Bridging the Language Divide in Texas Hospitals

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By Luann Glowacz

Texas hospitals place interpretation services front and center when making health care accessible for non-English-speaking patients.

“Something is wrong with my body,” answered a non-English-speaking patient when a nurse trained in medical interpretation called to ask her, “What do you know about your diagnosis?” Medical City Healthcare in Dallas, where the woman is a patient, operates a call center with nurses who reach out to non-English-speaking patients within 24-48 hours of a diagnosis. In this situation, the nurse was able to walk through her diabetes diagnosis and treatment plan in Spanish, the language the patient understands best.

“It was a transformational conversation for her, I hope. She was so thankful and receptive,” the nurse told us.

While language assistance services aren’t new to Texas hospitals, the technology available has evolved, as has our understanding of the improvement to patient care by bridging the language divide.

The Evolution of Language Services

Making health care accessible for non-English-speaking patients can include outreach programs and other welcoming ways to ensure they feel culturally embraced. But every effort of inclusion will fall short if it doesn’t start by breaking down language barriers.

Language assistance, including interpretation services for non-English-speaking patients, has been a priority for Texas hospitals for decades. Title VI of the 1964 Civil Rights Act was the first legislation to formalize the effort, giving patients with limited English proficiency (LEP) a legal right to language assistance. A series of rulings followed over the years, including requiring all health care entities that receive federal funding (including Medicare and Medicaid) to provide interpretation and translation services. By 2016, Section 1557 of the Affordable Care Act added requirements that launched the current era of LEP access, which includes providing and posting written notices of free, qualified language assistance in the top 15 languages spoken regionally.

It’s no secret that there are two main languages in Texas: English and Spanish. But Texans are more culturally diverse than this bird’s-eye view portrays.

According to U.S. Census data, about 35% of Texans live in limited English-speaking households. About 83% of those individuals speak Spanish at home. Beyond Spanish, however, the variety of non-English-languages relied upon by hundreds of thousands of Texans divides into an impressive mosaic of more than 150.

Vietnamese, Chinese (primarily Mandarin), Tagalog, French, Hindi, Urdu, Korean, and Arabic are among the languages most spoken throughout the state. Trends in languages also change as immigration patterns change. For instance, in the past decade, Texas has been a top state for resettling thousands of refugees from both Myanmar (formerly Burma) and Somalia. While most immigrants and refugees speak at least some English, about 2 million Texas residents are not fluent in English.

Ensuring that these non-English-speaking patients gain quality access to health information when they need it is no small feat, as Medical City Healthcare illustrates.

Terri Nuss
Nuss

“Across our North Texas system of 16 hospitals, Medical City Healthcare had 56,000 interpretation sessions with patients of more than 100 languages in the past six months,” said Terri Nuss, MS, MBA, CPXP, Medical City Healthcare Division V.P. of Patient Experience.

Understanding Matters

Language accessibility takes on even greater importance when considering how it’s been shown to improve treatment and outcomes. One study published by the National Institute of Health shows that, for LEP patients, professional language interpretation at admission and discharge can reduce hospital stays by an average of 1.5 days. These patients are also less likely to be readmitted within 30 days.

Higginbotham

However, two common scenarios prevent professional language interpreters from being called in. The first is a family member or loved one volunteering to interpret for the patient. The second is a bilingual doctor, nurse or staff member using their conversational skills to communicate. Both can complicate outcomes for the patient, says Manuel Higginbotham, CMI, CHI™, manager of Language Access Services for The University of Texas Medical Branch (UTMB) at Galveston and the current president of the Texas Association of Healthcare Interpreters and Translators.

In the case of a loved one interpreting, Higginbotham explains, “They want to be helpful, but leaving it up to loved ones to interpret diagnosis and treatment information is problematic. First, they probably don’t have the training in both languages to know medical terminology and concepts to interpret a diagnosis or treatment accurately. This is especially true if the loved one is a child.”

A second complication of family members wanting to interpret, he says, is that they can bring bias into the encounter.

“For one reason or another, loved ones tend to filter the message. This can be done out of love, but it still can lead to changing or not fully divulging the diagnosis or telling the patient that everything is fine. This bias—even when based on good intentions—can affect outcomes.”

MANUEL HIGGINBOTHAM, CMI, CHI™, MANAGER OF LANGUAGE ACCESS SERVICES FOR THE UNIVERSITY OF TEXAS MEDICAL BRANCH (UTMB) AT GALVESTON

Often, this miscommunication can be culturally influenced. The Centers for Disease Control and Prevention (CDC) offers one such explanation in its Burmese Refugee Health Profile at cdc.gov:

“Compared to American culture, the Burmese are considerably more collectively oriented and less direct in communication,” the CDC wrote. “Limitation of self-expression…may lead to misinformation and poor communication with health care providers.”

Bilingual medical professionals using their own language skills to interpret is also common, particularly in areas of Texas where Spanish is prevalent and is spoken among both the community and staff. However, a 2019 study published in Health Equity Magazine acknowledged several documented risks surrounding medical professionals interpreting for themselves. These include bilingual physicians becoming overburdened with interpretation duties and medical providers with limited Spanish overestimating their competence without recognizing their limitations (a concept known as false fluency).

Texas medical schools are addressing this issue related to Spanish-speaking physicians by providing and working to strengthen the curriculum of medical Spanish education programs. UTMB Health, for instance, offers a bilingual health scholarly concentration aimed at educating and graduating culturally competent bilingual physicians. Students must already have Spanish proficiency to participate. The program’s website states that students with the concentration graduate with experience utilizing medical-Spanish terminology in patient education and care. They also gain cultural competency in Hispanic health. There are combined concentrations, too, including one that focuses on rural medicine and clinical service to Spanish-speaking patients to better serve specific populations of Spanish-speaking communities common to Texas.

Balancing Technology and the Human Touch

While many Texas hospitals have dedicated interpreters onsite, the sheer volume and variety of sessions that occur around the clock require a combination of in-person, telephone and video remote interpreting (VRI). All three services were well-used before the COVID-19 pandemic, but the combination has evolved since.

“The challenges of COVID-19, including staffing and infection prevention precautions, helped reinforce the importance of providing remote and virtual interpretation on-demand,” Nuss told us.

Pre-pandemic, the deaf and hard of hearing community advocated for innovations in video interpretation. Children’s hospitals also put VRI to use in creative ways. El Paso Children’s Hospital uses a combination of InSight video interpreting and an Interpreter on Wheels™ device to connect to interpreters in just seconds, at the touch of a button.

These advances were put to the test by COVID-19. VRI, for one, was thrust into the forefront early in the pandemic as patients underwent video conferencing consults from home, and social distancing protocols were put in place in hospital settings.

But technology and language services require a balanced approach. While VRI can allow for the visual cues crucial for good communication, the technology can also be limiting. One challenge is that it relies on high-speed bandwidth or wireless for a high-quality connection, which isn’t always possible.

The pandemic also drove home the importance of using interpretive services to support patients once they’re released from the hospital or sent home after a diagnosis.

“The pandemic has brought to the forefront a heightened need to make sure non-English-speaking patients who seek us for emergency care receive a call at home—conducted in their language—to ensure they understood their discharge instructions, can follow up with a provider if recommended, have access to medications prescribed, and have a chance to ask questions.”

TERRI NUSS, MS, MBA, CPXP, MEDICAL CITY HEALTHCARE DIVISION V.P. OF PATIENT EXPERIENCE

These lessons have helped broaden Texas hospitals’ understanding and commitment to serving their LEP community members. This commitment continues for individuals like Medical City Healthcare’s Spanish-speaking patient—newly diagnosed with diabetes—who is now empowered with the information she needs to feel better and live a healthy lifestyle.

But technology and language services require a balanced approach. While VRI can allow for the visual cues crucial for good communication, the technology can also be limiting. One challenge is that it relies on high-speed bandwidth or wireless for a high-quality connection, which isn’t always possible.

The pandemic also drove home the importance of using interpretive services to support patients once they’re released from the hospital or sent home after a diagnosis.

These lessons have helped broaden Texas hospitals’ understanding and commitment to serving their LEP community members. This commitment continues for individuals like Medical City Healthcare’s Spanish-speaking patient—newly diagnosed with diabetes—who is now empowered with the information she needs to feel better and live a healthy lifestyle.