Health Centers: Improving Health Care Access for Limited English Proficient Patients

Concept paper for linguistic access grants, developed by AAPCHO.

Communication between patients and their health care providers is fundamental for ensuring quality health care and developing trusting relationships. It is an important component of patient satisfaction, compliance, and outcomes.1 Although challenging for all populations, communication is especially a barrier for limited English proficient (LEP) patients, and the lack of accurate oral interpretation with this population results in decreased quality of care, increased medical errors, greater disparities, and diminished access.

In 1990 there were over 32 million Americans who spoke a language other than English at home. By 2000, that number had increased to almost 45 million.2 Of these Americans who speak another language than English at home, high percentages of various ethnic groups are LEP. According to the Centers for Disease Control and Prevention, 77.8% of Latinos in the United States speak a language other than English, and 39.4% do not speak English “very well.”3 Among Asian Americans and Pacific Islanders, 76% of Hmong, 70% of Cambodians, 68% of Laotians, 61% of Vietnamese, 52% of Koreans, 51% of Chinese, 39% of Tongans, and 22% of Samoans are LEP.4 There are also high percentages of LEP individuals among other immigrant communities, such as those from Africa and Eastern Europe.

LEP patients have long faced difficulties in accessing health care due to the lack of language interpretation services, and for many LEP patients, their situation is exacerbated by their lack of health insurance. Almost 60% of low-income immigrants under 200% of the federal poverty level were uninsured in 2000.5 For over 40 years, health centers have provided care to underserved populations including the immigrant and LEP communities. In 2001, health centers served over 10 million patients and almost 30% of these patients were LEP.6

The federal government has recognized the importance of language access for LEP individuals. In 2000, the Department of Health and Human Services (DHHS) Office for Civil Rights (OCR) issued a guidance that provides important clarifications of the existing law and responsibilities under Title VI of the 1964 Civil Rights Act. The guidance also specifies the flexibility that agencies have in meeting these requirements. That same year, President Clinton signed Executive Order 13166 which confirmed support for Title VI of the 1964 Civil Rights Act and required federal agencies to comply with its provisions and issue guidance documents. As the agencies have implemented Executive Order 13166, the DHHS OCR guidance was recently revised this year.

Language access has also been included as an important component of federal cultural competence initiatives. DHHS Office of Minority Health created National Standards for Culturally and Linguistically Appropriate Services in Health Care as a guide for health care providers. Of the 14 standards, there are four that relate directly to language access.

Importance of Language Services

In providing services to LEP populations, health centers recognize the enormous benefits that arise from accurate and quality communication. Just as syringes are needed for drawing blood, communication between providers and patients is critical for discussing issues such as diagnoses, treatment plans, medication adherence, and disease management techniques. A Robert Wood Johnson Foundation survey found that 94% of providers cite communication as a top priority in delivering quality care. Over 70% reported that language barriers compromise the patient’s understanding of treatment advice and their disease, increase the risk of complications, and make it harder for patients to explain their symptoms.7

Research studies illustrate the importance of language services for LEP patients. The lack of language services has been shown to affect access to health care services and preventive care. A Canadian study found that women who did not speak English were less likely to receive breast exams, mammograms or pap smears.8 The inability of patients to access proper care causes increased reliance on emergency rooms, resulting in greater costs to the health care system. Spanish-speaking patients with English-speaking only physicians were found to be more likely to make at least one additional visit to the emergency room as compared to Spanish-speaking patients with Spanish-speaking doctors.9

The lack of language services also results in poor communication of important information between the provider and patient, with significant negative outcomes on patient health and treatment. One study found that patients with language barriers were unable to comprehend diagnoses, resulting in them not being able to ask questions and having to guess what was being told to them.10 Other studies show that patients who did not speak the same language as their physician were more likely to miss an appointment, to not comply with follow-up instructions including taking medications, and to not be as satisfied with their health care experience.11 These types of incidents can significantly increase the likelihood of medical errors and distrust between providers and their patients.

In addition, communication between government agencies and patients is indispensable to ensuring that LEP individuals have access to public programs for which they are eligible, such as Medicaid, SCHIP, and Medicare. For example, the partnership between health centers serving Asian populations and state agencies conducting outreach for the Healthy Families program (California’s State Children’s Health Insurance Program) has resulted in significantly high enrollment rates among Asian children. In the first months of the program, approximately 79% of San Francisco’s Healthy Families enrolled children were Chinese, largely due to outreach efforts conducted in the language and targeted to the population.12

Challenges Faced by Health Centers

Health centers recognize the importance of language services for LEP patients; however, they also are experiencing numerous challenges in providing these services. The following examples illustrate the myriad of difficulties that health centers face in providing language services without additional resources:

• Currently, there are only a few states that provide reimbursement for language services through their Medicaid and SCHIP programs; no reimbursement is provided for Medicare or uninsured patients. Many health centers have made the commitment to provide language services to the best of their ability, but additional financial support is needed to improve their programs and ensure access for all LEP patients.
• There is an increasing diversity among the languages spoken by LEP communities across the country. For example, in California, health centers are encountering a growing number of Latino patients who come from indigenous communities in Mexico who may not speak Spanish. The new waves of migrant farmworkers include people who speak Zapotec, Mixteca, and Trique. The diversity of languages and the recent arrivals of some groups pose challenges in finding interpreters who can speak uncommon languages and in financing arrangements to support access for a wide variety of languages.
• Another challenge is the provision of services in multiple languages. Because the country’s demographics are increasingly diverse, there are certain areas where there may be high concentrations of multiple languages. Health centers must consider not only arranging interpreter services, but also performing translations of materials and understanding different cultural beliefs.
• Some clinics serve a small percentage LEP population, and cannot cost-effectively hire bilingual staff to cover their needs. Under these circumstances clinics often rely on remote interpretation to meet their patient’s needs. Traditional remote interpretation has utilized phone lines where the interpretation is done in a consecutive manner. However, in recent years, innovative ideas using the latest technology have focused on using two-way audio and video equipment to connect patients and providers with interpreters located hundreds of miles away. The costs associated with technological equipment and access to remote interpretation approaches are expensive and require additional financial support.
• Health centers already face difficulties in recruiting and retaining health care staff due to health care shortages. An even greater challenge has been recruiting and retaining bilingual providers and interpreters who are in short supply and strong demand. Many health centers would like assistance in providing incentives for staff who are bilingual and who use their language skills in a professional capacity as a recruitment and retention tool.
• As part of the hiring process of bilingual staff, there are costs associated with testing language capabilities. Health centers would benefit from resources to measure the level of language proficiency of staff that is hired, as well as from the development of a test that is easy to administer and cost-effective.
• Besides creating approaches for delivering language interpretation services, health centers could also utilize additional resources to develop training programs for staff and interpreters. An integral part of the mission of health centers is responding to community needs and promoting cultural competency. Many have elected to better care for their LEP patients by hiring people directly from the community to serve as interpreters. They often have a larger role than simply interpreting by helping to navigate cultural differences between providers and patients. However, there are costs associated with the trainings, as well as opportunity costs associated with providers not seeing patients when attending the trainings. These lost opportunity costs could be avoided with additional resources.

Language Access and the President’s Initiative to Expand Health Centers

The Health Care Safety Net Amendments Act of 2002 recognized some of the challenges that health centers face in providing language services by granting authority to the Department of Health and Human Services to create access grants. These access grants would fund health centers to “provide translation, interpretation, and other such services for such clients with limited English speaking proficiency.” The intent of this legislation is to provide resources for health centers to develop a variety of approaches that meet the different needs of LEP patients. One program that may work in one health center may not be the best method for another. The grants provide flexible funding for health centers to assess the needs of their LEP patients and to develop innovative mechanisms for improving access.

Language access is an important component of the President’s Initiative to expand health centers. As the nation continues to become more diverse with large numbers of LEP individuals, it is critical that resources are devoted to assisting health centers with language services that reach greater numbers of uninsured patients, including those who are linguistically isolated. By strengthening the infrastructure of health centers to respond to the needs of LEP patients, the linguistic access grants will achieve gains in the following elements of the President’s Initiative:

1. Workforce Development: Approximately 30,000 new employees will need to be recruited, including 4,500 new clinicians to staff new and expanded health centers. In order to best serve multi-lingual and multi-ethnic patient populations, health centers will need to develop or expand strategic plans for the retention, training, and recruitment of bilingual/bicultural staff and health care providers.
2. Operating Systems: Numerous research studies illustrate the importance of language services for improving quality of care, reducing disparities, and increasing access to needed prevention and treatment services. Health centers can utilize the linguistic access grants to improve their operating systems for serving LEP patients.
3. Continuum of Care Linkages: Health centers also need resources to improve collaborations with specialists and other community partners and to ensure improved continuum of care for LEP health center patients.
4. Outreach to Special Populations: The development of programs to provide access to language services will result in greater capacity to outreach to LEP communities and remove the additional barriers faced by LEP individuals seeking to access health care services.
5. Service Delivery Adaptations for Special Populations: Language access is one component of a health center program that meets the language needs of an increasing and evolving LEP population.

Implementation of the Linguistic Access Grants

The health center program delivers quality, cost effective primary health care to the nation’s underserved and vulnerable populations including a large number of LEP patients. To provide the necessary linguistically and culturally appropriate services necessary to serve LEP patients, it has been necessary for health centers to develop innovative and cost effective methods. It is the intent of the linguistic access grants to: 1) provide additional funds to promote and support health centers as they meet the challenge of providing appropriate services for LEP patients and 2) encourage the development of cost-effective and innovative methods that eliminate barriers to care faced by LEP patients.

Additionally, it will be useful to document tools and model practices that will assist other health centers in serving LEP patients. As part of this program, it will be beneficial to look at funding grantee meetings to share best practices and resource tools, as well as to support Primary Care Associations for the provision of technical assistance.

Availability of Federal Funds

Currently, the total appropriation to support the Linguistic Access grants for FY ’04 is unknown13. If funds are set aside for this program, then single grants of up to, but not exceeding $150,000 annually will be awarded on a competitive basis for multi-year funding periods ranging from 2-3 years. Support for subsequent budget periods within the approved project period will be based on satisfactory progress and availability of funds.

The intent of this funding is to assist health centers in meeting the varying language needs of the communities they serve. Therefore the grant process should allow for flexibility by funding different approaches and models including but not limited to:

• Recruiting, hiring, training and retaining bilingual/multilingual providers
• Contracting/hiring interpreters and translators
• Training staff to work with interpreters
• Increasing organizational ability to use new technology such as telemedicine and video conferencing for interpretation services
• Developing incentive programs for bilingual staff
• Forming partnerships and networks for the provision of language services
• Training of board and staff on the organizations response to the language needs of the community
• Monitoring and updating language access services

Additionally, it is necessary to recognize the importance of funding a variety of different projects reflecting both diverse strategies and levels of development of language services. Health centers at all stages of implementation will be considered for this funding.

Eligibility

Any organization funded under Section 330 of the PHS.

Funding Criteria

Organizations seeking funding under this announcement will be evaluated on their ability to increase access to health care for limited English proficient (LEP) patients. Applications should demonstrate the applicant’s understanding of the problem, outline a comprehensive and realistic program plan and budget, and demonstrate the organization’s capacity to implement the program and meet the needs of the LEP populations they serve.

Additionally, the Department of Health and Human Services Office of Civil Rights has published “Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons” concerning the provisions of linguistic services to LEP patients. This guidance includes a four part assessment which evaluates: (1) The number or proportion of LEP persons eligible to be served or likely to be encountered by the program or grantee; (2) the frequency with which LEP individuals come in contact with the program; (3) the nature and importance of the program, activity, or service provided by the program to people’s lives; and (4) the resources available to the grantee/recipient and costs.

Below are suggested criteria for providing competitive grants to assist health centers in addressing the language needs of their communities.

Criteria 1: Needs Assessment

The applicant will submit a needs assessment that will describe, at minimum, the language needs of the service population including the specific language groups to be targeted, the number of LEP patients, the percentage of the total health center population that is LEP, the frequency with which LEP individuals come in contact with the health center, the diversity of language services in the community, the existence of newly emerging and/or growing LEP populations, and the applicant’s past experience in providing services for the targeted population.

The applicant should also identify any challenges to providing language services to the targeted LEP community (i.e. geographic isolation, rapid growth of LEP population, lack of bilingual providers, lack of access to interpreters, lack of technology necessary to access services, lack of resources available and the costs of existing programs, presence of communities in which language barriers prohibit outreach, lack of community data).

Criteria 2: Program Plan

The applicant will submit a detailed program plan that proposes specific goals and objectives. The program plan should outline the importance of the program for the target populations, describe how the proposed program will improve services for existing users and/or bring in additional users, demonstrate integration of language services into the overall clinic operations (such as integration into quality assurance programs), identify existing linkages, partnerships and collaboration in the community and those that need to be developed, and outline program staffing needs. Effectiveness measures and an evaluation component should also be included. It is important for applicants to demonstrate the rationale for choosing a particular approach to address the need and why this approach would be more advantageous than other available options.

The program plan should also describe why the proposed model is best suited for addressing the health center’s language needs as outlined in the Needs Assessment section and illustrate how the program will address the challenges reported in the needs assessment. For instance, if the applicant has indicated that hiring bilingual staff is a challenge, the program plan should include a detailed plan for how the health center shall utilize funding from the linguistic access grants to improve recruitment and retention of the necessary bilingual staff.

Criteria 3: Budget and Budget Narrative

The applicant’s budget and budget narrative will

• Provide an estimate of the cost of the proposed program (ie. the cost of interpreters, use of language lines, training of staff, translation of written material, the cost of recruiting and retaining the staff necessary to meet the objectives of the program plan)
• Provide information on projected expenses and revenue including an examination of existing resources
• Outline the health center’s plans for leveraging funding to support their program in the long term
• Clearly outline the link between the program plan and the budget

1. Betancourt, J., et. al. (1999). “Hypertension in Multicultural and Minority Populations: Linking Communication to Compliance,” Current Hypertension Reports, 1:482-488.
2. U.S. Census Bureau (2001). “Census 2000 Supplementary Survey, National & State Profiles,” website http://www.censu.gov/c2ss/www/.
3. The Status of Latino Health in California, Latino Coalition for a Healthy California, (2000), p. 1, citing Centers for Disease Control and Prevention, Tobacco Use Among U.S. Racial/Ethnic Minority Groups: A Report of the Surgeon General, (1998).
4. Hendriksson, Marla (2002). “Asian & Pacific Islander American Demographis,” Office of Environmental Justice citing US Census 2000.
5. Hudman, J. (2002). “Immigrants’ Health Care: Issues Related to Coverage and Access,” presentation for the Dataspeak audioconference of the Maternal and Child Health Bureau, June 13, 2002.
6. Bureau of Primary Health Care (2002). “National Summary for 2001,” table 3A and 3B, printed July 2002.
7. Robert Wood Johnson Foundation, “New Survey Shows Language Barriers Causing Many Spanish-speaking Latinos to Skip Care,” Media Release, December 12, 2001.
8. Woloshin, S., et. al. “Is Language a Barrier to the Use of Preventative Services?” JGIM, 12: 472-477, August 1997.
9. Manson, A. “Language Concordance as a Determinant of Patient Compliance and Emergency Room Use in Patients with Asthma,” Medical Care, 26 (12), p. 1119-1128, December 1988
10. Smith, M. and Ryan, A. “Chinese-American families of children with developmental disabilities: an exploratory study of reactions to service providers,” Mental Retardation, 23: 345-350, 1987.
11. Manson, A. “Language Concordance as a Determinant of Patient Compliance and Emergency Room Use in Patients with Asthma,” Medical Care, 26 (12), p. 1119-1128, December 1988. And
12. Woloshin, S. and Bickell, N. “Language barriers in medicine in the United States,” Journal of the American Medical Assocation, 273: 724-727, 1995.
13. Medi-Cal Community Assistance Project. “Healthy Families at Year One: Outreach, Application, and Enrollment Issues,” July 1999.
14. There are efforts to secure funding for the linguistic access grants program in the amount of $10 million. However, it is possible that a smaller amount could be secured to begin a pilot demonstration project.