Download KP-Southern California Physicians Language Concordance Program

Kaiser Permanente-Southern California
Physicians Language Concordance Program
Meeting the Needs of LEP Patients
Lakiesha Tidwell
Regional Senior Consultant
Culturally Responsive Care, SCAL
July 16, 2009
Efforts toward establishing
Linguistically Appropriate Health Care
 Overcoming Barriers
Establishing Facts
 Engaging Physicians
Developing and Implementing a
Sustainable Program
Evaluating Program Outcomes
Overcoming Barriers
 Are there real issues with limited English
proficient patients?
 Does matching clinicians and patients by
language preference make a difference?
 Do clinicians need to be tested for language
proficiency?
 Will access to appointments be affected?
 Will language concordance affect HEDIS
measurements?
Overcoming Barriers
 Recent Legislation answered many of the questions
regarding who and how LEP patients should receive
linguistic services
 Focus on quality of care
 Focus on meeting needs of growing of patient
populations
 Focus on developing a comprehensive program that
addresses access and infrastructure
 Focus on improving healthcare outcomes
Establishing Facts:
Is Limited English Proficiency really a Problem?
Internal & External Review conducted by KP Spanish Language Task Force
 Hispanic population concentrations are increasing in Southern California.
 This is not a short-term phenomenon that will disappear when everyone learns how
to speak English.
 KP SCAL Population Demographic Trends inform us that appointment demand by
LEP patients will continue to be a challenge.
 On average, 10-12% of the members in our region prefer languages other than
English. 11 Threshold Languages: Arabic, Armenian, Khmer, Cantonese, Farsi,
Korean, Mandarin, Russian, Spanish, Tagalog, and Vietnamese
 By the year 2010, 6 medical center areas will be in a service area that is over 45%
Hispanic and all but one medical center area will be in an area that is over 30%
Hispanic
Establishing Facts:
Is Limited English Proficiency really a Problem?
DKA (Did Not Keep Appt) rate
 Spanish LEP patients rate is similar to non Spanish
LEP patients when physician speaks their language
 Spanish LEP patients rate is higher than non Spanish
LEP patients when physicians does not speak their
language
Visit rate
 Spanish LEP patients rate is similar to non Spanish
LEP patients when physician speaks their language
 Spanish LEP patients rate is lower than non Spanish
LEP patients when physicians does not speak their
language
Establishing Facts:
Does matching clinicians and patients by
language preference make a difference?
Language Concordance Story II
Mrs. X is a 70 y/o Latina woman who has been a KP member in Southern California for over 10 years.
She speaks limited English and prefers to communicate in Spanish, but in the past had been
reluctant to request a Spanish-speaking primary care physician.
In early November of 2007 she noticed a painful bruise on her right foot; she thought she must
have injured her foot in some way, although she couldn’t remember how. She did not mention it
to her primary care physician during a visit later that month. In December of 2007 she decided
to request a Spanish-speaking physician and got an appointment to see him in January of 2008.
At this first visit she was able to communicate the details and symptoms associated with the
“bruise” to her new physician in her native language. Mrs. X description of her symptoms was
enough to prompt the doctor to immediately order a work-up for suspected deep vein
thrombosis. The results of the tests confirmed the diagnosis of DVT and Mrs. X started a
course of heparin and regular monitoring.
Thanks to her ability to communicate with her physician in her preferred language Mrs. X was
able to comprehend the seriousness of the diagnosis and the importance of complying with her
physician’s instructions and treatment plan. She was successfully treated for DVT and is
currently doing well.
Engaging Physicians:
Do clinicians need to be tested for language
proficiency?
 An established, accredited language assessment tool
mitigates personal and organizational liability
 Regulatory agencies will be auditing how hospitals are
providing linguistic services
 Language concordance supports equitable, quality care
for all patients
 Patients are informed of their rights to interpretive
services
 Improves communication and quality of outcomes
Engaging Physicians:
What do the experts say about language
concordance?




Language concordance is the “gold standard” in language assistance to patients. \1
Greater physician language fluency was strongly associated with positive patient
assessment of physicians’ abilities to elicit and respond to patients’ problems and
concerns.\2
Even with the provision of interpreters important errors in communication can occur. \3
Emergency Department
 Cases with interpreters…had longer ED visits and were more likely to be admitted.
 Cases without language assistance had a higher incidence and cost of testing and was
most likely to be admitted.
 Decision-making was most cautious and expensive in the absence of a bilingual
physician or professional interpreter.\4

Latinos responding in Spanish were significantly more dissatisfied with communication
with health care providers than Latinos responding in English or non-Latino whites
responding in English….less likely to feel that the medical staff listened to them, answered
their questions, or explained medications, procedures, or test results.\5
\1 Jean Gilbert, PhD, presentation to Spanish Language Task Force, 8/31/06
\2 Fernandez, et al. Journal of General Internal Medicine, 2004 Feb 19(2):167-74
\3 Flores et al. Pediatrics, 2003 Jan 111(1):6-19.
\4 Hamers & McNulty. Archives of Pediatric and Adolescent Medicine, 2002 Nov 156 (11):1108-13
\5 Morales et al. Journal of General Internal Medicine, 1999 14:409-417
Are Clinical Strategic Goals (CSGs) worse for Spanish
LEP members, making them harder to care for?
CSGs that are worse in Spanish LEP members than the general
population





Lipid Control in members with diabetes
HbA1c<=9% in members with diabetes
Colorectal Cancer screening
Antidepressant Medication Management is worse
Timeliness of prenatal care
CSGs that are better in the Spanish LEP members than the general
population
 Breast cancer screening is a little better
 Cervical cancer screening is better
 Immunizations are better
Other CSG differences are not noted because sample sizes are very
small
Spanish LEP patients have some CSGs that are better than the general
population and some that are worse. Improvements have been shown after
concordance implementation.
Developing and Implementing a Sustainable
Program
Testing
 Provide $250- stipend for taking the test (40min)
Participation
 Reward clinician for increasing the number of Limited
English speaking patients under their care
 Provide clinician with staff that speaks the same
language if have < 20% patients on panel
Monitoring
 Updating Language preference of patients for accuracy
 Panel assignments
 Ensure internal processes for capturing, updating,
and reporting data are in place
Developing and Implementing a Sustainable
Program
Program Guidelines:











No Harm to Access (ie: <14 days)
Must be feasible
Must be able to implement regionally
Have a measurable tracking system
Must be fair among specialties
Be affordable
Fair between specialty and primary care
Incentive must drive concordance
Must be patient-focused
Easy to understand and administer
Does not disadvantage monolingual doctors
Referral Guidelines
Book with first
available provider
Referral
Guidelines
Is Patient
Limited
English
Proficient
(LEP)?
Yes
Proposed Referral
Guidelines
Is
referral
for
an urgent
patient?
Is
language
concordant
provider
available
within 14
days?
Book
with
language
concordant
provider
Book with
any
available
provider
within
14 days
It is important that the program not harm access. These guidelines will help.
13
Program Outcomes
• Increased Language concordant visits from 24.6 % to
35.4% over a 1 year period (93,000 visits language
concordant)
• 50% of eligible self reported fluent physicians have
taken the assessment since programs 2008
implementation
• 86% pass rate for Primary Care and 84% pass rate for
Specialty Care
• CSGs are improving for patients with concordant visits
• Improved communication between clinician-patient thus
increase bonding rate, health outcomes and patient
satisfaction
Q&A