Strategies for Language Barriers in the Healthcare Sphere

A CHANGING LANGUAGE LANDSCAPE

The 2015 US Census Bureau’s American Community Survey estimated that English is not the primary language spoken by individuals in 21% of US homes. More than 63 million Americans over the age of five, speak a language other than English. The Census Bureau survey included over 350 different languages, which was expanded from previous surveys. Outside of English, Spanish is the most often spoken language in the US. In addition, there are over one million individual speakers of Chinese, Tagalog, Vietnamese, French, German, and Korean. Arabic stands as the fastest growing language—increasing nearly 30% since 2010—followed by Urdu and Hindi. Forty percent of these individuals self-reported that they do not speak English “very well".

In 2012, the Agency for Healthcare Research and Quality (AHRQ) published Improving Patient Safety Systems for Patients With Limited English Proficiency, A Guide for Hospitals. This publication identified several areas of concern in regards to patient safety. It includes situations related to:

1. Patient comprehension of medical conditions, treatment plans, discharge instructions, complications, and follow-ups;
2. Inaccurate and incomplete medical history;
3. Ineffective or improper use of medications or serious medication errors;
4. Improper preparation for tests and procedures; and
5. Poor or inadequate informed consent

UNIQUE HEALTHCARE CHALLENGES

The diversity in languages spoken in the US poses unique challenges for those in the healthcare field, where miscommunication can have serious and even fatal consequences. The field of medicine is filled with unique, technical, and often confusing language. Many of these medical terms require an intuitive translation service in order to be completely understood.

The cost of translating medical information to multiple languages is a difficult one to predict. Interactions and appointments between providers and patients may have to be extended in order to accommodate for translations. This often results in a loss of efficiency and potentially higher costs of care. In emergent settings, the time for translation between patients, family members, and providers could result in delays in diagnosis and treatment.

In many instances, healthcare has relied on children or family members who have learned English to interpret medical information for parents who either don’t speak the language or who have limited English skills. This reliance can be problematic, especially when asking the child or family member to translate confidential or potentially embarrassing data such as alcohol or drug use or sexually related topics.

REGULATORY REQUIREMENTS

The US Department for Health and Human Services requires recipients of federal financial assistance to take reasonable steps to provide meaningful access to Limited English Proficient (LEP) individuals (Title VI and Department of Health and Human Services regulations, 45 C.F.R. Section 80.3(b)(2)). This scope includes hospitals, clinics, nursing homes, home health, and entities that offer health or social services (including universities). State and local agencies may also have additional regulatory requirements.

The HHS Guidance explains that the obligation to provide meaningful access is fact-dependent and starts with an individualized assessment that balances four factors:

(1) The number or proportion of LEP persons eligible to be served or likely to be encountered by the program or grantee;

(2) The frequency with which LEP individuals come into contact with the program;

(3) The nature and importance of the program, activity or service provided by the recipient to its beneficiaries; and

(4) The resources available to the grantee/recipient and the costs of interpretation/translation services.

While the guidance provides a helpful reference, each organization will need to perform an assessment and determine what constitutes “reasonable steps” to be implemented to meet regulations.

INNOVATIVE SOLUTIONS FOR HEALTHCARE

After completing an assessment and determining what services are required to meet need and regulatory requirements, there are several options that are available for translation services. The AHRQ Patient Safety Systems document makes three recommendations to address language needs. They include requiring the presence of qualified interpreters, providing materials that have been translated to the preferred language, and employing a “teach-back” methodology to confirm that the patient clearly understands what's being discussed.

There are several strategies available to meet the recommendation for requiring the presence of qualified interpreters. One strategy is to employ staff members (or qualified volunteers who have medical training and speak a second language fluently) who can be physically present to translate information. While bilingual individuals can provide in-person translation services, there are some challenges to providing 24/7 staffing and also sufficient coverage in organizations that may require simultaneous translations. It may also be difficult or not cost efficient to have staff or volunteers available who are fluent in the variety of languages that may be required, especially in metropolitan areas where multiple languages are spoken.

Teleconferencing with professional translation services personnel is another option to meet the language needs of patients. These services can be delivered via computer, tablet, or telephone 24/7. The benefits include having services available for languages that are unique to a location, as well as having translators available on an ‘on-call’ basis, which could provide a cost-effective solution versus employed staff.