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In these days of changing reimbursement and continual focus on cutting costs, it may seem ridiculous for a rehab facility to spend thousands of dollars on a service that is not reimbursable. However, that’s exactly what health care providers, including those in the rehab industry, might have to do if they want to ensure compliance with federal law and accreditation standards.
The service in question relates to interpreter and translation services for people who do not speak English or who are hearing-impaired. While this type of service might not have been given a second thought 10 years ago in many small and medium-sized communities across the nation, it rapidly is becoming essential nearly everywhere. Small towns, suburban communities, and other places that never attracted immigrants in the past now are the destinations of Hispanic, Asian, Eastern European, and other immigrants who are drawn to the area because of jobs in technology, construction, and other fields.
"We’re seeing a lot of places where the non-English-speaking population used to be migrant — where people would come through, pick crops, and leave — but now they’re settling down," says Cindy Roat, MPH, a quality assurance specialist for Pacific Interpreters in Portland, OR, and the executive director of Pacific Language Consultants. Roat also is the co-chair of the Board of the National Council on Interpretation in Health Care, also in Portland.
"I still do a lot of consulting around the country, and we’ve gotten an incredible number of calls coming from the South — North Carolina, South Carolina, and Georgia," Roat adds. "That Spanish-speaking population is now permanent, and we’re seeing a lot of secondary relocation of refugee groups, so there is more diversity in those areas than there used to be."
Crozer-Keystone Health System in Upland, PA, has recognized the importance of interpreter/ translation services as a way to offer better service to non-English speaking patients, says Bonnie Breitt, OTR, MHSA, administrative director of rehabilitation services for four Crozer-Keystone hospitals. "With the 2000 census numbers, we’ve seen that our population in this country is changing," Breitt says. "And because rehab services focus so much on the needs of the person being served, we as providers need to be sensitive to the fact that the population we’re serving is changing."
In Upper Darby, PA, there’s been a significant increase in the Asian population, so the hospital obtained a grant two years ago in order to improve health care among that population. Also, the communities served by Crozer-Keystone have a large Hispanic population, Breitt says. "We’ve translated numerous documents into Spanish, although the law only requires individuals to translate 3%," Breitt says. "Also, we’ve created a systemwide interpretation process so that you can access an interpreter any time in the day or night."
The health system contracts with Phoenix Language Services in Huntington Valley, PA, to provide interpretation and translation services. "Our interpreters are primarily a conduit of information and also a culture broker," says Bill Martin, executive director of Phoenix Language Services. For instance, interpreters are trained to use the body language that is mandated by various cultures, such as avoiding eye contact with Asian patients, who might view it as a sign of disrespect, Martin says.
In addition to legal and humanitarian reasons, there are some very practical reasons why the hospital pursued interpretation/translation services so aggressively, Breitt says. "If you believe a patient has understood what you’ve said, but you’ve not appropriately assessed the situation, then you may lead the patient to inappropriate care," she explains.
Legal problems sometimes can arise when a hospital relies on a patient’s family to translate the patient’s questions and answers. For example, at one of the many hospitals receiving translation services by Phoenix Language Services, a woman was scheduled for a tubal ligation to prevent further pregnancies, Martin says. "The woman’s husband was doing the interpreting and had his own agenda," Martin explains. "The nurse realized something was wrong and so we had a professional interpreter sit in to get the woman’s perspective, and we found out she didn’t want the operation at all; it was her husband’s idea."
Most problems with using family members as interpreters are less dramatic. For instance, suppose an older Asian male who is receiving physical therapy is being asked by his therapist to move in a way that the man finds very painful. The patient’s daughter, who is interpreting, might not be able to ask him to follow the therapist’s directions because she has been taught to respect her elders’ right to do as they please, Breitt suggests. "We probably use interpreter services every day," Breitt adds. "It’s expensive and nonreimbursable, but we have to reinforce the importance of this, and it’s required."
According to Title 6 of the federal Civil Rights Act of 1964, all patients who have difficulty with written or spoken English have the right to a qualified interpreter. In the past, hospitals and rehab facilities might have gotten by with having a Spanish-speaking employee serve as an on-call interpreter, but this type of practice may not be adequate, Martin says.
"Interpreters need training in terms of confidentiality and technique, and the phlebotomist or cleaning lady may not know these things," Martin says. "So from a risk-management point of view, the hospital is putting itself at risk for a potential medical malpractice suit if it uses staff as interpreters."
The 1964 Civil Rights Act has always had guidelines for providing language access to non-English-speaking patients, who fall under its umbrella because refugees are entitled to eight months of Medicaid when they arrive in the United States. But the law’s intent was reinforced in 2000 when the OCR issued a memo making it clear that health care providers must make interpretation and translation services available to patients, Roat says. "This caused all sorts of brouhaha around the country, and doctors were saying they couldn’t do it," Roat adds. "They can look at this in terms of the cost of providing an interpreter, or they can look at the cost of not providing an interpreter: How can you provide quality health care to a patient with whom you cannot communicate clearly?"
In addition, research suggests that patients receive better health care when qualified interpreter services are available to them.1-3
1. Leman P. Interpreter use in an inner city accident and emergency department. J Accid Emerg Med 1997; 14:98-100.
2. Hornberger JC, Gibson CD, Wood W, et al. Eliminating language barriers for non-English-speaking patients. Med Care 1996; 34845-856.
3. Pochhacker F. Language barriers in Vienna hospitals. Ethn Health 2000; 5:113-119.