Centers offer ways to bridge language, cultural differences

Community health centers find that hiring bilingual staff and installing telephone translation lines are key to providing the best care.

By Susan J. Landers — Posted July 7, 2008

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The Upper Cardozo Health Center, located in an economically and ethnically diverse section of Washington, D.C., has enrolled more than 17,000 low-income individuals, and most are non-English speakers. These patients, who hail from more than 90 countries, still receive a full range of primary and preventive health services.

Across the river in Virginia, the Community Health Network in Fairfax is providing similar care for a similarly diverse population.

How do they do it?

More physicians than ever would like to know. Encountering patients whose grasp of English is less than proficient is not unusual in medical practices. More than 55 million people in the nation, or nearly 20% of the population, speak a language other than English at home. And more than 24 million residents speak English less than "very well" and may be considered limited English proficient, or LEP, according to Steve Hitov, managing attorney of the National Health Law Program's Washington, D.C., office. He moderated a June 16 briefing on the importance of language services for quality health care.

The National Health Law Program also released a report, "Serving Patients with Limited English Proficiency," that resulted from a 2007 survey of 260 members of the National Assn. of Community Health Centers.

"Eighty-one percent of general internists treat LEP patients frequently -- 54% at least once a day or a few times a week," Hitov said.

Luis Padilla, MD, the medical director of the Upper Cardozo center, which operates under the umbrella of Unity Health Care Inc., and Christina Stevens, program director of the locally funded Fairfax Community Health Network, provided examples of the problems faced by safety net health care centers as well as their solutions.

Both centers recruit bilingual staff members. At the Cardozo Health Center, whose patients speak primarily Spanish or Amharic, an Ethiopian language, 17 of the 19 primary care professionals speak Spanish, Dr. Padilla said. More than 90% of the support staff are bilingual or multilingual. In addition to Spanish and Amharic, the staff speaks French, Chinese, Tagalog, Farsi, Vietnamese and Tigrinya, a language spoken in the African country of Eritrea.

"We have one of the few pharmacies to provide Spanish labels," Dr. Padilla added.

Reading skills count, too

Many of the patients seen at Dr. Padilla's health center also are illiterate in their own languages, and a national community partnership program called Reach Out and Read has been adopted to promote childhood literacy. Literacy promotion is a focus at well-child visits, he said.

The center also has a language line with interpreters available for more than 100 languages and dialects. The service is accessed via speaker phone in exam rooms.

Underlining all this activity is the 2004 D.C. Language Act, which was enacted to provide residents with limited proficiency greater access to services and activities in their own languages. To comply with the law, the health center faces ongoing challenges, Dr. Padilla said. Among them are the continued recruiting of bilingual health care professionals and the development of resources and staff to assess how patients process the information provided and to measure the degree to which it is understood.

The Fairfax safety net program was established to provide primary health care services to low-income, uninsured residents. It was begun as a temporary operation until a federal program came along. But they are still awaiting the feds' arrival, Stevens said.

Eighty percent of their patients are LEP and, although Spanish is the primary language for more than half, there are at least 70 other languages represented at the clinic.

Referrals to specialists who do not offer interpreters was cited as a major problem by Stevens. Another is family members who wish to serve as interpreters but also interfere with the clinical process and insert their own views.

The Fairfax center found similar solutions to those used in in the district. All health care professionals are bilingual, and there are language service lines in all exam and interview rooms, Stevens said.

To guide the way toward a world in which there are more health centers like the two featured in the briefing, the AMA and other organizations developed in 2001 a set of principles for providing health care access to people with limited English proficiency.

They include offering language assistance at no cost at all points of contact and in a timely manner; providing both verbal and written notice of the right to receive language services in a patient's preferred language; and assurances that the language assistance is competent.

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Treatment tips

A new report based on a poll of members of the Assn. of Clinicians for the Underserved, an organization of physicians and others based in McLean, Va., was released at a June 16 briefing in Washington, D.C. The survey resulted in a number of recommendations for treating patients with limited English proficiency.

Among the recommendations

  • Develop written operating procedures and human resource policies to support language access.
  • Schedule appointments that correspond to the availability of language services and track the language services needed by the community.
  • Install telephone language service lines in exam rooms.
  • Provide employees with mandatory training to enhance their language, cultural competency and communications skills.
  • Require interpreters and bilingual staff to adhere to the National Center on Interpreting for Health Care Code of Ethics and Standards of Practice.

Source: "Language Access: Understanding the Barriers and Challenges in Primary Care Settings," The Assn. of Clinicians for the Underserved and the National Health Law Program, May

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