1. Interpreters for the Community The MAMI Model and Suggestions for NY State Cornelia E. Brown, Ph.D.

2. Our “Innovation” I was drawn into community service from the Ivory Tower Founding Director of the non-profit: Multicultural Association of Medical Interpreters [“MAMI”] of CNY Located in Utica (60,000 on Erie Canal) “When in trouble, call….”

3. Overview of Talk Review of MAMI How it works What it does What elements reproducible Make suggestions for NYS policy Based on MAMI model and experiences

4. How to Create Language Access around the State? LEP in NY scattered over whole state* 300,000 – 500,000 Upstate My focus – helping area-wide Not in-house service All around community smaller cities enclaves in large cities City/country: all live in a community

5. 1996 in Oneida County: LEP Language Barrier 20k immigrants, 10% of County Dearth trained interpreters (clinic>court) Friends, family, untrained employees, passers-by, gesture used for access Bilingual case-management from resettlement agency (gov’t funded) “It was a big problem, especially w/feelings because you feel helpless everywhere.”

6. November 1996 Utica, NY Public health Clinic (TB control) acted on need for trained medical interpreters [MI]: 10-hour course funded by NYSDOH 30 bilingual, volunteer MI gather to train We learned that 1964 Civil Rights Law requires use of trained interpreters for LEP patients

7. The Urgency We Felt Shared horror stories: health care with poor communication across system No Patient self-determination: elderly Chinese man “signs” form (dentist) No Confidentiality: church friend interprets for mental health visit (mental health) Hidden conflict of interest: DV victim Culture bumps: Vietnamese father (HD)

8. First Steps Start a service to help patient and provider understand each other? Volunteer community interpreters met monthly over 1997 Hospitals, insurers, child protective, perinatal, health dept, nurses, college teachers join

9. Could We Train Interpreters Locally and Make Them Available to All? Training interpreters costs money! Who will want to take a long training if there’s no paid work? Even if some people train, what’s to keep them available? Where to house the service? Who pays?

10. Interpreter-Training Easiest Part Received start-up funds for training NY Task Force for Immigrant Health 1998 Train-the-trainer for continuity Trained 17 interpreters in 4 languages No host organization found as of June 1998

11. Choice Made -- Fall 1998 Recruited Board of existing partners Hoped for support from fees for skilled services: interpreting, translating, training Chose “multicultural” name of MAMI Started an independent 501©3 corporation No income yet

12. Thumbnail History (1) August ’99 dispatched first paid MI services, echoing office, 2 paid staff, 20 appts/mo. MMIA Certification Committee made us written, oral exams, internship ’99-2000 2000 SCORE Small Business of the Year Basic Medical Interpreting 2x/year

13. Thumbnail History (2) 2001: 200 appointments/month 2002-2003 Legal interpreting course (DV) 2004-2005 Mental health course 2004: On-site 24/7 service 2006: Syracuse hospitals choose MAMI. Open SYR branch office (50 miles west).

14. Thumbnail History (3) December 2006: 900 appointments/mo. (Utica) and 20 (Syracuse) Hired Coordinator Legal Interpreting Teach 20 th course Medical Interpreting April ’07: 9 office staff, 8 MI staff, 65 independent contractor-MI in 28 languages. Only agency w/MI throughout CNY

15. Changing Context: Expanded LEP Services Utica 2007 Interpreting agency explosion Resettlement agency: trained fee-based MI Small “agencies”: ad hoc, fee-based MI More interpreters available Most trained interpreters: hospitals Still need MI: small doctor’s (Medicaid), DSS, jobs service, police, corrections, courts, schools

16. Why the Improvement? More hospital regulations Attorney General Decisions NYS DOH Law JCAHO regulations NCIHC Ethics and standards CLAS standards Providers start seeing patient viewpoint

17. MAMI Services Skilled on-site medical / legal interpreting Written translation Interpreter training (medical, legal, mental health, train-the-trainer apprenticeship) Provider cultural competency Advocacy Labor-readiness: Driving ESL, nursing home

18. Dangers of Being Rural/ Suburban and Independent Lower quality standards Isolation: powerless and unawares Unqualified personnel and poor access to new technologies

19. Meeting the Challenge: Model for Success Economic Self-sufficiency Community roots (refugees, providers) Skilled services

20. Self-sustaining (1): Overall 95% supported by fee-for-service Despite competition w/free services Quality of service draws customers Interpreters paid not volunteer ($14.50-$23 Survives on gap between cost and fees Grants only for start-up agency or new projects, e.g. 24/7 self-sufficient after 4 months.

21. Self-sustaining (2): Basic Medical Interpreting Course Cost of 72-hour course, internship, oral Certificate exam: $575 Some scholarships available Total of 20 courses taught Completed by about 200 individuals Self-funding gives MAMI flexibility

22. Community Roots (1) MAMI reaches out to LEP Patients On-site interpretation core of caring Patients visit office w/interpreting requests 1/3 of appointment requests initially from patients Patients visit office w/advocacy requests Calling the prison Patients ask MAMI for special courses: e.g. driving-ESL

23. Community Roots (2) MAMI reaches out to interpreters MAMI Alumni Association Presentations: “Can My 7-year-Old Interpret for Me in Emergency Room?” Advocacy: Organize LEP forums Publish in newspapers Publicize right to interpreter services

24. Community Roots (3) MAMI Reaches out to providers Help Design and teach interpreter course Mutual learning process DA, Judges, lawyers, police, victims services helped w/legal interpreting course (40 hr) Mental health providers helped w/mental health interpreting course (40 hr) Hospice added to basic medical course Develop joint protocols; umbrella fees

25. Skilled: Foremost Interpreter Training Program in Upstate New York Medical Interpreting 72-hour course, NCIHC standards. 6-mo. paid internship, then Oral exam MAMI (in-house) Certificate (MMIA pilot) Interpreting for DV/SV Victims, Police/Courts (40 hrs) Interpreting for Mental Health (40 hrs)

26. Skilled: State and National Contacts Statewide partners: Perinatal network, Family Planning Advocates, Voices Since 1998 member Massachusetts Medical Interpreter Association Since 1998 on board of National Council on Interpreting in Healthcare

27. Skilled: New Technologies Multilingual voice mail (language access for MV Perinatal Network) Web-based interpreter dispatch and billing system (provider ease-of-access) Two-tiered interpreting program: on-site default with video back-up (hospital partners)

28. Skilled: Testimonials CPS Social worker “For psych eval, sigh of relief if it’s at City Court because MAMI has a contract” Head of Patient services large mental health clinic: “I don’t work for MAMI. Use them constantly. MAMI interpreters clearly superior to untrained, and to the less-well trained.”

29. Generalized “MAMI”/ Community Model for Interpreting Services Self-sustaining center for training/dispatch Used by all local health care facilities Sharing of interpreting costs Holistic*: sharing protocols, provider training, MI and provider regular meetings Beyond medical: legal too Credential and income stays at home

30. MAMI/ Community Model Makes Trained On-site Available Facilitate communication & understanding Retain the visual: body language, check for understanding Easier to intervene to clarify*, broker cultures Lobby to registration desk Especially needed: mental health, child, elderly or deaf, teaching session, group, regional dialect, complex situations

31. Why on-site: Visibility Key to Understanding Technical and Health Committee of the International Association of Conference Interpreters (2004): Interpreters need the visual just like actors who “must be able to tell that the message is getting across. Without this feedback, interpretation runs the risk of becoming mechanical and the quality goes down automatically.”

32. Remote as Back-up; Can Be Local Too Crucial part of fully-functioning system Circumstances: emergency, unusual language, what normally done on telephone, back-up availability Many types. Video preserves visual. Remote can be offered locally by cadre of on- site MI: economy and continuity of care

33. Policy Recommendations (1) (1) Funding language access Ensure that publicly-funded agencies offer trained interpreting only. Don’t create preference for remote over on- site. Patient understanding is key. Fund interpreter recruitment. Bilinguals don’t fill whole need for language access.

34. Policy Recommendations (2) (2) Enforcement, Interpreter Competency NCIHC Standards of Practice/ Ethics NYS AG Settlements with Hospitals MA Office of Minority Health Best Practices Enforcement at all health facilities: small doctor’s offices, Medicaid clinics Enforcement at government sites: DSS, corrections, CPS, drugs

35. Policy Recommendations (3a) (3) Workforce Development Statewide clearing house. RFP for translations. LLD done locally w/community back-translation. To identify promising practices: collaborative of stakeholders. Upstate and Downstate meet separately and together.

36. Policy Recommendations (3b) Establish MI training & dispatch centers throughout state Develop local capacity for medical and legal interpreting Self-sufficient, community cost-sharing for economies of scale. High-need areas all over state. Don’t forget migrants.

37. Policy Recommendations (3c) Precedents for local training centers AHEC in Massachusetts, Virginia, Florida AHEC in Massachusetts, Virginia, Florida Texas training/dispatch centers Texas training/dispatch centers Philadelphia “global” program Philadelphia “global” program Why? Why? MI needed everywhere not just in hospitals MI needed everywhere not just in hospitals Reduce healthcare cost for all. Reduce healthcare cost for all. Income stays in state and helps economy Income stays in state and helps economy Once refugee, trained MI gives back to all. Once refugee, trained MI gives back to all.

38. Conclusion “When In trouble…” In the rush to high-tech, don’t forget the human and immediate Lyuba: “Before MAMI, it was a big problem, especially w/feelings, because you feel helpless everywhere. Now, I’m glad there’s help, she said, lowering her bright green eyes to a notebook sitting on a desk in the MAMI office. Because I was in their place too.”