How to Help Patients with Limited English Proficiency
As with many other unfunded federal mandates, interpretation services in hospitals face a variety of resource challenges, including insufficient staff training, too few interpreters, and cumbersome technological solutions.
“It’s easier for people to grab whoever is around than it is to call an interpreter,” 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. “We have to make it easier for people to call the certified healthcare interpreter, who is the professional meant to fill that role. I have been trying to figure out how we can make the right thing to do the easy thing to do as well.”
To surmount communication barriers, case managers and other healthcare professionals should pay attention to language access, such as interpreters and translations, usable health information (which is eliminating medical jargon), and cultural humility, Taira says. Cultural humility is knowing patients might not understand health the same way as a provider. Their goals might not be the same.
“Being open as a provider is to ask patients what health means to them and what are their goals for a treatment,” Taira explains.
Research shows interpretation is important to quality care transitions.1 “Based on our findings, health systems need to address the lack of integration and integrate the different workflows when bringing in interpretation — whether by phone, video, or in-person,” says Esteban A. Barreto, PhD, director of evaluation of equity and community health at Massachusetts General Hospital and research fellow at Harvard Medical School.
Discharging patients in a fast-paced environment can be a challenge, particularly when case managers and providers need extra time to locate an interpreter or find translated material, he adds.
Because free interpretation for patients is an unfunded mandate, some hospitals will tell staff it is available, but might not make it user-friendly.
“Most hospitals do not have standardized training,” Taira says. “You’d think it would be part of orientation, but it’s almost an afterthought.”
Title VI of the 1964 Civil Rights Act requires healthcare facilities that receive federal funds to provide interpretation services.2 “But it doesn’t require them to train people on using the services or to help them understand why it’s necessary,” Taira says.
Healthcare staff need to understand why interpretation services are important, she adds.
These are suggested tactics for improving language access for patients with limited English proficiency:
• Find resources on the issue. One book that captures cultural and language differences that affect patient care is The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures, by Anne Fadiman. The book is part of the curriculum at some universities and medical schools.3
One website explains the differences between interpretation and translation, noting interpretation is a service that happens in the moment and is delivered simultaneously or consecutively with the original speech. Interpreters do not receive help from scripts or reference materials. Translators can use computer-aided tools in their work and can work on information in any written form.4
• Provide accurate and up-to-date translated educational materials. “This is a massive challenge,” says Chris Kirwan, PhD, director of medical interpreter services at Massachusetts General Hospital. “Translated materials are a great thing to be able to put into the hands of a patient. The problem is when you look at the size of the discharge instructions, translating a document is very costly. The electronic medical record may do a very poor job of translating sections of the discharge instructions.”
Sometimes, the discharge instructions for Spanish-speaking patients include English words in as much as half of it.
“We have a translation specialist who does work with the unit staff to get sections of the discharge instructions translated for patients,” Kirwan says. “We have them identify key things the patient needs to know, and focus our efforts on those.” It also is helpful to include an interpreter during discharge.
Case managers also can provide discharge materials with pictures and/or colors patients can understand. For instance, a hospital can use a wallet-sized medication pamphlet that is color-coded with the medication bottle, Kirwan suggests.
Some translated material can be created in advance and used for many patients with the same needs. These could include physical therapy and occupational therapy instructions translated into many different languages.
“The challenge comes with individualized discharge instructions and medication instructions,” Kirwan says.
• Look at interpretation needs through equity lens. “This goes back to the importance of increasing diversity in the health profession because people with diverse backgrounds will have that equity lens,” Barreto says. “I’ve gone through the health system with family members with limited English proficiency, and I do have that experience. That is the lens I look through for all the different issues that come to us. I always ask myself if these options are available in different languages.”
Racial and cultural equity rose to the forefront of the national conscience with the glaring healthcare inequities laid bare in the pandemic, and with the social justice movement given new energy by the 2020 summer protests over the police killing of George Floyd.5
“The sociopolitical climate has health systems thinking about structural racism and equity issues,” Taira says. “The climate is ripe now to act on improving language access.”
There is growing understanding that patients with limited English proficiency are treated inequitably if they cannot access interpreters and translated materials.
“Not providing language access is a contributor to health disparity within groups,” Taira says.
- 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. Improving communication with patients with limited English proficiency. JAMA Intern Med 2018;178:605-606.
- Uy T, Dimaano C. Lessons learned from The Spirit Catches You and You Fall Down: Student perspectives on how cultural differences can lead to health disparities. Health Ed J 2020;79:73-81.
- Lionbridge. 5 key differences between interpretation and translation. March 14, 2020.
- Perdomo A. ‘A movement, not a moment’: Racial and social justice reform efforts in the year since George Floyd’s death. WLRN Miami. May 23, 2021.
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