University of Chicago Ethnogeriatrics Seminar Micah Croft, Beth VanOpstel, Ron Maggiore, and Julie Helms Feb. 25, 2011 OVERVIEW OF MEDICAL INTERPRETER SERVICES (MIS) FOR LIMITED ENGLISH PROFICIENCY (LEP) PATIENTS

LEP Prevalence 262 million in U.S. aged 5 and older 47 million of those (18%) speak a language other than English at home (projected to have increased to 69 million for 2010 US Census) 21 million (8%) have LEP (projected to have increased to 28.4 million for 2010 US Census) 60% of these are Spanish-speaking

Existing Laws Regarding MIS/LEP Title VI of the Civil Rights Act of 1964  Prohibits discrimination by organizations that receive federal funds. Medicaid Laws and Related Regulations The Hill-Burton Act  Hospitals receiving certain government funding cannot discriminate. Executive Order  Agencies receiving federal funding must improve access for those with LEP.

Dept. of HHS/Office of Minority Health Recommendation: Healthcare organizations must offer and provide language assistance services, including bilingual staff and MIS at no cost to the patient or consumer with LEP at all points of contact during all hours of operation

MIS Utilization in Medical Settings 79% of hospitals in one study by the Joint Commission on Accreditation of Health Care Organizations said that they used family and friend frequently to translate Yeo G. How Will the U.S. Health Care System Meet the Challenge of the Ethnogeriatric Imperative? JAGS 2009; 57:

MIS Utilization ctn’d. In another study: - 20% of pt encounters need interpreters - Only 32% of these get a trained one - 11% don’t get one at all - 56% use staff or family member

Case: 2008 Lawsuit New Jersey rheumatologist Did not provide ASL interpreter to deaf patient Sued under disability discrimination law Defense: Cost was $150, Medicare reimbursement was $50. Award: $400,000

Snapshot of Potential Costs Telephone: $132 / hour In-person (Outside agency): $79 per interpretation In-person (full-time): $20-26/hour Medicaid may pay part of interpreter services fees (currently in 12 states and DC). Some hospitals include interpretation costs as part of overall payment rate. Lack of payment options creates disincentives

Risks Associated with MIS Under- use or Misuse Use of ad hoc interpreters have been shown to lead to medical errors based on errors in interpreting, such as omission, false fluency, substitution, editorialization, and addition. 73% of false fluency errors are attributable to lack of knowledge of medical terminology ~25% higher error rate than when compared to hospital interpreters Frequently involve instructions/directions for medications or for procedures

Adverse Outcomes Associated with MIS-Related Errors 1.Lower levels of self-rated satisfaction with medical care. 2.Lower levels of self-reported understanding of diagnostic information or treatment planning. 3.Communication errors in misinterpretation of medical information. 4.Potential and actual adverse drug events due to communication errors. 5.Potential for increase use of diagnostic testing, urgent care services, IV hydration, risk for hospitalization Karlner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res Apr;42(2): Review. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. MCR&R 2005;62:

Should We Use Family At All? Family interpreters and bilingual physicians may be preferred when sensitive information is discussed but otherwise should be discouraged Recommendation supported by the Dept of HHS/Office of Minority Health Both professional and family interpreters for psychiatric evaluations may be fraught with problems (here bilingual physician may be preferred) Levels of self-rated satisfaction of LEP patients utilizing professional in-person MIS are equivalent to those with EP patients in several studies and often highest among various types of MIS provided

Potential Benefits of Having Professional MIS Available for LEP Patients Higher self-rated satisfcation with clinical encounters Lower rates of communication errors Increased use of some preventative health services (I.e., FOBT, influenza vaccination) Overal visit times have not shown to be significantly different between LEP patients requiring in-person professional interpeters vs. EP patients although obtaining a full history may take longer Urgent care visits may take less long with professional interpreters than with ad hoc interpreters

Research Knowledge Gaps Growing need to evaluate outcomes (clinical, communication- related, patient-rated satisfaction and other quality indicators) among different types of interpreters: ad hoc, bilingual providers, professional in-person vs. telephone Differences in outcomes among language types? Do other factors play a role in outcomes? Gender of the interpreter? The role of training requirements for professional interpreters; state vs. national certification/credentialing Differences in state-level outcomes in states that reimburse via Medicaid vs. those that currently do not? Certification/level of training for bilingual providers?

Proposed Solutions National/State-Level: Provide Medicare or other reimbursement for MIS, including telephone services Increase the number of states providing Medicaid reimbursement Standards across states vs. national policy in which services are covered, how, and to what extent. More uniform regulations in certification procedures (I.e., ensuring all MIS professionals have passed the national board exam for their language(s) of concentration) Institutional: MIS utilization training for all new staff and students as part of hospital orientation Online training/renewal for staff (similar to infection control training, HIPPA, etc.) Individual: Learn how to contact and arrange for MIS for LEP patients to avoid potential risks in providing care to them Learn to become a MIS-certified bilingual provider based on institutional and/or state regulations