Language Access Equity: A Roadmap for Improving Care for Language-Minority Patients

Disclaimer: The views presented here are of the authors and do not necessarily reflect the views of United Hospital Fund, its staff, or its board of directors.

Growing up as teenagers in our respective immigrant households, we both embraced the many joys as well as challenges of navigating everyday life in English and our first language. That experience included accompanying family members to medical appointments and emergencies. However onerous a responsibility, being a family interpreter carried a certain degree of bittersweet satisfaction—from putting our budding English fluency to work to realizing that we had become indispensable to our parents and grandparents at their most vulnerable moments. 

Like many child interpreters, we held an implicit expectation that this role would be temporary and that the language barrier would eventually dissipate. This optimistic view was buoyed by the general belief in progress and the upward trajectory of the immigrant narrative. Naturally, we were oblivious not only to the negative effects that could result from parent-child role reversal— or the hazards of compromised patient-provider communication on our family members—but also the enormous societal costs of the language barriers at the systemic level. 

LANGUAGE GAP AS A POPULATION HEALTH BURDEN

A growing body of research reveals that, compared to the general population, patients with limited English proficiency (LEP) experience 20 percent longer emergency department visits, 4.3-day longer hospitalizations, and 30 percent higher readmission rates. In addition to the costs incurred by health systems as they struggle to deliver equitable care, the population health burdens affect 2.5 million people in New York State alone, 1.2 million of whom are enrolled in Medicaid, Medicare, or both. To put these numbers in perspective, the population of New Yorkers who suffer from diabetes stands at approximately 2 million. If these barriers gravely harming patient health were tackled as a chronic condition, successfully eliminating the language gap would be tantamount to eradicating a major chronic disease. 

Note: Figures in table include hyperlinks to their source.

What we had also underestimated was the intractable nature of the language gap, which has grown wider and more complex as the number of languages and dialects spoken has increased. The COVID-19 pandemic has only further exacerbated the health disparities that have afflicted marginalized populations for decades. Now more than ever, we need a paradigm shift to tackle this persistent barrier to care that affects 26 million people nationwide and to elevate language access to the higher plane of health equity. 

Compelled by recent reports of disparities in care for language-minority communities, we are joining forces in our present-day roles—Helen as a health care leader and CEO of Elmhurst Hospital, and Bill as a health-tech entrepreneur and CEO of Canopy Innovations, Inc.—to reenvision the LEP patient experience by transforming language service operations. 

ACTION PLAN FOR REINVENTING LANGUAGE ACCESS

Building on the NIH-supported work at Canopy and extensive stakeholder needs assessment at Elmhurst and other facilities, we have devised an action plan for reinventing language access to achieve this equity-driven vision. Some of the steps include: 

• Invest in your organization's multilingual talent. We are rolling out a continuing education course to promote staff awareness of federal and local regulations about language access and acquaint staff with facility-specific practices (e.g., protocol for accessing vendor-supplied interpreters vs. Qualified Bilingual Staff, translated documents, and technology-enabled language tools). We’re also launching an e-learning platform for interested staff members to develop bilingual fluency in medical Spanish and other target languages. A corresponding proficiency exam and credentialing program will be implemented to give qualified employees due recognition for their bilingual skills. 
• Maximize reusable language resources and reserve interpreters for complex, non-routine patient encounters. Besides pre-translated documents and wayfinding signage, reusable assets, such as multilingual explainer videos, interactive voice response (IVR) calls, and in-language texts and emails, will be made available. The use of medical interpreters, while the gold standard, currently reaches only one in every three LEP patients, thus representing an insufficient and costly option that quickly exhausts a hospital’s language operations budget. To effectively deploy this valuable and scarce resource, we plan to implement a triage system that routes requests for interpreters based on predefined factors and optimally balances the use of vendor-supplied interpreters and in-house, verified bilingual talent in a way that is minimally disruptive to their primary job responsibilities. To the extent practicable, interpreter calls will be prescheduled for patients in order to avoid reactive scrambles and long wait times for interpreters.
• Monitor and analyze language access metrics as a part of overall Diversity, Equity, and Inclusion (DEI) performance. Elmhurst is working with Canopy to develop a comprehensive Language Access Dashboard to track the utilization of the above-mentioned resources and tools, compare performance between departments/sites for serving language-minority patients, and tie language accessibility to patient care quality indicators such as 30-day readmission rates and length of stay. A Language Accessibility Index will be developed as the yardstick for gauging success and progress.

Elmhurst’s overall plan is for an innovation partner such as Canopy to fully manage its day-to-day delivery of language assistive services, so that its patient experience and DEI executives can be freed up to focus on the strategic priorities of connecting the dots between language services, patient outcomes, and reimbursement from New York State Medicaid and other payers.

A SYSTEMIC CHALLENGE 

While the burden of mitigating the language gap too often falls on the shoulders of patients’ family members and communities, and already over-extended health care facilities, language access presents a systemic challenge against which the state of New York should deploy much greater resources. The State Medicaid Office should convene an innovation pilot that demonstrates how language access can be transformed into a strategic driver for health equity in New York. The under-publicized and even more underutilized Medicaid matching funds provision for language services should be revamped, ideally with a value-based formula: high-performing health systems (as measured by the Language Accessibility Index) should be reimbursed at higher rates than facilities that are still improving. Those performing in the top quartile, for example, may be reimbursed 100 percent for their language assistance expenses, while those in the lowest quartile may receive a 50 percent reimbursement. Beyond interpreters provided by third-party vendors, however, reimbursement should be extended to all of a hospital’s language access efforts—including deployment of bilingual staff, delivery of pre-translated content, and utilization of technology-enabled language tools—so that investment can be steered to more sustainable resources. 

These are just a few of many possible action steps. Transforming language access is a collaborative effort, and we invite your perspectives and expertise in this process. For questions or comments, please contact us at arteagah@nychhc.org and btan@withcanopy.com. 

Helen Arteaga Landaverde is the CEO of Elmhurst Hospital. Bill Tan is the CEO of Canopy Innovations, Inc. Special thanks to Joshua Bednorz at Harvard Graduate School of Education for assisting with the iterative drafts. 

United Hospital Fund has a long history of bringing together diverse perspectives to address critical challenges in health care in New York. In the current crisis, it’s more important than ever to hear from all parts of the health care system. Today’s commentary from Helen Arteaga Landaverde and Bill Tan examines the crucial issue of language access equity in health care. – UHF President Tony Shih