San Mateo County Health Department Linguistic Access Study ... · improved linguistic access. This may include an annual report, with opportunity for client and employee input, community

San Mateo County Health Department

Linguistic Access Study:Summary of Model Programs & Promising Practices in Linguistic Access

mc

Prepared by Brightstar Ohlson, Gibson & Associates

2

INTRODUCTION

Many local and statewide studies on thehealth of immigrant communities haveshown that linguistic barriers contributesignificantly to poor access, misdiagnosis,and health disparities among LimitedEnglish Proficient clients. In recent years,demographic shifts in immigrant popula-tions, greater linguistic diversity amonghealth plan members, lawsuits from theOffice of Civil Rights, new state legislation,and recent findings from health disparitiesresearch have compelled many healthcareorganizations to examine and address thelevel of access and quality of care availableto Limited English Proficient clients. Inmany discussions on immigrant health, theissue of linguistic access has been identifiedby stakeholders as a primary barrier toimproving the health of LEP clients. Whilemany healthcare organizations are aware of the acute need to improve their level oflinguistic access, they face a myriad of chal-lenges, including ad-hoc policies and pro-cedures on language assistance services,limited financial and human resources, and competing organizational priorities.

Despite these challenges, models of successexist in a wide range of healthcare organiza-tions, from community-based clinics topublic health departments in both rural andurban communities. A wealth of resourcesand publications documenting exemplaryprograms and practices in linguistic accessis available from health policy organizationssuch as Diversity RX, The CommonwealthFund, The California Endowment, TheHealth Law Program, and California PrimaryCare Associates, among many others.Publications and articles from these organi-zations and many others have beenreviewed and summarized in this report.Because many excellent publicationsalready exist for specific types of healthcareorganizations seeking to improve their linguistic access, the scope of this report is broad, with the hope that the policies, practices, and guidelines outlined here willhelp healthcare organizations in San MateoCounty better meet the language needs oftheir LEP clients.

Summary of Best Practice Research: Introduction

San Mateo County Health Department Linguistic Access Study

Summary of Best Practice Research

3

This report addresses the following areas:

C Reviews of guidelines from the Office of Civil Rights

C Policies on language assistanceC TranslationC Oral language services C Program monitoring

GUIDELINES FROM THE OFFICEOF CIVIL RIGHTS ON PROVIDINGLANGUAGE SERVICES TO LEPINDIVIDUALS

WHY PROVIDE LANGUAGE ASSISTANCESERVICES?

There are many benefits to providing lan-guage assistance services to LEP clients,including better health outcomes, higherpatient satisfaction, fewer medical errors,and long term cost savings. The most pow-erful reason, however, is a legal and ethicalone. Title VI of the Civil Rights Act and sub-sequent legislation mandate that federalfund recipients provide meaningful accessto LEP clients seeking healthcare services.Failure to do so can mean lawsuits from LEP

clients or the Office of Civil Rights and lossof funding. While the wording of the legisla-tion allows a certain degree of flexibility, themessage is clear—LEP individuals cannotbe discriminated against on the basis oftheir linguistic background and are entitledto access to the same services as English-speaking clients.

THE OFFICE OF CIVIL RIGHTS GUIDELINESFOR HEALTHCARE ORGANIZATIONSThe Office of Civil Rights (OCR) issuedguidelines to help health service organ-izations that receive federal funds complywith Title VI of the Civil Rights Act. Theseguidelines represent a framework for

n A Note on Terminology

Translation refers to written materials only.

Interpretation refers to the oralprocess of converting a message in onelanguage to another language.

Oral Language Services encom-passes the use of resources such asbilingual employees and staff, as wellas interpreter services.

Summary of Best Practice Research: Guidelines from the Office of Civil Rights


4

organizations working to provide LEPclients with meaningful access to health-care. With the hope that language assis-tance services reflect both communityneeds and individual organizational capacity, the OCR guidelines are both broad and flexible. The guidelines do notreflect additional legislation or obligations,but are intended instead to clarify existing ones.

The chart below outlines the legal require-ments of Title VI and the recommendedguidelines. Health care organizations haveused these guidelines to fulfill the federal

mandate through a wide range of policiesand practices.

Note: Additional California state legislation applies to

Medi-Cal health plans. See the Resource section, General

Legal Guidance for more information.

PLANNING FOR LANGUAGE ASSISTANCESERVICESOrganizations that engage in a formalassessment and planning process oftenexperience a greater reduction in languagebarriers, than those who implement an ad-hoc or division-by-division approach.Many organizations integrate linguisticaccess into their planning efforts on cultural

THE LAW RECOMMENDED GUIDELINES

Title VI mandates that recipients of federal fundsprovide LEP clients with meaningful access tohealthcare.

C Title VI applies to all entities that receive federal funds.

C Organizations must provide free language assistance services to LEP clients.

C Recipients of federal funds cannot exclude or limit participation of LEP individuals.

C Failure to comply can result in loss of federal funding.

Source: www.lep.gov

Health service organizations should:

C Assess the language needs of the population served

C Develop a comprehensive written LEP policy to address those needs

C Train staff on this policyC Monitor compliance with this policy



5

competence or health disparities initiatives.A steering committee comprised of employ-ees, stakeholders, community leaders, andclients may be convened to oversee theplanning process. It is important to note,that organizations who successfully engageall employees in the planning process expe-rience more significant and long-lastingchanges. Many start by revisiting and revis-ing their vision or mission to incorporatethe goal of serving all clients, regardless oflanguage or ethnic background. The nextstep is to identify high priority objectivesfor both the short and long term andappoint committees and/or sub-commit-tees to oversee the implementationprocess. Community input from LEP com-munities and a review of best practicesrelated to linguistic access should be inte-gral parts of the priority-setting phase. Asstated in the OCR guidance, organizationsshould include processes to both train staffon new practices and procedures and tomonitor progress towards the goal ofimproved linguistic access. This may includean annual report, with opportunity forclient and employee input, communitymeetings, and client and employee satisfaction surveys or focus groups.

n Program Snapshot: Innovative Assessment and Planning at the County Level

In 2000, Contra Costa Health Servicesembarked on a planning process toreduce health disparities. Improved linguistic access was identified as a primary objective of this initiative. ADiversity Advisory Committee wasformed and identified increased cultural and linguistic competenceamong Health Service employees as atop priority. The organization decidedto use a cultural and linguistic compe-tence self-assessment with all staff andemployees. Led by a team of consult-ants, the county allocated time andresources to implement a multi-pronged approach, including:

1Interviews and focus groups withclients, employees, and board

members

2A three-day Diversity Futures conferences to share the results of

the assessment and attended by repre-sentatives from every division

3A Walk of Silence to display and useself-assessment results

4A process to elicit and use staff andsenior management feedback in the

strategic plan.



6

POLICY

A clear and comprehensive written policyon serving Limited English Proficient clientsprioritizes the goal of improved linguisticaccess within an organization and is oftenthe first step in planning for language assis-tance services. If upon review organizationsfind that their policies are nonexistent orout-dated, the creation of such policiesshould be undertaken with urgency. Thereare many model policies available as aresource to hospitals, non-profit healthplans, county agencies, and small familypractices seeking to update or create newpolicies on serving LEP clients. (See theResource Section at the end of this report.)The purpose of this section is to identify keyareas to include in a policy on serving LEP clients.

POLICY RECOMMENDATION: ASSESSINGTHE LANGUAGE NEEDS IN THE SERVICEAREAWhile many health care organizations havean informal sense of the language needs ofnon-English speaking clients in their com-munity, the policy should outline proce-dures for identifying the language needs ofLEP individuals. This information will beused to inform programming for languageassistance services and help health careorganizations comply with the state andfederal legislation.

Use of Multiple Data Sources inAssessment: Organizations will need toanalyze multiple sources of data to deter-mine the percentage of individuals who arelimited English proficient and not merelybilingual. Both user and population-leveldata should be reviewed, including:

C Census-level dataC Medi-Cal dataC Language line or telephonic interpreter

usage dataC Internally generated user-level dataC Community informants

The county identified key objectives toreduce health disparities through astrategic planning process thatinvolved staff, clients, and communitymembers. In addition, the county hascommitted significant fiscal andhuman resources to this initiative.

Summary of Best Practice Research: Policy


7

Because of the limitations of each of thesedata sources, it is important to use a varietyof sources. While Census and Medi-Cal dataare the primary population-level datasources, low penetration rates and a highnumber of invalid entries on the languageitem mean that some immigrant groupsmay be under-represented in the Medi-Caldata. In addition, the presence of small eth-nic and linguistic enclaves often goes unde-tected in both data sources. Communityinformants from organizations and agencieswith established relationships with immi-grant communities may alert health careorganizations to new demographic shiftsand trends. When triangulated with otherdata, internally generated user data canreveal the level of penetration amongLimited English Proficient communities.

Internal System to Track LanguageBackground of all Clients: Few health careorganizations have created procedures orsystems to internally track the languagebackground and abilities of their clients. Asa result, clients, instead of health careorganizations bear the brunt of securinglanguage assistance. The creation of suchinformation systems could go a long way

towards ensuring that each client receivesappropriate language assistance services, aswell as informing quality improvementefforts. Procedures to collect data on eth-nicity, primary language and level of profi-ciency in English of all clients should beoutlined in the policy. The following recom-mendations should be included:

C Information should be collected via self-report and should follow the Census methodology of determining LEP status. The Census asks if the individual speaks a language other than English, then asks how well they speak English. If the response is other than “very well,” the individual should be classified as Limited English Proficient. (See: http://www.census.gov/prod/2003pubs/c2kbr-29.pdf for Census questions on language ability.)

C Language background and abilityshould be recorded in the medical chart and stored in a system database. Some hospitals and clinics use color coding tabs on the medical chart to identify clients who need language assistance services.



8

POLICY RECOMMENDATION: RIGHT TOFREE INTERPRETER SERVICESFederal fund recipients are required to provide free interpreter services to LEPclients. A commitment to fulfill this man-date should be outlined in the policy. As acorollary, organizations must also providenotification to LEP clients of this right. Thepolicy should outline a variety of mecha-nisms in which notification may be given.Notification and availability of languageassistance services should be provided at all points of entry and afforded to a client’srepresentative or decision-maker in addi-tion to the client, as necessary. Some waysof providing notification include:

C Signage in the primary language(s) of LEP clients in waiting rooms and/or exam rooms

C Translated forms, including applications, medical-intake forms, and health education materials

C Recorded greetings in the client’s primary language

C Oral Notification by bilingual employees at reception or in the exam room

POLICY RECOMMENDATION: HEALTHCARE INTERPRETER GUIDELINES ANDREQUIREMENTSMany organizations have informal practicesrelated to the provision of interpreter serv-ices, which can result in long wait times,inadequate interpretation, and over-reliance on interpreter services. The policyshould offer guidelines for contracting withinterpreters, including the acceptable meth-ods of providing interpretation. The goal ofbuilding internal capacity through bilingualstaff and in-house interpreters should beexplicitly stated in the policy. The policyshould outline the following:

C Types of acceptable interpreter arrangements, such as in-person contract interpreters, bilingual staff, and telephonic interpreting

C Certification, training, and language level assessment requirements for all bilingual staff and contractors who provide interpretation

C Prohibit the use of minors as interpreters during the medical visit

C Limit the use of family members as interpreters to emergency or non-medically related situations (such as reception)



9

C Outline interpreting options for rarely encountered languages

C Outline interpreting options for emer-gency or crisis situations, including a bilingual option on the crisis telephone line

Guidelines on Situations Requiring anInterpreter or Oral Language Services:In addition, the policy should outline thesituations in which an interpreter or bilin-gual provider is required for LEP patients.Such situations include when obtainingconsent, obtaining a medical history, providing medication instructions, and anyother situations in which clear communica-tion between provider and patient isdeemed essential to the success of the visit.

Guidelines on an Acceptable Wait Time foran Interpreter: According to providers,unreasonable wait time is a primary barrierto the consistent use of interpreters duringthe medical visit. A commitment to reduc-ing this barrier should be addressed in thepolicy, with a policy statement ensuringthat clients and providers wait no morethan 30 minutes for an interpreter. Becausemany organizations have contracts with

telephonic interpreting services, this goalshould be attainable. Many strategies forstreamlining the logistics of working withan interpreter are also outlined in the OralLanguage Services section.

POLICY RECOMMENDATION:TRANSLATION REQUIREMENTS ANDGUIDELINESThe policy should outline the accreditationand certification requirements of those whoprovide written translation, as well asguidelines for determining which docu-ments need to be translated into anotherlanguage. The policy should specify the following:

C Language proficiency assessment through the human resources depart-ment or an external agency for all bilingual employees who provide translation

C A list of documents requiring translationC Protocols for contracting with transla-

tors, including certification and training requirements

C Guidelines for complying with the Safe Harbor Limits on Written Translation (See next page)



10

Organizations may consider the adoption ofstate-developed protocols on translation.The California State Personnel Board andthe Department of Health Services bothhave state adopted translation policiesmodeled after the MassachusettsDepartment of Public Health’s policies, amodel agency in serving LEP clients.

For model protocols, see: www.spb.ca.gov/BILINGUAL/

DOCUMENTS/transwrittendoc.pdf

Safe Harbor Limits on Written Translation:Threshold and Concentration Languages:The Office of Civil Right’s guidance estab-

lished the Safe Harbor limits for translationof written materials. Compliance with theseguidelines represents a good faith effort toensure linguistic access for LEP clients andcould shield organizations from regulatoryaction from the OCR. The guidance statesthat organizations must identify the mostfrequently encountered languages in theirservice area, commonly referred to as thethreshold and concentration languages. At a minimum, organizations should pro-vide translation of written materials accord-ing to those guidelines, though many usethis information to inform programming for



SAFE HARBOR LIMITS ON TRANSLATION OF WRITTEN MATERIALS

LANGUAGE GROUP GUIDELINES EXAMPLES

Threshold Each language group in the service area thatconstitutes 10% or 3,000individuals, whichever is less.

C Written materials which are provided in English should be provided in the threshold language(s).

C Vital documents, important notices, and notification of right to language assistance services should be provided.

Client InstructionsConsent formsClient rights and

responsibilitiesIntake formsHealth Education

materialsMedication instructionsSignage

Concentration Each LEP languagegroup in the service areathat constitutes 5% or1,000 individuals,whichever is less

C Vital documents should be translated at a mini-mum and notification should be provided.

Consent forms Intake formsMedication InstructionsClient instructions

Source: California Primary Care Association: Manual of Promising Practices

11

oral language services as well. The policyshould include procedures for identifyingthe threshold and concentration languagesand a requirement to comply with the OCRguidelines. (See the Translation sectionbelow for additional information.)

POLICY RECOMMENDATION: TRAININGEMPLOYEES ON SERVING LEP CLIENTSOrganizations that train staff on languageassistance services and cultural and linguis-tic competence have better client satisfac-tion, as well as improved adherence toorganizational policies. A commitment totraining staff in the following areas shouldbe outlined in the policy:

C Organizational policies on serving LEP clients.

C Legal requirements of Title VI of the Civil Rights Act and California legislation for state and local agencies

C How to access, use, and work with an interpreter

C Role of bilingual staff in translation and interpretation

C Cultural competence and cross-cultural communication with LEP clients

POLICY RECOMMENDATION: HUMANRESOURCESWhile there are many options for the provision of oral language services, themost desirable one for those with a largeLEP clientele is to hire bilingual staff andproviders. The policy should explicitly outline the priority of attracting and retaining bilingual providers and staff.Policies on recruitment, language testing,and pay differential for bilingual staffshould also be included here.

The Role of Bilingual Staff: Many bilingualemployees perform informal translationand interpretation, without appropriatetraining in these areas. Rarely are theseduties included in the job description. The policy should formalize the role of bilingual staff by requiring that all transla-tion and interpretation duties be includedin their job descriptions. A commitment toprovide appropriate training and time tofulfill these duties should be articulated as well.



12

POLICY RECOMMENDATION: PROGRAMMONITORING AND QUALITYIMPROVEMENTIn order for a language assistance programto be successful, organizations must imple-ment systems that facilitate on-going plan-ning and evaluation of programs and services. As outlined in the guidance fromthe Office of Civil Rights, organizations whoadopt a system-wide, rather than ad-hocapproach to planning and evaluation havesignificantly reduced linguistic barriers to care. The policy should include the following:

C Identification of a point person, position, or committee responsible for coordinating and monitoring language assistance services.

C A range of procedures and practices for program monitoring, including an annual review, cost analysis, review of utilization and population-level data, client and provider satisfaction surveys and/or focus groups.

Assessing Need for Services: The policyshould also outline procedures for deter-mining the need for language assistanceservices in each program or service area.

The following criteria, drawn from theOffice of Civil Right’s guidance to healthcare organizations, should be used to make such determinations and included in the policy:

1Demographic Data: Organizationsshould review this data and seek to provide language assistance services in languages that are most frequently spoken by LEP clients.

2Frequency of Encounter: The higherthe frequency of contact with LEPgroups, the great the need for language assistance services. However, organiza-tions should rule out low penetration rates in immigrant communities or other language barriers if a program or service has low utilization rates among LEPclients.

3Importance of Encounter: The level ofimportance of the service or program being offered should be weighed when determining whether or not language assistance services are needed.

4Resources: Organizations will want toknow the language abilities of current



13

staff, available resources for language assistance services and cost of providing oral language services for a given service or program.

The results of each assessment can be usedto inform hiring and programming efforts.For information see: http://www.hhs.gov/ocr/lep/revisedlep.html

Sources: “Providing Health Care to LEP Patients: A Manual of

Promising Practices.” California Primary Care Association.

“Guidance on the Prohibition Against National Origin

Discrimination as it Affects Persons with Limited English

Proficiency.” Department of Health and Human Services.

“Straight Talk: Model Hospital Policies and Procedures on

Language Access,” Safety Net Institute.

LANGUAGE ASSISTANCE SERVICES

Language assistance services include anymechanism which reduces language barri-ers and facilitates LEP client’s access tohealth care. While language assistance hastraditionally referred to translation andinterpretation, signage, bilingual staff andemployees, the availability of translatedforms, proficient bilingual providers, andwell qualified interpreters all affect the

quality of the clinical encounter for the LEPclient and should be considered as well.Leaders in serving LEP clients have notedthat a holistic, rather than ad-hoc approachis more effectively reduces language barriers.

PROMISING PRACTICES INTRANSLATION OF WRITTENMATERIALS

While translation of written materialsseems like the most straightforward com-ponent of a language assistance program,the quality of translated materials cansometimes prevent LEP clients from receiv-ing adequate health care. Materials areoften translated on an ad-hoc basis by bilin-gual staff whose written abilities in the tar-get language have not been assessed. Thewritten materials produced by translationservices often fail to reflect the vernacular,dialect, and literacy level of the target audi-ence. When materials are poorly translated,the original meaning may not be communi-cated, clients may complete forms inaccu-rately, and client education materials maygo unread. Some health care organizations

Summary of Best Practice Research: Language Assistance Services, Promising Practices


14

have met these challenges by adoptingmore in-depth processes for translation sothat the translated written materials consistently reflect the intended meaning,as well as the cultural, linguistic, and educa-tional background of their LEP clients.

Policy on Translation: The first step toaddressing ad-hoc translation of materials is to develop a comprehensive policy on the protocol for translating materials. Thepolicy should include:

C A plan for translation of materials. Plan should include the identification of a person or position within the organi-zation who is responsible for coordin-ating translation

C A method for identifying threshold and concentration languages

C A list of materials which require translation

C Credentialing or certification require-ments of all translators

C Language-level assessment for bilingual staff who provide translations

n Promising Practice: State and Local Standards for Translating Spanish Materials

In the last decade, the state of NorthCarolina has seen its Latino populationincrease by more than a third. In aneffort to improve the quality of trans-lated materials, the Department ofPublic Health developed standards forthe translation of Spanish materials forlocal and state agencies. The impor-tance of culturally appropriate andgrammatically correct publications is clearly articulated in this guide. Inaddition, the publication is reader-friendly and accessible, with many useful examples and recommendationsfor improving the quality of writtentranslation. The guide includes:

C Standards for creating culturally and literacy-level appropriate written materials in Spanish

C Steps for ensuring accurate and grammatically correct publications

C Guidelines for complying with state policies and legal mandates

C Tips on contracting with a transla-tor, including a sample application and interview form

Summary of Best Practice Research: Promising Practices in Translation of Written Materials


15

What to Translate: The OCR recommendsthe following guidelines:

C Organizations should translate most materials available in English into the threshold language(s) in their service area.

C Vital documents should be available in concentration languages and commonly encountered languages.

Use of Translators: While some health serv-ice agencies may have the internal capacityto translate materials, most contract withoutside agencies. Unfortunately, no nationalor statewide standards exist for translators.Several organizations offer credentialingand certification for translators, includingthe American Translators Association andThe Translators and Interpreters Guild.Diversity RX and the State of CaliforniaDepartment of Personnel recommend thathealth service organizations follow theseguidelines:

C Use a certified or credentialed translator with staff trained in medical translation.

C Use at least two translators to complete the translation

C Discuss the target audience and intend-ed reading level with the translators.

C Incorporate back translation (i.e. retrans-lation of document into English by a separate translator) to ensure accurate communication of meaning.

C Pilot the translated forms with intended clientele in a structured focus group to ensure that meaning is well communi-cated. Use feedback to make revisions.

Culturally and Linguistically CompetentTranslation: Low literacy levels amongsome LEP clients can present an additionalbarrier to care, especially if materials aretranslated at an academic level. In additionto the recommendations above, DiversityRX suggests the following:

C If feasible, develop materials from scratch based on information from focus groups conducted in the native lan-guage of the target group. Cultural norms, dialects and vernacular terms are better reflected this way.

C Involve native speakers of the dialect of the target audience in the translation of materials. Incorporate cultural knowl-edge and norms into the materials.

Summary of Best Practice Research: Promising Practices in Translation of Written Materials


16

C If the materials are translated directly from English to another language, literal translations should be avoided, with the level of detail and type of language reflective of the education and literacy backgrounds of the LEP client pop-ulations. In general, the reading levelof translated materials should be at thefourth grade.

Source: Diversity RX: “Models and Practices: Written Materials

in Other Languages.” California State Personnel Board:

“Recommendations and Resources for the Translation of

Written Documents.” Department of Health Services:

“Translation of Written Informing Materials.”

PROMISING PRACTICES IN ORALLANGUAGE SERVICES

Oral language services include the use of bilingual staff and providers, as well as in-person and telephonic interpreters. Theycan be the most expensive and challengingcomponent of a language assistance

n Program Snapshot: Introducing LEP Members to Healthcare Services

One non-profit HMO in Minnesotaserving a large number of LEP clientswith low literacy levels produced a video in multiple languages, with the purpose of orienting new members to the healthplan. The video covers many topicsthat LEP clients may be unfamiliar within regards to navigating managed care,including accessing care, medication,mental health, and preventive care.Peer educators facilitate groups wherethese videos are shown and help toanswer any questions about managedcare. In addition, many videos andtapes on health education and preven-tion have been produced as well. Source: Lovelace Clinic Foundation: Providing OralLinguistic Services: A Guide for Managed Care Plans

n Program Snapshot: The Translation Room

One small community clinic serving alarge number of Latino immigrantswith low literacy levels noticed thatintake and medical history forms werebeing completed inaccurately or leftblank. A bilingual community workerwas trained to help workers completethe forms. To minimize shame and protect privacy, the clinic instituted a“Translation Room” where the commu-nity worker helps clients fill out theforms.Source: California Primary Care Association: Manualof Promising Practices

Summary of Best Practice Research: Promising Practices in Oral Language Services


17

program, as organizations contend withworkforce shortages of bilingual staff andqualified interpreters. Insufficient or ad-hocoral language services are often the sourceof misdiagnosis, incorrect treatment, andlow penetration rates among LEP popula-tions. In order to meet client needs, manyhealth care organizations offer a range oforal language services. When developing or restructuring an oral language program,clinics and hospitals must carefully considerthe needs of their LEP clients, as well astheir own organizational capacity. The percentage of LEP clients in the servicearea, the human and fiscal resources avail-able, and types of services provided all factor into the planning and programmingof oral language services.

POLICIES ON ORAL LANGUAGE SERVICESA well defined policy on the provision oforal language services is the first step toensuring that a wide range of options areavailable to LEP clients. The policy shouldaddress the following areas:

C Identify a range of oral language ser-vices, including bilingual staff, in-person interpreters, and telephonic interpreters.

C Limit or prohibit use of minors and restrict the use of family members to emergencies or situations in which the client has declined an interpreter.

C Procedures for assessment of oral language ability. Delineate required certification/training of bilingual staff, providers, and interpreters.

C Address recruitment, training, andretention strategies for bilingualemployees.

C Outline procedures for accessing and using an interpreter, including situa-tions in which an interpreter is requiredand acceptable wait times.

C Require a bilingual option for crisis and emergency telephone lines.

TYPES OF ORAL LANGUAGE SERVICESOrganizations have several options in termsof providing oral language services to theirclients. If organizations serve a large num-ber of LEP clients, the use of bilingualproviders and staff is the most desirableoption, followed by in-person interpreters,and lastly, telephonic interpreters. Each ofthese options has its costs, benefits, andlimitations. Most organizations use a combi-nation of services to meet the language



18

needs of their LEP clients, including:

C Bilingual ProvidersC Bilingual Staff as InterpretersC In-person Interpreter ServicesC Telephonic InterpretersC Family and Friends as Interpreters

Bilingual Providers: The advantages ofemploying bilingual providers to provideoral language services are many, especiallyfor clinics and programs serving high num-bers of LEP clients. The clinical encounter ismore seamless and the cost savings are significant. Though some smaller clinicsrequire that all providers are bilingual, larger health care organizations face manychallenges in attracting and retaining a significant number of bilingual providers,including:

C A workforce shortage of qualified, bilin-gual providers. Bilingual and bicultural candidates are under-represented in the health care field.

C Poor retention strategies- bilingual and bicultural staff may feel culturally alien-ated within the larger context of an organization, especially if a commitment

to serving LEP clients hasn’t been clearly articulated.

C Competition from other health care organizations for bilingual staff.

C No procedure for assessing language level of self-identified bilingual staff. Providers possess varying degrees of second language proficiency. Some have limited knowledge of medical terminology.

C Lack of cultural competence trainings for all employees.

Addressing the Workforce Shortage ofBilingual Providers: Despite these chal-lenges, all health care organizations with anidentified threshold language should makereasonable efforts to attract and retain acadre of bilingual providers. With this goalin mind, many organizations have imple-mented the following strategies:

C Partnerships: organizations have part-nered with medical and nursing schools to attract more bilingual and bicultural candidates to the health professions and have served as training sites for residencies and internships for nurses and doctors.



19

C Assessment: some organizations have implemented language proficiency testing to assess oral proficiency and knowledge of medical terminology.

C Continuing Education: for providers with a proficient level of second lan-guage competency, some organizations pay for courses in medical terminology. Others partner with universities to train bilingual entry-level employees as nurses or mid-level practitioners.

C Mid-Level Practitioners: organizations are increasingly hiring mid-level practi-tioners, such as nurse practitioners and physician assistants with bilingual abili-ties to provide direct care.

C Trainings: organizations have offered mandatory, all-staff cultural competence training to foster a more inclusive envi-ronment for bilingual and bicultural employees.

C Financial Incentives: many organiza-tions offer a bilingual stipend, offered as an addition to the hourly rate or as a monthly stipend. Others offer a signing bonus for newly recruited staff.

C Coordination: some organizations implement scheduling systems to match LEP clients with bilingual providers.

Health plans may indicate language ability of providers in their plan directory so that LEP cients may better access bilingual providers.

Bilingual Staff: Bilingual staff (medicalassistants, administrative support staff, etc.)can play an important role in the provisionof effective oral language services, servingas outreach workers, patient navigators, orin-house interpreters. However, all toooften, bilingual employees in many organi-zations find themselves serving as informal

n Program Snapshot: Diversifyingthe Workforce

A non-profit HMO in Colorado is part ofINROADS, a national program toencourage minorities to enter leader-ship positions in a variety of fields,including those in healthcare. The HMOemploys students enrolled in pre-medi-cine, nursing, and administration dur-ing the summers while they are in col-lege and helps them gain career skills.The program supports them in main-taining high academic standing, identi-fying career goals, and completingtheir education. The HMO hopes toemploy them in the future.Source: Providing Oral and Linguistic Services: AGuide for HMOs



20

interpreters, while juggling their regular jobduties. Many health care organizations havebegun to formalize the role of bilingualemployees as interpreters, through newpolicies and trainings. In recent years, somehave trained their bilingual staff as in-houseinterpreters or created new positions forthem, resulting in significant fiscal savingsand improved quality of care. Organizationshave a couple of options for using bilingualemployees to provide oral language servic-es, including:

C In-house Interpreters: may be part--time or full-time employees whose soleresponsibility is to provide interpreta-tion. This is a more cost-effective meas-ure than contracting with interpreter services if need is high.

C Bilingual Employees with Interpreter Capacity: the employee still maintains another position, such as outreach worker or patient navigator, but has time allocated to provide interpretation. This option can work if duties are clearly outlined and staff understands the role of this type of employee.

Important practices for working with bilin-gual staff include:

C A clearly written job description, with duties well outlined. This description should stipulate that bilingual staff may only serve as interpreters if they have received appropriate training or credentialing.

C Language assessment for bilingualstaff providing interpretation. Indivi-duals have varying levels of proficiency in a second language. Knowledge of medical terminology should be includ-ed, as it is is essential for those employ-ees who provide medical interpretation.

C Interpreter training for all bilingual employees providing interpretation. Un-trained employees should not provide interpreter services. Training should address interpreting skills, medical terminology, and cross-cultural communication.

C Whole staff training on protocols and procedures for working with in-house interpreters.



21

CONTRACTING WITH INTERPRETERSERVICESIdeally, organizations should strive to buildthe internal linguistic capacity of their staff.However, when bilingual providers and in-house interpreters are unable to meet thelanguage needs of an organization, contractinterpreters, be they from a language bankor community organization, are valuableresources. Telephonic interpreter servicesare another important option, serving asback up when in-person translation isunavailable or when serving clients whospeak rare languages.

has been used to train healthcare staffacross the country in cultural compe-tence and interpreting. The curriculumcovers interpreting skills, the healthcare system, basic health concepts, cul-ture, communication skills, and profes-sional development. CCHCP has alsodeveloped a handbook for interpreters,with information about different cul-tural concepts of medicine, medicalterms, and medications.Source: The Commonwealth Fund: ProvidingLanguage Interpretation Services in Health CareSettings

n Program Snapshot: Ensuring Competency among In-house Interpreters

Many hospitals and health plans, in aneffort to cut costs and improve serviceshave developed a corps of full or part-time employee interpreters. Many hos-pitals have used the Bridging the Gapcurriculum to build the competency oftheir interpreters, providers, andadministrators. Bridging the Gap wasdeveloped by the Cross Cultural HealthCare Program (CCHCP) in Seattle, but

n Program Snapshot: Community Outreach Workers and Interpreters

In several clinics across the country,native speakers of target languageshave been trained as outreach work-ers/interpreters by community organi-zations and/or community colleges.Such employees receive training inmedical terminology, cross culturalcommunication, interpretation, andWestern and non-western concepts inmedicine. They may work half timedoing outreach or health educationand the other half providing interpre-tation during clinic appointments. Source: California Primary Care Association: Manualof Promising Practices



22

CHOOSING AN INTERPRETEREnsuring high quality interpretation is apotential barrier to care. Organizations canchoose from a variety of interpreter servicearrangements including:

C Free-lance interpreters: interpreters who are usually self-employed and charge an hourly rate.

C Interpreter services: interpreters who work for a for-profit company. The company is usually responsible for training and verification of credentials.

C Non-profit community organizations: Interpreting services are offered at free, reduced or regular rates and coordinat-ed through a non-profit language bank or other community organization. Such organizations can be of enormousbenefit to large hospitals or health plans that encounter a wide range of languages.

C Telephonic Interpreter Services: Telephonic services are useful for rarely encountered languages, for large hospitals or health plans that serve clients from a wide range of language backgrounds, or for those facing a scarcity of bilingual providers and staff.

Organizations must weigh the costs andbenefits of each of these different options,including the financial cost, level of addi-tional support, interpreter capacity, andavailability of interpreters. Organizations should also consider the following recommendations:

C Plan: develop a plan for interpreterservices, which addresses projected needs, costs and logistical support. A review of utilization data from the past year can help organizations determine what types of services are appropriate.

C Work with an Accredited Service:Work with a contractor or language bank accredited by Language Line or CHIA.

C Work with a Medical Interpreter:Ensure that interpreters have a back-ground in medical interpretation. Cross-cultural communication trainings are an added benefit.

The value of working with an interpreterservice whose employees are trained ininterpreting, as well as cultural responsive-ness cannot be underestimated. The abilityof an interpreter to understand, respect,



23

and communicate cross-cultural conceptsof health is essential to the success of themedical visit.

STANDARDS FOR HEALTH CARE INTERPRETERSThis year, the National Council onInterpreting in Health Care (NCIHC) devel-oped the first set of national standards forhealth care interpreters. In addition, theCalifornia Health care InterpretersAssociation (CHIA) recently created a set ofstandards on health care interpreting,which all of its member uphold. Clearly,familiarity and adherence to these stan-dards should be the minimum criteria forselecting an interpreter service. The stan-dards address the following areas:

C ConfidentialityC ImpartialityC Respect for individuals and their

communitiesC Professionalism and integrityC Accuracy and completenessC Cultural Responsiveness

For full description of CHIA standards see: http://www.

calendow.org/reference/publications/pdf/cultural/ca_

standards_health care_interpreters.pdf)

For NCIHC Standards, see: http://www.ncihc.org/NCIHC_

PDF/National_Standards_of_Practice_for_Interpreters_

in_Health_Care.pdf

HOW TO MAKE INTERPRETER SERVICESWORK?Health care organizations must carefullyconsider logistics and operations to ensurethat an interpreter program runs smoothlyand is well accessed. Studies show thateven when interpreter services are avail-able, they are often under-utilized becauseof lack of awareness, poor coordination, orlong wait times. Organizations should con-sider the following recommendations toimprove the quality and use of interpreterservices.

Streamline the logistics: Interpreter serviceprograms often run into logistical problems,which can discourage use and compromisequality.

C Health care organizations should imple-ment systems to provide interpreter services at all points of contact for LEP clients.

C For non-emergency situations, adminis-trative support staff should be respon-



24

sible for scheduling interpreters. Organizations may coordinate scheduling of appointments for LEP clients for select time slots when interpreters are available.

C Offer a variety of options for self-identification of language ability. Some health care organizations use “I Speak”cards in a number of languages for clients to choose from, which assists in arranging for an interpreter.

C Arrange for a variety of options for inter-preter services. If in-person interpreters are unavailable, have a telephonic option for when an unexpected need arises. Telephones, instructions, andhands-free devices in the exam room can facilitate use.

Create Incentives: Organizations haveincreased usage of interpreter servicesthrough a variety of measures:

C Awareness campaigns and trainings on the legal requirements of Title VI

C A waiver requirement for LEP clients declining an interpreter

C Documentation of the use or decline of an interpreter on the medical record or in the system database.

C Financial incentives, such as stipends, for providers who use interpreters.

services to streamline interpreter serv-ices. Some have computerized systemswhich allow for scheduling of providerand interpreter appointments simulta-neously. Others have developed con-tracts with interpreter services and lan-guage banks to ensure that inter-preters are available within 30 minutesof the request. A few programs haveadopted remote simultaneous interpre-tation, a new technology using head-sets, where interpretation is providedsimultaneously to provider and client.Source: Office of Minority Health, State ofMassachusetts: Best Practice Recommendations forHospital-Based Interpreter Services

n Program Snapshot: New Technologies, Improved Interpreter Services

The state of Massachusetts has been atthe forefront of providing effective lan-guage services in hospital settings,driven by statewide legislation focusedon reducing linguistic barriers inhealthcare. Hospitals across the statehave added new technologies and



25

Provide Appropriate Training: Staff andproviders need training on how to accessand work effectively with interpreters.Ideally, training should be incorporated intopre-existing administrative structures ormeetings. The areas to be addressedinclude:

C Organizational policies on serving LEP clients

C Health disparities research and the role of language barriers

C How to determine if an interpreter is needed during a clinical encounter. Share a list of situations in which an interpreter is required.

C How to access, arrange, and work effectively with an interpreter

C Role of bilingual staff in interpretationC Cross-cultural communication and

cultural competence training

FAMILY AND FRIENDS AS INTERPRETERSMany LEP clients rely on family and friendsto serve as interpreters. The Office of CivilRights, however, strongly discourages thispractice during clinical encounters. Familyand friends have no formal training as inter-preters, may have limited knowledge ofmedical terminology, and may provideincomplete interpretation. In addition, family dynamics may prevent a client fromcommunicating sensitive information totheir family member. Many complicationscan arise from the use of untrained inter-preters, including uninformed consent, mis-diagnosis, inappropriate treatment, andpoor health outcomes. While some clientsmay insist on using their family and friends

n Program Snapshot: Provider Incentives

A non-profit health plan in California,serving a large number of LEP clientshas implemented a stipend programfor participating providers who con-tract with interpreters. It also pays forthe cost of interpreter services. Thehealth plan has a large number ofproviders in private practice. Aprovider survey revealed that very fewoffered oral language services, thoughthey saw a large numbers of LEPclients. Most cited cost and logistics.The health plan works with a languagebank and has implemented awarenesscampaigns among its providers toincrease usage of interpreters.Source: The Commonwealth Fund: ProvidingLanguage Interpretation Services in Health CareSettings: Examples from the Field



26

as interpreters, organizations should usethe following guidelines:

C Always inform clients of their right to receive free interpreter services and inform them of the importance of using a trained interpreter.

C Allow family or friends to be present during the visit if the client prefers this arrangement.

C Have clients sign a waiver if they choose to use a family member or friend.

C Make prior arrangements for an inter-preter to be present during clinical encounter to ensure accuracy of interpretation.

C Maintain a policy prohibiting or limiting the use of minors to emergency situations.

By having other systems in place to provideoral language services, health care organi-zations can greatly reduce the reliance onfamily and friends as interpreters.

PROGRAM MONITORING ANDQUALITY ASSURANCE FOR LAN-GUAGE ASSISTANCE SERVICES

A process for monitoring quality andevaluating effectiveness is an importantpiece of any language assistance programand is usually led by a committee or individ-ual. An annual or bi-annual review shouldbe part of routine operating procedures,with data collected across all programs onutilization rates, language backgrounds, use of interpreter services, and employeelanguage abilities. Organizations will wantto know:

C Client, Provider and Interpreter Satisfaction

C Effectiveness of Current Programming and Service Gaps

C Funding Language Assistance Services

Client, Provider and InterpreterSatisfaction: It is important to gather per-spectives from clients, providers, bilingualstaff, and interpreters when assessing lan-guage assistance services. What may workfor providers may not work well for clients.It is useful to understand satisfaction levels

Summary of Best Practice Research: Program Monitoring and Quality Assurance


27

among interpreters as well, if they are used.Low levels of satisfaction, for example, mayindicate the need for more provider train-ings. Surveys and focus groups are usefulways of assessing the quality of languageservices from multiple perspectives.

Culturally Competent Evaluation:Organizations should make efforts to incor-porate qualitative methods into their evalu-ation plan. Research has shown that somecultural groups are reluctant to expressnegative opinions on a survey and that afocus group format elicits more honestopinions. In addition, the survey format haslow levels of reliability among clients withlow-literacy levels. In addition, hospitals andHMOs may consider developing a formalgrievance process for LEP clients, whichshould be adequately publicized and frequently reviewed.

Assessment of Current Programming:Programs will want to develop a process fordetermining whether documents, pro-grams, activities, or services need to beadded, reduced, or modified to improveservice to LEP clients. When assessing thelevel of language assistance services or

programs, organizations should considerthe frequency of encounters with LEPclients, the importance or nature of theactivity, staff training needs, and potentialresources or partnerships to meet the need.Periodically, organizations should reviewcensus and utilization data and/or meetwith community leaders to assess anydemographic changes in the LEP popula-tion in the service area and to determinewhether or not linguistic access hasimproved. If, for example, a review of censusand utilization data shows a significant LEPpopulation in the service area, but low penetration rates, an organization may need to address barriers to access moreaggressively.

n Program Snapshot: Community Needs Assessment

A community-health collaborative inOakland wanted more informationabout the uninsured and under-servedresidents, especially immigrants inAlameda county. The collaborative con-ducted a randomized telephone surveyin seven languages, including English,Spanish, Cantonese, Mandarin, Korean,Vietnamese, and Dari. The results of the



28

FUNDING LANGUAGE ASSISTANCESERVICESA primary challenge for large healthcareorganizations seeking to reduce languagebarriers is the cost of language assistanceservices, particularly the cost of interpreterservices. The mandate of providing writtenand oral language services has been calledan unfunded mandate by health careadministrators and policy advocates alike.The cost of interpreter services can rangeanywhere from $25–$130 an hour, withmany services, such as Language Linerequiring a one hour minimum. Hospitals,health departments, and clinics often payfor these costs out of their operating budg-et or through public and private grants.Despite recent legislation in several statesto reimburse providers and hospitals for thecost of interpreter services, the majority ofhealth care organizations must still grapple

with funding issues at an organizationallevel. Issues of funding have beenaddressed in a variety of ways, influenced inpart by the individual organization’s sizeand budget, as well as the language back-ground(s) of LEP clients. While policychanges at the state and federal levelscould significantly reduce funding barriers,at an organizational level there are fewshort-term solutions. Instead, organizationsmust focus on long-term, system-wide andcost-effective strategies to improve thelevel of access and quality of care availableto non-English speaking clients. The follow-ing recommendations are based on thepractices of health care organizations whohave met this challenge:

Plan for Language Assistance Service:Many experts in linguistic access to healthcare have noted that organizations experi-ence greater financial costs when servicesand programs are designed without a consideration of the needs of LEP clients.Competing priorities, lack of time, and lackof awareness of linguistic barriers are oftenthe source of ad-hoc practices, whereexpensive, short-term solutions are used to compensate for system deficiencies.

survey will help inform estimates forstatewide programs, guide countywidehealth priorities, and identify targetgroups for outreach efforts.Source: California Primary Care Association: Manualof Promising Practices



29

Extensive reliance on telephonic interpret-ing is one such example. Many hospitalsand large healthcare organizations haveused Language Line to meet the majority of oral language needs of their clients.Telephonic interpreting is very expensiveand is considered by many experts in lin-guistic access to be best used as a back-upsystem for rarely encountered languages oremergency situations. When healthcareorganizations engage in system-wide planning efforts for linguistic access, programming is often better informed,more coordinated across divisions, and bet-ter aligned with client needs and prefer-ences. While the upfront costs of planningmay require a commitment of funds andtime, the long term benefits and cost savings of improving linguistic access havebeen well documented. When it comes toplanning, organizations may engage in anindependent linguistic access planningeffort or integrate it with cultural compe-tence planning, strategic planning, countyplanning or health disparities reduction initiatives.

Conduct a Cost Analysis: Programs lookingto reduce funding barriers will want to

assess the cost effectiveness of current language assistance services. A review ofusage levels and costs of in-person andtelephonic interpreter services can providevaluable information about the allocation of resources, especially when viewed inconjunction with population-level data. Forexample, if an organization spends a greatdeal on contract interpreters for servicesprovided to speakers of their threshold language, they may want to consider alter-natives. Hiring and training bilingual staff to provide interpretation is often more costeffective than working with a contract inter-preter. In regards to translation, manylibraries of translated materials exist, wheredocuments are available at low or no cost. A centralized system to store and share documents can also result in fiscal savings.Organizations that strategize around maxi-mizing their use of technology, communityresources, and internal human resourcescan successfully reduce costs.

Build Internal Capacity: Small community-based clinics have modeled the benefits ofbuilding internal capacity to meet the lan-guage needs of non-English speakingclients for decades. Many small clinics



30

require that all staff are bilingual and under-go a language proficiency assessment priorto employment, resulting in a significantreduction or elimination of language barri-ers. Their ability to meet the languageneeds of their clients has elevated the levelof client trust, as well as the overall healthof the communities they serve. In recentyears, larger organizations, such as KaiserPermanente, have sought to emulate themodel of the small community-based clinic,through clinics geared to the cultural andlinguistic needs of specific ethnic communities (see below). Kaiser’sCenters of Excellence represent a respon-sive, rather than reactive approach to meet-ing the cultural and linguistic needs of theirnon-English speaking members. Buildinginternal capacity is holistic in nature, focus-ing on long-term strategies to meet clientneeds, rather than on short-term remedies.Hiring bilingual and bicultural staff is central to this type of effort, but not with-out initiatives to address the shortage ofbilingual healthcare workers and the creation of programming that is culturallyand linguistically responsive.

n Program Snapshot: Kaiser Permanente’s Centers of Excellence, Building Internal Capacity

Many large healthcare organizationslocated in urban areas face the challenge of serving members from awide range of cultural and linguisticbackgrounds. Kaiser’s Institute forCulturally Competent Care, created tobetter address the needs of its diverse clientele, developed an innovativesolution to this barrier. Building on the model of community-based clinics,which have a long tradition of provid-ing culturally and linguistically compe-tent care, Kaiser has developed six centers of culturally targeted care incommunities across the country. In SanFrancisco, Kaiser’s Center of Excellencefocuses on the specific cultural, linguis-tic, and healthcare needs of Latino andAsian members. The Center is staffedby a multidisciplinary team of doctors,case managers, and health educatorswho are proficient in the languagesand cultures of Latino and Asianclients. All staff receives training in cultural and linguistic competence.Providers receive a culturally specificprovider handbook, in which theyreceive extensive training. The centersare currently being evaluated for



31

Build Partnerships: Many healthcare organizations have developed cost-savingsolutions by partnering with other healthcare organizations, colleges and universi-ties, immigrant health advocacy organiza-tions, and community-based organizations.Such efforts are often mutually beneficialand creatively solve funding barriers andbuild internal capacity. Partnershipsbetween hospitals and colleges or universi-ties have focused on addressing work-forceshortages of licensed bilingual staff andqualified interpreters. In SouthernCalifornia, one hospital worked with a stateuniversity to recruit bilingual and biculturalsupport staff to participate in nursing train-ing programs. Another worked with admis-sions staff of nursing, dietician, and medicalprograms to strategize around recruitingand retaining bilingual and bicultural candi-dates for licensed medical professions.Other organizations have partnered with

community colleges or national experts oncultural and linguistic competence to trainbilingual staff as interpreters or to serve aspipelines for recruiting interpreters.Recently, hospitals have begun to forminterpreter pools and implement new videotechnology to improve their capacity, cutcosts, and provide more client andprovider-friendly interpreter services.

n Program Snapshot: Remote Video/Voice Medical Interpreter Bank Project San Joaquin General Hospital

Consortiums of hospitals in New York,Boston, and cities in the Midwest haveformed interpreter pools with otherhospitals in their communities, whereeach consortium pays, trains, andshares interpreters to meet the language needs of their clients. InNorthern California a group of ruraland urban hospitals have formed ahealthcare interpreter network usingremote video/voice medical interpret-ing technologies (RVVMI), instead oftraditional telephonic interpreting. The RVVMI directs calls through a callcenter to an interpreter in a roomequipped with video-conferencingtechnology. Interpreters can be located

evidence of improved health outcomesand client satisfaction among themembers they serve.Source: “Kaiser Permanente’s Centers of Excellence.”www.ckp.kp.org



32

Creating language assistance services thatare responsive to the needs of non-Englishspeaking clients takes planning, collabora-tion, and time, as well as a commitment offunds. Initiatives like the RVVMI were made

possible through the collaboration ofNorthern California hospitals and throughgrants from federal agencies, counties andprivate foundations. While some organiza-tions draw from their own operating budget, many have accessed externalresources to finance their planning and programming efforts.

CONCLUSION

While the work of improving access tohealth care for LEP individuals can seemdaunting, the costs of language assistanceprograms are offset by many long termgains- an overall reduction in unnecessarytests and procedures, more accurate medical diagnosis, appropriate levels of treatment, a reduction in health dispari-ties, and better penetration rates among historically underserved communities. Byconducting a self-assessment, developing a plan, and learning from the successes of others, organizations can embark on the journey toward providing meaningfulaccess to health care for all clients they serve.

at any network hospital and can pro-vide health care interpreting withinfive minutes to any of the participatinghospitals. Interpreters cover a widerange of languages and participate inan interpreter training course. Thetechnology has been implemented atSan Joaquin General Hospital and isbeing rolled out at other network hospitals this year, including the SanMateo County Medical Center. The benefits of the RVVMI project aremany, including:

C Reduced wait timeC Improved client and provider

satisfaction (through video-conferencing)

C Expanded capacity to handle multiple languages, including rarely encountered languages.

C Significant cost savings (interpretersare in-house healthcare interpreters and/or trained bilingual employees)

C Uniform standards for healthcare interpreting, training, pricing and governance.

Source: “The RVVMI Project” by Melinda Paras

Summary of Best Practice Research: Program Monitoring and Quality Assurance, Conclusion


33

RESOURCES

HEALTH CARE ORGANIZATIONS:The California Endowment: Funds pro-grams and research on multicultural healthand has produced many publications on linguistic access. Publications are availableon its website. www.calendow.org

California Healthcare InterpretersAssociation: An interpreter’s association inCalifornia with published standards forhealthcare interpreters. Advocates for cul-tural and linguistic competence in health-care. www.chia.ws

The Commonwealth Fund: Funds researchon multicultural health, with many publica-tions addressing issues of linguistic accessand immigrant health. Publications areavailable online. www.cmwf.org

Diversity RX: An online resource with manyarticles on cultural competence, linguisticaccess and multicultural health. www.diver-sityrx.org

LEP.gov: An online resource sponsored bythe federal government with planning tools

and guidance on how to comply with TitleVI of the Civil Rights Act. www.lep.gov

National Council on Interpreting inHealthcare: A national interpreter’s associa-tion, which recently published the firstnational standards on medical interpreting.www.ncihc.org

National Health Law Program: A nationalprogram with many publications and arti-cles on immigrant health and the legalrequirements of Title VI of the Civil RightsAct. This organization also publishes anewsletter called NHelp, addressing theseissues. www.healthlaw.org andwww.nhelp.org

Office of Minority Health, State ofCalifornia: The Office of Minority healthmaintains a list of many resources to helphealthcare organizations improve their lin-guistic access, including planning guidesand model policies. www.dhs.ca.gov/direc-tor/omh/html/language.htm

Summary of Best Practice Research: Resources


34

PLANNING RESOURCES:General Legal Guidance“Guidance on the Prohibition againstNational Origin Discrimination as it AffectsPersons with Limited English Proficiency.”Department of Health and Human Services.

“Health Care Providers’ Language AssistanceResponsibilities: Major Federal andCalifornia Requirements.” UCSF Center forthe Health Professions.

“Checklist for Developing a Limited EnglishProficiency (LEP) Plan.” National Associationof State Workforce Agencies.

TRANSLATION“California State Personnel Board:Recommendations and Resources for theTranslation of Written Documents.”California State Personnel Board.

“Developing, Translating and ReviewingSpanish Materials: RecommendedStandards for State and Local Agencies.”Suzanna Aguirre Young, State of NorthCarolina, Department of Health and HumanServices.

Community Clinics“Providing Language Services in SmallHealth Care Provider Settings: Examplesfrom the Field.”The Commonwealth Fund.

“Providing Health Care to Limited EnglishProficient Patients: A Manual of PromisingPractices.” California Primary CareAssocaition.

Hospitals“Best Practice Recommendations forHospital-based Interpreter Services.”Brunilda Torres, Office of Minority Health.

“Straight Talk: Model Hospital Policies andProcedures on Language Access.” MelindaParas, Safety Net Institute.

Health Plans and Managed Care“Addressing Language Access Issues in YourPractice: A Toolkit for Physicians and theirStaff Members.” California Academy ofFamily Physicians.

“Providing Oral Linguistic Services: A Guidefor Managed Care Plans.” by Kathryn Paez,Lovelace Clinic Foundation.

Summary of Best Practice Research: Resources


35

“Providing Language Interpretation Servicesin Health Care Settings: Examples from theField.” By Mara Youdelman and JanePerkins, National Health Law Program.

“Limited English Proficient Enrollee’s Accessto Health Plan Grievance Systems.”California Pan Ethnic Health Network.

REFERENCES

Addressing Language Access Issues in Your Practice: AToolkit for Physicians and their Staff Members.California Academy of Family Physicians and theCalifornia Endowment, 2005.

Aguirre Young, Suzanna. Developing, Translating andReviewing Spanish Materials: RecommendedStandards for State and Local Agencies. State of NorthCarolina, Department of Health and Human Services.

Bridging Cultures and Enhancing Care: Approaches toCultural and Linguistic Competency in Managed Care.U.S. Department of Health and Human Services,2002.

Chin, Jean Lau. Cultural Competence and Health Carein Massachusetts. 1999.

California Standards for Health care Interpreters:Ethical Principles, Protocols and Guidance on Roles and

Intervention. California Health Care InterpretersAssociation, 2002.

Federal Laws and Policies to Ensure Access to HealthCare Services for People with Limited EnglishProficiency. National Health Law Program and theAccess Project, 2004.

Health Care Providers’ Language AssistanceResponsibilities Major Federal and CaliforniaRequirements. UCSF Center for the Health Professionsand National Health Law Program, 2003.

Language Assistance Self-Assessment and PlanningTool for Recipients of Federal Financial Assistance. Civil Rights Division, Department of Justice.

Latino Access Study. Quality ImprovementCommittee, San Mateo County Mental HealthDepartment, 2004.

Martin, Jose. Reducing Health Disparities Initiative:Progress Report and Plan for 2005 and 2006. ContraCosta Health Services, 2005.

Mateo, Julio, et al. Providing Health Care to LimitedEnglish Proficient (LEP) Patients: A Manual of PromisingPractices. The California Primary Care Association.

McDonald, Marian. “Recruitment, Retention andTraining of Bilingual/Bicultural Staff.” Migrant HealthIssues. Monograph 9: 9-50.

Summary of Best Practice Research: References


36

Mertz, Beth. “Innovative Solutions to HealthWorkforce Shortages: Communities in Crisis.” Centerfor the Health Professions, 2002.

Models and Practices: Culturally Competent HealthServices. Diversity RX.

National Standards of Practice for Interpreters in HealthCare. National Council on Interpreting in Health Care,2005.

Ore, Peggy and Kelly Darmody. “Wisconsin Coalitionfor Linguistic Access to Health care: Resource andNeeds Assessment.” Wisconsin Area Health EducationCenter System, 2004.

Paez, Kathryn. Providing Oral Linguistic Services: AGuide for Managed Care Plans. Lovelace ClinicFoundation.

Paras, Melinda. Remote Video Medical Interpreter BankProject San Joaquin General Hospital. 2005.

Paras, Melinda. Straight Talk: Model Hospital Policiesand Procedures on Language Access. Safety NetInstitute, 2005.

Providing Language Services in Small Health CareProvider Settings: Examples from the Field. TheCommonwealth Fund: Fund Report.

Providing Linguistic Access to Limited English ProficientIndividuals. Contra Costa Health Services, 2003.

Straight Talk: Model Hospital Policies and Procedureson Language Access. California Health Care, SafetyNet Institute, 2005.

Torres, Brunilda. Best Practice Recommendations forHospital-Based Interpreter Services. Commonwealth ofMassachusetts Department of Public Health, Officeof Minority Health.

Summary of Best Practice Research: References
