Integrating Health Literacy, Cultural Competence, and Language Access Services Workshop Summary (2016) / Chapter Skim
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3 Issues and Challenges
3 Issues and Challenges
Pages 27-42
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From page 27... ...
Using a phone interpreter, her young, earnest, and wonderful physi 1 This section is based on the presentation by Alicia Fernandez, professor of clinical medicine at the University of California, San Francisco, and an attending physician in the General Medical Clinic and the Medical Wards at San Francisco General Hospital, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.
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From page 28... ...
To illustrate why this is the case, she started by providing some statistics. Using the strict definition of a low English proficiency -- those who report speaking English "not well" or "not at all" -- there are about 14 million people living in the United States, 11 million of whom speak Spanish.
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From page 29... ...
As examples, Fernandez noted that some physicians might believe it is equitable to offer genetic counseling to all pregnant patients regardless of cultural background, or to let the patient choose between two different medication regimens regardless of their level of health literacy. On the other hand, she added, substituted judgment or paternalism can rob patients of agency and autonomy, yet an emphasis on shared decision making can leave patients feeling confused, left alone, or deprived of professional services (Penchaszadeh, 2001)
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From page 30... ...
In one study Fernandez conducted using data from Kaiser Permanente in northern California (Wilson et al., 2005) , she and her colleagues found that even patients who are treated by physicians who use trained interpreters and certified bilingual staff still feel as if they are treated poorly because the physician is not showing them respect by speaking their language, a
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From page 31... ...
One solution is to structure health systems to require professional interpreters for patients with low English proficiency, and, at a minimum, every hospitalized patient with low English proficiency should have at least one conversation per day with the treating clinician mediated by an interpreter if the clinician does not speak the preferred language of the patient. This requirement, she said, could be integrated easily into a patient's EHR.
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From page 32... ...
Some systems, she said, are investing in interpreter technology, but that technology, she cautioned, is only good if it is used with the recognition that patients are likely to have low English proficiency and health literacy. Health systems are starting to experiment with ideas such as "teamlets" that match a primary care physician with language and culturally competent medical assistants or creating modules or grouped care.
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From page 33... ...
He recalled walking by the exam room and seeing the genetic counselor from Children's Hospital in Oakland working with an interpreter to explain dominant and recessive genes using a pile of pegs and being impressed that these professionals were truly trying to enable this patient to be empowered. Wong noted that because this woman had recently emigrated from China and had a fairly low level of education, he perceived at the time that much of her value to her family and community was being a mother who could bring a first child into the family.
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From page 34... ...
This is particularly challenging given that each situation is unique, and what these two cases illustrate to him is the need to better support providers, not just through medical education and training, but with point-of-care support to help them navigate the information needs of each specific patient. Such an approach, he said, would be low-hanging fruit that health care systems could address while taking longer-term steps to increase workforce diversity and hire clinical care staff that is fluent in various languages.
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From page 35... ...
He commented that when the discussion turns to provider training, the claim is made frequently that training does not seem to have a lasting impact on provider behavior, and one way to address that issue is to include provider behavior in meaningful quality indicators that have regulatory or payment consequences. He expressed the frustration that he said many in the health literacy field experience about how much longer it will take to convince regulators and payers that the evidence base is sufficient to mandate certain best practices.
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From page 36... ...
Alvarado-Little also commented on the resistance she gets whenever she talks about cultural competence or interpreting services because some of the requirements are thought of as unfunded mandates. However, federal agencies take the position that anyone accepting federal funding agrees as part of the funding agreement to provide language access services and meet all regulatory requirements concerning literacy, language, and culture.
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From page 37... ...
Services supporting adherence to the medication regime could be embedded in that kind of bundled reimbursement. In addition to using the metrics Fernandez and Wolf proposed, Alvarado-Little suggested involving risk management and patient relations as partners in these discussions.
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From page 38... ...
Other members of the clinical care team, including pharmacists and nurses, need to be involved in interpreter training as well. Rush then mentioned a metric called the net promoter score,2 a measure of patient satisfaction, and wondered if that metric could be tied into cultural competence.
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From page 39... ...
She pointed to a recent study showing that 70 percent of the patients with low English proficiency seen in an outpatient setting were cared for by members of an ethnic minority, which she said is another great reason to diversify medical schools. Rima Rudd asked if it would be appropriate to expand the notion of culture and language to include the millions of Americans who now have health insurance for the first time and are essentially new to the culture and language of health care.
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From page 40... ...
He noted there is a substantial amount of data showing the benefits of integrating health literacy, cultural competence, and language access services, which is why it is important to make the case that spending more time with patients will pay off in terms of increased satisfaction and better care. "This is what patient centered means," said Wolf.
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From page 41... ...
The hope, though, is that because the patient feels respected and heard and treated with dignity, a better relationship is formed between patient and provider. The hope is also that by communicating information in a way that resonates with the patient, by impressing upon the patient the need to return for additional services, then health care systems can improve compliance and the overall health of the individual.
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