Work with interpreters to plan discharge at admission

Social issues are identified early

By using the hospital’s on-site interpreters when they make assessments of patients who don’t speak English, staff at Boston Medical Center are able to start the discharge plan early in the stay and identify resources in the community that provide services for people of different religions and ethnic backgrounds.

About 30% of the medical center’s patients do not speak English and need an interpreter. The hospital’s interpreter services department provides on-site translation in 17 languages and is available 24 hours a day.

"If someone comes in from Cape Verde, the first thing we do is to get an interpreter so we can identify who they live with in the United States, what is their functional status, if they are on medications, how they are paying for their medications, and other information that will help us plan for their discharge needs," says Monica Ferraro, RN, MS, clinical supervisor of the care management department.

The interpreters are scheduled over a customized web-scheduling system that helps reduce wait times. In addition, the interpreters routinely perform rounds on the patient floor and cover the emergency department as needed.

Even so, staff recognize that patients who have to wait for an interpreter or a family member who can interpret to find our what is happening are more likely to be apprehensive and mistrustful than someone who can engage in a free-flowing dialogue with his or her caregivers. "As much as we accommodate for cultural differences, it’s still difficult for these patients because their language is not the primary language spoken in this hospital and that creates some anxiety about the care," Ferraro says.

Determine expectations early

The staff try to identify social issues early and work through the interpreters to determine the patient’s and family’s expectations for care while they are in the hospital and what their feelings are about post-discharge care. For instance, one Hispanic patient was suffering from dementia to the point of needing almost total care. His wife told the case manager, through interpreters, that she felt strongly about wanting him discharged to home. "We had to respect that, even though we knew it would be hard for her to have him at home. In this case, her daughter intervened. But if she hadn’t, we would have worked with her to make sure she could care for him at home," Ferraro says.

The staff go through the same steps with all patients, regardless or race or ethnic background, when they create a discharge plan, but with patients from other cultures, they may have to make accommodations. "We honor the family’s wishes as long as [they are] reasonable and they are competent and understand the risk and potential complications or adverse outcomes of their decision," Ferraro explains.

Be flexible whenever possible

Accommodating a patient’s cultural beliefs and practices sometimes requires a balancing act between the patient’s beliefs and the hospital’s standard procedures, she points out. "We follow the direction of the patient and family to meet their needs and at the same time provide the care and plan the discharge according to hospital state, and federal regulations," Ferraro says.

At admission, all patients are asked their religious preferences, and if they want to see a religious leader from their particular religion. If necessary, the staff involves religious leaders who understand the beliefs and cultural practices of the patient and who can help interpret for the patient and family. In one case, the staff brought in a physician from another hospital who was of the same religion of the patient to help create an end-of-life plan for the patient.

"In end-of-life decisions, we are involved in working as a team with a family. This is where religion plays a huge role, and we have to take their beliefs into account," Ferraro says.

Many of the patients who don’t speak English are not aware of social programs and resources that can help them, she points out. "It’s up to us to be familiar with resources and to recommend them to all our patients."

For instance, one patient was paying for his medicines out of pocket. Ferraro asked a social worker to investigate the possibility of accessing a drug manufacturer’s indigent care fund on The web site provides information and links to programs that help patients get assistance obtaining medications, she adds.

The staff maintain files on ethnicity-specific community resources in case a patient needs them. In addition, the staff often do research on-line or through Boston Medical Center’s web site to find patient resources.

The hospital’s human resources department and interpreter services have developed a four-hour class on language barriers and customer services for all staff with direct patient contact. All management staff go through eight hours of training each year, two hours of which are focused on cultural diversity training. A cross-functional team develops and delivers workshops for managers and staff addressing the diverse needs of patients and families.


For more information about incorporating interpreters in the admissions process, contact:

Monica Ferraro, RN, MS, Telephone: (617) 638-7271. E-mail: