What Language do you Prefer: Care of Patients with Limited English Proficiency (Jordan, 11/2020)

Limited English Proficiency (LEP) refers to anyone above the age of 5 who reported speaking English less than “very well,” as classified by the U.S. Census Bureau. Though most LEP individuals are immigrants, nearly 19 percent (4.7 million) were born in the United States, most to immigrant parents

            The US Department of HHS  defines LEP as “individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English.”

• Overall, the LEP population represents about 8% of the total US population ages 5 and older.

• Between 1990 and 2013, the LEP population grew 80% from 14 million to 25.1 million.

• California has a high proportion of people with LEP, almost 20%

• Sonoma County is higher than the national average, at 10.5-11.5%. The overwhelming majority of people with LEP in SoCo speak Spanish.

Medical interpreters are trained to interpret the spoken word, whereas translators work with written words. Although the two professions are often confused, they require different skill sets, with interpreters working in live situations.

Professional Medical Interpreter: An individual who has been assessed for professional skills, demonstrates a high level of proficiency in at least two languages and has the appropriate training and experience to interpret with skill and accuracy (certification varies).

A bilingual individual is a person who has some degree of proficiency in two languages. A high level of bilingualism is the most basic of the qualifications of a competent interpreter, but by itself does not ensure the ability to interpret. A bilingual employee may provide direct services in both languages but, without additional training, is not qualified to serve as an interpreter.

LEP impacts health.

• Lower likelihood of having a regular source of care
• Lower rates of preventive services (mammogram, colonoscopy, paps)
• Less likely to receive standard care for chronic medical illnesses
• Increased rates of medication complications
• Higher acuity of illness at presentation to the hospital
• Longer length of hospital stay

Medical Interpretation impacts health. 

• Access to medical interpretation improves patient experience
• Patients who need but do not get interpreters have a poor self-reported understanding of their diagnosis and treatment plan and frequently wish their provider had explained things better
• Ad hoc interpreters
•     misinterpret or omit up to half of all physicians’ questions
•     are more likely to commit errors with potential clinical consequences
•     have a higher risk of not mentioning medication side effects
•     ignore embarrassing issues (esp when children are interpreting)

Who are our patients at SSRRH?

• 13.8% of ALL patients prefer a language other than English
• 12.6% of ALL patients prefer Spanish
• In addition to Spanish, languages include Vietnamese, Khmer (Cambodian), Tigrinya, Laotian and Mandarin

How are we doing on interpreter use?

• In 2020, 88% of minutes used were Spanish
• 5.7% American Sign Language (ASL), 2% Cambodian, 2% Lao
• Some departments in the hospital use interpreters more than others. Specifically L&D has increased their use of interpreters over the last year due to intensive interdepartmental work and the placement of an interpreter device in every room.
• ED and Women's Services also have high number of minutes
• 

That being said, our documented of use of interpreters is pretty depressing.

See graphic below which shows which percentage of patients with LEP have documented use of interpreter at least ONE time on their chart.

Some questions to ponder with regards to interpreters:

• Identification of language preference: How should we ask? How do we document that we asked? How do we not miss this? 

• Ad hoc Interpreter: When is it appropriate to use a family member as interpreter? Who decides? How can we best use family?

• Medical error and/or adverse outcome: Who is responsible for communicating medical error or bad outcomes? How should that be done for LEP patients?

• Family Meetings, Family with mixed language status: How should complex conversations with interdisciplinary teams  and multiple family members be conducted? When should bilingual staff be used vs. VRI vs. both?

We need to cultivate the expectation that we use the interpreter just like we use hand sanitizer. Every. Single. Time.