1. Caring for Limited English Proficient Patients and Families Bria Chakofsky-Lewy, RN, MN bria@uw.edu April 15, 2015

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9. King County, Washington, USA, 2010 21% of our population identify as foreign born. 22% speak a language other than English at home. 150 languages are reported to be spoken by children in our public schools.

11. COMMUNICATION is an essential key to being able to provide good health care, in the ER, to a patient in the hospital, in the clinic, IN THE HOME.

12. Language congruency is usually the best option for good communication. TRAIN AND HIRE CAREGIVERS WHO SPEAK THE LANGUAGES OF THE POPULATIONS YOU SERVE.

13. When patients and caregivers don’t speak the same language, access to interpreters is necessary in order to provide safe care.

14. “The legal foundation for language access lies in Title VI of the 1964 Civil Rights Act, which states: 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.” Chen A, Youdelman M, Brooks J J Gen Intern Med. 2007 Nov; 22(Suppl 2): 362–367. Published online 2007 Oct 24. doi: 10.1007/s11606-007-0366-210.1007/s11606-007-0366-2

15. Executive Order 13166 and the Office of Civil Rights Policy Guidance “In August 2000, President Clinton drew national attention to the issue of limited English proficiency when he issued Executive Order (EO) 13166, Improving Access to Services for Persons with Limited English Proficiency.9 EO 13166 reiterates Title VI requirements for federal fund recipients and directs all federal agencies to ensure that their own programs provide equal access to LEP individuals. In response to this, OCR issued an extensive Policy Guidance to assist healthcare providers and other federal fund recipients in meeting their obligations to LEP individuals.” Chen A, Youdelman M, Brooks J; J Gen Intern Med. 2007 Nov; 22(Suppl 2): 362–367.

16. Medical interpreters are fully bilingual individuals who have been trained for the role. are familiar with medical terminology. have passed the Washington state certification examination and/or a national certification examination. subscribe to a code of ethics.

17. Family members are usually not trained as interpreters. have an important role already which can be compromised when they take the additional role of interpreter. may consciously, or unconsciously, have their own agenda, rather than adhering to the patient or caregiver’s agenda. Using non-adult children to interpret inverts the power structure in a family.

18. Medical interpreters transmit the meaning of the message from the speaker to the listener. In many cases this is not “word for word.”

19. In-person interpreter vs. phone In-person Use for initial assessment, family conferences, deaf and hard of hearing patients, patients who would be confused by the telephone. Paid by the hour Notusually immediately available Phone Use for intermittent communication Paid by the minute Often immediately available

20. The pre-conference Introduction Establish the context, nature, goal of visit. Is there cultural information that would be helpful in this encounter?

21. The encounter Be aware of positioning. Consider using speaker function on the phone. Articulate or reinforce confidentiality. Establish that anything that anyone says will be interpreted. Speak to the patient, not the interpreter. Speak in relatively short segments.

22. Post-conference Is there additional cultural information that will help me to care for this patient?

23. Avoid Medicalese Jargon Acronyms Idiomatic speech Complicated sentence structure Changing ideas mid-sentence Asking more than one question at a time

24. Remember Concepts that can be expressed briefly in English may have no linguistic equivalent in the target language.

25. “Cultural competence is defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations. “ Cross T., Bazron, B., Dennis, K., & Isaacs, M. ( 1989).

27. The fish and the monkey

28. The platinum rule Do unto others as the other would want to be done to.

29. What is culture?

30. Culture: “is the way people do things.” Antonio Guzman, Desana tribesman and anthropologist “is the way people do things.” Naomi Lewy in 8 th grade

31. Cultures Ethnicity Religion Sexual orientation Occupation Class

32. The culture iceberg Above the water: Behavior Language, customs Artifacts: clothing, food Below the water: Beliefs Values Assumptions Adapted from Benson-Quaziena and Distelhorst, 2006

33. We need to learn about the cultures of the populations we serve but “Data about the beliefs, attitudes, preferences and behaviors of groups cannot be used to predict the beliefs, attitudes, preferences and behaviors of individuals.” Blackhall, L. et al (2001) We need to learn about the beliefs, attitudes, preferences and behaviors of the individuals and families with whom we work.

34. What are our tools for assessing cultural issues? Knowledge of the cultures of the populations we serve. Reading www.ethnomed.org Cultural consultation Contact with the communities Asking patients and families. Eliciting an explanatory model. Kleinman’s questions

35. Two views Illness Client, family, community view Elicited by listening Disease Medical diagnosis Elicited by history, physical exam radiologic and laboratory tests

36. Kleinman’s Explanatory Model What do you call this problem? What do you believe is the cause of this problem? What course do you expect it to take? How serious is it? What do you think this problem does inside your body? How does it affect your body and your mind? What do you most fear about this condition? What do you most fear about the treatment? PLoS Medicine | www.plosmedicine.org 1673, October 2006 | Volume 3 | Issue 10 | e294

37. The LEARN Model Listen Explain Acknowledge Recommend Negotiate Berlin EA, Fowkes WC,1983

38. Resources Interpretation agencies Ethno Med: http://ethnomed.orghttp://ethnomed.org Cultural consultation

39. http://ethnomed.org/