5 keys to understanding the LEP patients healthcare services landscape in the US

Imagine a patient who doesn’t speak English and runs into a hospital with a severe wound after a car crash. From the moment the patient enters the hospital, any delay in communication could result in a life-threatening situation. All the treatment decisions depend on interpreting, and the clock is ticking. 

Let’s suppose now that the language the patient speaks is fairly common, and there’s a person in the building who speaks that language too and offers to volunteer an interpreter. It sounds like a solution, right? But if that person doesn’t have the proper training, that intervention could rapidly become a risk for the patient’s confidentiality and safety as well. 

What are hospitals expected to do in these situations? What are the obligations the healthcare community has towards a patient with a limited ability to read, speak, write, or understand English? And what kind of solutions can be implemented for service improvement?

In this article, we’ll cover briefly and concisely the key factors involved in these types of situations, regarding its legal, social, and linguistic perspectives:

  1. The number of persons with limited English skills living in the United States is growing.
  2. The increasing diversity calls for a political approach that addresses the change of sociocultural environments.
  3. The legal framework demands federal assisted entities to guarantee their services and benefits for every person in the United States.
  4. On the healthcare system, the challenges concern an effective assessment of the local communities’ demographics and the resources of each provider to meet their needs.
  5. As communities become more diverse, the language services industry follows, creating solutions with a broader reach.
  6. Three takeaways

The number of persons with limited English skills living in the United States is growing.

Individuals aged 5 and older who have a limited ability to read, speak, write, or understand English are considered Limited English Proficient or “LEP.” The number and diversity of LEP speakers in the United States has significantly increased  in the last decades, explained by the raising of immigrant populations with a significant part coming from countries where English is not an official language. According to 2018 data, more than 25.6 million people were LEP, accounting for 9 percent of the overall US population.

Limited language proficiency is related to low health literacy, a common phenomenon that affects 40% of the US population. Among other factors as lower socioeconomic status, long-term illness or disability, and old age, a language barrier denies patients the possibility to obtain, understand, and act on health information.

According to the 2018 US Census Bureau data, the highest concentrations of LEP individuals reside in the six traditional immigrant-destination states: California, Texas, New York, Florida, Illinois, and New Jersey. Spanish is the predominant language spoken (62 percent), followed by Chinese (7 percent), Vietnamese (3 percent), Korean (2 percent), and Tagalog (2 percent). Close to 76 percent of the LEP population communicates in one of these five languages.

Socioeconomically speaking, the overall LEP population (immigrant and US-born) was less educated and more likely to live in poverty than the English-proficient population. In 2015, 45 percent of all LEP individuals aged 25 and older lacked a high school diploma (compared to 9 percent of the English-proficient population), and about 23 percent lived in households with an annual income below the official federal poverty line. 

On health-related issues, and as Glenn Flores points out, “LEP patients often defer needed medical care, have a higher risk of leaving the hospital against medical advice, are less likely to have a regular health care provider, and are more likely to miss follow-up appointments, to be non-adherent with medications and to be in fair/poor health.”

The increasing diversity calls for a political approach that addresses the change of sociocultural environments. 

The demographic impact of an increasing population with limited English skills concerns the entire social fabric and presents a series of questions about the ability of the political, economic and legal structures to adapt to this evolving scenario. 

With increased diversity, social structures and behaviors face the challenge to ensure that everyone in the nation, whether they speak English proficiently or not, has equal access to the available systems. 

The labor market, the educational system, the legal system, and the healthcare and social assistance services deal with this issue on a daily basis and constantly seek more efficient management strategies.

The legal framework demands federal assisted entities to guarantee their services and benefits for every person in the United States. 

This obligation is supported by a series of laws, national and local. In regards to language access, the cornerstones are Title VI of the Civil Rights Act of 1964 and the Presidential Executive Order 13166. 

Title VI of the Civil Rights Act of 1964 states: 

“No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.”

The purpose of this title is to prohibit discrimination. It demands police departments, hospitals, housing authorities, unemployment centers, and any program or activity that receives Federal funding to provide meaningful and equal access to its services and benefits to all the inhabitants.

In 2000, Presidential Executive Order 13166 was issued to expand the reach of the Civil Rights Act Title VI, addressing the language issue. The goal of the new norm, titled “Improving access to services for persons with limited English proficiency” is “to improve access to federally conducted and federally assisted programs and activities for persons who, as a result of national origin, are limited in their English proficiency (LEP)”.

To fulfill its objective, it requires federal agencies to “develop and implement a system by which LEP persons can meaningfully access those services consistent with, and without unduly burdening, the fundamental mission of the agency.” This means that people who are LEP should have meaningful access to federally conducted and federally funded programs and activities.

On the healthcare system, the challenges concern an effective assessment of the local communities’ demographics and the resources of each provider to meet their needs.

According to the legal framework described above, once healthcare providers accept federal funds like Medicaid payments, they are responsible for providing language access to all their patients.

The landscape on how these laws are applied varies from State to State. Some have issued one or more laws to address language access in healthcare settings, California being the State that has the most laws. Some states expand their legal framework on specific topics/areas like intake forms, abortion risks, mental institutions,  HIV documentation, etc.

Each federal department has an Office of Civil Rights (OCR). OCRs are in charge of ensuring that no discrimination occurs in their Department’s programs and they have the authority to investigate complaints related to linguistic barriers, to initiate audits and to withhold federal funds for noncompliance. 

As a response to the Executive Order 13166, the OCR issued a Policy Guidance to help healthcare providers and other federally funded programs meet their new obligations. As part of that guide, four factors were defined to help make decisions on the extent of the language services that need to be provided. Those factors are:

  1. Number or proportion of LEP persons in the community. The more people in the community who speak a language, the more language assistance there will be in that language.
  2. Frequency of contact between recipient and LEPs. The more frequent the contact, the greater the need for language services.
  3. Nature and importance of the service to the LEP. The more important the recipient’s service or program (the bigger the risk if the person can’t communicate effectively), the more likely language services are needed. That implies better timelines and quality of the service.
  4. Resources available and cost. The level of language services required has to match the recipient budget. But economic limitations must be well-substantiated before using this factor as a reason to limit language assistance. 

As communities become more diverse, the language services industry follows, creating solutions with a broader reach.

To resume the initial question on the resources that healthcare communities have for LEP patients, we need to delve into the range of language solutions at hand. The first step to select an adequate solution is to identify the languages the LEP patients speak. The second is to evaluate the key factors about the community in which these patients participate (number of LEP persons who need assistance, frequency of services, nature and importance of the services they need, and resources and costs).  

Once the data has been gathered and the situation has been assessed, it is time to select the more appropriate language solution for a successful treatment. Today, there’s a wide spectrum of strategies and resources, which varies from voluntary work to an end-to-end language service provider. 

Community volunteers. In small communities with a limited budget, the institution can benefit from the help of multilingual staff members. In these cases, it’s best to work with people who do have some level of competency in the interpreting field or consider to invest in training.

Interpreting services on-demand. For healthcare centers with a low level of LEP patients, an interpreting provider who works on-demand will be the best solution. A service that continues to grow because it’s fast and practical is over the phone (OPI) and video remote interpreting (VRI). They are normally billed by the minute and are affordable because the interpreter can be anywhere. Interpreters in these networks are HIPAA certified and they are familiar with medical terminology. For more delicate situations, where every gesture and detail is critical, in-person interpreting will be the right approach.

A full high-volume program developed by a language services provider. When the healthcare institution receives a large amount of LEP patients or a demand for multiple languages, it is recommended to select a language service provider. Signing a service level agreement (SLA) ensures lower costs and a quick and tailored response, including not only interpreting services, but also translations of forms and documents, and localization of websites, patient information leaflets (PIL), apps for patients, etc. This kind of consultative approach also covers the (often unknown) benefit of the creation of terminology bases and style guides, two linguistic resources that help to save time and costs, and optimize communication across all channels.

Three takeaways

1. The increasing number of persons with limited English skills living in the US requires the social and political structures to evolve in order to ensure access to public systems to every member of the community. To fulfill this objective, the legal framework not only must prevent discrimination but also ensure real resources to reach the non-English speakers.

2. For the healthcare providers that receive federal funding, the main challenge is to add interpreters to their clinical practices to guarantee an equal quality treatment for LEP patients. To assess the level of linguistic resources that a provider must include in their service, they must take into account the demographics of the community (number of LEP persons, languages they speak, frequency of their service requests) and the resources available to the institution. 

3. The healthcare provider can opt for various strategies to meet its community linguistic needs, in a range that goes from including community volunteers as interpreters to hiring a language service provider. Like any other global service, the language industry has evolved to create diverse and customized responses, and there are plenty of tailored solutions for every community, scope, and budget. 

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