WORKING WITH INTERPRETERS

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WORKING WITH INTERPRETERS Powered By Docstoc
					Enhancing Cultural Competency:
Working with Limited English
Proficient Patients and Interpreters


         Leah S. Karliner, MD MCR
Assistant Professor, Department of Medicine
Graduate Medical Education Grand Rounds
                 July 2007
Outline
 Language Barriers
 Interpreters
     Definitions
     What the data shows
 Language Access at UCSF: Systems Change
 Working With Interpreters
     Professional
     Non-interpreter staff
     Family and Friends
Language Barriers
Limited English Proficiency
 Unable to speak, read, write or understand
  English at a level to interact effectively with
  health care providers

 Different from primary language spoken at home

 U.S. 2000 Census:
     47 million non-English primary language at home
     Half report speaking English less than very well
 Language Barriers & Health Disparities
 Less access to usual source of care
 Fewer physician visits & preventive services
 Poorer adherence to treatment & follow-up for chronic
    illnesses (e.g. asthma)
   Lower comprehension of dx & treatment after ED visit
   Less satisfaction with care
   Increased medication complications
   Increased admissions from the ED
   Increased length of stay in hospital

        Language Barriers in Healthcare Settings: An Annotated Bibliography of the
        Research Literature; 2003. The California Endowment.
        http://www.calendow.org/reference/publications/cultural_competence.stm
 Language Concordance
 Patient and physician speak the same language
 Associated with increased:

     Patient satisfaction
     Patient-reported health status
     Adherence with medication
     Adherence with follow-up
  Language Concordance
Why we cannot rely on language concordance alone
 >100 languages spoken commonly in U.S.
 At UCSF in our survey of primary care clinicians, 20
  different languages reported
 Patients maneuver through entire healthcare system
      Registration
      Lab
      Radiology
      ED
      Hospitalization
      Cashier
  What does the law say?
 Civil Rights Act of 1964 – Title VI

      If providers receive Federal financial assistance, and

      If language is a ‘threshold’ language (>=5% of patient
       population), then

      Must offer language assistance
What actually happens in practice?
 Bilingual clinicians
 Bilingual staff – clinical and non-clinical
 Family & friends
 Telephone – e.g. Language Line
 Video conferencing professional interpreters
 In-person professional interpreters
Outline
 Language Barriers
 Interpreters
     Definitions
     What the data shows
 Language Access at UCSF: Systems Change
 Working With Interpreters
     Professional
     Non-interpreter staff
     Family and Friends
  Definitions
 Interpreter: 3rd party present in clinical interaction
  whose role is to facilitate oral language interpretation

 Ad Hoc Interpreter: Untrained person called upon to
  interpret
    e.g. family member/friend, bilingual staff pulled away
     from other duties, self-declared bilingual who
     volunteers (other patients)

 Professional Interpreter: Person paid & provided by
  hospital or health system to interpret
    Training not standardized
Do Interpreters Make a Difference?
 Systematic review of literature 1966-9/2005
 28 published papers comparing at least 2
  language groups & reported data about
  medical interpreters in following areas:
     Communication (errors and comprehension)
     Utilization
     Clinical outcomes
     Satisfaction
 21 assessed professional interpreters
  separately from ad hoc interpreters
 Do Interpreters Make a Difference?
 In all four areas

      Use of professional interpreters was associated
       with improved clinical care approaching or equal to
       that of English-speakers

      This improvement was more than with use of ad
       hoc interpreter



               Karliner, et al. Health Services Research, April 2007
Outline
 Language Barriers
 Interpreters
     Definitions
     What the data shows
 Language Access at UCSF: Systems Change
 Working With Interpreters
     Professional
     Non-interpreter staff
     Family and Friends
Interpreter Services Systems Changes at
UCSF

 Mulit-pronged approach to improvement with
  goals of:
     Increasing access to professional interpretation
     Maximum flexibility in meeting patient/clinician
      needs
 Interpreter Services Systems Changes
 at UCSF
 Increased hours of staff Spanish interpreters
 Multiple modalities:
     In-person (gold standard, but access an issue)
     Telephonic
          Dual-handset (inpatient in particular)
          Speed Dial to interpreter services
          Language line

     Video-conferencing
 Interpreter Services Systems Changes
 at UCSF
Video Medical Interpretation
(VMI)
   Interpreters positioned at dedicated
    station
   Available in real-time at a distance
    via video-conferencing
   Dispatcher directs call
   Interpreter can see and hear patient
    and clinician
   Patient and clinician can see and
    hear interpreter
 Interpreter Services Systems Changes at
 UCSF: Video Medical Interpretation (VMI)
Advantages:
  -- reduces wait time: allowing patients to be seen
     when clinician is available
  -- reduces travel time for interpreter
  -- increases encounter capacity for interpreter
  -- potential for sharing across hospital systems &
     thus increasing language/interpreter capacity
  -- maintains visual and physical cues
  -- requires a dispatch system: improves
     effectiveness and efficiency of resource allocation
    Interpreter Services Systems Changes
    at UCSF: Guidelines for Choosing Modality
In-Person Professional Interpretation
Cantonese/Mandarin, Russian, Spanish (UCSF Staff)
   Psychiatric Patients
   Patients with Impaired cognition
   Patients with impaired hearing
   Patients with impaired vision
   Large family meetings
   End of life conference/discussions
   Delivery of bad news
   Patient or family in emotional distress
   Actively psychotic patients
 American Sign Language (outside agency)
Interpreter Services Systems Changes at
UCSF: Guidelines for Choosing Modality
VMI or Telephonic:
 If video is available, this will be default (pilot now in
  Children’s Hospital and Pediatric Specialty clinics)

 Telephonic
    Language not offered at UCSF
    On-demand via Interpreter Services
    After-hours / weekends
    Non-clinical encounters (e.g. billing, registration, front-desk)
Outline
 Language Barriers
 Interpreters
     Definitions
     What the data shows
 Language Access at UCSF: Systems Change
 Working With Interpreters
     Professional
     Non-interpreter staff
     Family and Friends
  How to work with a professional
  interpreter: The Ideal
 Allow extra time for an interpreted visit;
 Select an interpreter keeping gender and
  confidentiality in mind;
 The interpreter is part of your therapeutic team:
  hold a brief pre-meeting with the interpreter:
      share relevant information about your patient and
       this visit;
      Ask the interpreter to cover everything that is said,
       conveying the tone and meaning of the message,
       rather than paraphrasing or rephrasing
 How to work with a professional
 interpreter
 Position yourself in a therapeutic triad
                 Interpreter
     Clinician                 Patient

   Introduce yourself directly to the patient;
   Introduce the interpreter to the patient;
   Address the patient directly;
   Watch the patient during the interpretation
       Body language
       Behavioral clues
 Invite correction: “this is what I understand so
    far…let me know if I missed something...”
How to work with a professional
interpreter
 Speak in short units


 Ask short questions


 Explain medical terms in simple language


 Ask the patient to repeat back any
  instructions
 How to work with an untrained/ad hoc
 interpreter:
 Untrained staff
     Language abilities may not be equal in both
      English and the 2nd language

     May not know medical terms in either English or
      the 2nd language

     Ask if comfortable interpreting with this particular
      patient (gender / confidentiality)
How to work with an untrained/ad hoc
interpreter
     Be explicit before they come into the room
      about what you need / give them guidance

          Word for word interpretation (preserving tone &
           meaning)
          Avoid answering for the patient
          Position them in triad (show them where)
          Give permission to ask you to slow down or
           rephrase something in easier terms
How to work with an untrained/ad hoc
interpreter
 Family and friends
     Avoid using minors!!!

          May be uncomfortable interpreting
           personal/intimate information
          May try to ‘protect’ parent/relative from
           information
          Alters relationship between parent and child
How to work with an untrained/ad hoc
interpreter
     Same techniques as with staff, but need to
      emphasize certain points even more:

          Ask them to avoid answering for the patient;
          Give them permission to ask you to slow down
           or rephrase something in easier terms
          Speak directly to the patient
          Keep your spoken units and questions short
Summary
 Like any other skills this takes practice

 When you have a language barrier with a
  patient, use a professional/trained interpreter
  if possible

 If you must use an ad hoc interpreter, give
  them guidance

 Avoid using minors to interpret
   Selected Online Resources
 CLAS standards:
  http://www.omhrc.gov/assets/pdf/checked/Executive%20Summary.pdf
 JCAHO:
  http://www.jointcommission.org/HLC/Resources_Standards.htm
 Unequal Treatment:
  http://www.iom.edu/?id=16740
 Lewin Report:
  http://www.hrsa.gov/culturalcompetence/measures/default.htm
 The Cultural Formulation
  http://www.med.uiuc.edu/m34/xcultopps/PDF/clinical%20cultural%20as
  sessment.pdf
  Selected Online Resources
 U.S. DHHS on-line/DVD CME:
  https://cccm.thinkculturalhealth.org/
 The Network for Multicultural Health Resource Page:
  http://futurehealth.ucsf.edu/TheNetwork/Default.aspx?tabid=387
 Diversity Rx: Models and Practices (cultural and linguistic
  access):
  http://www.diversityrx.org/HTML/models.htm

				
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