Addressing language barriers and improving quality of transitions and discharge

Abstract

The article by Rayan et al., “Transitions from Hospital to Community Care: the Role of Patient-Provider Language Concordance”, highlights the importance of language-concordant communication and care during the hospital discharge process. These findings are completely in line with previous research on the impact of language barriers on quality of care. We strongly agree with Rayan et al. and the findings of this important research, and support efforts that help meet the cultural and linguistic needs of patients. Undoubtedly, patient–provider language concordance during the hospitalization discharge process and post discharge follow-up have important implications for health care transitions, quality, and costs. How can hospitals improve their performance in this area? Based on extensive research, there are currently two major hospital guides that were developed in the United States that focus on this area—improving communication and care for patients of diverse backgrounds and with language barriers. One, Project RED—or Re-Engineered Discharge, and the second, Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals, both aim to address these challenges. If we are to truly delivery high-quality, safe, cost-effective care, meeting the needs of patients who experience language barriers during health care will be essential as global migration and diversity increases every day.

The article by Rayan et al., “Transitions from Hospital to Community Care: the Role of Patient-Provider Language Concordance” [1], highlights the importance of language-concordant communication and care during the hospital discharge process. This multi-method prospective study of care transitions of 92 patients demonstrated that language concordance between providers and patients was associated with higher Care Transition Measure (CTM) scores. The CTM allows patients to rate the discharge process, including their understanding of how to manage their health, how their preferences have been taken into account, and whether they understand their medication treatment. In sum, if the provider and the patient spoke the same language—or were language concordant—the patient had a better understanding of the key aspects of his/her discharge, as highlighted by their higher CTM score. One can therefore assume from these findings that patients with lower CTM scores would be more likely to have complications after discharge—and potentially be readmitted to the hospital—than those with higher scores. In this study, unmet language needs put patients at higher risk for these untoward outcomes.

These findings are completely in line with previous research on the impact of language barriers on quality of care. Countless studies have demonstrated that when language barriers aren’t addressed, low quality, unsafe, costly care is commonly the result. For example, when compared to their English-speaking counterparts, patients with limited-English proficiency (LEP) in the United States have longer hospital stays for the same clinical condition [2]; are at greater risk of intravenous line infections, surgical infections, falls, and pressure ulcers [3]; and have a higher likelihood of being readmitted for chronic conditions such as congestive heart failure. These complications are no doubt due to patients having difficulty navigating their hospital stays, as well as problems understanding how to manage their condition once they are discharged (including how to take their medications, and understanding which symptoms should prompt a return to care or follow up) [4–7].

As the US pursues value-based health care contracting and implements health insurance expansion [8], efforts to improve care transitions and the discharge process have taken center stage. For example, as part of health care transformation, hospitals are now subject to financial penalties for patients who are readmitted within 30 days of discharge for conditions such as acute myocardial infarction, congestive heart failure and community acquired pneumonia. Interestingly, a review of the latest round of hospital readmission penalties demonstrates that hospitals that serve vulnerable, minority and limited-English proficient patient populations were the most heavily penalized and most impacted financially by this policy [9–11]. It is widely understood that these findings were explained, in part, by the higher proportion of patients who experience language barriers and receive care at these hospitals.

We strongly agree with Rayan et al. and the findings of this important study, and support efforts that help meet the cultural and linguistic needs of patients. Undoubtedly, patient–provider language concordance during the hospitalization discharge process and post discharge follow-up have important implications for health care transitions, quality, and costs. It should come as no surprise that when providers speak the same language as their patients, they can tailor their explanations to meet patients’ needs and prevent misunderstandings. In the absence of provider-patient language concordance, trained interpreters are essential to meet the needs that emerge when language barriers are present. This is especially important in very critical health care scenarios where clear communications are key, such as discharge instructions. Furthermore, programs that train the health care team to be more culturally competent—skilled at understanding, communicating with, and providing high-quality care to patients of diverse backgrounds—are also critical.

How can hospitals improve their performance in this area? What are the key steps they need to take to assure care transitions and an effective discharge process for all patients, including those who experience language barriers? Based on extensive research, there are currently two major hospital guides that were developed in the United States that focus on this area—improving communication and care for patients of diverse backgrounds and with language barriers. One, entitled Project RED—or Re-Engineered Discharge[12] and funded by Agency for Health Research and Quality (AHRQ) and the National Heart, Lung and Blood Institute (NIH NHLBI), is a set of 11 distinct components designed to prepare patients for discharge. Project RED, created by a research group at Boston University Medical Center, in Boston, USA, develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization rates. Project RED was adapted with a particular focus on meeting the needs of diverse populations, and provides three major recommendations, as well as strategies to implement them. The three major recommendations are: (1) hiring bilingual, bicultural discharge educators; (2) providing cultural and linguistic competence training; and (3) ensuring availability of interpreter and translation services. More detail can be found at http://www.bu.edu/fammed/projectred/index.html.

A second guide for hospitals, Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals[13], was developed by the Disparities Solutions Center at Massachusetts General Hospital in Boston, USA, and Abt Associates in Cambridge, USA. It represents the culmination of a two-year, comprehensive research project funded by AHRQ focused on how to better identify and prevent medical errors in patients who experience language barriers. The Guide identifies certain high-risk clinical scenarios where language barriers can significantly compromise care. These include medication reconciliation, informed consent, emergency department care, surgical care, and most relevant to this discussion—patient discharge. Similar to Project RED, this Guide recommends that the management of these high-risk scenarios should (1) require the presence of a qualified interpreter; (2) provide translated materials; and (3) use teach-back (where the patient restates what they’ve understood) to confirm patient understanding. The Guide is accompanied by a TeamSTEPPS® Training Module that teaches health care teams a set of behaviors and structured communication tools designed to reduce medical errors in patients with language barriers. This includes, for example, guidance on how to incorporate the interpreter as part of team-based care during a high-risk scenario such as patient discharge. The Guide and Training Module can be found at http://www.ahrq.gov/legacy/teamsteppstools/lep/. These are but just two guides that provide practical, actionable strategies to improve communication and care of patients with language barriers during such critical situations such as patient discharge.

In summary, the article by Rayan et al. highlights the importance of addressing language barriers in care, and sets the stage for the use of innovative solutions such as Project RED and Improving Patient Safety Systems for Patients with Limited English Proficiency: A Guide for Hospitals, among others. If we are to truly deliver high-quality, safe, cost-effective care, meeting the needs of patients who experience language barriers during health care will be essential, as global migration and diversity increase every day.

Authors’ information

Joseph Betancourt, MD, MPH, is the Director of the Disparities Solutions Center.

Aswita Tan-McGrory, MBA, MSPH, is the Deputy Director of the Disparities Solutions Center.