Kaiser Permanente-Southern California Physicians Language Concordance Program Meeting the Needs of LEP Patients Lakiesha Tidwell Regional Senior Consultant Culturally Responsive Care, SCAL July 16, 2009

Efforts toward establishing Linguistically Appropriate Health Care  Overcoming Barriers  Establishing Facts  Engaging Physicians  Developing and Implementing a Sustainable Program  Evaluating Program Outcomes

Overcoming Barriers  Are there real issues with limited English proficient patients?  Does matching clinicians and patients by language preference make a difference?  Do clinicians need to be tested for language proficiency?  Will access to appointments be affected?  Will language concordance affect HEDIS measurements?

Overcoming Barriers  Recent Legislation answered many of the questions regarding who and how LEP patients should receive linguistic services  Focus on quality of care  Focus on meeting needs of growing of patient populations  Focus on developing a comprehensive program that addresses access and infrastructure  Focus on improving healthcare outcomes

Establishing Facts: Is Limited English Proficiency really a Problem? Internal & External Review conducted by KP Spanish Language Task Force  Hispanic population concentrations are increasing in Southern California.  This is not a short-term phenomenon that will disappear when everyone learns how to speak English.  KP SCAL Population Demographic Trends inform us that appointment demand by LEP patients will continue to be a challenge.  On average, 10-12% of the members in our region prefer languages other than English. 11 Threshold Languages: Arabic, Armenian, Khmer, Cantonese, Farsi, Korean, Mandarin, Russian, Spanish, Tagalog, and Vietnamese  By the year 2010, 6 medical center areas will be in a service area that is over 45% Hispanic and all but one medical center area will be in an area that is over 30% Hispanic

Establishing Facts: Is Limited English Proficiency really a Problem? DKA (Did Not Keep Appt) rate  Spanish LEP patients rate is similar to non Spanish LEP patients when physician speaks their language  Spanish LEP patients rate is higher than non Spanish LEP patients when physicians does not speak their language Visit rate  Spanish LEP patients rate is similar to non Spanish LEP patients when physician speaks their language  Spanish LEP patients rate is lower than non Spanish LEP patients when physicians does not speak their language

Establishing Facts: Does matching clinicians and patients by language preference make a difference? Language Concordance Story II Mrs. X is a 70 y/o Latina woman who has been a KP member in Southern California for over 10 years. She speaks limited English and prefers to communicate in Spanish, but in the past had been reluctant to request a Spanish-speaking primary care physician. In early November of 2007 she noticed a painful bruise on her right foot; she thought she must have injured her foot in some way, although she couldn’t remember how. She did not mention it to her primary care physician during a visit later that month. In December of 2007 she decided to request a Spanish-speaking physician and got an appointment to see him in January of At this first visit she was able to communicate the details and symptoms associated with the “bruise” to her new physician in her native language. Mrs. X description of her symptoms was enough to prompt the doctor to immediately order a work-up for suspected deep vein thrombosis. The results of the tests confirmed the diagnosis of DVT and Mrs. X started a course of heparin and regular monitoring. Thanks to her ability to communicate with her physician in her preferred language Mrs. X was able to comprehend the seriousness of the diagnosis and the importance of complying with her physician’s instructions and treatment plan. She was successfully treated for DVT and is currently doing well.

Engaging Physicians: Do clinicians need to be tested for language proficiency?  An established, accredited language assessment tool mitigates personal and organizational liability  Regulatory agencies will be auditing how hospitals are providing linguistic services  Language concordance supports equitable, quality care for all patients  Patients are informed of their rights to interpretive services  Improves communication and quality of outcomes

Engaging Physicians: What do the experts say about language concordance?  Language concordance is the “gold standard” in language assistance to patients. \1  Greater physician language fluency was strongly associated with positive patient assessment of physicians’ abilities to elicit and respond to patients’ problems and concerns. \2  Even with the provision of interpreters important errors in communication can occur. \3  Emergency Department  Cases with interpreters…had longer ED visits and were more likely to be admitted.  Cases without language assistance had a higher incidence and cost of testing and was most likely to be admitted.  Decision-making was most cautious and expensive in the absence of a bilingual physician or professional interpreter. \4  Latinos responding in Spanish were significantly more dissatisfied with communication with health care providers than Latinos responding in English or non-Latino whites responding in English….less likely to feel that the medical staff listened to them, answered their questions, or explained medications, procedures, or test results.\5 \1 Jean Gilbert, PhD, presentation to Spanish Language Task Force, 8/31/06 \2 Fernandez, et al. Journal of General Internal Medicine, 2004 Feb 19(2): \3 Flores et al. Pediatrics, 2003 Jan 111(1):6-19. \4 Hamers & McNulty. Archives of Pediatric and Adolescent Medicine, 2002 Nov 156 (11): \5 Morales et al. Journal of General Internal Medicine, :

Are Clinical Strategic Goals (CSGs) worse for Spanish LEP members, making them harder to care for? CSGs that are worse in Spanish LEP members than the general population  Lipid Control in members with diabetes  HbA1c<=9% in members with diabetes  Colorectal Cancer screening  Antidepressant Medication Management is worse  Timeliness of prenatal care CSGs that are better in the Spanish LEP members than the general population  Breast cancer screening is a little better  Cervical cancer screening is better  Immunizations are better Other CSG differences are not noted because sample sizes are very small Spanish LEP patients have some CSGs that are better than the general population and some that are worse. Improvements have been shown after concordance implementation.

Developing and Implementing a Sustainable Program Testing  Provide $250- stipend for taking the test (40min) Participation  Reward clinician for increasing the number of Limited English speaking patients under their care  Provide clinician with staff that speaks the same language if have < 20% patients on panel Monitoring  Updating Language preference of patients for accuracy  Panel assignments  Ensure internal processes for capturing, updating, and reporting data are in place

Developing and Implementing a Sustainable Program  No Harm to Access (ie: <14 days)  Must be feasible  Must be able to implement regionally  Have a measurable tracking system  Must be fair among specialties  Be affordable  Fair between specialty and primary care  Incentive must drive concordance  Must be patient-focused  Easy to understand and administer  Does not disadvantage monolingual doctors Program Guidelines :

13 Referral Guidelines Is Patient Limited English Proficient (LEP)? Book with first available provider Is language concordant provider available within 14 days? Book with any available provider within 14 days Book with language concordant provider Yes NO YES NO It is important that the program not harm access. These guidelines will help. Referral Guidelines Proposed Referral Guidelines Is referral for an urgent patient? Yes

Program Outcomes Increased Language concordant visits from 24.6 % to 35.4% over a 1 year period (93,000 visits language concordant) 50% of eligible self reported fluent physicians have taken the assessment since programs 2008 implementation 86% pass rate for Primary Care and 84% pass rate for Specialty Care CSGs are improving for patients with concordant visits Improved communication between clinician-patient thus increase bonding rate, health outcomes and patient satisfaction

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