1. Legal and Financial Parameters & Promising Practices for Language Access in Healthcare Settings Mara Youdelman National Health Law Program Youdelman@healthlaw.org April 25, 2007

2. National Health Law Program NHeLP is a national, non-profit law firm working on health care access and quality With the generous support of The California Endowment, NHeLP began the National Language Access Advocacy Project in 2003 With the generous support of The Commonwealth Fund, NHeLP has issued three “promising practices” reports on language services in healthcare settings

3. Federal Civil Rights Law Title VI has been in existence since 1964  “No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” 42 U.S.C. § 2000d “National origin” includes individuals with limited English proficiency (LEP)

4. What Has Recently Focused Attention on Linguistic Access? August 11, 2000 – Executive Order 13166 August 31, 2000 – Letter from Department of Health & Human Services re: funds available August 2003 – HHS Office for Civil Rights guidance on language access Recent federal legislation –  Patient Navigator Outreach and Chronic Disease Prevention Act of 2005  Ryan White HIV/AIDS Treatment Modernization Act  Homeland Security Appropriations Bill – FEMA

5. The States – a Better Stage 43 states have language access laws  comprehensive  targeted (e.g. emergency room, hospital) More and more states are enacting laws/policies to expand language access Not necessarily needed b/c of Title VI’s scope but appropriate given limitations of enforcement The carrot rather than the stick – little appetite for enforcement by individuals but other deterrents

6. Statewide Medicaid/SCHIP Programs Only a handful of states have set up programs to provide direct reimbursement using federal matching funds to pay for language services  DC, HI, ID, KS, ME, MN, MT, NH, UT, VA, VT, WA, WY  TX to start pilot program  NC initiating credentialing prior to reimbursement  CA – Medi-Cal Language Access Taskforce  MA – previously had reimbursement for hospitals

7. Medicaid Reimbursement for Language Services Four models –  contract with language service agencies (DC, HI, UT, VA, WA)  reimburse providers for hiring interpreters (ID, ME, MN, VT)  reimburse interpreters (MT, NH, WY)  provide access to language line (KS)

8. Current State Reimbursements (2007) StateEnrollees Covered Providers Covered Who the State PaysReimbursement RateAdmin or Service DCFFSFFS < 15 emp.Lang. agency $135-$190/hour (in-person) $1.60/min (telephonic) Admin HIFFS Lang. agencies$36/hrService IDFFS Providers$12.16/hrService KSManaged Care EDS (fiscal agent)Spanish – $1.10/min. other languages – $2.04/min. Admin MEFFS ProvidersReasonable costsService MNFFS Providerslesser of $12.50/15 min or usual and customary fee Admin MTAll Interpreters$6.25/15 minutesAdmin NHFFS Interpreters$15/hr; $2.25/15 min after 1 st hourAdmin UTFFS Lang. agencies $28-35/hour (in-person) $1.10/minute (telephonic) Service VAFFS AHEC & 3 health depts.Reasonable costsAdmin VTAll Language agency$15/15 minAdmin WAFFSPublic entities 50% expensesAdmin WAFFS BrokersBrokers receive an admin. fee Language agencies – $33/hour Admin WYFFS Interpreters$45/hourAdmin

9. CME requirements NJ – each medical school must educate students on cultural competency; CME must include cultural competency for physician relicensure CA – requires all clinically oriented CME for physicians and surgeons to include cultural and linguistic competency WA – each health professions training program must integrate issues of multicultural health into its curriculum ; authority for continuing ed

10. Other State Activities NHeLP 50-state survey CA – private insurers, C&L data collection RI & MA – hospital requirements Information from “Promising Practices” reports

11. Measuring Nature/Frequency of Contacts Important to identify individuals being served and eligible to be served Determining language needs at first points of contact – notations in schedule/patient records; language notification flyers; “I Speak” cards/posters Recording language needs  L.A. Care Health Plan – color-coded stickers designate language needs  Women’s Health and Education Center – notes language needs in schedule and computer data system

12. Identifying Language Needs WA Department of Social and Health Services – requires noting the client’s primary language in its computer system KY Cabinet for Health and Family Services collects language information and specifics on each encounter using language services

13. Arizona Department of Economic Security – database does not proceed past certain fields without noting the client’s language needs  clients are asked their primary language at initial and renewal interviews  includes 68 language choices plus an open- ended option

14. Los Angeles County Department of Public Social Services collects language information at initial eligibility and renewals County compiles a report to show the number of LEP individuals in the Medicaid caseload, by language spoken, served by each eligibility office during the month

15. Washington D.C. Medical Assistance Administration worked with community advocates to develop its “I Speak” poster and cards and a “Know Your Rights” pamphlet

16. Identifying Available Resources Need to identify both internal and external resources NHeLP’s Language Services Resource Guide for Healthcare Providers helps identify external resources including interpreter/translator associations and providers; training programs; translated materials; symbols; etc.

17. Training Neponset Health Center (MA) – employs native Vietnamese speakers trained as medical interpreters through the MMIA or Mass. DPH L.A. Care Health Plan –  offers medical interpreter training for bilingual staff of participating clinics and medical groups  training for health care providers (for continuing medical education credit) on how to work with interpreters

18. Testing and Certification No federal standards for interpreter certification NCIHC has National Code of Ethics and Standards of Practice WA – has had state-based certification since early 1990’s State laws – state-wide (OR) Other states starting the discussion – IN, MA, CA

19. Testing and Certification WA has the only statewide interpreter assessment program – candidates who want to work as DSHS interpreters (staff and contract) must pass the state certification test KY Cabinet for Health and Family Services worked with a consortium of local colleges and universities to develop an assessment program  only those who pass are “deemed qualified” to provide services in languages other than English or act as interpreters

20. Testing and Certification NE Health and Human Services System plans to develop an assessment test for new hires – only those who pass will be allowed to use their non- English language skills on the job; also plans to develop an assessment test for outside interpreters NC Department of Health and Human Services is working with other agencies to develop system-wide standards and payment rates for interpreters and establishing credentialing as pre-cursor to Medicaid reimbursement

21. Assessing Competency St. Joseph Health System Community Health Programs (CA) – requires assessment of staff providing services in non-English language or as interpreter North DeKalb Health Center (GA) – requires all bilingual staff to attend training sessions and pass test

22. Bilingual Staff KY Cabinet for Health and Family Services – designated Language Access Section with four trained interpreters LA Cty. DPSS – human resources division certifies language skills of bilingual staff WA DSHS – bilingual employees can provide interpretation only if certified as interpreters and documented in the employee’s classification questionnaire

23. Bilingual Staff – Compensation AZ Department of Economic Security offers a stipend of $1,000 a year NC Department of Health and Human Services – pays bilingual employees at a higher grade level LA Cty. Department of Public Social Services gives $100 monthly to certified bilingual workers KY Cabinet for Health and Family Services plans to pay qualified bilingual employees at a higher pay level

24. Contract interpreters KY Cabinet for Health and Family Service – qualifies community partners (both individual interpreters and language agencies) to interpret for the agency WA DSHS – comprehensive process to certify contract employees and only those who pass certification (in the state’s seven most common languages) or assessment (for other languages) may provide services to the agency

25. Community Resources ID Department of Health and Welfare contracts with local community organizations NC Division of Public Health is working with the United Hmong Association to translate its fact sheets IL Department of Human Services funds the IL Coalition on Immigrant and Refugee Rights

26. Community Resources PPPBTC – La Promesa and Los Promotoras program St. Joseph Health System – promotoras and promotoritas Cooley-Dickinson Hospital – interpreters in affiliated providers’ offices L.A. Care Health Plan – training for bilingual staff and providers; medical glossaries

27. Translation of Written Materials NE – uses designated translators with a degree from translation program ID Department of Health and Welfare – works with the Idaho Migrant Council and the Hispanic Commission to review benefits forms for appropriate Spanish translation

28. Where do we go from here? Explore potential for new state and federal laws and policies, inc. expectations for non-hospital settings (private insurance, nursing homes, etc.), Medicaid reimbursement, funding for workforce/training, training/certification standards Link to quality of care to change the debate – healthcare is different The demographic changes won’t stop so change is likely inevitable