How to Work Effectively With Interpreters

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How to Work EffectivelyWith Interpreters
Photo credit Billie Young from the book My Heart
is Delicious
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Workshop Goal

• To improve communication with patients with
  Limited English Proficiency by learning
  techniques for working with interpreters.

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Workshop Objectives

• At the end of the session, participants will be
  able to
• Describe the advantages for patient satisfaction
  and safety of working with a qualified
  interpreter.
• Describe the requirements for reducing language
  barriers.
• Define the relative roles of the provider,
  patient, and interpreter.

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Hold Your Breath

• 1/ What went wrong?
• In each circle on your handout describe the
  persons behavior and the role they are playing.
• 2/How could this situation have been improved?
• Turn your handout over and on the other side
  suggest better behaviors and/or an appropriate
  role for each person.

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Patients with language barriers

• Have longer hospital stays
• Make fewer visits and receive fewer preventive
  services
• Are less likely to use or return to clinics
• Score lower on health knowledge and understanding
  of diagnosis and treatment
• Are less satisfied
• Fortier, J., Bishop, D. Developing a Research
  Agenda for Cultural Competence in Health Care,
  Rockville, MD OMH and AHRQ, 2002.

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LEP patients who need, but do not get interpreters

• Are more likely to receive intravenous hydration
  and to be admitted to the hospital (Hampers and
  McNulty 2002)
• Are at greater risk of being discharged from the
  emergency department without a follow-up
  appointment (Sarver and Baker 2000)
• Have more tests done, creating a higher overall
  cost (Hampers and McNulty 2002)

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Use of trained professional interpreters was
associated with

• Lower admission rates from the ED (Hampers and
  McNulty, 2002)
• A decrease in utilization disparities for
  outpatient preventive services (Jacobs et al,
  2001)
• Reduced ED return and referral rates (Bernstein
  et al. 2002)

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In summary

• Using trained interpreters can
• Improve patients health outcomes
• Improve patients primary care utilization
• Increase patients perceived understanding of
  their care
• Increase patient and provider satisfaction
• Using trained interpreters may
• reduce medical complications
• lower the cost of care in the long run
• (Interpreter Services Workgroup report, Feb 2008)

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Requirements to use language services

• Quality health care
• Demographics increase in limited English
  proficient (LEP) clients
• Regulatory
• Federal law (Title VI of Civil Rights Act), CLAS
  Standards
• State law (Minnesota statutes)
• Accreditation mandates (JCAHO)
• Financial reduce ER use, reduce unnecessary
  admissions, decrease diagnostic test costs
• Like, R., et al. Cross-Cultural Communication
  in Health Care Building Organizational Capacity,
  HRSA and OMH, DHHS Satellite Broadcast, June 4,
  2003.

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Key ethical principles for interpreters

• Accuracy
• Confidentiality
• Impartiality
• Acting in a professional and ethical manner
• National Council on Interpreting in Health
  Care, 2004
• www.ncihc.org

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Guidelines for Working Effectively with
Interpreters

• Before the appointment
• Make sure that you are working with a qualified
  interpreter and not a family member or friend.
• Brief the interpreter on what to expect in the
  meeting, where necessary.
• Plan enough time it may take longer than an
  English-only appointment.

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During the appointment

• Expect and encourage the interpreter to avoid
  spending time alone with the patient when not
  providing language services.
• Remember that the interpreter is required to
  interpret everything said in the room curse
  words, side conversations, and irrelevant or
  repetitive comments included.
• Face the patient and talk to them directly, as if
  you both spoke the same language.

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During the appointment II

• Dont speak too fast. Pause after each complete
  thought and/or when the interpreter signals to
  you to allow for the interpretation.
• Ask only one question at a time. Dont chain
  your questions.
• Confirm understanding by asking the patient to
  repeat key information back to you.

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During the appointment III

• Be aware of the education level and/or health
  literacy of your patient in order to phrase your
  message at an appropriate level. Avoid using
  acronyms and idioms.
• You are communicating THROUGH the interpreter but
  TO the patient. Dealing with cultural differences
  and the personality of the patient is primarily
  your job, not the interpreters. Some examples of
  things to keep in mind regarding cultural and
  linguistic differences
• There may be less eye contact with the patient
  than you customarily expect
• A smile or nod on the part of the patient may not
  indicate total agreement.

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After the appointment

• Debrief with the interpreter, if necessary, about
  the communication process.

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• Questions?
• Thank you for coming!

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Objectives of Session 2

• At the end of the session, participants will be
  able
• to
• Demonstrate specific techniques for working with
  trained and untrained interpreters
• Identify the importance of using alternative
  laymans terms to explain medical terminology
• Identify core competencies they have acquired
  through a post-test activity

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Video Vignette 1

• Have you experienced a situation similar to that
  portrayed in this vignette?
• What factors from the cheat sheet distributed
  in Part 1 of this training are at play in this
  scenario?

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Video Vignette 2

• Have you experienced a situation similar to that
  portrayed in this vignette?
• What factors from the cheat sheet distributed
  in Part 1 of this training are at play in this
  scenario?

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Final vignette

• How might you implement these strategies in your
  work environment?
• What challenges might you face implementing these
  strategies?

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Post Test Question 1

• Which of the questions below would encourage
  direct
• communication with your patient?
• Please ask him why he came to see me today.
• Are you still having stomach pains?
• Fatima, could you ask her if she is currently
  taking any medications?

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Post Test Question 2

• Draw an arrow to
• demonstrate how you might
• move one of the parties out of
• this positioning in order to
• communicate as directly
• as possible with your
• patient.

INTERPRETER
PROVIDER
PATIENT
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Post Test Question 3

• If you, the provider, feel that the communication
  is
• being impeded by inaccurate interpreting, a good
• option to check understanding is
• a) Ask the patient to repeat the information back
  to you.
• b) Ask the interpreter whether they are
  interpreting accurately.
• c) Ask the interpreter if they think the patient
  understood.

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Post Test Question 4

• It is appropriate to ask the interpreters
  opinion about cultural
• issues
• Whenever you are working with a patient from a
  different culture.
• When you are uncertain what cultural factors are
  at play in the patients care.
• When you are unable to get an explanation from
  the patient him/herself.

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Post Test Question 5

• Name two possible consequences when patients
• with LEP are not provided a qualified
  interpreter.

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How might these concepts be explained in laymans
terms?

• Autism
• PTSD
• Food support
• Retrospective eligibility

• Pap smear
• Inhaler
• CAT scan
• Angiogram
• Preeclampsia

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Post Test Question 1

• Which of the questions below would encourage
  direct
• communication with your patient?
• Please ask him why he came to see me today.
• Are you still having stomach pains?
• Fatima, could you ask her if she is currently
  taking any medications?

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Post Test Question 1

• b) Are you still having stomach pains?

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Post Test Question 2

• Draw an arrow to
• demonstrate how you might
• move one of the parties out of
• this positioning in order to
• communicate as directly
• as possible with your
• patient.

INTERPRETER
PROVIDER
CLIENT
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Post Test Question 2

• Draw an arrow to
• demonstrate how you might
• move one of the parties out of
• this positioning in order to
• communicate as directly
• as possible with your
• patient.

INTERPRETER
PROVIDER
CLIENT
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Post Test Question 3

• If you feel that the communication is
• being impeded by inaccurate interpreting, a good
• option to check understanding is
• a) Ask the patient to repeat the information back
  to you.
• b) Ask the interpreter whether they are
  interpreting accurately.
• c) Ask the interpreter if they think the patient
  understood.

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Post Test Question 3

• a) Ask the patient to repeat the information back
  to you.

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Post Test Question 4

• It is most appropriate to ask the interpreters
  opinion about
• cultural issues
• Whenever you are working with a patient from a
  different culture.
• When you are wondering whether cultural factors
  are at play.
• When you are unable to get an explanation from
  the patient him/herself.

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Post Test Question 4

• c) When you are unable to get an explanation from
  the patient him/herself.

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Post Test Question 5

• Name two possible consequences when patients
• with LEP are not provided a qualified
  interpreter.

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Post Test Question 5

• Patients are more likely to receive intravenous
  hydration and to be admitted to the hospital
  (Hampers and McNulty 2002)
• Patients are at greater risk of being discharged
  from the emergency department without a follow-up
  appointment (Sarver and Baker 2000)
• Patients have more tests done creating a higher
  overall cost (Hampers and McNulty 2002)
• Patients are more likely to be admitted to the ED
  (Hampers and McNulty, 2002) and to return to the
  ED (Bernstein et al. 2002)
• Patients are less likely to use outpatient
  preventive services (Jacobs et al, 2001)

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Q A

• Please feel free to ask the facilitator any
  questions you have.
• Thanks for coming!

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Supplementary Materials

• Shadowing and role play activities

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Interpreting simulation experience

• The following exercise illustrates the
  dual-tasking challenge of simultaneous
  interpreting.
• You dont need to speak another language to
  participate.

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What to do

• The facilitator will read you an English text.
• As the facilitator reads the text aloud you
  should try to quietly repeat out loud EXACTLY
  what s/he says, lagging behind the original
  speaker by a few seconds.
• You should try to make your speech as smooth as
  possible.
• Again, you should repeat EVERYTHING the
  facilitator says.

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Role-play Activity

• Participant 1 Interpreter
• Participant 2 Provider
• Participant 3 Patient
• You will be observing an improvised
  provider-patient interaction, in which some of
  the typical challenges of triadic communication
  (without a trained interpreter) occur.
• Observe this role-play and call freeze when
  you see a challenge for the provider. Then, as a
  group, you will need to decide how best to
  respond to the situation.

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Role-Play Questions

• Which standards of the interpreting profession
  were not adhered to in this case?
• What could the interpreter, client (and perhaps
  the provider) have done differently to improve
  the communication?

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Supplementary Materials FAQs

• How do I know if my patient needs an interpreter?
• What is the difference between working with a
  telephonic and an in-person interpreter?
• Are interpreter services reimbursed? If so, how?
• How can my interpreters get trained?
• Why has the need for interpreting services
  occurred?
• What is the difference between translation and
  interpreting?

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Identifying your patients language needs

• Some points to consider
• The patient may not be able to talk comfortably
  about the complexities of health care even if
  they are proficient in conversational English.
  In order to save face patients may claim to
  understand more than they actually do.
• The patient may not know that they have a right
  to an interpreter, or may think that they will
  have to pay extra for interpreting services.

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Continued

• It is often awkward for reception staff to ask
  patients about their language proficiency, and
  difficult for either the staff or patient to
  assess English language skills.
• A screening question such as In which language
  would you prefer to receive your medical care?
  can garner more accurate information than Do you
  need an interpreter?

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Working with telephonic interpreters

• A dual handset telephone should be used for
  decent sound quality. Ensure you have the
  necessary number and, if necessary, access
  code(s).
• Minimize background noise
• Many of the techniques for working with in-person
  and telephonic interpreters are the same. For
  example, always speak directly to the patient.
• When working with a telephonic interpreter it is
  important to brief the interpreter by introducing
  everyone present in the room and stating the
  purpose of the encounter before starting the
  conversation.

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telephonic interpreting continued

• Telephonic interpreting can be extremely useful
  for short calls to and/or conversations with
  patients. It is certainly preferable to use a
  phone interpreter rather than family members,
  friends, or other unqualified bilinguals.
• The phone is not suitable for certain situations,
  including giving bad news, mental health,
  teaching scenarios requiring physical
  demonstration, and times when the patient cannot
  use the phone easily.
• Video interpreting technology is opening up new
  possibilities in the area of remote interpreting.
  

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Interpreter Services Reimbursement Minnesota Law

• 256B.0625 COVERED SERVICES
• Subd. 18a. Access to medical services
• (d) Regardless of the number of employees that
  an enrolled health care provider may have,
  medical assistance covers sign and oral language
  interpreter services when provided by an enrolled
  health care provider during the course of
  providing a direct, person-to-person covered
  health care service to an enrolled recipient with
  limited English proficiency or who has a hearing
  loss and uses interpreting services

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MA Fee-for-service Policy

• This policy applies to Fee-for-Service MA and
• MnCare enrollees
• For enrollees of managed care plans contact the
• individual health plan for coverage policy
• Any questions contact
• MHCP Provider Relations
• [phone] or [phone]

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MA Fee-for-service Policy

• Providers are responsible for arranging and
  paying the interpreter.
• Providers are encouraged to use the same
  principles when hiring, contracting or arranging
  for interpreting services.
• Providers office staff members competent in
  spoken language interpretation may interpret the
  medical service and are reimbursed.
• Interpreter services provided to the
  parent/guardian when the patient is a minor are
  reimbursed.
• Providers are encouraged not to use family
  members and are not reimbursed if they do so.

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MA Fee-for-service Policy

• Interpreter services provided during a covered
  medical service are reimbursed.
• Three people must be present for the service to
  be covered (but the interpreter can be on the
  phone)
• Bill only for direct face-to-face/video/phone
  service time
• Use HCPCS code T1013 (1 unit 15 minutes)
• MHCP payment rate is the lower of 12.50, or the
  usual and customary charge, for each 15-minute
  unit
• Bill DHS directly for dual eligible recipients

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Interpreter training opportunities

• Interpreting Stakeholder group
• www.umtia.org/isg/isg.html
• Program in Translation and Interpreting,
• University of Minnesota
• 612-625-0591 www.cce.umn.edu/pti
• Interpreting Program, Century College

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Changing demographics
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U.S. Hispanic Population growth
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Interpreter or translator?

• Interpreting
• The conversion of spoken
• messages from one language
• to another

• Translation

The conversion of written messages from one
language to another
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One job, three modes

• Consecutive Interpreting
• The interpreter interprets
• AFTER you have uttered a
• sentence of a few sentences

• Simultaneous Interpreting
• The interpreter interprets while you
• continue to talk. The interpreter
• may lag a few seconds behind you
• in order to understand the message
• as fully as possible before
• interpreting.

• Sight translation
• The interpreter converts a written message in one
  language into an oral
• message in another language