10/11/19 • I have no relevant financial relationships Disclosure with any companies related to the content of this course. Gayle Tang, MSN, RN Communic Com ication ion Barrie iers: s: 8 th Asian Health Symposium Go Good Medicine Poorly Ex Executed! University of California San Francisco Friday, October 11, 2019 Marriott Fisherman’s Wharf, San Francisco 1 2 Cultural & linguistic barriers and Language Access Demands implications • Changing Demographics Objectives Language access strategies • Patient Satisfaction and Health Care Quality and Effectiveness • Federal and State Mandates and Accreditation requirements Commitment for change to promote quality, dignity, and patient safety 3 4 1
10/11/19 Over 200 CULTURAL AND LINGUISTIC BARRIERS CAN RESULT IN: languages in CA A. Misdiagnosis, increasing cost and inefficiencies B. Higher medical error rates San Francisco Metro Area C. Lower patient satisfaction and lower patient comprehension At least 163 languages • • 40% of the metro area D. All of the above population age 5 and over speak a language other than English at home • Asians are now the majority in Santa Clara, Alameda, and SF ARS 5 5 6 Linking Disparities to Service and Quality Federal and State Mandates and Accreditation Requirements: Embracing the National Culturally and Linguistically Appropriate Services (CLAS) Standards LANGUAGE BARRIERS RANKED AMONG THE TOP THREE OBSTACLES PREVENTING MINORITIES AND THE POOR FROM RECEIVING NECESSARY HEALTH CARE CMS DHS DMHC Medicaid NCQA ¡ Fewer physician visits and lower use of preventive care ¡ Diminished comprehension of medical information, affecting the Joint EMTALA DHHS SCHIP OCR Commission quality of health care ¡ Reduced abilities to follow provider instructions, adhere to treatments, or to comply with instructions for follow-up care CLAS ¡ Compromise the quality of care due to misdiagnosis , increasing costs and inefficiencies in the health care system due to unnecessary testing because of lack of a proper medical history ¡ Medical error rates are higher when physician and patient speak different languages ACA Others Federal ¡ Lower patient satisfaction for those with LEP Local ¡ 4 issues affecting their perceptions of health care: provider cultural State MU Purchasers competence; patient education; medication adherence; and difficulty Source: Journal of Health Disparities Research and Practice communicating symptoms without language services Volume 3, Number 3, Spring 2010 7 8 2
10/11/19 HEALTH SYSTEMS • Increasing workforce diversity • Qualifying bilingual staff and clinicians RESPONSE • Dedicating personnel resources • Hiring dedicated interpreters and/or contracted vendors Policy • Developing or purchasing in-language materials Dedicated • Setting policies and procedures Procedures Fiscal Resources • Ensuring compliance with federal and state Cultural My super heroes… My mandates and meeting accreditation requirements Linguistic Competence • Creating structures to support services Dedicated Structures • Dedicating fiscal resources Personnel Resources Aim towards creating a culturally and linguistically Practices competent system of care *Adapted National Center for Cultural Competence, 2011 9 10 ARE THERE ORGANIZATIONAL POLICIES AND/OR GUIDELINES ON THE APPROPRIATE USE OF THE DIFFERENT INTERPRETING SERVICE MODALITIES? A. Yes, and followed B. Yes, but NOT followed Health Inequities C. No D. Don’t know ARS 11 12 3
10/11/19 Ke Key Drivers: Linking Disparities to to Quality ( IOM 6 Aims) • Safe: Minorities have more medical errors with greater clinical consequences • Effective: Minorities received less evidence-based care • Patient-centered: Minorities less likely to provide truly informed consent • Timely: Minorities more likely to wait for same procedure (transplant) • Efficient: More test ordering in ED for minorities due to poor communication • Equitable: Want no variation in outcomes Top 3 Causes of Death in the U.S. • Also: Minorities have more CHF readmissions, ACS admissions, and longer LOS 2013 13 14 Ke Key Drivers: Linking Disparities Ke Key Drivers: Linking Disparities to Quality ( IOM 6 Aims) to to Quality ( IOM 6 Aims) to • Safe: Minorities have more medical • Safe: Minorities have more medical errors with greater clinical errors with greater clinical consequences consequences • Effective: Minorities received less evidence-based care (diabetes) • Effective: Minorities received less evidence-based care (diabetes) • Patient-centered: Minorities less likely to provide truly informed • Patient-centered: Minorities less likely to provide truly informed consent consent • Timely: Minorities more likely to wait for same procedure • Timely: Minorities more likely to wait for same procedure (transplant) (transplant) • Efficient: More test ordering in ED for minorities due to poor • Efficient: More test ordering in ED for minorities due to poor communication communication • Equitable: Want no variation in outcomes • Equitable: Want no variation in outcomes • Also: Minorities have more CHF readmissions, ACS admissions, and • Also: Minorities have more CHF readmissions, ACS admissions, and longer LOS longer LOS 15 16 4
10/11/19 Ke Key Drivers: Linking Disparities to Quality ( IOM 6 Aims) to Key Drivers: Link nking ng • Safe: Minorities have more medical errors with greater clinical Dispa parities to Qua uality consequences ( IOM 6 Aims) • Effective: Minorities received less evidence-based care (diabetes) • Patient-centered: Minorities less likely to provide truly informed consent Safe: Minorities have more medical errors with greater clinical consequences • • Effective: Minorities received less • Timely: Minorities more likely to wait for same procedure (transplant) evidence-based care • Efficient: More test ordering in ED for minorities due to poor communication • Patient-centered: Minorities less likely to provide truly informed consent • Timely: Minorities more likely to wait for same procedure (transplant) • Equitable: Want no variation in outcomes • Efficient: More test ordering in ED for minorities due to poor communication • Also: Minorities have more CHF readmissions, ACS admissions, and longer LOS • Equitable: Want no variation in outcomes • Also: Minorities have more CHF readmissions, ACS admissions, and longer LOS 17 18 Key Drivers: Linking Disparities Ke to Quality ( IOM 6 Aims) to Key Drivers: Linking Disparities Ke to Quality ( IOM 6 Aims) to • Safe: Minorities have more medical errors with greater clinical consequences • Safe: Minorities have more medical errors with greater clinical consequences • Effective: Minorities received less evidence-based care • Effective: Minorities received less evidence-based care (diabetes) (diabetes) • Patient-centered: Minorities less likely • Patient-centered: Minorities less likely to provide truly to provide truly informed consent informed consent • Timely: Minorities more likely to wait for same procedure (transplant) • Timely: Minorities more likely to wait for same procedure • Efficient: More test ordering in ED for minorities due to poor (transplant) communication • Efficient: More test ordering in ED for minorities due to • Equitable: Want no variation in outcomes poor communication • Also: Minorities have more CHF readmissions, ACS admissions, and longer LOS • Equitable: Want no variation in outcomes • Also: Minorities have more CHF readmissions, ACS admissions, and longer LOS 19 20 5
10/11/19 Li Linking Di Dispari rities to Se Service and Quality • Language barriers ranked among the top three obstacles preventing minorities and the poor from receiving necessary health care. Source: Journal of Health Disparities Research and Practice Vol 3, No. 3, Spring 2010 21 22 COMPLIANCE WITH LANGUAGE ACCESS REQUIREMENTS The Joint Commission accreditation Title VI of the Civil Rights National CLAS (Culturally standards mandate providers ensure Act and the corresponding and Linguistically Appropriate meaningful access to health care for DHHS Guidance Services) Standards patients with limited English proficiency “Recipients should be CLAS Standard 7: “HR.01.06.01 Staff are aware that competency “Ensure the competence competent to perform requires more than self- of individuals providing their responsibilities.” identification as language assistance…” Is the he pl plan n compl plianc nce dr driven n or mission n bilingual.” and nd value ues dr driven? n? 23 24 6
10/11/19 Why do health and healthcare disparities matter? Diversity & Inclusion Social Justice Limit overall Cost improvement in quality for all populations 25 26 Cost of Health Disparities – substantial 3 Key Takeaways: annual economic losses nationally • ~ $93 billion in excess medical care costs • ~ $42 billion in illness-related lost productivity • ~ $200 billion economic losses due to premature deaths PATIENT & FAMILY USE APPROPRIATE SET EXPECTATIONS WITH THE CENTERED - THE TYPES OF LANGUAGE INTERPRETER AND HELP VOICE OF THE SERVICES MANAGE THE FLOW OF CONSUMER COMMUNICATION Source: NEJM Catalyst, The Costs of Racial Disparities in Health Care, February 15, 2016; Ani Turner, The Business Case for Racial Equity, A Strategy for Growth , (W .K. Kellogg Foundation and Altarum, April 2018) 27 28 7
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