless patients and families come to the United States from abroad to seek medical care each year, yet few are familiar with their options for receiving access to language services – such as interpreting and translation – along with culturally sensitive care. Standards for culturally and linguistically appropriate services (CLAS) are promoted at a federal level and are widely observed within the U.S. health care system. This article introduces the range of cultural and linguistic services commonly offered within the United States that are available to international visitors seeking health care.
An Overview of Language and Cultural Requirements

With more than 300 languages spoken within its borders, the United States is one of the most linguistically diverse countries in the world. While the majority of its population speaks English, the most recent Census data reveals that roughly 18% of residents speak other languages at home [1].

Given the country’s incredible diversity, the federal government has long recognized, through Title VI of the Civil Rights Act of 1964, the rights of individuals to be free of discrimination on the basis of language [2]. However, it is only in recent years that greater emphasis has been placed on the rights of patients with limited English proficiency (LEP).

The landscape of language access in the U.S. health care system changed dramatically in August 2000, when President Clinton signed Executive Order 13166, “Improving Access to Services for Persons with Limited English Proficiency.” This order requires all recipients of federal funding to provide “meaningful access” to services for individuals with LEP [3].

The federal Office of Minority Health (OMH) made important strides by developing national standards for culturally and linguistically appropriate services (CLAS) [4]. After the standards were published in 2000, the OMH made a series of web-based cultural competence training programs available to help nurses, physicians, and emergency responders become more familiar with the CLAS standards. While the courses were designed for U.S. clinicians, health care providers can access these programs for free, online, from anywhere in the world.

In addition to the federal support for language services, nearly every state has also passed laws requiring language services. According to research from the National Health Law Program, the State of California alone has more than 150 laws on the books related to language access. Five states – California, New Jersey, New Mexico, Maryland and Washington – also require or strongly recommend that physicians obtain cultural competence training.
Typical Components of a Language Access Program

Because health care organizations are required to provide language services to meet the needs of diverse patient populations, they rely on a myriad of technologies and techniques. Here are some of the most common features of linguistic programs at U.S. hospitals:

* Bilingual staff: Health care workers need different levels of language competence, depending on their role. If clinicians have been properly tested for language proficiency, they may be able to treat patients directly in the patients’ native tongue, without the need for an interpreter. Reception staff may be able to greet patients in other languages with less advanced levels of proficiency.
* In-person interpreters: Nearly every hospital offers interpreters who are physically present on site to assist with language needs directly in person. Often, having a person who is familiar with the patient’s native culture also provides a sense of being “at home” in what can be an intimidating place.
* Telephone interpreters: Typically, telephone interpreting services are used when no in-person interpreters are available. However, some patients may prefer not to have another person physically in the room with them, especially for cultures where privacy and modesty are important.
* Video interpreters: Some hospitals also offer interpreters by using videoconferencing technology. Interpreters may be located in a remote center, or directly in the facility. This service is most commonly used for American Sign Language. Recently, some facilities have begun to offer Mexican Sign Language, as well as spoken language interpreting via video.
* Written translation: Many hospitals offer written translations of certain critical information, such as discharge instructions and consent forms. However, a large number of facilities address this need by having interpreters perform what is called “sight translation.” In this process, the interpreter reads the document in English and renders a verbal rendition of the information in another language. This is not ideal. However, more and more facilities are recognizing the best practice of procuring written translations in advance to ensure accuracy and quality.
* Signage: It can be confusing to navigate a sprawling hospital campus, especially when basic words to designate place names are in another language. Some hospitals have multilingual maps available at the main entrance, while others make sure that prominent signs like “Emergency Room,” “Radiology” and “Labor and Delivery” are clearly marked in multiple languages.
* “I Speak” cards: Many facilities give patients pocket-sized cards that state “I speak [language]” and advises individuals of the bearer’s need for an interpreter. The U.S. government has printable versions of a language identification sheet available online [5]. Immigrant and refugee support organizations also make these tools available to members of their communities. However, many organizations create branded, laminated cards that are convenient for patients to carry with them in a wallet or clip onto another identification tag.
* Language identification tools: Some hospitals place posters throughout the facilities to advise patients of their right to receive language services and to help providers identify which language is needed. Posters typically display only the most common languages, so some organizations have other language identification tools – such as a binder that patients can flip through until they find their language, or tri-fold cards that include dozens of languages.

In addition to these core components, many organizations are recognizing the benefits of new technologies, such as clip-on microphones that physicians can wear in order to conference in a telephone interpreter, and multilingual software programs that enable a patient to register and answer basic intake questions without the need for an interpreter.
Case in Point ~ Mayo Clinic

Renowned the world over for its quality of care, the Mayo Clinic annually treats more than half a million people at its sites in Minnesota, Florida and Arizona. Each year, approximately 8,000 patients travel from more than 150 different countries in order to receive diagnoses, second opinions and treatment from Mayo. The Rochester-based health care facility is a medical tourism veteran, with more than 100 years of experience in treating patients from around the world.

Patients from abroad – and their families – have access to a hospitality center where they can read newspapers from their home countries and obtain other services to make their stay easier. As Jane Hughes, supervisor of the facility’s language department explains, “International patients face the logistical challenges of traveling outside of their country for medical care and Mayo Clinic makes every effort to meet these needs.”

Language support is one of the most common requests. According to Hughes, interpreters were dispatched to 66,000 outpatient and inpatient appointments in the past year alone. The top three languages are Arabic, Spanish and Somali. The Mayo Clinic has 23 languages covered through its staff interpreters, who work on site and accompany patients directly to their appointments. Because of its diverse patient population, the facility also has access to two telephone interpreting suppliers, enabling clinicians to dial up language assistance for more than 180 languages.

The qualifications of interpreters are of critical importance – it isn’t enough to just find someone who happens to speak the language of the patient. All interpreters undergo specific training to interpret in medical settings. In keeping with federal guidelines, the Mayo Clinic also discourages the use of family members, friends and minors as interpreters. Mayo Clinic draws a clear distinction between the two separate disciplines of spoken language interpreting and written translation. “Translation of key written materials are either provided by in-house translators or outsourced according to policy,” Hughes explains.

Knowing how to adeptly manage all of these resources is a core component of the language access strategy at Mayo Clinic. Patient language preferences are noted during the registration process and forwarded to the department that generates the interpreters’ daily schedules. As Jane Hughes points out, “Notifications that interpreter services are provided at no charge are posted in key locations and patients are given a business-size card indicating that they need an interpreter.”

Clinicians also attend classes to learn how to properly work with interpreters and patients from diverse cultural backgrounds.
The Costs of Catering to Multilingual Patient Populations

Of course, providing language services comes at a price. A 2008 study conducted by Common Sense Advisory revealed that hospitals spend an average of $56 USD per day for every bed that corresponds to a person with limited English proficiency. Many hospitals spend in excess of one million dollars per year on translation and interpreting services.

However, the benefits far outweigh the costs. Multiple studies show that when language access is not provided, providers conduct expensive diagnostic tests to determine problems instead of simply communicating with patients. Also, federal language access requirements are an “unfunded mandate” – meaning that hospitals do not receive funding for language services, but must provide them regardless.

Still, technology offers an array of possibilities for making language services more affordable. Already, shared networks of interpreters improve resource utilization and decrease costs. Software programs reduce the reliance on human hours to book and dispatch interpreters. Repositories of pre-translated documents enable hospitals to benefit from economies of scale.

Budgets aside, providing language access is not only a requirement in the United States. More and more, patients are coming to expect information – be it spoken or written – in their native languages. For patients who travel to the United States specifically to purchase high-quality health care services, language services are not only an amenity, but a right.

References

[1] http://www.mla.org/census_main
[2] http://www.archives.gov/eeo/laws/title-vi.html
[3] http://www.usdoj.gov/crt/cor/Pubs/eolep.php
[4] http://www.omhrc.gov/assets/pdf/checked/finalreport.pdf
[5] http://www.lep.gov/ISpeakCards2004.pdf

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