RESOURCES FOR PRACTICE

Primary care for limited English-speaking patients and parents Rebecca Regan Freeman, CPNP, MPH (Pediatric Nurse Practitioner) Denver Health Medical Center, Denver, Colorado

Keywords Language; primary care; public health; health disparities. Correspondence Rebecca Regan Freeman, Denver Health Medical Center, Denver, CO. Tel: 303-602-8361; E-mail: [email protected] Received: 1 June 2012; accepted: 1 November 2012 doi: 10.1002/2327-6924.12148

Abstract Purpose: The number of persons in the United States who have a primary language other than English has been steadily increasing for decades. The latest census information reveals that citizens with limited English proficiency (LEP) represent approximately 16% of the population. The inability to effectively communicate creates stark challenges in the delivery and receipt of health care. Language discordance in the healthcare setting has been firmly established as a source for health disparities among LEP patients and families. Poorer health outcomes are seen across the healthcare setting for LEP patients and children of LEP parents. Data sources: Scientific literature review, scholarly databases, Internet sites. Conclusions: There are various systems and methods that can be implemented in order to help improve health outcomes for LEP patients. There are benefits and challenges to each of the methods available for LEP patients and their providers. Improvements must be made on numerous levels including in clinical settings, in training curricula, and system wide. Implications for practice: The risks associated with decreased quality of communication between patient and provider merit an earnest consideration of the methods available for LEP patients and implementing some of these services for those patients.

The United States is a diverse nation, compromising hundreds of different cultural and linguistic groups. According to the 2007 U.S. Census, 55.4 million citizens speak a language other than English at home, roughly 20% of the population. Of these, 16.3% categorize their ability to speak English as “not well” and 8.1% as “not at all” (U.S. Census Bureau, 2010). The term limited English proficiency (LEP) refers to the population who is self-rated as speaking English less than “very well” (Flores, Abreu, & Tomany-Korman, 2005). The number of LEP persons in the United States continues to grow. The 2010 Census data indicate that “minority” groups (people who reported their ethnicity and race as something other than non-Hispanic white alone) are now the majority in several states including California, Washington, DC, Hawaii, New Mexico, and Texas (Humes, Jones, & Ramirez, 2011). The impacts of these statistics are perceived strongly in the healthcare setting. Clinicians and clinical staff are faced with the challenge of providing care and services to patients whose primary language is not English. Language barriers in

Journal of the American Association of Nurse Practitioners 27 (2015) 167–176  C 2014 American Association of Nurse Practitioners

the clinical setting have been well documented and have significant consequences in regards to health outcomes (Brach, Fraser, & Paez, 2005; Flores & Tomany-Korman, 2008; Gadon, Balch, & Jacobs, 2007; Smedley, Stith, & Nelson, 2003). Disparities in health care for LEP patients create a strain for families, providers, and the community. This article will identify the health disparities for LEP patients and describe the challenges, solutions, and suggestions to providing care when language discrepancies exist.

Why language matters in the clinical setting Patients with a limited ability to communicate in English face challenges at every level of the healthcare system (U.S. Department of Health and Human Services [USDHHS] Office of Minority Health, 2005). There are five specific disparities that affect LEP patients: (a) decreased access to care, (b) decreased quality of care, (c) decreased patient–provider bond, (d) patient dissatisfaction, and (e) provider dissatisfaction.

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Decreased access to care Patients with poor or fair English language proficiency report longer wait times at clinics, greater difficulty getting information by phone, and no regular source of care as compared to those with good or excellent English proficiency (Pippins, Algeria, & Haas, 2007). Children from LEP families are less likely to have a regular source of care, less likely to complete recommended preventative care visits, more likely to be uninsured or have sporadic insurance, and have greater problems accessing specialty care (Cohen & Christakis, 2006; Flores et al., 2005; Flores & Tomany-Korman, 2008; USDHHS Office of Minority Health, 2005). Parental LEP inhibits medical care visits for their children because of language barriers and difficulty making appointments (Flores et al., 2005).

Decreased quality of care Patients with language-discordant providers, meaning they do not use or understand the same language, reported receiving less health education compared to those with language-concordant providers in a study of 2746 Chinese and Vietnamese patients receiving care at 11 health centers in eight cities (Ngo-Metzger et al., 2007). Children from LEP families have poorer management of medical conditions such as asthma (Chan, Keeler, Schonlau, Rosen, & Mangione-Smith, 2005), decreased adherence to medical regimens and prescriptions (Flores & Tomany-Korman, 2008), and receive less counseling than their English-speaking peers (Hambridge, Emsermann, Federica, & Steiner, 2007). Additionally, LEP children are more likely to utilize acute or emergency care services and have increased rates of diagnostic testing (Smedley et al., 2003).

Decreased patient–provider bond Trust and confidence are crucial to the provider–patient relationship, bonding leads to greater provider and patient satisfaction. Language barriers make it more difficult to establish and maintain a patient–provider relationship. Kanter et al. (2009) conducted six focus groups with 29 men and women ages 21–65 years old who were patients at Kaiser Permanente Southern California. They found that bonding rates for Spanish-speaking patients with English-speaking providers was 42%, while 72% of Spanish-speaking patients paired with Spanish-speaking providers reported good bonding.

Patient dissatisfaction Patients with language-discordant providers reported worse interpersonal care and were more likely to give 168

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low ratings to their providers (Ngo-Metzger et al., 2007). The National Survey of Childhood Health conducted a random-digit-dial telephone survey of 102,353 parents of children 0–17 year olds from English- and non-Englishspeaking households to gather data on prevalence rates of critical children’s health indicators. In this survey, LEP parents reported that their provider never or only sometimes took the time to understand their child’s specific needs, explained things in an understandable way, or was able to provide telephone advice or help (Flores & TomanyKorman, 2008).

Provider dissatisfaction Providers are frustrated when they feel that pertinent information is not being communicated (Gadon et al., 2007; USDHHS Office of Minority Health, 2005). Providers and staff are concerned over the risks regarding patient safety and care when language discordance exists (Gadon et al., 2007). A study on the challenges providers face when communicating with LEP patients was conducted using six focus groups with eight generalist or specialist providers whose patient population was at least 5% LEP. Common themes that emerged were (a) inability to establish rapport, (b) miscommunication when using a family or friend as interpreter, (c) difficulty making a diagnosis or explaining care options, and (d) difficulty meeting informed consent requirements (Lake, Snell, Perry & Associates, 2004). Language discordance is a significant barrier to health services and to achieving positive health outcomes. LEP patients or children with LEP parents are in a compromised position. Recognition of these consequences is growing by providers, staff, administration, and public officials. While the negative health outcomes have been acknowledged, significant barriers still exist for LEP children.

Key challenges Obstacles to providing care to LEP patients are numerous. In addition to the problems identified above, several specific barriers are routinely cited as preventing adequate care to LEP patients.

r r r

Lack of access to or convenience of interpreter services (Gadon et al., 2007; Ku & Flores, 2005; USDHHS Office of Minority Health, 2005). Cost of implementing language services (Gadon et al., 2007; Ku & Flores, 2005). Lack of regulations and enforcement regarding language services (Au, Taylor, & Gold, 2009; Jacobs, Shepard, Suaya, & Stone, 2004).

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Solutions To decrease health disparities and improve the health outcomes of patients from LEP families, strategies must be implemented at all levels of the healthcare system. Initiatives must target patients, families, providers, clinic staff, delivery systems, and regulatory and policy organizations. Collaboration between every sector of the healthcare system is crucial.

Interpreter services One of the most important methods to bridge a language gap is through interpreter services. There are several styles of interpreter services including professional in-person, telephonic, video, and ad hoc (see Table 1). Numerous studies have researched the efficacy of various interpreter methods (see Table 2). Several of these suggest that professional in-person interpreter services have the greatest positive impact on clinical visits between LEP patients and English-speaking provider (Flores et al., 2003; Karliner, Jacobs, Chen, & Mutha 2006; Locatis et al., 2010). Telephonic interpretation has also been shown to be effective in improving visit outcomes (Crossman, Wiener, Roosevelt, Bajaj, & Hampers, 2010; Locatis et al., 2010). In studies evaluating ad hoc interpretation, it was consistently found to be less beneficial than the other methods (Cunningham, Cushman, Akuete-Penn, & Meyer, 2008; Gadon et al., 2007; Lee, Batal, Maselli, & Kutner, 2002). In certain circumstances, ad hoc interpretation has negative impacts on visit outcome, such as errors in interpretation, omission of pertinent information, and decreased satisfaction (Flores et al., 2003). Karliner et al. (2006) found that the

use of professional interpreters correlated with improved quality of health care for LEP patients. Additionally, they found that the positive impact is greater with professional interpreters than with ad hoc. Telephonic interpretation was also found to be useful and effective. It is important to consider that children are often used as ad hoc interpreters in the pediatric setting. This practice is generally discouraged (Flores, 2005). Children, particularly young children, often lack the maturity and knowledge to interpret in a medical setting and can result in the miscommunication of pertinent information (USDHHS Office of Minority Health, 2005). The cost of providing interpreter services is a worthwhile investment (Jacobs et al., 2004; Ku & Flores, 2005). Jacobs et al. studied four health centers that served approximately 122,000 patients in a Massachusetts health maintenance organization that offered comprehensive interpreter services to Spanish- and Portuguese-speaking patients. Jacobs et al. estimated the cost per person per year of these interpreter services to be $279. They also found that the patients who received interpreter services received more recommended preventative services, made more office visits, and had more prescriptions written and filled (Jacobs et al., 2004). The Office of Budget and Management estimated that interpretation services costs an average of $4.04 per person per visit, depending on the interpretation method (Office of Budget and Management, 2002). The risk of misdiagnosis, increased rates of diagnostic testing and invasive procedures, and poor disease management and health outcomes in the LEP population, justifies the use of interpreter services to enhance provider and patient communication (Ku & Flores, 2005; USDHHS Office of Minority Health, 2005).

Bilingual providers Table 1 Definition of interpreter methods Interpreter method Professional in-person Telephonic

Video

Ad hoc

Definition A trained individual provided by the healthcare organization to interpret (Karliner et al., 2006) Utilizes telephone headsets and remote interpreters. Includes consecutive with one or dual handsets (waiting for the person to finish their statement and then interpreting) and remote simultaneous (interpretation within milliseconds of speech; Cunningham et al., 2008) Live interpretation via an off-site interpreter utilizing video cameras and digital screens (Locatis et al., 2010) An untrained person who is called upon to interpret, such as a family member or a bilingual staff member whose job description does not include interpreter services (Karliner et al., 2006)

Another way to enhance communication is to pair patients with providers who are fluent in the patient’s primary language. This may require hiring providers who are bilingual in the primary languages of their population and scheduling patients on the particular days that the provider is in the clinic. It is important to ensure that providers are truly fluent in the language and in the translation of medical terminology, which can be verified by language audits and proficiency tests (USDHHS Office of Minority Health, 2005). A guide published by the Robert Wood Johnson Foundation identifies six components that should be included in a language proficiency exam: (a) basic language skill, (b) ethical case study, (c) cultural issue, (d) healthcare terminology, (e) integrated interpreting skills, and (f) translation of simple instructions (Robert Wood Johnson Foundation, 2002). Proficiency testing can be done within an organization or by outside agencies that offer 169

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Table 2 Summary of studies for interpreter methods

References

Sample

Type of interpreter service

Design

Cunningham et al. (2008)

98 mothers with limited English proficiency presenting for first or second well-baby visits

Anonymous survey

Ad hoc and telephonic

Crossman et al. (2010)

1201 families presenting to a pediatric emergency room and indicating that they prefer to communicate in Spanish

Prospective randomized

Telephonic, professional, and bilingual providers

Flores et al. (2003)

13 audio-taped and transcribed pediatric encounters from an outpatient clinic

Professional and ad hoc

Jacobs et al. (2004)

4499 patients enrolled in an HMO serving Spanish- and Portuguese-speaking patients

Before and after implementation of interpreter services

Lee et al. (2002)

233 English-speaking patients and 303 Spanish-speaking patients visiting an urban walk-in clinic

Postvisit questionnaire

Locatis et al. (2010)

241 Spanish-speaking patients at a university postpartum or pediatric clinic

Quasi-randomized control

proficiency testing. Tests should include the previously mentioned items in a combination of written and oral formats.

Language appropriate materials Written material should be available in the languages most prevalent in a particular setting. Written materials supplement verbal communication and provide a visual tool for sharing information. Certain documents are legally required to be available in a patient’s primary language: consent forms, acknowledgment of receipt of privacy practice, patient bill of rights, and vaccine information statements. Other materials are aimed at disseminating information such as healthy lifestyle recommendations, pamphlets, and resources. While it is important to make all written materials available in prevalent languages, certain documents are of greater importance. Priority materials include consent forms, intake forms, contact information, patient bill of rights, and appointment slips (Youdelman, 2007). 170

Language concordant providers, telephonic, and ad hoc Professional in-person, telephonic, and video

Results Mothers using telephonic interpretation reported significantly greater communication and overall satisfaction compared to mothers using ad hoc or no interpretation All groups had similar rates of concordance between diagnosis in the medical record and patient reported diagnosis. Noninferiority for telephonic and professional in-person interpreters was reported for quality and satisfaction using bilingual provider as the gold standard Errors in medical interpretation are more common with ad hoc interpretation than with professional, though both methods result in some error Patients who used interpreter services received significantly more recommended preventative services, made more office visits, and had more prescriptions written and filled Patients with language concordant providers and patients using telephonic interpretation were much more satisfied than patients using ad hoc interpretation All methods of interpretation were highly rated, video, and in-person were significantly higher than telephone

Providing written materials is crucial to improving patient outcomes (USDHHS Office of Minority Health, 2005). Sanders, Shaw, Guez, Baur, and Rudd (2009) assert that healthcare offices should provide easy-to-use print materials that are audience appropriate. Providing written materials for patients can increase awareness and understanding of the healthcare system, the practices of a particular organization, and specific health topics.

Precautions When providing language services to patients, a solid understanding of the nuances within a language is important. Languages can have distinct idioms and vernacular that vary by country and region. A Spanish-speaking patient from Ecuador and a Spanish-speaking patient from Mexico may have different words to describe symptoms and feelings. Staff and clinicians must ensure that the patient is receiving language services that are pertinent and useful. Interpreters must be cognizant of the distinct language preferences of patients and prevent errors by

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evaluating the patient’s understanding throughout the clinical encounter.

Health information technology Health information technology (HIT) is quickly becoming a critical component in health care (D’Alessandro & Dosa, 2001; Gibbons, 2011; Institute of Medicine, 2001; Neuhauser & Kreps, 2003). The use of information technology has the potential to improve healthcare systems and health outcomes (Gibbons, 2011). Fundamentals of HIT include (a) electronic medical records, (b) eprescribing, (c) clinical decision support, and (d) audio and visual aids. Several reports have projected that advances in this field will lead to greater quality of care (Chaudry et al., 2006; Chou, Hunt, Beckjord, Moser, & Hesse, 2009). The benefits of increased HIT utilization can also be applied to LEP patients and may decrease the health disparities in this population (Gibbons, 2011). A summary of HIT components and their potential impacts is presented in Table 3. Electronic medical record. The electronic medical record is increasingly used in health organizations today (Hsiao et al., 2009) and can be employed to assist LEP patients. The electronic medical record can alert staff and providers of a patient’s language preference to ensure appropriate interpreter services can be scheduled prior to the encounter (Regenstein, Trott, West & Huang, 2008). Clinical decision support. In conjunction with the increased utilization of electronic medical records, the use of clinical decision support systems is also increasing (Bryan & Boran, 2008). Clinical decision support is a software algorithm that provides care recommendations and alerts at the time of care. The algorithm can incorporate information related to ethnicity, language, and culture and facilitate population-specific recommendations (Gibbons, 2011). Thus, clinicians would get feedback and resources that are pertinent to the patient in a cultural

and linguistic context. This system could also link the provider to language appropriate materials (e.g., vaccine information sheets, informational handouts, etc.), websites, and additional resources pertinent to the patient’s language needs. In studying HIT at community health centers in New York City, Calman, Kitson, and Hauser (2007) noted that computerized support, such as electronic medical records and clinical decision support, can generate appropriate material from multilingual patient education databases. This streamlines the process for providers to supply their patients with language appropriate materials during the office visit. Video. Visual aids are another method that can enhance LEP patients’ understanding of health-related issues. The use of language appropriate educational videos has the potential to disseminate necessary information to a great number of patients. Videos can be presented in the waiting room, utilizing that “down time” and allowing more time to be spent with the provider (Gibbons, 2011; Pignone, DeWalt, Sheridan, Berkman, & Lohr, 2005; Sanders et al., 2009). Videos can provide information on healthy lifestyle options, the well-child visit schedule, common illnesses, and anticipatory guidance. Providing this generic information in a video can supplement visit discussions and written information. Videos are particularly useful for patients with lower literacy abilities (Pignone et al., 2005). LEP patients would benefit from information being presented in an audio/visual format in their preferred language. Telephonic and text messaging. Many clinical practices utilize telephonic reminders for upcoming appointments. Reminders should be available in the languages most prevalent in the clinic. Language appropriate reminders that are specific to LEP patients can facilitate appointment adherence and improve health outcomes (USDHHS Office of Minority Health, 2005). Additionally, current research is looking into programmed text message reminders for appointments, follow-up, medications, and vaccinations (Krishna, Boren, & Balas, 2009).

Table 3 HIT intervention and projected outcomes for LEP patients Health information technology element Electronic medical record

Language component

Video

Automatic alert of language preference and need for interpreter services Cultural, ethnic, and language-specific entry and recommendations Language specific

Telephonic reminders

Language specific

Social media

Language specific

Decision support

Projected outcomes Increased staff awareness, increased opportunity to provide resources Increased accuracy and relevance of diagnoses and recommendations for specific patient populations Increased delivery of health information to patients, increased patient education Increased adherence to appointments, increased preventative care encounters Increased patient support, interaction, and empowerment

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Utilizing a cell phone or text message system to contact patients may be useful with LEP families and help to increase appointment attendance and adherence to healthcare regimens. Social media. The Internet, web-based, and mobile technologies have been proposed as forums in which patients can be actively involved in receiving, processing, and responding to health information (Martinasek et al., 2011; van Uden-Kraan, Drossaert, Taal, Seydel, & van de Laar, 2009). Social media includes online groups, blogs, and social networks. In the past decade, the use of social media as a healthcare tool has greatly increased (Gibbons, 2011; van Uden-Kraan et al., 2009). Examples of social media in the healthcare system include health-oriented social networks, online patient communities, and wellness tools and applications. Online groups such as “PatientsLikeMe” provide forums for patients to communicate with each other, receive support and advice, and find resources specific to their medical condition. Additionally, social media has been used successfully in smoking cessation through web-assisted tobacco interventions that address cessation, prevention, social support, and professional development and training (Norman, McIntosh, Selby, & Eysenbach, 2008). Several studies indicate that social media is empowering for patients and their families (D’Alessandro & Dosa 2001; van Uden-Ksaan et al., 2009). The utilization of social media in health has also been studied specifically in LEP and racial and ethnic underserved populations. Chou et al. (2009) evaluated social media as a method of health communication. They concluded that social media is effective at reaching patients regardless of socioeconomic and health status and may help to reduce the disparities currently seen in health care. Gibbons (2011) examined the use of HIT among racial and ethnic minorities. He found that increasing the use of social media in health care had the potential for greater patient interaction, engagement, and selfmanagement for racial and ethnic underserved populations. Both Chou et al. and Gibbons indicate that social media can be a tool to decrease health disparities. Because minorities and LEP patients utilize mobile technology significantly online healthcare systems are a viable method to reach, support, and empower LEP patients and families. However, the use of social media in health care remains controversial. There are strong arguments for and against using social media in health care (see Table 4). The debate over the use of social media in health care brings up valid points. The steps going forward should consider the risks, patient protection, safety, and credibility of the information.

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Table 4 Pros and cons of social media in health care Pro Increased patient participation and empowerment Increased support from peers Consumer centered Successful use in public health initiatives Successful use in adolescent population Interactive venue for information exchange

Con Dissemination of information that may not be research based or verified Possibility of privacy violations Possibility of HIPPA violations and professional consequences Exclusion of patients who have lack of comfort with technology Exclusion of patients who have limited Internet access Time consuming

Note. The data in column 1 are adapted from Gibbons (2011) and Norman et al. (2008). The data in column 2 are adapted from Martinesk et al. (2011) and Chou et al. (2009).

Group health services Another method to increase the quality of care for LEP patients is through group health services. Group health has become an increasingly popular method of healthcare delivery particularly in prenatal care and patients with chronic conditions such as diabetes (Jaber, Braksmajer, & Trilling, 2006; Noffsinger, Sawyer, & Scott, 2003). Group health care can include health education classes, parenting classes, chronic disease management, and group well visits. Group health care has promise for LEP patients who may lack familial or other support systems. Group health care has the potential to increase support, patient empowerment, knowledge, and understanding (Coker, Chung, Coegill, Chen, & Rodriguez, 2009; Page, Reid, Hogland, & Leonard, 2010). Several studies have shown parental enthusiasm for group well child care (Coker et al., 2009; Page et al., 2010). Spanish-speaking patients expressed interest in utilizing group health education classes (Kanter et al., 2009). In an LEP population, a group or class lead by a language-concordant instructor can be an effective method of communication.

System-wide changes In addition to changes and implementations in the clinical setting, changes must also be made on a system-wide level. In 2003, the USDHHS Office of Minority Health created the National Standards on Culturally and Linguistically Appropriate Services (CLAS). There are 14 standards, four of which are mandates, nine guidelines, and one recommendation (see Table 5). These guidelines are evidence of the national awareness of health disparities for LEP

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Table 5 Culturally and linguistically appropriate services (CLAS) standards for healthcare organizations Mandatea

Standard (1) Health care organizations should ensure that patients/consumers receive from all staff member’s effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language. (2) Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area. (3) Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. (4) Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. (5) Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. (6) Health care organizations must assure the competence of language assistance provided to limited English-proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). (7) Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. (8) Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services. (9) Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations. (10) Health care organizations should ensure that data on the individual patient’s/consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated. (11) Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area. (12) Health care organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities. (13) Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers. (14) Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information.

Recommended

Suggested

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Note. Adapted from “National Standards on Culturally and Linguistically Appropriate Services (CLAS),” by the Office of Minority Health U.S. Department of Health and Human Services (2007). a Federal requirements for all recipients of Federal funds.

persons and an initiative to improve services for LEP patients. These federal directives are critical to addressing healthcare disparities for LEP patients nationally and should be enforced in the healthcare setting (Jacobs, Chen,

Kareliner, Agger-Gupta, & Mutha, 2006). Standards must be in place to ensure that organizations abide by the current regulations and provide the services necessary for quality care (Brach et al., 2005; Regenstein et al., 2008). 173

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Another opportunity for systemic change is to provide compensation for interpreter services. Currently, there is a lack of insurance coverage for interpreter services (Ku & Flores, 2005). Medicare does not cover interpreter services, and Medicaid coverage varies by state. Certain states have enacted regulations and policies to increase language services to LEP patients (Au et al., 2009). California has been leading the way in legislation that promotes access for LEP patients. In 2008, their legislature finalized a bill that mandates health plans to provide enrollees with translated documents as well as interpreter service at all points of contact. California is the only state to require commercial health plans to provide this extensive service. Several states’ Medicaid programs reimburse providers for language services including Minnesota, Iowa, New York, and Washington. Other states reimburse the language agencies or the interpreter directly such as Washington, DC, Hawaii, and Utah (Youdelman, 2007). New York City passed an agreement requiring all CVS pharmacies and Rite-Aid pharmacies to provide translated prescription labels in the six most commonly spoken languages (Au et al., 2009). These initiatives on the state and local level can be a guide for national policy. Incorporating the provision of language services into insurance programs is one method to creating a healthcare environment beneficial to LEP patients.

Data gathering and monitoring In order to best serve LEP patients in a clinical setting, one must be aware of the populations prevalent in the organization. This requires continual assessment and data collection of the primary language of the patients enrolled at a clinic (Regenstein et al., 2008; USDHHS Office of Minority Health, 2005), which could be obtained during the registration or intake process. Information regarding primary or preferred language, proficiency in written and spoken English, and interest in interpreter services should be obtained (USDHHS Office of Minority Health, 2005). In addition, regular monitoring of patient satisfaction can increase the quality of care for all patients. Language appropriate questionnaires give patients the ability to voice their concerns, ideas, and suggestions (Regenstein et al., 2008).

Language and culture training in academic settings Incorporating language, second language, and/or cultural training into healthcare provider education programs can help prepare health professionals to meet community needs. A number of programs exist in medical schools, residency programs, and advanced nursing programs. Programs range from mini-immersion trips dur174

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ing residency to formal language classes built into the curricula. The family nurse practitioner (FNP) and Nurse Midwifery Diversity Education Project included a Clinical Communication Program for advanced practice nurses and nurse midwives that integrated second language learning, multimedia, web-based technologies, and the Internet. This program included in-classroom training, online projects, and health assessment scenarios for 108 students and faculty at Georgetown University. Participants found the training to be helpful and relevant to their practice (Kelley & Klopf, 2008). These programs can be integrated formally or as electives for students during rotations or breaks. Investing in provider capacities to effectively collaborate with patients from other cultures and with different languages is a sound method for improving care to entire communities. In addition to language training, there may also be a need for NP, and all healthcare providers, to learn to work effectively with interpreters. A recent study by Phillips, Lie, Encinas, Ahearn, and Tiso (2011) assessed the impact of current NP training curricula the University of California, Irvine on the ability of students to communicate in interpreted encounters. The authors assessed students incoming to the program (n = 26) as well as students graduating (n = 31) using three standardized rating scales. Interestingly, the authors found no improvement in skills after completing the current curriculum for 10 students with pre- and postperformance data. These results are significant and suggest that the current curriculum does not prepare students for interpreted encounters. Training students to work effectively with interpreters is another mechanism to improve health outcomes for LEP patients.

Role of the NP The NP is in a unique position to address some of the issues identified in this article and offer solutions. It is crucial that nurses identify language barriers and initiate changes within their respective practices to address them. Starting within one’s own practice and with one’s own patients is an important first step in decreasing some of the health disparities for LEP patients. NPs can collaborate with colleagues to urge their employers to institute necessary changes or improvements. Additionally, publishing position statements is a formal and unified way to highlight and speak out about specific issues. A position statement published by the National Association of Pediatric Nurse Practitioners (NAPNAP) in 2007 underlines the organizations commitment to access to comprehensive, preventative, and quality care for pediatric patients (NAPNAP, 2007). In this statement they cite non-English proficiency as a barrier to care and

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articulate their support for interpreters and culturally sensitive care. Supporting initiatives and legislation that advocate for patient rights and improved care can be done on an individual or organization wide level. Organizations such as the American Academy of NPs have advocacy centers on their websites that allow members to become involved in a variety of issues. Contacting local and stateelected officials is an important way to affect legislation and can be particularly effective when valid and reliable data are presented to support an argument. As this article suggests, there is ample evidence that LEP patients have poorer health outcomes, which translates to communitywide consequences.

Discussion The negative consequences of language discordance between patient and provider have been well established. LEP families tend to have decreased access to care, poorer health outcomes, and less satisfaction than English-speaking patients. There is recognition that health disparities exist for LEP patients and systems must be implemented to improve their health outcomes. The challenges are significant; however, improvement is possible. Implementing language services provides benefits to the patients, families, providers, staff, and communities. A number of different methods have been put forth in this article; some address clinical changes, others are systemwide strategies. It is important to assess the care that LEP patients receive and take the steps necessary to improve that care. The long-term consequences of decreased quality of care merit immediate action to improve the health outcomes of LEP patients. The growing LEP population in the United States requires that systems be in place to accommodate their healthcare needs. With the implementation of language services, it is possible to improve the health status of millions of patients.

Acknowledgment Special thank you to Rita Marie John of Columbia University School of Nursing for her guidance with this manuscript.

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Primary care for limited English-speaking patients and parents.

The number of persons in the United States who have a primary language other than English has been steadily increasing for decades. The latest census ...
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