for Individuals Who Are LIMITED ENGLISH PROFICIENT (LEP) and - - PowerPoint PPT Presentation

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for Individuals Who Are

LIMITED ENGLISH PROFICIENT (LEP)

and Individuals Who Are

DEAF OR HARD OF HEARING

Office for Civil Rights U.S. Department of Health and Human Services

EFFECTIVE COMMUNICATION IN HOSPITALS

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A Shared Commitment

Access to Healthcare, Patient Safety, and Quality Healthcare Are Directly Dependent on Effective Communication

The HHS Office for Civil Rights and the health care community share a common goal: ensuring that all individuals have equal access to quality, safe health care.

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America’s Population Reflects Diverse Communication Needs

• Approximately 28 million Americans have hearing

loss.

• In 2000, 18% of the population (47 million

people) spoke a language other than English at home.

• 63% of hospitals treat LEP patients daily or

weekly.

• More than 15 languages are frequently

encountered by at least 20% of hospitals.

Sources: National Institute on Deafness and Other Communication Disorders, “Statistics about Hearing Disorders, Ear Infections, and Deafness” (2007); Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (HHS), “2006 National Healthcare Disparities Report”; Health Research and Education Trust (HRET), “Hospital Language Services for Patients with Limited English Proficiency: Results from a National Survey” 2-3 (2006)

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Hospitals Face Challenges Meeting Diverse Patient Communication Needs

• Identification of patients who need language

services in a timely manner

• Staff discomfort in inquiring of patients about their

primary language

• Cost
• Lack of tools and training resources
• Lack of community level data

Source: HRET, Issue Brief, “Patients with Limited English Proficiency: Results from a National Survey” (2006)

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Language Services Programs in Hospitals Are a Work in Progress

A report issued by The Joint Commission in 2007 found that:

• A majority of hospitals surveyed had mechanisms for identifying

linguistic needs of patients and written policies on language services, but …

• Many did not provide ongoing training or assess competency of

interpreters and bilingual staff;

• Few had policies regarding use of family members as interpreters;

and

• Defined policies and procedures for the provision of language

services in hospitals serving linguistically diverse patient populations are needed.

Source: The Joint Commission, “Hospitals, Language and Culture: A Snapshot of the Nation” 7 (2007)

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What Tools and Training Do Hospitals Need to Meet These Challenges?

• In-service training programs
• Model approaches/promising practices
• Self-assessment tools
• Sample case studies
• Cultural competency training
• Training on how to respond to patients or family members

who do not speak English

• Training on how to collect primary language data
• Training on how to use the data

Source: HRET, Issue Brief (2006)

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Effective Communication is Critical

• “Appropriate communication and understanding between

patient and provider is essential to safe, quality health care…. [H]ospitals need to seek ways of enhancing communication and understanding with diverse

• populations. Failing to do so may contribute to recognized

racial and ethnic disparities in health care.”

Source: The Joint Commission, “Hospitals, Language, and Culture: A Snapshot of the Nation” 14 (2007)

• “A study of health plan members and use of interpreters

showed that the use of interpreters reduced disparities for Hispanics and [Asian and Pacific Islander] members (28% and 21%, respectively).”

Source: AHRQ, “2006 National Healthcare Disparities Report”

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Effective Communication is Critical

• “Communication barriers contribute to reduced quality,

adverse health outcomes, and health disparities. Solid evidence also shows that language barriers between a patient and provider may result in increased use of expensive diagnostic tests, increased use of emergency services and decreased use of primary care services, and poor or no patient follow-up when follow-up is indicated.”

Source: HRET, Issue Brief (2006), citing the Institute for Medicine (2003)

• “Inadequate communication with deaf and hard-of-hearing

patients can lead to misdiagnosis and medication errors, as well as patient embarrassment, and fear….”

Source: AHRQ, “Communicating about health care: Observations from persons who are deaf or hard of hearing” (2004)

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The Effective Communication in Hospitals Initiative

A Collaborative Initiative of the Office for Civil

Rights, U.S. Department of Health and Human Services (HHS), the American Hospital Association (AHA) and State Hospital Associations

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What the Effective Communication in Hospitals Initiative Is All About

Through a tailored program of technical assistance, OCR helps state hospital associations and their members to:

• Develop a process for assessing the communication needs of

patients and their families;

• Identify tools and strategies for developing training, best practices,

educational materials, technical assistance activities and other resources;

• Respond appropriately and efficiently to the communication needs
• f individuals who are LEP or deaf or hard of hearing;
• Share the results of efforts to assist other hospitals and state

associations facing similar communication issues; and

• Identify potential resources and creative approaches to cover

costs.

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Today, We Will Talk About …

• Federal civil rights and privacy laws that apply to these

issues – the basics

• Federal reimbursement for language services
• Important hospital accreditation standards
• Strategies and approaches that hospitals can use for

effective communication

• A self-assessment tool developed by the Office of Minority

Health in HHS

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The Law, in General

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Three Civil Rights Statutes Apply

• Title VI of the Civil Rights Act of 1964 prohibits

discrimination on the basis of race, color, and national

• rigin by recipients of Federal financial assistance.
• Section 504 of the Rehabilitation Act of 1973 prohibits

discrimination on the basis of disability by recipients of Federal financial assistance.

• The Americans with Disabilities Act of 1990 prohibits

discrimination on the basis of disability by covered entities.

• Title II applies to public entities.
• Title III applies to places of public accommodation.

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The Three Statutes Apply to All Programs and Services in Hospitals, such as:

• Emergency room care
• Patient admission and discharge activities
• Public education events
• Communications about patient diagnosis and treatment

with family members and companions

• Outpatient surgery, clinics, and therapy
• Cafeterias and gift shops
• Other inpatient services, tests, and procedures that follow

the patient from intake through discharge

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The Law on Communication with Individuals Who Are LEP

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Title VI – General Principles

• Title VI and the implementing regulations prohibit conduct

that has a disproportionate adverse effect on the basis of national origin. Failure to provide LEP individuals meaningful access may constitute national origin discrimination.

• An LEP individual is a person whose primary language is

not English and who has a limited ability to read, write, speak or understand English.

• Hospitals, must take reasonable steps to provide LEP

persons with a meaningful opportunity to participate in Federally funded programs.

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Application

Hospitals must provide language access services at no cost where necessary to ensure that persons, on the basis of national origin, are not:

• Denied a service, aid, or other benefit generally available to
• thers, or
• Provided the same in a different manner, or
• Provided the same in a segregated setting, or
• Provided separate treatment.

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Examples of Language Access Services

• Bilingual staff
• Contract interpreters
• Telephonic interpreters
• Videoconferencing interpretation
• Translated materials
• Way-finding symbols

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Determining What Language Services A Hospital Needs to Provide

The “four factor analysis”

• Number or proportion of LEP persons eligible to be

served or likely to be affected by the program or service

• Frequency of contact
• Nature and importance of the program, activity, or service
• Costs and resources available

Source: Executive Order 13166, “Improving Access to Services for Persons with Limited English Proficiency” (2000); United States Department of Justice (USDOJ), “Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons”, 67 Fed. Reg. 41455 (2002)Sho

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When an Interpreter Is Needed and Reasonable …

• Hospitals should ensure that a competent language

service provider is used. A competent provider:

• Is proficient and communicates accurately in English and the other

language

• Uses appropriate mode of interpreting
• Knows specialized terms and concepts in both languages
• Understands and follows confidentiality and impartiality rules
• Understands and adheres to the role of the interpreter
• Hospitals should avoid planning to rely on an LEP

person’s family and friends.

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Common Characteristics of Effective Language Access Service Programs

• Leadership
• Commitment to access
• Success in securing resources
• Emphasis on quality
• Strong relationship to community-based
• rganizations

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The Law on Communications with Individuals Who Are Deaf or Hard of Hearing

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Section 504 and Title II of the ADA – General Principles

• These laws prohibit discrimination on the basis of disability

and require hospitals to ensure effective communication with individuals who are deaf or hard of hearing.

• Hospitals must provide auxiliary aids and services where

necessary to avoid discrimination.

• Hospitals may not charge for the auxiliary aid or service.
• Hospitals do not need to provide an auxiliary aid or service if

doing so would fundamentally alter the nature of the program or result in an undue financial and administrative burden.

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Examples of Auxiliary Aids and Services

• Qualified interpreters
• Note takers
• Transcription services
• Written materials
• Assistive listening devices and systems
• Telephone communication devices for deaf

persons

• Telephone handset amplifiers
• Video interpretive services
• Open and closed captioning

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Qualified Interpreters

• A qualified interpreter is an interpreter who is

able to interpret effectively, accurately and impartially, both receptively and expressively, using any specialized vocabulary required by the circumstances.

• A hospital should not ask a family member or

friend to serve as an interpreter.

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Determining What Auxiliary Aid or Service a Hospital Needs to Provide

• The hospital should consult with the individual

who is deaf or hard of hearing for a needs assessment.

• The hospital should make an individualized

determination that takes into account the needs

• f the individual and the type of communication

expected.

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When Considering Auxiliary Aids and Services, Take into Account …

The individual’s needs and circumstances

• Individuals who are deaf or hard of hearing have different

degrees of hearing loss.

• Some individuals may speak though they cannot hear.
• Individuals have different skills and use a variety of ways to

communicate, including different types of interpreters.

Source: USDOJ, ADA Business Brief, “Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings” (2003)

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When Considering Auxiliary Aids and Services, Take into Account …

The type of communication

• Length of communication
• Number of persons involved
• Purpose of communication
• Complexity of information being communicated

Source: USDOJ, ADA Business Brief, “Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings” (2003)

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An Interpreter May be Necessary When ...

• Discussing a patient’s symptoms, diagnosis, medical tests,

prognosis, treatment options, or discharge instructions

• Obtaining informed consent
• Providing information in physicians’ rounds
• Providing mental health services
• Discussing complex billing or insurance information
• Making educational presentations
• Discussing a hearing patient’s medical condition with a deaf
• r hard of hearing family member or companion

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When Must a Hospital Provide the Auxiliary Aid or Service?

• The auxiliary aid or service must be provided in a timely

manner to avoid denying or limiting the individual’s receipt

• f a benefit or service.
• A hospital should provide required interpreter services with
• nly minimal delay. Until the interpreter is available and if

necessary to ensure effective communication, the hospital needs to make available other auxiliary aids and services.

Source: USDOJ ADA Business Brief (2003); 45 C.F.R 84.52; 28 C.F.R.35.160;35.164

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Strategies for Providing Effective Auxiliary Aids and Services

• Develop procedures and protocols for staff to follow

when an individual needs an auxiliary aid or service.

• Provide training on the procedures for all staff who may

encounter deaf or hard of hearing individuals.

• Provide signs and notice at locations where individuals

typically seek assistance, advising that auxiliary aids and services are available and instructing how to obtain them.

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The Law: HIPAA

The Health Insurance Portability and Accountability Act of 1996 Privacy Rule

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HIPAA Privacy Rule – the Basics

Who is covered? Among others, health care providers, including hospitals, who transmit health information electronically in connection with standard transactions (e.g. billing)

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HIPAA Privacy Rule – the Basics

What is covered?

• Protected Health Information
• Individually identifiable health information (other than

certain education and employment records)

• Transmitted or maintained in any form or medium
• Maintained or transmitted by covered entities or

their business associates

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HIPAA Privacy Rule: Business Associates

• Business associates are contactors or other non-workforce

members hired to do work of or for a covered entity that requires protected health information. Includes interpreter services, such as:

• Private commercial companies
• Community-based organizations
• Telephone interpreter service lines
• Hospitals must obtain satisfactory assurance – usually a

contract – that a business associate will safeguard protected health information and limit its use and disclosure

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Use and Disclosure of Protected Health Information: In General

Must be limited to what is permitted under the law, which includes:

• For treatment, payment, and health care operations
• To the individual
• Pursuant to a valid written authorization
• When the individual agrees, or does not object in

circumstances that give the individual an opportunity to agree or object

• For specific public policy purposes, such as public health or

law enforcement purposes

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Use and Disclosure of Protected Health Information: To Interpreters

• Provision of interpreter services usually will be a

health care operations function of the covered entity.

• When using or disclosing protected health

information to an interpreter, hospitals must take reasonable efforts to limit protected health information to the minimum necessary to accomplish the intended purpose of the use or disclosure.

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HIPAA Privacy Rule: Using Interpreters

A hospital may use and disclose protected health information, without an individual’s authorization, when:

• The interpreter is a member of the hospital’s workforce (e.g.,

bilingual employee, contract interpreter on staff, volunteer), or

• When the hospital engages the services of a person or entity to

perform interpreter services on its behalf as a business associate, or

• The patient identifies a family member, close friend, or any
• ther person (e.g., a telephone interpreter services or

telecommunications service) as his or her interpreter for a particular health care encounter.

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Federal Reimbursement for Language Services

• Federal funding is available to help states and

health care providers pay for language services under Medicaid and the Children’s Health Insurance Program (CHIP).

• How much is available depends on the state, the

program (Medicaid or CHIP), and how the state chooses to be reimbursed (“covered service,” “administrative cost,” “disproportionate share hospital costs”).

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Federal Reimbursement for Language Services

Enhanced Federal Reimbursement

in 2009: The Children’s Health Insurance Program Reauthorization Act of 2009 provides enhanced Federal reimbursement for language services for enrollees in CHIP and for child enrollees in Medicaid.

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Strategies & Approaches

Hospitals Can Use Different Strategies and Approaches for Ensuring Effective Communication

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Example of Voluntary Compliance Activity: Services for Deaf & Hard of Hearing Individuals A Maryland hospital agreed to:

• Assess the communication needs of individuals upon arrival
• r when an appointment is scheduled
• Provide qualified interpreters as soon as possible (and within

specified time limits) when necessary, especially during lengthy or complex interactions

• Implement procedures to expedite the provision of auxiliary

aids on successive visits

• Provide auxiliary aids, when needed, to companions as well

as patients

• Maintain a staff of nationally certified on-call interpreters

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Example of Voluntary Compliance Activity: Services for Deaf & Hard of Hearing Individuals A Maryland hospital agreed to:

• Periodically review the system and its effectiveness
• Maintain a detailed record of the individual’s request for

auxiliary aid or service and the hospital’s response

• Take steps to ensure that all personnel who may have

contact are made aware of the individual’s disability

• Provide notice of the hospital policy and procedures to the

community, hospital staff and physicians

• Conduct training of hospital personnel
• Meet standards for video interpreting services.

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Example of Voluntary Compliance Activity: Services for Deaf & Hard of Hearing Individuals A Maryland hospital agreed to standards for Video Interpreting Services:

• High quality
• Clear
• Delay-free
• Full motion video and audio over a dedicated high-speed Internet

connection

• Sufficiently large and sharply delineated picture of the interpreter’s

head, arms, and fingers, regardless of body position

• Clear and easily understood voice transmission
• Training of non-technicians in set-up and operation.

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Resources for Achieving Effective Communication

A Range of Resources: Tools, Toolkits, Best Practices …

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HHS Office of Minority Health (OMH) A Patient-Centered Guide

OMH: A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations

Purpose of the Guide: To provide healthcare

• rganizations and providers with practical, research-based,

and action-oriented steps for implementing language access services to better serve their LEP patients

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Components of the OMH Guide

• Step 1: Assessing the language needs of

patients

• Step 2: Assessing organizational capabilities
• Step 3: Planning and implementing language

access services

• Step 4: Evaluating the quality of language access

services

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Supplemental Slides on Additional Resources

• http://www.hhs.gov/ocr/civilrights/resources/specialtopics/hospital

communication/index.html

• http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/polic

yguidancedocument.html

• http://www.minorityhealth.hhs.gov/templates/browse.aspx?lvl=1&l

vlID=3

• http://www.ada.gov/hospcombr.htm
• http://www.lep.gov/