Limited English Proficiency Can Impede the Transition Process
As the United States becomes more diverse, healthcare facilities treat more patients with limited English proficiency. This highlights the need for more effective interpreter services, especially at discharge.
- Patients with language barriers can struggle to transition from the hospital to community-based settings, research suggests.
- The 1964 Civil Rights Act, Title VI, requires healthcare facilities that receive federal money to provide language assistance.
- The optimal goal is to have a certified medical interpreter present, but this happens too infrequently.
The 2020 U.S. Census data show the nation is becoming more diverse. Anecdotal reports from some health systems suggest hospitals are seeing the same trend — particularly an increase in patients with limited English proficiency.1
Care coordination and transitions could improve if health systems provide more consistent and adequate interpretation help to patients with limited English proficiency, research shows.2-5
Patients with language barriers can struggle to transition from the hospital. Investigators found more than half of patients with limited English proficiency did not have access to medical interpreters and translated materials at discharge.2
“It’s a huge problem, and it is a problem not only in Los Angeles — where there is a high number of people with limited English proficiency — but throughout the country,” says Breena R. Taira, MD, MPH, associate professor of clinical emergency medicine with the David Geffen School of Medicine at UCLA. Taira also is the director of social medicine at Olive View-UCLA Medical Center. “There are more than 25 million people in the U.S. who have low English proficiency. It is definitely a potential communication barrier, and health systems do a variable job in terms of providing the frontline staff with the resources they need to surmount that barrier.”
Title VI of the 1964 Civil Rights Act requires healthcare facilities that receive federal money, such as Medicare and Medicaid, to provide language assistance as part of its ban on discrimination based on race, color, or national origin. Federal funds can be withheld if there is evidence of discrimination.6
Healthcare organizations are required to provide interpretation and translation assistance to patients, but health providers often rely on patients’ family members or other non-certified interpreters, the results of a recent study show.2
“More than half of patients with limited English proficiency said they did not have an interpreter present at the time of discharge, and they did not receive translated materials in their respective languages,” says Esteban A. Barreto, PhD, director of evaluation of equity and community health at Massachusetts General Hospital and research fellow at Harvard Medical School. “There are a lot of reasons why a medical interpreter may not be present. Some patients may bring a family member — although it’s not recommended — or there may be other caregivers who can provide help and communication.”
When providers ask patients if they need an interpreter, they often decline because they are accompanied by a family member who can speak English, or there is a provider or staff member who can speak their language.
“Our question was whether there was a certified medical interpreter present, and we couldn’t really tell if these patients were able to have their communication needs addressed,” Barreto says. “What we know is that more than half of these patients did not have a certified medical interpreter present, which is essential because these medical interpreters are trained in a way to provide not only communication, but also anything related to culture competency.”
Emergency department (ED) providers often resort to automated translation software like Google Translate for patient instructions. Researchers found using Google Translate for discharge instructions in the ED is inconsistent between languages, and providers should not rely on it for patient instructions.7
“If you think about it from an emergency medicine standpoint, time is often of the essence — either in the ED or inpatient setting,” Taira says. “A lot of providers feel like it’s a tradeoff with their own efficiency because some of the language assistance provided can be clunky to interface with. Providers try to avoid them in some circumstances.”
A better practice is for health systems to establish an interpreter services department, says Chris Kirwan, PhD, director of medical interpreter services at Massachusetts General Hospital.
It is challenging for health systems to recruit qualified and certified medical interpreters. “At a major academic medical center, the types of patient encounters are so wide-ranging that it becomes a challenge. You need someone who is certified and has that experience and competence in medical interpreting,” Kirwan explains. “Quite frankly, there is a shortage of qualified medical interpreters across the country.”
It even is challenging to find medical interpreters for Spanish. “As a result, every hospital has a back-up service because the law requires us to provide interpreter services 24 hours a day, seven days a week, free of charge to the patient,” Kirwan explains. “It’s an unfunded mandate, although some states have a very small Medicaid reimbursement.”
There is no guarantee that providers will use a certified medical interpreter, even when one is available. “If you’re working with an interpreter, the conversation will take twice as long,” Taira says. “That’s a good thing in terms of clarity, but for someone who is hurried and who doesn’t have time for 20 minutes, they may think they can do it in five minutes [without an interpreter] — even if [the conversation] is muddled.”
Remote interpretation networks also can be difficult to access. They might require a certain device that has to be charged, and staff need to know how to use it. All these barriers to ease of use slow down patient encounters and create disincentives to using interpretation services.
“From the health system side, you have to think about how they can make this easy for their frontline staff,” Taira says. “That’s where health systems can fail — if they’re providing something that is not easily accessible, then staff won’t use it.”
Academic medical centers and public hospitals in urban areas often treat many patients with limited English proficiency. For example, at Olive View-UCLA Medical Center, which is a public safety net hospital, more than 55% of patients requested an interpreter, Taira says.
“Up until six months ago, we had one interpreter on staff, and everything else was done by a remote interpreter network,” she notes.
Taira’s research and advocacy has helped convince leadership to improve its interpretation process. “We are currently approved to hire an interpretive staff of 10 people,” she says. “It really shows that this is an issue that’s coming to the forefront. Health systems are starting to realize it’s a safety issue, a quality issue, and a social justice issue.”
The COVID-19 pandemic also has affected some hospitals’ need for interpreters. “We average between 100 and 120 patients per day who have language access needs,” Kirwan says of Mass General operations. During the height of the pandemic, Kirwan reports the number of patients who needed language assistance exploded, from 10% during normal operations to 55% during the height of the first wave.
While many of these patients could ask for and receive interpretation service, few do, Kirwan adds.
Hospitals’ interpretation challenges were augmented because of COVID-19, but they also were given more attention by health system providers, Barreto notes. “Maybe a physician would see one to three patients a day with limited English proficiency, but when they start seeing dozens of patients a day, that could really change how they go about their work,” he says.
The interpretation gap is further complicated at discharge when clinicians might rely on the patient’s English-speaking family member to interpret instructions, Kirwan says. “Just the chaotic pace at which inpatient units work kind of mitigates against using interpretation at the time of discharge,” he says.
During the pandemic, when family members were not allowed to be with patients at discharge, the hospital’s interpretation demand skyrocketed.
“We were being used for these discharge situations more through the pandemic than previously,” Kirwan explains. “Now that visitors are allowed, our volume still is increasing overall.”
- USA Facts. How is the population changing and growing?
- Barreto EA, Guzikowski S, Michael C, et al. The role of race, ethnicity, and language in care transitions. Am J Manag Care 2021;27:e221-e225.
- Taira BR, Kim K, Mody N. Hospital and health system-level interventions to improve care for limited English proficiency patients: A systematic review. Jt Comm J Qual Patient Saf 2019;45:446-458.
- Taira BR, Orue A. Language assistance for limited English proficiency patients in a public ED: Determining the unmet need. BMC Health Serv Res 2019;19:56.
- Taira BR, Onofre L, Yaggi C, et al. An implementation approach improves language access in the emergency department. J Immigr Minor Health 2021; Jan 2. doi: 10.1007/s10903-020-01127-x. [Online ahead of print].
- Taira BR. Improving communication with patients with limited English proficiency. JAMA Intern Med 2018;178:605-606.
- Taira BR, Kreger V, Orue A, Diamond LC. A pragmatic assessment of Google Translate for emergency department instructions. J Gen Intern Med 2021; March 5. doi: 10.1007/s11606-021-06666-z. [Online ahead of print].
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