The Role of Advocacy in Ensuring Quality Health Care for Families Marty Martinez, MPP Policy Director

CPEHN – Together We’re Stronger Ethnic organizations joined together in 1992  APIAHF  CBHN  CRIHB  LCHC

Creating Change Advocating for public policies Sharing data and resources Uniting communities of color

5 Advocacy Strategies Legislative/Budget Advocacy Administrative Advocacy Media Advocacy Policy Analysis Community Organizing Developed by Regina Aragon, Health Policy and Communications Consultant

Race and Ethnicity in California Majority is made up of minorities: – Hispanic/Latino 32.4% – Asian 10.9% – African American 6.7% – American Indian/Alaska Native 1% – Native Hawaiian/Other Pacific Islander.3% – White 46.7%

Language Needs in California 40% of Californians speak a language other than English Of these: – 65 % speak Spanish – 22% speak an Asian or Pacific Islander language – 0.4% speak an African language

Cultural and Linguistic Issues Studies show that the lack of language services affects:  Access to health care services and preventive care  Result in greater emergency room use  Impedes patients from comprehending diagnoses Misunderstandings of cultural practices and beliefs can result in negative health outcomes

Linguistic Access Issues Consumers who are Limited-English Proficient (LEP) may be unable to communicate effectively with their health care provider, seriously compromising quality of care Many LEP clients rely on family and friends to serve as interpreters. Using anyone other than a trained interpreter violates confidentiality and quality of the interaction Translation of documents is vital to consumer understanding

Interpretation vs. Translation Interpreters work with the spoken word. – When oral language services are necessary, organizations and providers should generally offer competent interpreter services free of cost to the LEP person Translators work with the written word. – Vital documents to be translated should be based on: Importance of the program, product or document Encounters with LEP persons Services involved Consequences to the LEP person if the information is not provided

Cultural Competence Understanding the background, cultural values, and beliefs of patients, and applying that understanding in a health context. Cultural competency is the genuine sensitivity and respect given to people regardless of their ethnicity, race, language, culture or national origin. Ability to anticipate and recognize misunderstandings that arise from the differing cultural assumptions and expectations of providers and patients and to respond to such issues appropriately.

Literature Review: Providing Language Assistance Services Increases consumer satisfaction Increases patient adherence/compliance with treatment/follow-up Increases consumer access Reduces medical errors/malpractice

Providing Language Assistance Services Increases Consumer Satisfaction Spanish-speaking patients less satisfied with care [Morales et al. JGIM (1999) 14: ] LEP patients less satisfied with emergency care [Baker, Hayes, Fortier (1998) Med Care 36: ] LEP patients less satisfied with emergency care, less willing to return for future care [Carrasquillo et al. (1999) JGIM 14:82-87]

Providing Language Assistance Services Increases Patient Adherence/Compliance LEP patients less likely to understand medication instructions, less likely to receive needed financial assistance, and less likely to return to the facility [Andrulis et al (2002) Access Project, What a Difference an Interpreter Can Make, 1-2] Spanish-speaking patients discharged from emergency room without interpreters less likely to understand diagnoses, prescribed medications, special instructions or plans for follow-up care [Crane (1997) J Emerg Med 15(1):1-7] Spanish-speaking patients more likely to miss appointments and be less adherent to asthma medication if physician did not speak Spanish [Manson (1988) Med Care 26(12): ]

Providing Language Assistance Services Increases Consumer Access Children whose parents responded in English 2.6 times more likely to have a usual source of care than parents who responded in Spanish [Weinick, Krauss (2000) Am J Pub Health 90: ] Disparities between LEP and non-LEP patients in rates of colorectal screening and flu shots decreased after implementation of interpreter services [Jacobs, et al. (2001) JGIM 16: ]

Business Case Changing demographics of consumers/ members – meet consumer needs – increase consumer satisfaction Marketing strategy – attract new consumers Risk management – indirect costs - increase patient compliance, reduce errors/malpractice Cost reductions – measure cost effectiveness

Efforts to Promote Cultural and Linguistic Competency Federal – Title VI, Civil Rights Act 1964 – Executive Order and LEP Guidances – Office of Management and Budget Report – Office of Minority Health Cultural and Linguistic Appropriate Services (CLAS) Standards California – Dymally-Alatorre Act – Kopp Act – Medi-Cal Managed Care Contract Provisions and Policy Letters – Healthy Families Contract Requirements – SB 853 (Escutia)

Title VI, Civil Rights Act of 1964 Applies to all entities that receive federal funding Prohibits discrimination on the basis of race, color, or national origin. (“national origin” includes Limited English Proficient persons)

Executive Order and LEP Guidances Executive Order issued by President Clinton in August 2000 – Federal agencies must ensure their funding recipients made services accessible to Limited English Proficient population – Federal agencies must make their services available to LEP persons – Federal agencies must develop and distribute guidance OCR Guidance Department of Justice Guidance

OCR LEP Guidance Four Keys to Compliance Assessment of language needs of the population to be served Development of a comprehensive written policy on language access Training of Staff Vigilant Monitoring

OMH CLAS Standards 14 standards organized by themes: – Culturally Competent Care (Standards 1-3) – Language Access Services (Standards 4-7) – Organizational Supports for Cultural Competency (Standards 8-14)

Dymally-Alatorre Bilingual Services Act Applies to State and local agencies Threshold is 5% of people served for State agencies Local agencies left to their discretion Requirements – employ sufficient numbers of bilingual personnel – translate materials explaining their services – translate notices that may affect individual rights No monitoring or enforcement

Kopp Act Passed in 1983 Cal. Health & Safety Code § 1259(a) Applies to all general acute care hospitals Applies to LEP populations who comprise 5% of the geographic areas served by the hospital or the actual patient populations of the hospital California Department of Health Services is authorized to enforce requirements through administrative sanctions

Kopp Act Basic Requirements Develop policies and review annually Ensure availability of interpreter services, to the extent possible, 24 hours/day Post multilingual notices of how to obtain interpreters and complaint process Notify employees about the requirements Review standardized forms for translation Prepare and maintain a list of qualified interpreters Consider establishing community liaison groups to LEP communities Identify and record patients’ primary languages in hospital records

Medi-Cal Managed Care Applies Medi-Cal managed care health plans – Threshold: 3,000 Limited English Proficient Persons in service area, 1,000 per ZIP code, or 1,500 per two contiguous ZIP codes. Requirements: – 24 hour free interpretation at all provider sites – Translation of key materials in threshold languages – Assess linguistic capabilities of interpreters and bilingual provider – Maintenance of Community Advisory Committee – Group Needs Assessment

Healthy Families Applies Healthy Families health plans – Threshold: Lesser of 5% or 3,000 enrolled members in a health plan. Requirements: – Prohibition of the use of minors as interpreters except in most extraordinary circumstances – 24 hour access to interpreter services – Demonstration of appropriate bilingual proficiency of providers listed in provider directories – Translation of key materials in threshold languages – Group Needs Assessment – Inclusion of race, ethnicity, and primary language as core data elements in standard measures

AB 1195 (Coto) Requires continuing education courses to include a component of cultural competency. Based on recommendations from the DHS & DCA Task Force on Culturally and Linguistically Appropriate Physicians and Dentists.

SB 853 (Escutia) Signed into law in 2003 Regulations by Department of Manage Health Care (DMHC) and Department of Insurance (DOI) finalized in 2007 Health Plans and Insurers compiling demographic data On line in 2009: Health Plans Jan 1, other insurers April 1

SB 853 Provisions Requires compilation of demographic profile Access to interpreter at all points of contact Vital documents must be translated into “threshold languages” Reporting by plans and insurers on cultural competency Reports by DMHC and DOI to legislature on compliance

Eliminating Health Disparities

SB 853 Translation Thresholds Plan or insurers with enrollment of a million or more: top 2 non-English languages, plus threshold of 0.75% or 15,000 of the enrollee population With enrollment of 300,000: top 1 non-English language plus threshold of 1% or 6,000 of the enrollee population With enrollment less than 300,000: threshold of 5% or 3,000 of the enrollee population

SB 853 Continuing Issues & Solutions Regulators must circulate information to health plans and insurers on best practices related to data collection, categorization, and usage. Requirements must be established to improve the cultural competency of care Patients must be notified of their right to an interpreter & how to complain

Board of Pharmacy SB 472 (Corbett) passed in 2007 Will address standardizing prescription labels Will address translation of labels Success in New York

Medi-Cal Language Access Services (MCLAS) Task Force 13 states have established a mechanism to reimburse providers in Medicaid for language services SB 1405 (Soto) in 2006 Task Force comprised of government, consumer advocates, and providers Report released March 2009

MCLAS Task Force Report California must draw down max Medicaid $ Mixed system: language brokers and direct enhanced payments to hospitals New quality control measures State certification of interpreters A pilot program (need state resources!)

Policy Issues - Interpreters Competency of interpreters must be assured – Use of minors should not be allowed – Friends and families should not be utilized – Use of a trained, tested interpreter is better for the patient and the provider

National Certification of Interpreters The National Council on Interpreting Health Care and the California Health Interpretation Association each developed standards for essential skills for interpreters: – Basic language skills – Recognition of ethical issues (a code of ethics) – Cultural competency – Health care terminology National efforts beginning

“So let there be no doubt: Health care reform cannot wait, and it will not wait another year.”

Federal Reform Proposals being released by congress. They vary in cultural and linguistic access Cultural and linguistic standards must be applied to all insurers Insurers must have sufficient reimbursement mechanisms Outreach and “Exchanges” must be culturally and linguistically appropriate

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