1. How to Work Effectively With Interpreters Photo credit: Billie Young from the book My Heart is Delicious

2. Interpreting Stakeholder Group, 20092 Workshop Goal To improve communication with patients with Limited English Proficiency by learning techniques for working with interpreters.

3. Interpreting Stakeholder Group, 20093 Workshop Objectives At the end of the session, participants will be able to: Describe the advantages for patient satisfaction and safety of working with a qualified interpreter. Describe the requirements for reducing language barriers. Define the relative roles of the provider, patient, and interpreter.

4. Interpreting Stakeholder Group, 20094 Hold Your Breath 1/ What went wrong? In each circle on your handout describe the person’s behavior and the role they are playing. 2/How could this situation have been improved? Turn your handout over and on the other side suggest better behaviors and/or an appropriate role for each person.

5. Interpreting Stakeholder Group, 20095 Patients with language barriers Have longer hospital stays Make fewer visits and receive fewer preventive services Are less likely to use or return to clinics Score lower on health knowledge and understanding of diagnosis and treatment Are less satisfied Fortier, J., & Bishop, D. “Developing a Research Agenda for Cultural Competence in Health Care, Rockville”, MD: OMH and AHRQ, 2002.

6. Interpreting Stakeholder Group, 20096 LEP patients who need, but do not get interpreters Are more likely to receive intravenous hydration and to be admitted to the hospital (Hampers and McNulty 2002) Are at greater risk of being discharged from the emergency department without a follow- up appointment (Sarver and Baker 2000) Have more tests done, creating a higher overall cost (Hampers and McNulty 2002)

7. Interpreting Stakeholder Group, 20097 Use of trained professional interpreters was associated with: Lower admission rates from the ED (Hampers and McNulty, 2002) A decrease in utilization disparities for outpatient preventive services (Jacobs et al, 2001) Reduced ED return and referral rates (Bernstein et al. 2002)

8. Interpreting Stakeholder Group, 20098 In summary Using trained interpreters can: Improve patients’ health outcomes Improve patients’ primary care utilization Increase patients’ perceived understanding of their care Increase patient and provider satisfaction Using trained interpreters may: reduce medical complications lower the cost of care in the long run (Interpreter Services Workgroup report, Feb 2008)

9. Interpreting Stakeholder Group, 20099 Requirements to use language services Quality health care Demographics: increase in limited English proficient (LEP) clients Regulatory: Federal law (Title VI of Civil Rights Act), CLAS Standards State law (Minnesota statutes) Accreditation mandates (JCAHO) Financial: reduce ER use, reduce unnecessary admissions, decrease diagnostic test costs Like, R., et al. “Cross-Cultural Communication in Health Care: Building Organizational Capacity, HRSA and OMH, DHHS Satellite Broadcast, June 4, 2003.

10. Interpreting Stakeholder Group, 200910 Key ethical principles for interpreters Accuracy Confidentiality Impartiality Acting in a professional and ethical manner National Council on Interpreting in Health Care, 2004 www.ncihc.org

11. Interpreting Stakeholder Group, 200911 Guidelines for Working Effectively with Interpreters Before the appointment Make sure that you are working with a qualified interpreter and not a family member or friend. Brief the interpreter on what to expect in the meeting, where necessary. Plan enough time – it may take longer than an English-only appointment.

12. Interpreting Stakeholder Group, 200912 During the appointment Expect and encourage the interpreter to avoid spending time alone with the patient when not providing language services. Remember that the interpreter is required to interpret everything said in the room – curse words, side conversations, and ‘irrelevant’ or repetitive comments included. Face the patient and talk to them directly, as if you both spoke the same language.

13. Interpreting Stakeholder Group, 200913 During the appointment II… Don’t speak too fast. Pause after each complete thought and/or when the interpreter signals to you to allow for the interpretation. Ask only one question at a time. Don’t ‘chain’ your questions. Confirm understanding by asking the patient to repeat key information back to you.

14. Interpreting Stakeholder Group, 200914 During the appointment III Be aware of the education level and/or health literacy of your patient in order to phrase your message at an appropriate level. Avoid using acronyms and idioms. You are communicating THROUGH the interpreter but TO the patient. Dealing with cultural differences and the personality of the patient is primarily your job, not the interpreter’s. Some examples of things to keep in mind regarding cultural and linguistic differences: There may be less eye contact with the patient than you customarily expect; A smile or nod on the part of the patient may not indicate total agreement.

15. Interpreting Stakeholder Group, 200915 After the appointment Debrief with the interpreter, if necessary, about the communication process.

16. Interpreting Stakeholder Group, 200916 Questions?  Thank you for coming!

17. Interpreting Stakeholder Group, 200917 Objectives of Session 2 At the end of the session, participants will be able to: Demonstrate specific techniques for working with trained and untrained interpreters Identify the importance of using alternative ‘layman’s terms’ to explain medical terminology Identify core competencies they have acquired through a post-test activity

18. Interpreting Stakeholder Group, 200918 Video Vignette 1 Have you experienced a situation similar to that portrayed in this vignette? What factors from the ‘cheat sheet’ distributed in Part 1 of this training are at play in this scenario?

19. Interpreting Stakeholder Group, 200919 Video Vignette 2 Have you experienced a situation similar to that portrayed in this vignette? What factors from the ‘cheat sheet’ distributed in Part 1 of this training are at play in this scenario?

20. Interpreting Stakeholder Group, 200920 Final vignette How might you implement these strategies in your work environment? What challenges might you face implementing these strategies?

21. Interpreting Stakeholder Group, 200921 Post Test Question 1 Which of the questions below would encourage direct communication with your patient? a) Please ask him why he came to see me today. b) Are you still having stomach pains? c) Fatima, could you ask her if she is currently taking any medications?

22. Interpreting Stakeholder Group, 200922 Post Test Question 2 Draw an arrow to demonstrate how you might move one of the parties out of this positioning in order to communicate as directly as possible with your patient. INTERPRETER PROVIDERPATIENT

23. Interpreting Stakeholder Group, 200923 Post Test Question 3 If you, the provider, feel that the communication is being impeded by inaccurate interpreting, a good option to check understanding is: a) Ask the patient to repeat the information back to you. b) Ask the interpreter whether they are interpreting accurately. c) Ask the interpreter if they think the patient understood.

24. Interpreting Stakeholder Group, 200924 Post Test Question 4 It is appropriate to ask the interpreter’s opinion about cultural issues: a) Whenever you are working with a patient from a different culture. b) When you are uncertain what cultural factors are at play in the patient’s care. c) When you are unable to get an explanation from the patient him/herself.

25. Interpreting Stakeholder Group, 200925 Post Test Question 5 Name two possible consequences when patients with LEP are not provided a qualified interpreter.

26. Interpreting Stakeholder Group, 200926 How might these concepts be explained in layman’s terms? Pap smear Inhaler CAT scan Angiogram Preeclampsia Autism PTSD Food support Retrospective eligibility

27. Interpreting Stakeholder Group, 200927 Post Test Question 1 Which of the questions below would encourage direct communication with your patient? a) Please ask him why he came to see me today. b) Are you still having stomach pains? c) Fatima, could you ask her if she is currently taking any medications?

28. Interpreting Stakeholder Group, 200928 Post Test Question 1 b) Are you still having stomach pains?

29. Interpreting Stakeholder Group, 200929 Post Test Question 2 Draw an arrow to demonstrate how you might move one of the parties out of this positioning in order to communicate as directly as possible with your patient. INTERPRETER PROVIDERCLIENT

30. Interpreting Stakeholder Group, 200930 Post Test Question 2 Draw an arrow to demonstrate how you might move one of the parties out of this positioning in order to communicate as directly as possible with your patient. INTERPRETER PROVIDERCLIENT

31. Interpreting Stakeholder Group, 200931 Post Test Question 3 If you feel that the communication is being impeded by inaccurate interpreting, a good option to check understanding is: a) Ask the patient to repeat the information back to you. b) Ask the interpreter whether they are interpreting accurately. c) Ask the interpreter if they think the patient understood.

32. Interpreting Stakeholder Group, 200932 Post Test Question 3 a) Ask the patient to repeat the information back to you.

33. Interpreting Stakeholder Group, 200933 Post Test Question 4 It is most appropriate to ask the interpreter’s opinion about cultural issues: a) Whenever you are working with a patient from a different culture. b) When you are wondering whether cultural factors are at play. c) When you are unable to get an explanation from the patient him/herself.

34. Interpreting Stakeholder Group, 200934 Post Test Question 4 c)When you are unable to get an explanation from the patient him/herself.

35. Interpreting Stakeholder Group, 200935 Post Test Question 5 Name two possible consequences when patients with LEP are not provided a qualified interpreter.

36. Interpreting Stakeholder Group, 200936 Post Test Question 5  Patients are more likely to receive intravenous hydration and to be admitted to the hospital (Hampers and McNulty 2002)  Patients are at greater risk of being discharged from the emergency department without a follow-up appointment (Sarver and Baker 2000)  Patients have more tests done creating a higher overall cost (Hampers and McNulty 2002)  Patients are more likely to be admitted to the ED (Hampers and McNulty, 2002) and to return to the ED (Bernstein et al. 2002)  Patients are less likely to use outpatient preventive services (Jacobs et al, 2001)

37. Interpreting Stakeholder Group, 200937 Q + A Please feel free to ask the facilitator any questions you have. Thanks for coming!

38. Interpreting Stakeholder Group, 200938 Supplementary Materials Shadowing and role play activities

39. Interpreting Stakeholder Group, 200939 Interpreting simulation experience The following exercise illustrates the dual- tasking challenge of simultaneous interpreting. You don’t need to speak another language to participate.

40. Interpreting Stakeholder Group, 200940 What to do The facilitator will read you an English text. As the facilitator reads the text aloud you should try to quietly repeat out loud EXACTLY what s/he says, lagging behind the original speaker by a few seconds. You should try to make your speech as smooth as possible. Again, you should repeat EVERYTHING the facilitator says.

41. Interpreting Stakeholder Group, 200941 Role-play Activity Participant 1: Interpreter Participant 2: Provider Participant 3: Patient You will be observing an improvised provider-patient interaction, in which some of the typical challenges of triadic communication (without a trained interpreter) occur. Observe this role-play and call “freeze” when you see a challenge for the provider. Then, as a group, you will need to decide how best to respond to the situation.

42. Interpreting Stakeholder Group, 200942 Role-Play Questions Which standards of the interpreting profession were not adhered to in this case? What could the interpreter, client (and perhaps the provider) have done differently to improve the communication?

43. Interpreting Stakeholder Group, 200943 Supplementary Materials: FAQs How do I know if my patient needs an interpreter? What is the difference between working with a telephonic and an in-person interpreter? Are interpreter services reimbursed? If so, how? How can my interpreters get trained? Why has the need for interpreting services occurred? What is the difference between translation and interpreting?

44. Interpreting Stakeholder Group, 200944 Identifying your patient’s language needs Some points to consider: The patient may not be able to talk comfortably about the complexities of health care even if they are proficient in ‘conversational’ English. In order to save face patients may claim to understand more than they actually do. The patient may not know that they have a right to an interpreter, or may think that they will have to pay extra for interpreting services.

45. Interpreting Stakeholder Group, 200945 Continued… It is often awkward for reception staff to ask patients about their language proficiency, and difficult for either the staff or patient to assess English language skills. A screening question such as “In which language would you prefer to receive your medical care?” can garner more accurate information than “Do you need an interpreter?”

46. Interpreting Stakeholder Group, 200946 Working with telephonic interpreters A dual handset telephone should be used for decent sound quality. Ensure you have the necessary number and, if necessary, access code(s). Minimize background noise Many of the techniques for working with in-person and telephonic interpreters are the same. For example, always speak directly to the patient. When working with a telephonic interpreter it is important to brief the interpreter by introducing everyone present in the room and stating the purpose of the encounter before starting the conversation.

47. Interpreting Stakeholder Group, 200947 telephonic interpreting continued… Telephonic interpreting can be extremely useful for short calls to and/or conversations with patients. It is certainly preferable to use a phone interpreter rather than family members, friends, or other unqualified bilinguals. The phone is not suitable for certain situations, including giving bad news, mental health, teaching scenarios requiring physical demonstration, and times when the patient cannot use the phone easily. Video interpreting technology is opening up new possibilities in the area of remote interpreting.

48. Interpreting Stakeholder Group, 200948 Interpreter Services Reimbursement: Minnesota Law 256B.0625 COVERED SERVICES Subd. 18a. Access to medical services (d) Regardless of the number of employees that an enrolled health care provider may have, medical assistance covers sign and oral language interpreter services when provided by an enrolled health care provider during the course of providing a direct, person-to-person covered health care service to an enrolled recipient with limited English proficiency or who has a hearing loss and uses interpreting services

49. Interpreting Stakeholder Group, 200949 MA Fee-for-service Policy This policy applies to Fee-for-Service MA and MnCare enrollees For enrollees of managed care plans contact the individual health plan for coverage policy Any questions contact MHCP Provider Relations (800) 366-5411 or (651) 431-2700

50. Interpreting Stakeholder Group, 200950 MA Fee-for-service Policy Providers are responsible for arranging and paying the interpreter. Providers are encouraged to use the same principles when hiring, contracting or arranging for interpreting services. Provider’s office staff members competent in spoken language interpretation may interpret the medical service and are reimbursed. Interpreter services provided to the parent/guardian when the patient is a minor are reimbursed. Providers are encouraged not to use family members and are not reimbursed if they do so.

51. Interpreting Stakeholder Group, 200951 MA Fee-for-service Policy Interpreter services provided during a covered medical service are reimbursed. Three people must be present for the service to be covered (but the interpreter can be on the phone) Bill only for direct face-to-face/video/phone service time Use HCPCS code T1013 (1 unit= 15 minutes) MHCP payment rate is the lower of $12.50, or the usual and customary charge, for each 15-minute unit Bill DHS directly for dual eligible recipients

52. Interpreting Stakeholder Group, 200952 Interpreter training opportunities Interpreting Stakeholder group www.umtia.org/isg/isg.html Program in Translation and Interpreting, University of Minnesota 612-625-0591 www.cce.umn.edu/pti Interpreting Program, Century College

53. Interpreting Stakeholder Group, 200953 Changing demographics

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60. Interpreting Stakeholder Group, 200960 U.S. Hispanic Population growth

61. Interpreting Stakeholder Group, 200961 ‘Interpreter’ or ‘translator’? Interpreting The conversion of spoken messages from one language to another Translation The conversion of written messages from one language to another

62. Interpreting Stakeholder Group, 200962 One job, three modes Consecutive Interpreting The interpreter interprets AFTER you have uttered a sentence of a few sentences Simultaneous Interpreting The interpreter interprets while you continue to talk. The interpreter may lag a few seconds behind you in order to understand the message as fully as possible before interpreting. Sight translation The interpreter converts a written message in one language into an oral message in another language