Patient and Family Engagement Across Languages Mursal Khaliif Senior Director Multicultural Affairs, Diversity, and Patient Services Cambridge Health Alliance Robert P. Marlin, MD, PhD, MPH Staff Physician Department of Medicine Primary Care Internal Medicine East Cambridge Health Center Cambridge Health Alliance
Limited English Proficient (LEP) Patients From 1980 to 2010 the use of a language other than English (LOTE) at home in the U.S. increased by 158% By 2011, nearly 60.6 million people spoke LOTE 41.8% (or 25.3 million) of these spoke English less than very well These numbers are projected to increase further over the decade, including this year with the ACA expansion sources: Ryan, C. (2013). Language Use in the United States: 2011: American Community Survey Reports. Washington, DC, U.S. Census Bureau; Shin, H and Ortman, J. (2011). Language Projections: 2010 to 2020. Washington, DC, U.S. Census Bureau.
Language Access Services and Quality 2001 – Institute of Medicine (IOM) releases Crossing the Quality Chasm calling for a radical reconceptualization of quality and safety Report found that U.S. healthcare not providing “consistent, high- quality medical care to all people” IOM sets forth 6 aims to improve U.S. healthcare source: Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st century. Washington, D.C., National Academy Press.
IOM: Six Aims for Improvement • Safe : avoiding injuries to patients from care intended to help • Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. • Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions source: Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st century. Washington, D.C., National Academy Press.
IOM: Six Aims for Improvement • Timely : reducing waits and sometimes harmful delays for both those who receive and those who give care. • Efficient : avoiding waste, including waste of equipment, supplies, ideas, and energy. • Equitable : providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. source: Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st century. Washington, D.C., National Academy Press.
Affordable Care Act (ACA): Triple Aim • better care for individuals • better health for populations • lower cost per capita source: Institute for Healthcare Improvement. (2013). IHI Triple Aim Improvement Community.. Cambridge, MA, www.ihi.org.
Cultural Competence • “the ability of systems and health care professionals to provide high quality care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients' social…and linguistic needs” • potential effect of these factors on patient’s ability to obtain quality care • recognition of structural factors source: Betancourt, JR et al. (2002). Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. New York, NY, The Commonwealth Fund.
Cultural Competence • skills to communicate effectively with any patient to understand practices, values, and health beliefs • treating each patient with respect and dignity • avoiding generalizations about social or cultural groups source: Betancourt, JR et al. (2003). Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep 118 (4): 293-302
Cultural Competence • building awareness vs. prescriptive knowledge • becoming competent in the “culture of one” • attitudes and skills rather than specific information source: Betancourt, JR et al. (2003). Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep 118 (4): 293-302
Cultural Competence • healthcare systems and settings as “another world” that must be interpreted and translated for patients • normalized for providers and staff, healthcare systems are “essentially strange” • healthcare providers as interpreters source: Sobo, E. J. (2009). Culture & Meaning in Health Services Research: A Practical Field Guide. Walnut Creek, CA, Left Coast Press.
Patient-Centered Medical Home • comprehensive care • patient -centered • coordinated care • accessible services • quality and safety source: (2013). Patient Centered Medical Home Resource Center. Rockville, MD, Agency for Healthcare Research and Quality. http://pcmh.ahrq.gov/
Rationale for Language Services • Federal laws - OCR - HHS - DOJ • State laws - Interpreter Laws • Accrediting Agencies - AHRQ - HCHC - NCQA
Federal Laws and Guidelines Title VI of the 1964 Civil Rights Act Executive Order 13166 Department of Health and Human Services (HHS) Office for Civil Rights (OCR) Guidance Office of Minority Health (OMH) Culturally and Linguistically Appropriate Standards (CLAS)
CLAS Standards 14 Standards: 9 are guidance & 4 are mandates Mandated standards (#4,5,6 & 7) Standard # 4 : Services at no cost, at all points of contact, in a timely manner, and during all hours of operation. Standard # 5: Inform patients in their preferred language & about their right to receive language services Standard # 6 : Ensure the competence of language assistance provided & not to use family and friends as interpreters Standard # 7 : In-language materials and signage for commonly encountered groups
Title VI of the 1964 Civil Rights Act "No person in the United States shall, on the ground of race, color, or national origin be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." 42 U.S.C. § 2000d Guiding principle: “Meaningful Access”
Language = National Origin Federal courts and agencies have interpreted discrimination by national origin to include language . In other words : In the U.S., if someone discriminates against a person because he/she can't speak English, this will be a violation of civil rights.
Overview of Cambridge Health Alliance 3 campuses with Emergency Services and Inpatient Psychiatry: The Cambridge Hospital Somerville Hospital Whidden Memorial Hospital Community-based Primary Care and Mental Health Services: services at hospital campuses, 18 neighborhood health centers, 4 school-based health centers CHAPO : Cambridge Health Alliance Physicians Organization Employer and contractor for MD services
Overview of CHA: Non-Provider Components Network Health - a statewide managed Medicaid health plan offering - Medicaid products - Commonwealth Care products Public Health: - Includes Cambridge Public Health Department and Institute for Community Health - Work closely with public health departments in Everett and Somerville Alliance Foundation for Community Health (Philanthropy) Academics: Teaching affiliations with: - Harvard Medical School - Tufts University School of Medicine - Harvard School of Public Health
CHA Multilingual Services Service Area: Cambridge, Somerville, Malden, Chelsea, Revere, Everett, and Winthrop Staffing: More than 135 employed interpreters based at three Hospital Campuses: Cambridge, Somerville & Whidden Health Centers: East Cambridge, Windsor St., Somerville PC, Broadway, Assembly Sq., Malden, and Revere Centralized Network Services: Dispatching, Telephone & Video Call Center
2012 Statistics During FY12: - 28% of In-Patients and 34% of Out-Patients required interpreter services - More than 170,000 interpreted visits and 3,200 pages translated - Completed over 150 education and training sessions - Improved patient experience through interpreter rounds
It All Starts with Data Collection - Understand your Patient Populations - Track outcomes and quality of care - Target interventions for Gaps - Develop Quality Metrics for Multilingual Services
Understand Your Patient Populations Data Collection Methods In person Over-the-phone On a form On EMR
Asking About Language - ALL patients should be asked about their race, ethnicity and language - Self-reporting is the most accurate source of information -Self-reporting will increase consistent reporting within a health care institution -Patients are more likely to select the same categories to describe themselves over time than staff who are assuming or guessing
Document Language Services Document how LEP patients’ language needs were met for each clinical encounter to: - Obtain complete record of all language assistance provided - Capture complexities involved in meeting language needs Use EMR to: - Make documentation quicker, easier, standardized, and required - Obtain reports to make data readily usable for QI Institutionalize EMR documentation tool across all sites Use data from tool for quality improvement to ensure patient language needs are met safely
Quick Questions Screenshot - Understand your Patient Populations - Track outcomes and quality of care - Target interventions for Gaps - Develop Quality Metrics for Multilingual Services
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