Guidance offered for patients who don't speak your language

New Title VI guidelines spell out the need for interpreter services for patients who speak little English.

By Susan J. Landers, amednews staff. Sept. 18, 2000.

Washington -- The federal government has published new guidelines to help physicians and others who receive federal funds to better understand their obligations to patients who have limited English skills.

Prime among those obligations is interpreter services.

Guiding the conversation
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"Effective communication is the key to meaningful access, whether it is a hospital, a clinic or a benefits program," Health and Human Services Office of Civil Rights Director Thomas Perez said when releasing the guidelines. "Failure to communicate effectively can have serious consequences for millions of Americans."

Robert Grover, MD, couldn't agree more. "I have to say, where we are, we couldn't function without interpreters." Dr. Grover, an internist who is now retired from private practice, volunteers at a clinic in Arlington, Va., a Washington, D.C., suburb where 30% of the population served by the clinic is foreign-born. Of those, roughly 30% have limited proficiency in English.

The OCR guidelines are intended to address this kind of situation. They explain in detail how health care providers, ranging from small physician practices to large public hospitals, can comply with Title VI of the 1964 Civil Rights Act, said Kathleen O'Brien, a special assistant to Perez.

Although Title VI may be better known for prohibiting discrimination on the basis of race, color or national origin, it also requires that physicians and others who accept federal funding ensure that individuals with limited English proficiency can meaningfully access programs and services.

"The new guidance doesn't change any requirements, but it does serve as a road map for health care providers and social service agencies," said Yolanda Vera, staff attorney with the Western Center for Law and Poverty in Los Angeles. "It puts them on notice about requirements under Title VI."

The guidelines emphasize flexibility in the design of effective programs, O'Brien said. The types of language assistance a physician must provide depends on the size of the facility, the size of the population to be served and the resources available, she noted.

Options could range from hiring bilingual staff or on-staff interpreters to contracting for services as needed, engaging trained community volunteers or using a telephone interpreter service, according to the OCR.

Although there is little disagreement over the need for the services, the question of who will pay for them is hotly debated.

Last spring the AMA objected strongly to the cost associated with another related proposal, new cultural competence standards by the HHS Office of Minority Health. These standards called for access to bilingual staff or interpretation services for all patients.

"In Chicago public schools, more than 100 languages are spoken," said AMA Executive Vice President E. Ratcliffe Anderson Jr., MD, in a letter to Nathan Stinson Jr., MD, deputy assistant secretary for minority health. "How would a health care institution or provider be able to identify and have available bilingual staff or interpreter services for each of these languages?"

Chicago is not unique. In many areas of the country, there is not just one dominant foreign language spoken, but many.

William Bateman, MD, director of business development at Gouverneur Hospital in New York City, acknowledged the high cost at an OCR briefing on the new guidelines. Yet, he noted, the cost of failing to obtain correct patient histories or make accurate diagnoses is greater.

Dr. Bateman is piloting a United Nations-style project at Gouverneur Hospital in which physician and patient are outfitted with headphones and both speak through an interpreter at a remote site.

Although Dr. Bateman's approach is promising, more conventional methods, such as pressing family members, friends or bilingual staff members into service, are likely to be around for some time.

Outside help

There are also organizations that help fill the void. The Northern Virginia Area Health Education Center, for example, provides interpreters to the Arlington clinic where Dr. Grover works. Specifically, the center supplies trained medical interpreters to clinics, health departments and -- for a $45-per-hour fee -- to private practices in northern Virginia.

Lyn Hainge, the center's executive director, emphasizes the importance of careful training of interpreters and cautions that just being bilingual is not a sufficient qualification.

"There are issues around confidentiality and ethics and giving advice," she said. "And even little things about who to look at, where to sit and who asks the questions are important."

Hainge's center is funded by HHS's Health Resources and Services Administration. There are about 400 centers like Hainge's around the nation, with each center mandated to respond to its community's needs.

The center's interpreter program seeks out bilingual members of the community, preferably those with some medical background, and puts them through a 40-hour training program in medical interpretation.

HHS's O'Brien recommended that physicians and other health care providers first determine the demographics of their pool of patients and assess the community's resources. Community groups already may have interpreters who can be provided medical training, she noted. Community colleges or local universities also may offer a good starting point for services, she added.

At times, the need to provide culturally competent care can be overwhelming, said Vincent Pasquariello, MD, physician health director of Kaiser Permanente's Diversity Council in Oakland, Calif. Among the resources he uses to meet patients' needs are a health care interpretive training program at a San Francisco college and a Spanish-language call center in Stockton, Calif.

"There is no cookie-cutter approach" to meeting a community's needs, Dr. Pasquariello said. "But there must be collaboration and sharing."

The guidelines were published in the Aug. 30 Federal Register and are effective immediately. Comments may be submitted by Oct. 30.

ADDITIONAL INFORMATION:

Guiding the conversation

The HHS Office of Civil Rights is providing guidance to physicians and others on federal requirements for providing satisfactory care to patients who speak little English. Among the requirements:

Develop policies and procedures to identify and assess the language needs of individual health care professionals and patients.
Offer a range of language assistance services appropriate to the facility's circumstances.
Notify those with limited English language skills that services are available.
Provide staff training and monitor the program.
Plan for providing necessary written materials in languages other than English.