1. Culturally Competent Health Services
Cultural competence is usually broken down into linguistic competence
and cultural competence, although true cultural competence recognizes
language and culture as inseparable. Although model practices and programs
have been developed in each sub-area for many years, methods of assessing
their impact have been limited, and few studies use rigorous quantitative
or qualitative techniques. In general, linguistically appropriate services
constitute a more targeted, measurable intervention--it's straightforward
(if not always easy or inexpensive) to track the language needs of individual
patients, whether that need was met, what points of contact in a facility
require additional resources, and how efficiently bilingual/interpreter
services are provided.
What can be considered a culturally competent activity is more amorphous--cultural
competence depends more on an institutional ethos, or the specific attitudes
and practices of individual practitioners. Most critically, it is difficult
to assess whether any given individual's cultural needs or concerns were
addressed, and what impact this might have on outcomes. Even patient satisfaction
is difficult to measure--most general patient satisfaction surveys do
not address these issues, and may not reflect a true picture of satisfaction
as many groups are not comfortable with direct expressions of dissatisfaction,
no matter what their true experience. Simply discontinuing use of a provider
may be the only indication of unmet needs or offense.
1.1 Linguistic Access Through Bilingual or
Interpreter Services
Health care organizations may use a wide spectrum of strategies
for overcoming linguistic and cultural barriers to care. These strategies
include the use of bilingual providers, bilingual/bicultural community
health workers, interpreters (onsite and telephone), and translated written
materials. Certain strategies may work best in a particular health care
setting, while others have wide application and can be useful in all settings--the
best programs frequently use a variety of approaches. An overview of these
strategies can be found in Appendix 1 (Riddick); the following discussion
will focus on implementation of these strategies in model programs at
community health centers, health departments, hospitals, managed care
organizations, and community interpreter banks. Overall, some highly developed
practices have emerged or been refined, in clinic and hospital settings,
and some have been more recently implemented in managed care organizations.
But the majority of practice settings identified below do not use these
model approaches--most health care and social service providers still
take a very ad hoc approach to dealing with the language barriers
presented by clients.
1.1.2 Community Health Centers and other community health organizations
Traditionally, Asian and Latino-oriented community health centers
(CHC) or migrant health centers have most fully developed their linguistic
capacity, although changing demographics have also motivated other centers
to address this issue. The Association of Asian Pacific Community Health
Centers wrote an excellent report in 1996 detailing the methods used and
challenges their member centers face in delivering linguistically and
culturally competent services (Appendix 2). Currently, HRSA is funding
a survey of CHC grantees to assess their capacity to deliver linguistically
appropriate services, and preparing a report on model cultural competence
practices among HRSA grantees. CHCs may use any of the strategies described
by Riddick, and are struggling with the same barriers to implementation
as other health providers: costs of interpreter services, training, recruitment,
soliciting community input, pay differentials, evaluation, data collection,
implementation, and organization reorientation. However their access to
financial resources may be more limited due to losses of cost-based reimbursement
under Medicaid and inadequate capitation from managed care contracts.
HRSA has not traditionally provided adequate grant resources to cover
the extra costs of bilingual recruitment or interpreter services.
Another excellent model of a community based provider addressing
language barriers is found at Asian Counseling and Referral Services,
of Seattle. Staff recruited from different Asian ethnic groups receive
training in interpreting and basic mental beliefs and practices for both
Asian and American cultures. Once trained, individuals act as co-providers
with a licensed mental health professional. Frequently staff who have
received this training go on to pursue formal training for mental health
practices such as counseling or social work.
The HHS Office of Minority Health has recently completed an
evaluation of its bilingual/bicultural services demonstration program,
which funded community based organizations to improve provide awareness
and services for limited English speaking populations.
1.1.3 State and Local Health Agencies
In the early 1990s, the HHS Office of Minority Health (OMH) funded
several survey and demonstration projects to assess the capacity of state,
county, and local health departments to deliver linguistically/culturally
competent services. These reports surveyed health department capacity
and practices, identified models, synthesized common issues and concerns.
In some cases, these projects provided seed funding for the development
or expansion of model programs. The best practices identified varied widely,
but frequently encompassed both linguistic and cultural competence activities.
They are not typically models of complete linguistic capacity in an organization,
but usually an attempt to address the needs of a specific program or ethnic
group.
The reports, models, and recommendations are summarized in
full in Appendix 3, and a longer description of one model in Seattle
is also included. Little followup has been done since the initial surveys
and reports, although the National Association of City and County Health
Officers (NACCHO) still honors model cultural competency programs
each year at its annual meeting.
1.1.4 Hospital and Medical Center Programs
A 1995 study by the National Public Health and Hospital Institute
indicates depressingly little capacity among public and teaching hospitals
with respect to quality interpreter service programs, and there is not
much reason to believe that the situation is much better among the broad
majority of other hospitals. Nevertheless, some of the most exciting and
sophisticated programs of interpreter services in health care settings
exist at a select group of hospitals in different parts the country. Massachusetts
and the Seattle area are noted for having the highest coverage
of interpreter services among hospitals in their regions; exceptional
model programs also found at the University of California-Davis, Stanford
University Hospital, Santa Clara Valley Medical Center, and Cedars-Sinai
Medical Center in California. Other notable programs have also been
developed in Oregon, Minnesota, Illinois, and Florida.
Characteristics of these model programs (which may provide more than
40,000 interpreted encounters/year) include: an organization-wide commitment
to develop, staff, and fund formal interpreter programs with administrative
staff and in-house or contract interpreters; 24-hour access to onsite
interpreters or telephone backup services; computerized tracking of
patient language characteristics, interpreter scheduling, and utilization;
formal assessment of interpreter skills and/or training; program evaluation;
and support from clinical staff for maintaining a trained interpretation
staff adequate to meet patient demand.
The Harborview Medical Center community house calls program
uses two kinds of LEP patient liaisons. Interpreter Case Managers
are bilingual/bicultural individuals who interpret in clinic and act as
outreach workers in the community. They explicitly address both language
and cultural issues in encounters. The Community Advisors are the
selected representatives of each cultural group served by the hospital,
and educate staff about the specific social needs of their communities.
Yet even these excellent programs are not spontaneously conceived,
accepted, or maintained. Almost all these model programs were started
in response to Title VI discrimination complaints filed by LEP individuals
that led to reviews and corrective consent agreements between HHS and
the facility (see the HHS Office for Civil Rights guidance at http://www.hhs.gov/progorg/ocr/lepfinal.htm
for a description of provider obligations to provide language access services).
Interpreter services can be increasingly expensive to maintain as ethnic
diversity increases; nevertheless, attempts to cut back programs are frequently
met with vocal resistance from clinical staff who have come to rely on
and respect trained interpreter assistance. At the same time, one hospital
interpreter manager reports that, despite an impressively well-funded
program, perhaps only 30 percent of clients needing interpreter services
receive them, mainly because staff are often too busy or too impatient
to wait for an interpreter to arrive.
Aside from the obvious deterrent factor of the cost of implementing
a comprehensive quality program (large programs may run over $1 million
per year), many hospitals do not systematically approach language barrier
remediation simply because they are not aware of models that exist or
the process involved in replicating such programs. The Advisory Board,
which assists hospital clients with research and technical consultation
services, has responded to many requests from hospitals about interpreter
services with information and contacts. A manual for developing and implementing
interpreter services in health facilities, written by staff from the University
of Massachusetts Medical Center (Appendix 4), was published in 1998.
1.1.5 Managed Care Organizations/HMOs
Perhaps the most challenging setting in which to successfully bridge
language barriers is the network or multi-facility managed care organization.
The sheer numbers of providers and facilities, combined with a ethnically
diverse and geographically dispersed client base, makes the replication
of other model practices or programs organizationally challenging. Nevertheless,
a handful of MCOs are attempting to tackle the problem.
Metropolitan Health Plan of Hennepin Co., Minnesota is a public
HMO with the Hennepin County Medical Center as its flagship facility.
The hospital already had a well-developed interpreter program, to which
the plan added translated patient forms, patient education material, and
audio visual programs.
Harvard Pilgrim Health Care has established an interpreter
training program and has both clinical and non-clinical interpreters at
several health center sites. It has policies that encourage pre-scheduling
of appointments with interpreters, and recommend providers allot an extra
15 minutes for initial LEP appointments.
Kaiser Permanente of Southern California actively recruits
and attempts to deploy bilingual health professionals at facilities where
demand is greatest, and also offers a pay differential for bilingual staff
who want to serve as interpreters and pass a proficiency exam.
These organizations each take a slightly different approach to meeting
language needs, and it is likely that a combination of strategies would
be the most flexible and comprehensive solution. This combination could
include: a bilingual provider roster; in-house or contract trained interpreters
that could be deployed for appointments with specialists or other non-bilingual
providers; bilingual/bicultural "case managers" to handle member services
calls, appointments, health education visits, and other non-clinical encounters;
and provider agreements with hospitals and other facilities that have
in-house language capacity. The greatest difficulty would probably remain
with contract pharmacy, laboratory and other diagnostic facilities that
typically do not offer language services.
1.1.6 Community Interpreter Banks
The development and use of community interpreter banks or services
has been quite successful in many areas and holds a great deal of promise
for offering a wide variety of different languages to many providers at
competitive rates. It is essentially a shared resource that allows many
providers to access interpreters, especially from small language groups,
when hiring them individually would be prohibitively expensive. The Seattle
area hospitals turned to a community based interpreter service for its
initial response to language discrimination complaints, and inaugurated
the Hospital Interpreter Program in the late 1980s. Similar community
services have been started up by university-based programs (Language
Link of Worcester, MA and Community Health Connect of Northern
Virgina), immigrant services agencies (Catholic Charities of San
Diego, CA and the Heartland Alliance of Chicago, IL), health departments,
and community clinics (Asian Health Services of Oakland CA). These
programs have a qualitative advantage over telephone interpreter services
in that they offer in-person, local ethnic community expertise at lower
rates, and their interpreters are usually trained specifically for medical
settings. These programs have the added bonus of possible job creation
and career paths for immigrants and refugees.
Although potentially competitive with commercial interpreter services,
community interpreter banks could offer the most cost-effective solution
to the greatest number of providers in many areas where a critical mass
would never be sustainable by any individual health care organization.
These programs are complex to set up, frequently require training medical
interpreters from scratch, and usually need financial assistance until
sufficient volume has developed to cover the costs of administration.
Most organizations that have recently initiated interpreter banks have
spent a great deal of time on the telephone and in-person, consulting
with other program directors on how to establish and manage such a program.
Summary Recommendations for 1.1
- Promote awareness of and dissemination of technical information, case
studies and summaries of model programs and strategies of bilingual/interpreter
services programs and strategies systematically to providers and provider
organizations (ie. hospital associations, primary care networks, patient
services directors associations).
- Support startup of bilingual/interpreter services programs or enhancement
components (such as evaluation or data collection systems) in areas
of high need or limited resources.
- Promote direct reimbursement or capitation differentials for interpreter
services by health plans and government agencies, including supporting
research on interpreter services cost and the calculation of appropriate
reimbursement/capitation levels.
- Support information sharing on best practices and lessons learned
by provider specific groups, ie. MCOs.
- Promote development of organization-wide models of linguistically
accessible services in MCOs.
- Support the development of a manual on how to startup and manage a
community interpreter bank.
- Support startup of community interpreter banks, including assistance
with marketing plans for long-term sustainability.
Contacts, Resources, References
1.1.2
Asian Health Services
The Language Cooperative
818 Webster St. #115
Oakland,CA 94607-4277
510-986-6830
Providence Ambulatory HCF
375 Allens Avenue
Providence, RI 02905-5010
401-444-0411
Asian Counseling and Referral Services
1032 S Jackson St, #200
Seattle, WA 98104
206-695-7600
Valerie Welsh
HHS Office of Minority Health
Rockwall II/5600 Fishers Lane, #1000
Rockville, MD 20857
301-443-9923
Development of Models and Standards for Bilingual/Bicultural Health Care
Services for Asian and Pacific Islander Americans: The Language Access
Project, Association of Asian Pacific Community Health Organizations,
1996.
1.1.3
ASTHO Bilingual Initiative--Report and Recommendations: State Health
Agency Strategies to Develop Linguistically Relevant Public Health Systems.
Washington, DC: Association of State and Territorial Health Officials,
1992
National Association of County Health Officials Multicultural Health
Project--Recommendations and Case Study Reports. Washington, DC: National
Association of County Health Officials, 1992.
Language and Culture in Health Care: Coping with Linguistic and Cultural
Differences: Challenges to Local Health Departments. Washington, DC: United
States Conference of Local Health Officers and United States Conference
of Mayors, 1993.
1.1.4
Monica Escobar Lowell
University of Massachusetts Medical Center
55 Lake Avenue
Worcester, MA 01655
508-856-3255
mlowell@banyan.ummed.edu
University of California Davis Medical Center
Interpreting Service
2315 Stockton Boulevard
Sacramento, CA 95817
Ellie Graham, MD
Harborview Medical Center
Community House Calls
325 Ninth Avenue
Seattle, WA 98104
206-223-3000
ellieg@u.washington.edu
Cedars-Sinai Medical Center
Interpreter Services
8700 Beverly Blvd., Room 1
Los Angeles, CA 90048
310-855-2653
Maria M. Durham, EdM,RN
640 165th Street, N.E.
Bellevue, WA 98008
206-562-0853
MariaDURHAM@msn.com
Establishing Interpreter Services in Health Care Settings. Amherst Educational
Publishing, 800-865-5549 (www.amedpub.com)
1.1.4
Harvard Pilgrim Health Care
Office of Diversity
10 Brookline Place West
Brookline, MA 02146-7229
617-730-7730
Ellen Rau
Hennepin County Medical Center
Interpreter Services
701 Park Avenue S.
Minneapolis, MN 55415
612-347-2248
Jean Gilbert, PhD, Director
Cultural Competence
Kaiser Permanente
393 E. Walnut, LR-6
Pasadena, CA 91208
626-564-3743
1.1.5
Gail Lewis, Director
Language Link
50 Lake Ave.
Worchester, MA 01604
508-756-6676
Karin Ruschke
Health Care Interpreting Services
1015 West Lawrence Ave., 2nd floor
Chicago, IL 60640
773-506-9851
Asian Health Services (above)
Priscilla Coudoux
Community Health Connect/ NVAHEC
5105-P Backlick Rd
Annandale, VA 22003
703-750-3248
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1.
Culturally Competent Health Services 