Quality Care and LEP: Sorting Through Regulatory Mandates and Suggestions and Developing Cost Effective Strategies for Compliance*

Almost every health care organization, regardless of its geographical location is serving an ever increasing number of patients who speak no or only limited amount of English. These patients are now commonly referred to as LEP or Limited English Proficient. At present, about 14% of the entire United States population speak a language other than English at home. This percentile is expected to increase steadily. The quality of patient care cannot be maintained unless health care organizations are prepared to serve these patients in their own languages.

This issue summarizes some of the governmental requirements, mandates and suggestions regarding the provision of care to patents of limited English proficient patients and then offers some practical strategies for compliance within the budgetary constraints of today's health care environment. We had also intended to include JCAHO's requirements, but were unable to reach them.

Office of Civil Rights

Many regulatory decisions regarding the provision of health and social services to limited English speaking persons were derived from the 1964 Office of Civil Rights Title VI prohibition against national origin discrimination as it affects person with limited English proficiency. OCR has defined LEP as people who "cannot speak, read, write or understand the English language at a level that permits them to interact effectively with health care providers and social service agencies." OCR found that persons who lack proficiency in English are also often unable to obtain the basic knowledge of services to which they are eligible, including the State Children's Health Insurance Program (SCHIP), Medicare, Medicaid or Temporary Assistance to Needy Families (TANF) benefits or basic health care services. They also found that professionals such as physicians, nurses, social workers, psychologists and other professionals were unable to establish the close trusting relationships and a free flow of information between themselves and their clients because of a lack of either a common language or the absence of qualified language assistance. As a result, the LEP client may be turned away, made to wait a long time until an interpreter is found, or asked to find their own interpreter. The latter violates Title VI, which states that the use of children or neighbors or strangers as interpreters should not be used since they do not provide LEP with "The equal access to federally assisted programs and activities."

The Keys to Compliance in the LEP Context

The OCR Policy Guidelines published in 2000 states that, "Although HHS recipients have considerable flexibility in fulfilling this obligation [to provide meaningful access to benefits and services] OCR has found that effective programs usually have the following elements"

1.        Assessment: the recipient entity conducts an assessment of the language needs of the populations served

2.        Comprehensive written policy on language access: accomplished through the development of a comprehensive language assistance program which includes oral language interpretation, the translation of written materials, methods of providing notice of LEP person of their right to receive language assistance without charge

3.        Training of staff: likely to have contact with LEP persons about its policies and procedures, how work effectively with in-person and telephone interpreters, and understand the dynamics of interpretation between clients, providers and interpreters

4.        Self monitoring: of the language assistance program to insure that all LEP persons have meaningful access to the program

Assistance in compliance

Contacts at a number of local offices of OCR have assured usthat they are very willing to make organizational visits to speak to groups and to make suggestions regarding how the institution can develop and or improve a language access program which complies with these mandates. They state that their goal is to assist rather than to monitor or report problems or issues faced by individual organizations.

Office of Minority Health and CLAS

In December, 2000, the Department of Health and Human Services Office of Minority Health published 14 Standards for Culturally and Linguistically Appropriate Services, commonly referred to as the CLAS Standards in the Public Register. These 14 standards are divided into three sections, Cultural Competence (Standards 1-3), Linguistic Competence (Standards 4-7), and Institutional Supports(Standard 8-14). Although Standards 1-3 and 8-14 are strongly recommended, only Standards 4-7 (Linguistically Appropriate Services) are published as mandates. This is because these standards are directly derived from the mandates listed in Title VI and the guidelines it published in 2000 (see above). They are summarized below:

Standard 4: Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.

Standard 5: Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance

Standard 6: Health care organizations must assure the competence of language assistance provided to limited English proficient patents/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services except on request by the patient/consumer)

Standard 7: Health care organizations must make available easily understood patient related materials and post signage in the languages of the commonly encountered groups or groups represented in the service area.

Implementation of the CLAS Language Access Standards

A Practical Guide for Implementing The Recommended National Standards for Culturally and Linguistically appropriate Services in Health Care by Suzanne Salimbene, Ph.D. is currently in the hands of DHHS editors and will, hopefully be published soon in both hard cover and on the OMHRC web site. The guide will be available free of charge to all health care organizations. Section 6 of this guide offers step by step assistance in the implementation of language access services.

CMS, the Centers for Medicare & Medicaid Services Guidelines for Providing Oral Linguistic Services

CMS, which handles federal funding for Medicare, Medicaid, SCHIP, HIPAA, and CLIA is also under the Policy Guidance on the Title VI Prohibition against National Origin Discrimination as it affects persons with limited English proficiency. Although the CMS Step by Step Guide to Oral Linguistic Services is intended specifically for Managed Care contractors receiving federal funding, it provides advice and information which is invaluable to any health care organization seeking to improve the linguistic access of limited English speaking populations. It includes information regarding how to identify oral linguistic needs of membership; how to assess the linguistic and cultural competence of the managed care plan; how to identify points of contact for members; options for different types of oral linguistic services; and instructions for developing an oral linguistic services plan.

As the reader can see, both the CLAS Standards and CMS Guidelines adhere to the original OCR Title IV document. However the CMS Guidelines have produced excellent tools to assist Managed Care organizations receiving federal funding actually implement the oral language access mandated by Title VI. The upcoming CLAS Guide is more general. It is directed at all health care organizations (from Managed Care to private clinics and practices) implement both linguistic and cultural competency within their various structures. Organizations may wish to consult both documents for a wider variety of options regarding how to make themselves compliant with these regulations. Inter-Face International developed a guide to implementing the CLAS Standards under contract to the Office of Minority Health. This guide is now available digitally through our organization for purchase. For more information about the Guide and see below.

* The announcement of our new digital guide: CLAS A-Z: Your step-by-step guide to implementing culturally and linguistically appropriate care and services can be found in out News & Events section. Order it by clicking on Order on Line.