Application of Strategies in Various Health Care Settings

While many health care organizations are just beginning to grapple with development of strategies for dealing with linguistic and cultural barriers, a few have many years of experience in this area. But even these few continue the struggle to find the best approach for serving their limited-English speaking clients, one that combines a high quality of service and access with efficiency and cost-effectiveness. Here we review the approaches most common in specific health care settings: community health centers, public health departments, hospitals, and managed care organizations.

 A. Community Health Centers

Having emerged from the grass-roots activism of the 1960s and 1970s, community health centers (CHCs) have historically focused on serving at-risk, underserved populations. This means that they have often been the first and in some locales the only health care providers to serve newly arrived refugees and immigrants who do not speak English. Generally, their community-oriented boards and staff have placed a high priority on hiring employees that reflect the communities they serve. CHCs have used a combination of approaches to serve their limited-English-proficient patients that include:

1. Hiring bilingual/bicultural provider staff as a top priority;
   
2. Hiring health aide/family health workers and other ancillary staff who are bilingual/bicultural and who also function as interpreters;
   
3. Hiring interpreters;
   
4. Implementing special projects of outreach, education, and advocacy that train and employ bilingual community members.

While culturally and linguistically appropriate care has been a special attribute of CHCs over the years, screening and training for language and interpreting skills of staff has varied. As in other health care settings, a lack of agreed upon interpretation standards, assessment tools, and training, has been a barrier to the provision of optimal linguistic services.

Examples of community health centers that have utilized the above strategies abound. Notable examples include the International District Community Health Center in Seattle, WA, Asian Health Services in Oakland, CA, and Providence Ambulatory Health Care Foundation in Providence, RI. A unique program developed in Seattle, WA, can serve as a model for communities with multiple language groups and several community health centers. The [Community Health Services Program], developed in 1980 as the Indochinese Language Bank, uses a shared service approach, with bilingual family health workers rotating through a group of clinics on a regular basis, providing interpretation, advocacy, and patient education services at the various sites.

B. Public Health Departments

Current practices of both state and local health departments vary significantly in serving LEP populations, and depend on a number of factors that include: the type of structural and financial arrangements within a given jurisdiction, the diversity of languages spoken, and the local experience in providing health services to limited-English speaking persons. Specific strategies used by state and local health departments include:

Providing translated health education and promotional materials, and disseminating them through mainstream media, community organizations, and ethnic newspapers, radio and television stations;

1. Hiring full-time or part-time interpreters;
   
2. Hiring bilingual/bicultural outreach workers or aides/advocates;
   
3. Utilizing employee language banks;
   
4. Setting up special clinics where language services are provided such as refugee screening clinics and migrant worker clinics;
   
5. Providing cultural training to staff;
   
6. Working with community advisory councils to help with needs assessments, problem-solving, and planning.

C. Hospitals

In the past, hospitals have relied heavily on the ad hoc use of bilingual staff or patients' family and friends to bridge the language gap for limited-English-proficient (LEP) patients. But in recent years, some hospitals have seen the need to go further to ensure that quality care is provided to all their patients. This is in part due to litigation and complaints of discrimination investigated Title VI of the Civil Rights Act of 1964 by the Office for Civil Rights, Department of Health and Human Services

The response of hospitals to meeting language needs depends on a combination of their language mix, bed size, number of LEP patients served, and linguistic abilities of their staff. Most common practices are using bilingual staff, volunteers, and family and friends as interpreters. Hospitals with large numbers of LEP patients are more likely than others to hire staff interpreters. However, few hospitals provide training for either paid or volunteer interpreters, and when training is provided, it tends to vary considerably.

Three model programs deserve mention here, and reflect different approaches to the provision of interpreter services in a hospital setting. Jackson Memorial Hospital, with only two major language groups to serve, has gone with an in-house staff interpreter model. The University of Massachusetts Medical Center in Worcester, MA, has also implemented a staff model, with a strong emphasis on both provider and interpreter training. In contrast, hospitals in Seattle, WA, found that their diverse patient population made a shared interpretation program an efficient and cost-effective mechanism for obtaining interpreter services. This led to the development of the Community Interpretation Service, a program sponsored by an outside, non-profit agency, that contracts with the hospitals.

We highly recommend that you refer to "Interpretation and Translation Services in Health Care: A Survey of US Public and Private Teaching Hospitals". This excellent report by the National Public Health and Hospital Institute contains valuable information on how hospitals currently address linguistic barriers and offers recommendations for improving services.

D. Managed Care Organizations

With the evolution of managed care as a dominant force in the health care marketplace, managed care organizations are now competing for Medicaid contracts and facing the needs of a clientele they may never before have served. For many managed care organizations, both new and old, the special needs of their limited-English-proficient (LEP) and other underserved populations present new issues. Although little documentation exists about how managed care organizations can best serve LEP consumers, many of the issues are the same as for the other health care organizations described above. In addition, Medicaid managed care organizations may face new requirements for ensuring language and cultural access. For example, the California Department of Health is developing cultural and linguistic service requirements for its Medi-Cal managed care program.

Some managed care organizations are finding that it is to their advantage to become more inclusive and reach out to underserved groups, a previously untapped market. Harvard Pilgrim Health Care (HPHC) serving the New England area has developed a site-specific pilot project, as well as an organizational approach to increasing access to bilingual health care services across geographic areas and departments. At the site-specific level, HPHC has focused on hiring and utilizing bilingual staff as interpreters. At the organizational level, a resource directory of bilingual staff has been developed, videos and telephone orientations for members have been produced, and a translation protocol developed for key corporate materials.

Another example of an HMO's efforts in this area is Kaiser Permanente of Southern California, which has a multi-pronged approach to serving the language and cultural needs of its diverse membership. With 10% of its 2.3 million members needing Spanish speaking providers or interpreters, efforts have centered on: hiring bilingual providers at appropriate sites, translating materials for members, utilizing tested and trained staff members as interpreters, contracting with AT&T Language Line, training providers to work with interpreters, conducting health education classes in Spanish, and conducting epidemiological research.

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