Patient and Family Engagement Across Languages Mursal Khaliif - - PowerPoint PPT Presentation

Patient and Family Engagement Across Languages

Mursal Khaliif

Senior Director Multicultural Affairs, Diversity, and Patient Services Cambridge Health Alliance

Robert P. Marlin, MD, PhD, MPH

Staff Physician Department of Medicine Primary Care Internal Medicine East Cambridge Health Center Cambridge Health Alliance

Limited English Proficient (LEP) Patients

• From 1980 to 2010 the use of a language other than English

(LOTE) at home in the U.S. increased by 158%

• By 2011, nearly 60.6 million people spoke LOTE
• 41.8% (or 25.3 million) of these spoke English less than very well
• These numbers are projected to increase further over the

decade, including this year with the ACA expansion

sources: Ryan, C. (2013). Language Use in the United States: 2011: American Community Survey

• Reports. Washington, DC, U.S. Census Bureau; Shin, H and Ortman, J. (2011). Language Projections:

2010 to 2020. Washington, DC, U.S. Census Bureau.

Language Access Services and Quality

• 2001 – Institute of Medicine (IOM) releases Crossing the Quality

Chasm calling for a radical reconceptualization of quality and safety

• Report found that U.S. healthcare not providing “consistent, high-

quality medical care to all people”

• IOM sets forth 6 aims to improve U.S. healthcare

source: Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st

• century. Washington, D.C., National Academy Press.

IOM: Six Aims for Improvement

• Safe: avoiding injuries to patients from care intended to help
• Effective: providing services based on scientific knowledge to all

who could benefit, and refraining from providing services to those not likely to benefit.

• Patient-centered: providing care that is respectful of and

responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions

source: Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st

• century. Washington, D.C., National Academy Press.

IOM: Six Aims for Improvement

• Timely: reducing waits and sometimes harmful delays for both

those who receive and those who give care.

• Efficient: avoiding waste, including waste of equipment,

supplies, ideas, and energy.

• Equitable: providing care that does not vary in quality because
• f personal characteristics such as gender, ethnicity, geographic

location, and socioeconomic status.

source: Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st

• century. Washington, D.C., National Academy Press.

Affordable Care Act (ACA): Triple Aim

• better care for individuals
• better health for populations
• lower cost per capita

source: Institute for Healthcare Improvement. (2013). IHI Triple Aim Improvement Community.. Cambridge, MA, www.ihi.org.

Cultural Competence

• “the ability of systems and health care professionals to provide

high quality care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients' social…and linguistic needs”

• potential effect of these factors on patient’s ability to obtain

quality care

• recognition of structural factors

source: Betancourt, JR et al. (2002). Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. New York, NY, The Commonwealth Fund.

Cultural Competence

• skills to communicate effectively with any patient to understand

practices, values, and health beliefs

• treating each patient with respect and dignity
• avoiding generalizations about social or cultural groups

source: Betancourt, JR et al. (2003). Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep 118 (4): 293-302

Cultural Competence

• building awareness vs. prescriptive knowledge
• becoming competent in the “culture of one”
• attitudes and skills rather than specific information

source: Betancourt, JR et al. (2003). Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep 118 (4): 293-302

Cultural Competence

• healthcare systems and settings as “another world” that must

be interpreted and translated for patients

• normalized for providers and staff, healthcare systems are

“essentially strange”

• healthcare providers as interpreters

source: Sobo, E. J. (2009). Culture & Meaning in Health Services Research: A Practical Field Guide. Walnut Creek, CA, Left Coast Press.

Patient-Centered Medical Home

• comprehensive care
• patient-centered
• coordinated care
• accessible services
• quality and safety

source: (2013). Patient Centered Medical Home Resource Center. Rockville, MD, Agency for Healthcare Research and Quality. http://pcmh.ahrq.gov/

Rationale for Language Services

• Federal laws
• OCR
• HHS
• DOJ
• State laws
• Interpreter Laws
• Accrediting Agencies
• AHRQ
• HCHC
• NCQA

Federal Laws and Guidelines

Title VI of the 1964 Civil Rights Act Executive Order 13166 Department of Health and Human Services (HHS) Office for Civil Rights (OCR) Guidance Office of Minority Health (OMH) Culturally and Linguistically Appropriate Standards (CLAS)

CLAS Standards

14 Standards: 9 are guidance & 4 are mandates Mandated standards (#4,5,6 & 7) Standard # 4: Services at no cost, at all points of contact, in a timely manner, and during all hours of operation. Standard # 5: Inform patients in their preferred language & about their right to receive language services Standard # 6: Ensure the competence of language assistance provided & not to use family and friends as interpreters Standard # 7: In-language materials and signage for commonly encountered groups

Title VI of the 1964 Civil Rights Act

"No person in the United States shall, on the ground of race, color, or national origin be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." 42 U.S.C. § 2000d Guiding principle: “Meaningful Access”

Language = National Origin

Federal courts and agencies have interpreted discrimination by national origin to include language. In other words: In the U.S., if someone discriminates against a person because he/she can't speak English, this will be a violation of civil rights.

Overview of Cambridge Health Alliance

3 campuses with Emergency Services and Inpatient Psychiatry: The Cambridge Hospital Somerville Hospital Whidden Memorial Hospital Community-based Primary Care and Mental Health Services: services at hospital campuses, 18 neighborhood health centers, 4 school-based health centers CHAPO: Cambridge Health Alliance Physicians Organization Employer and contractor for MD services

Overview of CHA: Non-Provider Components

Network Health - a statewide managed Medicaid health plan offering

• Medicaid products
• Commonwealth Care products

Public Health:

• Includes Cambridge Public Health Department and Institute for Community

Health

• Work closely with public health departments in Everett and Somerville

Alliance Foundation for Community Health (Philanthropy) Academics: Teaching affiliations with:

• Harvard Medical School
• Tufts University School of Medicine
• Harvard School of Public Health

CHA Multilingual Services

Service Area: Cambridge, Somerville, Malden, Chelsea, Revere, Everett, and Winthrop Staffing: More than 135 employed interpreters based at three Hospital Campuses: Cambridge, Somerville & Whidden Health Centers: East Cambridge, Windsor St., Somerville PC, Broadway, Assembly Sq., Malden, and Revere Centralized Network Services: Dispatching, Telephone & Video Call Center

2012 Statistics

During FY12:

• 28% of In-Patients and 34% of Out-Patients required interpreter

services

• More than 170,000 interpreted visits and 3,200 pages

translated

• Completed over 150 education and training sessions
• Improved patient experience through interpreter rounds

It All Starts with Data Collection

• Understand your Patient Populations
• Track outcomes and quality of care
• Target interventions for Gaps
• Develop Quality Metrics for Multilingual Services

Understand Your Patient Populations

Data Collection Methods

• In person
• Over-the-phone
• On a form
• On EMR

Asking About Language

• ALL patients should be asked about their race, ethnicity and language
• Self-reporting is the most accurate source of information
• Self-reporting will increase consistent reporting within a health care

institution

• Patients are more likely to select the same categories to describe

themselves over time than staff who are assuming or guessing

Document Language Services

Document how LEP patients’ language needs were met for each clinical encounter to:

• Obtain complete record of all language assistance provided
• Capture complexities involved in meeting language needs

Use EMR to:

• Make documentation quicker, easier, standardized, and required
• Obtain reports to make data readily usable for QI

Institutionalize EMR documentation tool across all sites Use data from tool for quality improvement to ensure patient language needs are met safely

Quick Questions Screenshot

• Understand your Patient Populations
• Track outcomes and quality of care
• Target interventions for Gaps
• Develop Quality Metrics for Multilingual Services

Lessons from the Field

Cambridge Health Alliance EPIC Quick Questions Language of Care flows automatically from patient demographic information.

• If English, clinicians are not required to answer “Language needs

met by” question.

• If NOT English, clinicians must answer the question for all office,

telephone, and home visit encounters in order to close the chart

• Clinicians able to select multiple options.
• Reminder with link back to the question included

Best Practices

Staff Training Interpreter Rounds Quality Metrics

• Responsiveness of interpreters
• Completed interpreter requests
• Press Ganey Survey – custom
• Use of software for translations
• Turnaround time for translations

Quality Metrics for LEP Patient Experience

At CHA, Multilingual Services quality measures are reported for: Timeliness of language services

 Turnaround time for translations  Responsiveness of interpreters

Patient-Centered Care

 Press Ganey Survey – custom questions  Telephone Abandonment

Equity of Care

 Completed interpreter requests

Best Practices

Track outcomes and quality of care

• Target interventions for Gaps
• Develop Quality Metrics for Multilingual Services

Press Ganey results from LEP patients (Goal: 85%) Quality of Language Services & Cultural Awareness of staff

Best Practices

Optimal Telephone Response is Essential for Service Excellence

• Track outcomes and quality of care
• Target interventions for Gaps
• Develop Quality Metrics for Multilingual Services

Best Practices

Optimal Telephone Response is Essential for Service Excellence

• Track outcomes and quality of care
• Target interventions for Gaps
• Develop Quality Metrics for Multilingual Service

Thank You