Innovative Strategies to
Improve Access and Quality
of Care to Individuals with
Limited English Proficiency
Doris F. Chang and Roberto Lewis-Fernández
The New York State Psychiatric Institute
Center for Excellence in Cultural Competence
Presented at the Behavioral Health Care Reform and Culturally Competent Care: A Closer Look conference February 28, 2014
Session Outline
1.  Language and Cultural Factors and
Disparities in Mental Healthcare
2.  Improving Access and Quality of Care:
Rethinking the Role of Interpreters
3.  Developing a Client-Centered, Culturally
Grounded Model of Interpretation: A pilot
study
Background and Significance
•  Increasing cultural and
linguistic diversity of the
United States
•  Limited English
Proficiency (LEP)
–  individuals who “have a
limited ability to read,
speak, write, or
understand English at a
level that permits him or
her to interact effectively”
with healthcare providers.
–  65% of immigrants from
Latin America and 47%
from Asia
Language and Cultural Factors Contribute
to Mental Healthcare Disparities by
Limi$ng Access to Treatment •  Only 13% of hospitals met all 4 of the language-­‐
related CLAS standards Impac$ng U$liza$on of Services •  LEP individuals underu$lize MH services •  Delay seeking help •  Have higher dropout rates •  Are less likely to receive language-­‐
intensive services Reducing Quality of Care •  LEP individuals par$cipate less in treatment decisions •  Report lower levels of sa$sfac$on and poorer treatment outcomes •  Report problems in the pa$ent-­‐provider rela$onship SOURCES: Baker, 1996; Baker, Hayes & For$er, 1998; Bauer & Alegria, 2010; Camarota, 2007; Eytan, Bischoff, Rrustemi et al., 2002; Fernandez, Schillinger, Warton, Adler, Moffet et al., 2011; Gandhi et al., 2000; Jacobs, Chen, Karliner, Agger-­‐Gupta, & Mutha, 2006; Kim et al., 2010; Manson, 1988; ; Marcos Uruyo, Kesselman et al., 1973; Moreno & Morales, 2010; Price & Cuellar, 1981; Sentell, Shumway, & Snowden, 2007; Stuart, et al., 1996) Bridging the Gap: The Role of Interpreters
•  Professional interpreters can play
an important role in addressing
these inequities. (Bauer, 2010;
Flores, 2005)
–  JCAHO, National Standards on Culturally and
Linguistically Appropriate Services (CLAS)
Use of Professional Language Interpreters:
ü  Results in fewer interpretation errors compared to ad hoc interpreters
ü  Reduces frequency of adverse events related to communication
errors (Divi et al., 2007)
ü  Improves client satisfaction (Flores, 2005)
Interpreter Roles
Neutral/
Unobtrusive
Active/
Involved
•  Conduit: Interpreter as a neutral “translation
machine”; goal of accurate and complete interpretation
with no additions or omissions.
Interpreter Roles
Neutral/
Unobtrusive
Active/
Involved
•  Conduit: Interpreter as a neutral “translation
machine”; goal of accurate and complete interpretation
with no additions or omissions.
LIMITATIONS: Does not address
–  Cultural barriers to patient engagement, treatment
adherence, and retention
–  Limitations of provider cultural competence
–  Ruptures and misattunements in the patientprovider relationship
Interpreter Roles
Neutral/ Inobtrusive •  Conduit: Interpreter as a neutral “translation machine”;
goal of accurate and complete interpretation with no
additions or omissions.
•  Clarifier: Elicits clarifying information prior to message transfer
and explain words or concepts that have no linguistic equivalent
•  Cultural Broker: Adds information regarding patients’ social
environments and cultural expectations to help bridge
communication gaps between patient and provider.
Active/
Involved
•  Client Advocate: Acts on behalf of the client to ensure quality
of care, including helping the client make more informed clinical
choices
Cultural brokering
•  Professional interpreters are
ideally positioned to serve as
cultural brokers
•  May help to improve the
patient-centeredness of care
•  by facilitating a contextual and
cultural understanding of the
patient, and addressing cultural
misunderstandings when they
arise.
•  However, conceptual models and best prac$ces for cultural brokering are currently lacking (Tribe, 2009). Improving Access and Quality via
Remote Video Interpretation
Benefits:
•  Takes less time than in-person methods
without reducing user satisfaction
•  Improves quality of interpretation
•  Improves communication: Incorporates
nonverbal behavior to foster understanding
•  Enhances collaboration between patient, interpreter, and provider
•  May facilitate the development of the triadic alliance
Pilot Study Aims
1.  Operationalize the cultural brokering function of
interpreters
2.  Develop in-session procedures to support
interpreters’ ability to adopt more active roles to
facilitate cross-cultural understanding and the
development of the patient-provider working
alliance
3.  Explore the initial feasibility and acceptability of a)
more active interpreter involvement and b) webbased video interpretation from the perspective of
patients, interpreters, and clinicians
Procedures
Par$cipants •  N= 35 LEP pa$ents (16 Spanish, 19 Chinese monolingual) •  6 English monolingual clinicians •  10 interpreter-­‐
brokers Clinical Assessment Post-­‐Session Debriefing •  English-­‐speaking clinician •  Video-­‐
interpreta$on •  Pre-­‐ and Post-­‐
session mee.ngs •  Individual post-­‐
session interviews with pa$ents, clinicians, interpreter-­‐brokers •  Working alliance; Client Sa$sfac$on •  Community partners/Clinic Sites: New York
Presbyterian Hospital and Hamilton Madison
House
Training Period of Interpreter-Brokers:
Communicative Goals
Goal # 1: Bridge
communication between
the clinician and client
(linguistic/cultural)
Goal # 2: Facilitate the
establishment of a strong
working relationship
between clinician and
client.
Analysis
•  A working model of the cultural brokering function was
developed in an iterative fashion, with findings used to
inform the structure, procedures, and brokering
strategies implemented in subsequent sessions.
•  Session videos viewed by coders (4-8) to identify:
1. 
2. 
3. 
4. 
communicative and interpersonal processes
linguistic and cultural knowledge
skills needed to effectively perform as a cultural broker
examples of effective brokering and missed opportunities/barriers to
brokering
•  Confirmation of themes and categories via separate review of
session transcripts by pairs of coders and group discussion
•  Thematic analysis of debriefing interviews
Results:
Model of the Cultural Brokering Function
A. Providing Cultural Information
1.  Explaining, providing context for “hinge words”
2.  Helping client to understand what the clinician was asking, or
helping clinician elicit key concerns and symptoms
B. Highlighting the Need for Clarification
3.  Clarifying the clinical significance of what the client was saying
4.  Clarifying the cultural and personal significance of particular
aspects of the client’s history
C. Promoting the Therapeutic Alliance/Relationship
5.  Promoting trust and a strong bond with the clinician
6.  Repairing (or attempting to repair) ruptures in the therapeutic
relationship due to cultural or communication factors
A. Providing Cultural Information
1. Providing Context for “Hinge Words”
•  Words with multiple meanings both within and
between ethnic and cultural groups.
•  “...pero ahora ya yo tengo más diplomacia y yo me
se controlar más y yo quiero tratar de echar para
adelante. Vamos a ponerlo de esa manera.”
•  “She's learned diplomacy and she's able to control
herself a great deal. Control is a key word in this
population as well, in terms of mental health, in
general.”
Case Illustration (Spanish)
Clinician (C): And what is the main problem that you got the treatment for?
Interpreter-broker (I-B): ¿Cuál es el problema principal por el que usted recibe
tratamiento?
Patient: Realmente, son muchos pero el principal es ataques de pánico,
ansiedad.
I-B:
In reality, there’s many problems but the main one is panic attacks and
anxiety. Panic attacks have different meanings, it could be just stress and the
same for anxiety it may not necessarily be anxiety, so you may want to
explore that.
C:
Thank you. So, can you describe what you mean when you say panic
attack?
A. Providing Cultural Information
2. Helping client to understand what the clinician is
asking, or helping clinician elicit key concerns and
symptoms
•  Broker: “She gives two symptoms in a rather descriptive way. She
says that one is like you imagine an orange that you squeeze
‘cause it’s really sweet and that’s how I feel in my chest. I
suppose she means squeezed rather than the feeling of eating
an orange. And the other is, you know how when you’re in Santo
Domingo at night, if there are a lot of crickets, I hear that in my
ears and that also happens a lot and it bothers me.”
•  Later in interview, the clinician refers to “chest tightness” and
“ringing in ears,” suggesting he has grasped the clinical
significance of these impressionistic symptom descriptions.
B. Highlighting the Need for Clarification
3. Clarifying the clinical significance of what the
client is saying
Client: My “brain power” [nao li] wasn’t good.
Broker: “…it can mean a lot of things. Brain power, energy,
concentration, alertness…I kind of know what he means,
his cognitive abilities, he felt tired, he feels that his brain
doesn’t work as good….but this may need clarification.”
B. Highlighting the Need for Clarification
4. Clarifying the cultural and personal significance of
particular aspects of the client’s history
Broker explained that when the client was talking about his
wife, he was talking about events that occurred during their
dating history. The broker wanted to make sure the clinician
knew that at that time in China, family arranged marriages
were quite common.
C. Promoting the Therapeutic Relationship
5. Promoting trust and a strong bond with the
clinician
•  Broker: “I just reminded him [client] to look at you instead of
looking at me while he's talking.”
•  Broker notices the client is looking at him instead of at the
clinician. Broker says to clinician: “If I may, I will remind her
to speak to you rather than to me.”
C. Promoting the Therapeutic Relationship
6. Repairing (or attempting to repair) ruptures in the
therapeutic relationship due to cultural or
communication factors
•  Broker eventually intervenes after clinician repeatedly tries
to move on, saying “He hasn't finished his story.”
•  Broker: “I just translated to her, asking if it is okay if you can
ask some questions because I know she's been talking a
lot.”
Results: Feasibility and Acceptability
More Active Interpreters
•  Feasibility: Training Needs of Interpreters
–  Clinical and cultural significance of patient disclosures
–  How to intervene once cultural or linguistic misunderstandings
are identified
•  Acceptability
–  Patients rated the approach as “helpful” to “very
helpful” (mean= 3.64 [SD=.78] on a scale from 1-4).
–  Spanish-speaking patient: “I get panic attacks if I feel someone
is judging or ridiculing me and she [the interpreter] explained [to
the doctor] the values I was raised with so he wouldn’t think
Latin America is full of ignorant people. She helped me 100%.”
–  Feedback from clinicians and interpreters
Results: Feasibility and Acceptability
Web-based Video
•  Feasibility:
–  Technical challenges in 37% of cases
•  Acceptability:
–  Ratings of comfort using web-based video during the session
were very high among patients (mean=3.59), clinician (mean=
3.60), and interpreters (mean=3.71), as were ratings of comfort
if continuing to receive interpreter services for ongoing
treatment.
–  One Spanish-speaking participant noted that even though she
did not have an email account and does not use computers, “it
felt just like having the interpreter in the room.”
Revised Model: WINS (Web-based
Interpreter-Negotiated Services)
1.  Reframes the interpreters’ role and targets
gaps in knowledge and skills
2.  Trains patients, clinicians, and interpreters
in triadic communication and collaboration
3.  Alters the session structure to assess and
address barriers to patient-centered care.
Project Team
Investigators: Roberto Lewis-Fernández, Doris F. Chang, Ph.D.
Consultants: Elaine Hsieh, PhD (University of Oklahoma),
Wilma Alvarado-Little, M.A., MSW (University of Albany,
SUNY)
Research Assistants: Iris Abreu, Linh An, Rebeca Aragón, Andel
Nicasio, Madeline Tavarez, Jon Dimond, Keri Duffy, Flora
He, William Somerville, Monica Thomas, Paula Yiu.
Funding support provided by the New York State Office of Mental Health
and institutional support from the NYS Psychiatric Institute and the New
School for Social Research