Ensuring Understanding: Language-Concordant Discharge Instructions

 

Introduction

When patients are discharged from the hospital, critical health-related information is communicated to them, their family, or other caregivers in the form of written discharge instructions. As we strive to provide equitable health care for the growing number of non-native English speakers, we must examine hospital practices and policies regarding discharge instructions and how best to communicate that information to departing patients.

Hospital discharge is a transition of care that requires careful and clear communication between patient and provider. Inadequacies and failures in this transition can lead to safety issues for patients, poorer health outcomes, and additional hospital visits, which can add to health care costs.

Discharge instructions are typically printed documents, provided at the time of departure, that contain crucial information for patients and their families about post-hospital care. They normally include information about personalized activity restrictions, necessary medications, diet recommendations, follow up appointments, return precautions (specifying when patients should return to seek medical care).

Based on the 2015 U.S. Census American Community Survey, over 25 million people spoke languages other than English (LOE) — at that time, roughly 9% of the American population. Within the U.S., the most common non-English languages spoken, by frequency, are Spanish, followed by Chinese, Tagalog, Vietnamese, and Arabic.[1]

Why Does Language Matter?

Language concordance in medicine is the provision of health care in a shared nondominant, minority language.[2] Put simply, it means that the provider and patient can speak to one another in the same language. In the hospital setting, language concordance has been found to provide increased satisfaction with care, fewer emergency department (ED) visits after discharge, and better-quality transition from hospital to home.[3] It has also improved health-related outcomes, including chronic disease management and adherence to treatment plans.[4] When patient and provider are unable to communicate in a shared language, interpretation and translation services must be consistently utilized.

Discharge instructions can be difficult for anyone to understand and the addition of a language barrier can make them even more challenging, and is especially nuanced when the patient is a child:

• More than 80% of English or Spanish speaking parents of hospitalized children make comprehension or adherence errors about discharge instructions.
• The majority of errors are related to medication dosage or side effects and return precautions.[5]
• For both English and Spanish speaking parents, medically-complex discharge instructions are associated with lower comprehension of, and poorer adherence to, those instructions.[6]
• LOE parents are more likely to make errors in dosing of prescribed medicines and to have poorer compliance with follow-up appointments than non-LOE parents.[7]
• LOE patients are more likely to have higher numbers of return visits to an ED.[8]

Federal Guidelines

Guidance on this subject originates from Title VI of the Civil Rights Act of 1964.[9] This act requires those receiving federal funds to take “reasonable steps to make their programs, services and activities accessible” by people with limited English proficiency (LEP).[10] Most often this is provided in the form of oral interpretation and written translation. A four-factor analysis was created by the U.S. Department of Health and Human Services (HHS) to help define what those “reasonable steps” entail. The analysis is meant to enable an individualized assessment that reflects on the factors listed in Table 1.[11]

Table 1 — Four-Factor Analysis

1) The number or proportion of limited English proficiency (LEP) persons eligible to be served or likely to be encountered by the program or grantee.

2) The frequency with which LEP individuals come into contact with the program.

3) The nature and importance of the program, activity, or service provided by the program to people's lives.

4) The resources available to the grantee/recipient and costs.

Source  https://www.hhs.gov/civil-rights/for-individuals/special-topics/limited-english-proficiency/guidance-federal-financial-assistance-recipients-title-vi/index.html.

Competency

Health care systems serving LOE populations need to ensure the competency of their translators for medical translation beyond simply identifying that these individuals are bilingual. Usually this is done via a certification or accreditation process to ensure quality and accuracy. If certification or accreditation is not available, systems should ensure competency in other ways such as having a second, independent translator check the work of the primary translator. An important difference to remember is that interpreters work with spoken language while translators work with written material.[12] The fact that an individual is certified to interpret does not mean they can competently translate.

Timeliness

Language assistance must be provided in a timely manner, but what “timely” means is subject to interpretation and can vary. HHS states clearly that assistance must be “provided at a time and a place that avoids the effective denial of the service, benefit, or right at issue or the imposition of an undue burden on or delay the important rights, benefits or services to the LEP person.” [13] This means efforts must be made to ensure language assistance is readily available so that care is not delayed. With the advent of virtual interpreter services — accessible by phone or tablet — assistance is more readily available as long as health care providers and/or organizations have the financial resources to pay for them. But timely access to a translator,  often a distinct and separate service, needs to be prioritized and not overlooked.

Which Documents Are Hospitals Required to Translate?

Hospitals are required to translate documents that are determined to be “vital.” Vital documents are defined as those that are critical to “ensuring meaningful access to the recipients’ major activities and programs.” To put it another way, vital documents are those that “affect access to, retention in, or termination or exclusion from a recipient’s program services or benefits.” While HHS provides several examples (Table 2), it acknowledges that making this distinction can be challenging and, further, it may change over time.[14] Thus, HHS recommends that hospital systems regularly assess the needs of their population and the services they deliver so that they always provide translated vital documents equitably.

Table 2 — Vital vs. Non-Vital Documents

Vital Materials	Non-Vital Materials
Consent and complaint forms	Hospital menus
Intake forms with the potential for important consequences	Third-party documents, forms, or pamphlets distributed by a recipient as a public service
Written notices of eligibility criteria, rights, denial, loss, or decreases in benefits or services, actions affecting parental custody or child support, and other hearings	Large documents such as enrollment handbooks
Notices advising LEP persons of free language assistance	General information about the program intended for informational purposes only
Applications to participate in a recipient's program or activity or to receive recipient benefits or services

Source https://www.hhs.gov/civil-rights/for-individuals/special-topics/limited-english-proficiency/guidance-federal-financial-assistance-recipients-title-vi/index.html.

Discharge Instructions

Are discharge instructions vital documents? While they are not listed as vital in Table 2, it is clear that these instructions are critical to ensuring a person’s access to information about post-hospitalization care. Every individual, regardless of their preferred language, should be provided equitable access to information recommended by their medical team upon discharge from a hospital.

Current Situation

Providing translated discharge instructions in a patient’s preferred language is time-consuming, costly and requires access to robust translation services. A prior study demonstrated that about half of national hospitals provide translated discharge instructions.[15] Commonly identified barriers to providing translated documents include operational complexity, funding, clinical staff awareness, and lack of translation services staff.[16] Another study showed that Spanish-speaking ED patients with less severe illnesses are more likely to receive translated Spanish discharge instructions as compared to higher acuity patients.[17] Clearly the current situation is far from ideal.

Costs and Reimbursement

The cost of translation services, and particularly the larger issue of reimbursement for all language services, must be readdressed on a systemic level. The following examples illustrate this need:

• When the HHS Inspector General’s Office conducted a study in 2008 examining Medicare providers’ compliance with language access policies, the number one barrier cited to providing access was cost.[18]
• Currently, most providers pay for interpreter services themselves, as few insurers reimburse this cost.
• In 2006, the Health Research and Educational Trust found that only 3% of surveyed hospitals received direct reimbursement for language services, with Medicaid providing the majority of that 3%.[19] Large- and medium- sized hospitals, hospitals in urban settings, teaching hospitals, and hospitals in the Northeast were more likely than others to receive reimbursement.
• Most hospitals pay for language services via per-hour charges. They “contract with or pay external interpretation agencies for freelance interpreters.”[20]
• The American Medical Association found that despite increased federal funding from the 2009 Children’s Health Insurance Program (CHIP) Reauthorization, only 14 states in the U.S. pay for language services using Medicaid or CHIP — the remainder of states opting out due to financial constraints. [21]

Overhead costs are hard to approximate and detailed reporting of annual total costs of language services per hospital are difficult to obtain. However, past studies have approximated costs ranging from $234 to $279 per Spanish speaking patient per year — a very small fraction of average hospital costs.[22] Interpreter services costs consistently cost more than the total amount reimbursed by Medicaid for the entire physician visit.[23] Effectively, this means some providers would lose money by seeing LEP patients.[24]

Future Directions

While the federal guidelines provide needed flexibility, they also leave the topic open to broad interpretation. Without more specific, standardized guidelines, variability in how providers and hospital systems approach the issue of discharge instructions is bound to remain. How to provide language-concordant discharge instructions in a timely, cost-effective, and accurate manner remains elusive.

Standardized, pre-translated patient education handouts regarding common diagnoses like asthma are readily available and many electronic health records integrate this feature for clinicians. However, individualized instructions from the patient’s provider — including specific reasons to seek medical care again, information about follow-up medical appointments, and diet or activity restrictions — require more personalized translation services. Using only machine translation for patient clinical information has been firmly discouraged as an alternative. This extends to the use of Google translate, which may be inaccurate and — without proper review and verification — a potential source of patient harm.[25]

To ameliorate the current situation, two distinct areas would benefit from further study and policy development:

• The question of cost of translation services and how it should be reimbursed (see above).
• Alternative, digital ways to provide discharge information.

New Formats for Instructions

Innovative ways to provide discharge instructions outside of printed documents need to be investigated further. Possible digital solutions include:

• Instructions provided via mobile portals. This method may be useful as long as 1) translation services are verified for accuracy, and 2) equity issues are kept in mind — access to internet, mobile devices, and/or computers.
• Audio or video-recorded instructions.

Conclusion

Challenges remain in providing timely and accurate language-concordant discharge instructions equitably to all patients and families. To improve care and advance health equity for those who speak languages other than English, it is vital to translate hospital discharge documentation. Through strong advocacy we must seek the commitment of health care systems to make this happen.

Endnotes

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[1] Sandy Dietrich and Erik Hernandez, Language Use in the United States: 2019 (August 2022), accessed May 25, 2023, https://www.census.gov/content/dam/Census/library/publications/2022/acs/acs-50.pdf.

[2] Maichou Lor and Glenn A. Martinez, “Scoping Review: Definitions and Outcomes of Patient-Provider Language Concordance in Healthcare,” Patient Education and Counseling 103, no. 10 (October 2020): 1883–1901, https://doi.org/10.1016/j.pec.2020.05.025.

[3] Lisa Diamond et al., “A Systematic Review of the Impact of Patient-Physician Non-English Language Concordance on Quality of Care and Outcomes,” Journal of General Internal Medicine 34, no. 8 (May 2019): 1591–606, https://doi.org/10.1007/s11606-019-04847-5.

[4] Lor and Martinez, “Scoping Review: Definitions and Outcomes.”

[5] Alexander Glick et al., “Discharge Instruction Comprehension and Adherence Errors: Interrelationship Between Plan Complexity and Parent Health Literacy,” Journal of Pediatrics 214 (November 2019):193–200.e3, https://doi.org/10.1016/j.jpeds.2019.04.052.

[6] Glick et al., “Discharge Instruction Comprehension and Adherence Errors.”

[7] Glick et al., “Parental Management of Discharge Instructions: A Systematic Review,” Pediatrics 140, no. 2 (August 2017): e20164165, https://doi.org/10.1542/peds.2016-4165; Leah Karliner et al., “Language Barriers and Understanding of Hospital Discharge Instructions,” Medical Care 50, no. 4 (April 2012): 283–89, https://doi.org/10.1097/MLR.0b013e318249c949.

[8] Rachel Gallagher et al., “Unscheduled Return Visits to the Emergency Department: The Impact of Language,” Pediatric Emergency Care  29, no. 5 (May 2013): 579–83, https://doi.org/10.1097/PEC.0b013e31828e62f4.

[9] U.S. Department of Health and Human Services (HHS), “Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons,” Office of Civil Rights, accessed May 27, 2023, https://www.hhs.gov/civil-rights/for-individuals/special-topics/limited-english-proficiency/guidance-federal-financial-assistance-recipients-title-vi/index.html.

[10] The words quoted are from the HHS’ definition of “limited English proficiency” (“Limited English Proficiency (LEP),” Office of Civil Rights, accessed May 27, 2023, https://www.hhs.gov/civil-rights/for-individuals/special-topics/limited-english-proficiency/index.html.

[11] HHS, “Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition.”

[12] See these definitions of the two terms from https://www.hhs.gov/sites/default/files/language-access-plan-2023.pdf (Appendix B).

Interpretation: The act of listening, understanding, analyzing, and processing a spoken communication in one language (source language) and then faithfully orally rendering it into another spoken language (target language) while retaining the same meaning.

Translation: The process of converting written text from a source language into an equivalent written text in a target language as fully and accurately as possible while maintaining the style, tone, and intent of the text, while considering differences of culture and dialect.

[13] HHS, “Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition.”

[14] HHS, “Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition.”

[15] Diamond et al., “Do Hospitals Measure up to the National Culturally and Linguistically Appropriate Services Standards?” Medical Care 48, no. 12 (December 2010): 1080–7, https://doi.org/10.1097/MLR.0b013e3181f380bc.

[16] Seethalakshmi H. Davis et al. “Translating Discharge Instructions for Limited English-Proficient Families: Strategies and Barriers,” Hospital Pediatrics 9, no. 10 (October 2019): 779–87, https://doi.org/10.1542/hpeds.2019-0055.

[17] Sarah Isbey et al., “Pediatric Emergency Department Discharge Instructions for Spanish-Speaking Families: Are We Getting It Right?” Pediatric Emergency Care 38, no. 2 (February 2022); e867–70, https://doi.org/10.1097/PEC.0000000000002470.

[18] Daniel R. Levinson, Guidance and Standards on Language Access Services: Medicare Plans, HHS, Office of Inspector General (July 2010), https://oig.hhs.gov/oei/reports/oei-05-10-00051.pdf.

[19] Romana Hasnain-Wynia et al., Hospital Language Services for Patients with Limited English Proficiency, National Health Law Program (October 2006), https://healthlaw.org/resource/full-report-hospital-language-services-for-patients-with-limited-english-proficiency/.

[20] Hasnain-Wynia et al., Hospital Language Services for Patients with Limited English Proficiency.

[21] Mara Youdelman, Medicaid and Chip Reimbursement Models for Language Services, National Health Law Program (February 7, 2017), https://healthlaw.org/wp-content/uploads/2017/02/Medicaid-CHIP-LEP-models-FINAL.pdf; William E. Kobler, CMS Rep. 5-A-11, Report of the Council on Medical Service,  accessed May 27, 2023, https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/about-ama/councils/Council%20Reports/council-on-medical-service/a11-cms-interpreter-services.pdf.

[22] Elizabeth A. Jacobs et al., “The Impact of an Enhanced Interpreter Service Intervention on Hospital Costs and Patient Satisfaction,” Journal of General Internal Medicine 22, Suppl 2 (October 2007): 306–11, https://doi.org/10.1007/s11606-007-0357-3; Jacobs et al., “Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services,” American Journal of Public Health 94, no. 5 (2004): 866–9, https://doi.org/10.2105/ajph.94.5.866.

[23] Kobler, CMS Rep. 5-A-11.

[24] Shivani A. Shah et al., “Reconsidering Reimbursement for Medical Interpreters in the Era of COVID-19,” JAMA Health Forum 1, no. 1 (October 2020): e201240, https://doi.org/10.1001/jamahealthforum.2020.1240.

[25] Davis et al. “Translating Discharge Instructions for Limited English-Proficient Families”; Sumant Patil and Patrick Davies, “Use of Google Translate in Medical Communication: Evaluation of Accuracy,” BMJ 349 (December 2014): g7392, https://doi.org/10.1136/bmj.g7392; and Elaine Khoong et al., “Assessing the Use of Google Translate for Spanish and Chinese Translations of Emergency Department Discharge Instructions,” JAMA Internal Medicine  179, no. 4 (February 2019): 580–2, https://doi.org/10.1001/jamainternmed.2018.7653.

 

 

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