LEP patients need solid translation services

Translation at discharge is crucial

Hospitals across the United States are seeing an increase in patients who have limited English proficiency (LEP), and this means discharge planners must plan accordingly.

A researcher who has studied the impact of having an enhanced interpreter service intervention says she conducted her study out of concern about LEP patients receiving substandard care.

"I was shocked as both a medical student and resident that patients who didn't speak English well didn't receive the standard of care," says Elizabeth Jacobs, MD, MPP, an associate professor of medicine in the collaborative research unit at the Stroger Hospital of Cook County and Rush University Medical Center in Chicago.

One of the most important facets of the standard of care is communication, and these LEP patients often lacked having a physician or discharge planner or other health professional who could communicate effectively with them, she notes.

"We need to understand what it is that patients need, what their conditions are like at home, and we need to give them adequate instructions about medications when they leave the hospital," Jacobs explains. "Or they'll return to the hospital."

Language barriers are addressed inconsistently across the continuum of care, Jacobs says.

"The problems that arise come when there are not people employed at the hospital who speak the language of LEP patients, including not having Spanish-speaking discharge planners," Jacobs says. "Interpreters can help overcome those barriers, but frequently those resources are not in place, and patients may not have access to video interpreters or telephone interpreters."

What happens instead is that hospitals rely on untrained bilingual staff or the patients' children, family members, or even the patient in the next bed to serve as ad hoc interpreters, Jacobs says.

This haphazard approach creates problems, especially since these ad hoc interpreters often would not test as truly bilingual, and they might not understand the medical terminology, she adds.

"So a discharge planner is trying to communicate, but the message is not communicated, or it's miscommunicated, and the discharge planner might never find out that the patient was given incorrect information," Jacobs says.

For instance, a patient who has heart failure might need to be told to take a certain medication, to weigh himself every day and then to call the nurse or doctor if the weight goes up, she says.

"But if the patient doesn't understand the discharge instructions and doesn't take his medication correctly, then he won't be adequately treated and will go back into the hospital," Jacobs adds.

"I'm someone who feels very strongly that we should provide good interpretation or good communication in a language the patient can understand throughout the hospital encounter," Jacobs says.

But there are three crucial points where having a medical interpreter is essential, she notes.

"One is when you make a diagnosis, the second is when you have to obtain informed consent for procedures and are trying to communicate to patients how to make decisions about their care," Jacobs says. "And the third is when they are being discharged and are receiving discharge planning."

If a hospital must prioritize the expense of professional interpreter services, then it should at least have a medical interpreter available at these three junctures, Jacobs says.

"I advocate for having them available at all points of care, but if you must prioritize, then I'd prioritize those three time points," she adds.

Jacobs' research concluded that having an enhanced interpreter service intervention did not significantly impact costs.1

Having this interpreter service available did reduce return emergency department visits, however.1

The study noted that the cost of having an enhanced interpreter service was $234 per Spanish-speaking intervention patient, and it represented just 1.5 percent of the average hospital cost. But it was even more cost-effective to have a Spanish-speaking attending physician, and this also significantly increased the Spanish-speaking patients' satisfaction with the doctor and hospital.1

"My research and other research have shown that if you provide adequate communication to a patient with LEP, then you have an opportunity to save on costs," Jacobs says.

"It's very inexpensive in the scheme of things compared with what we pay for in health care," she adds.

"For instance, in this study, I showed that providing the interpreter intervention represented just 1.5% of total hospital costs, which is incredibly small and represents the amount hospitals pay for an X-ray for hospitalized patients," Jacobs says.

Also, there are many costs that researchers have difficulty capturing, but they're still important for hospitals to think about, including the issues of malpractice, she adds.

"It only takes one million-dollar case to wipe out the cost of providing interpreter services over a three-to-five-year period in a hospital," Jacobs explains. "And there are health costs to the patient with not receiving adequate medical care."

In Stroger Hospital, there are interpreters who speak Spanish, Polish, Russian, and a couple of Chinese dialects, Jacobs says.

"The staff interpreters mostly are here during the week, but there's always somebody available 24 hours a day for Spanish," she says. "And there's always access to telephone interpretation services 24 hours a day, so we have 24/7 coverage, but it's just not all face-to-face interpreters."


1. Jacobs EA, Sadowski LS, Rathouz PJ. The impact of an enhanced interpreter service intervention on hospital costs and patient satisfaction. J Gen Intern Med. 2007;22[Suppl2]:306-311.


For more information, contact:

• Elizabeth Jacobs, MD, MPP, associate professor of medicine, Collaborative Research Unit, Stroger Hospital of Cook County & Rush University Medical Center, Chicago, IL. Phone: (312) 864-7311.