Providing Linguistically Competent Care for Refugee Patients in Clarkston, Georgia Interprofessional Quality Improvement Team Initiative

Julia Schiff, BA1,2; Lacey Gleason, BA2; Cricket Gullickson, BA1; Reem Hamoda, BA2

Julie Flores, BA2; Rebecca Engels, MD, MPH1,2; and Joyce Kim, BA1

1: Emory University School of Medicine 2: Emory University Rollins School of Public Health

Background

•  From March 2016 to March 2017, at least 40% of CCHC patients needed interpretative services, excluding patients with accompanying family members who could interpret for them

•  The four languages with greatest unmet need for interpretation were Arabic, Burmese, Nepali, and Amharic

Measures

Lessons Learned & Future Direction

Results

Analysis

Outcome Measure (Entire Team): % of patients who receive

adequate interpretation services (defined as interpretation services provided by fluent provider,

medical student, in person interpreter, or a tele-interpreter) =

# patients who receive adequate interpretation services

# patients who need interpretation services

Process Measures (Sub-teams) 1.  Utilization of translated materials by language:

printed materials (# used/# printed), website (# of clicks)

2.  Number of tele-interpreters reliably available each week (recruited and vetted)

3.  Number of community members interested in medical interpretation certification training

Baseline Conditions

•  The Clarkston Community Health Center (CCHC) is a volunteer-run, free clinic

•  CCHC was founded in 2013 to provide primary and preventive healthcare services to refugee and indigent populations in Clarkston, GA

•  Limited culturally and linguistically appropriate resources for this diverse community (including speakers of >60 languages) present a significant barrier to healthcare utilization

•  IHI partnered with CCHC in Spring 2016 and received a grant in Winter 2016 to improve interpretive services

Aims

•  Reduce barriers to healthcare access by providing translated materials

•  Build capacity and community engagement through strengthening and expansion of interpreter network

•  Pilot medical interpreter system based on point-of-care modified community health worker model

•  Implemented changes have been positively received by the clinic staff and volunteers

•  Successfully increased % of patients who receive appropriate interpretation services

•  Future implementation will include improving and standardizing tele-interpreter training

•  Patient satisfaction surveys will be conducted

•  New undergraduate QI team is working on continued development of projects at CCHC

•  Continued interpreter commitment to community following internship period

Tests of Change (Plan ➤ Do ➤ Study ➤ Act)

Aim Statement By December 31, 2017, increase by 50% the percentage of patients at Clarkston Community Health Center who receive

appropriate interpretation services from a provider, trained volunteer, or tele-interpreter during their clinic visit.

Acknowledgements Funding: Supported by PHS Grant UL1TR000454 from the Clinical and Translational Science Award Program, National Institutes of Health, National Center for Advancing Translational Sciences IHI Language QI Team: -  Rollins School of Public Health: Cami Barton, Olivia

Paige -  Goizueta Business School: SE Chang, Aakriti

Tandon -  Emory School of Medicine: Yafet Mamo -  Nell Hodgson Woodruff School of Nursing: Dria

Abramson CCHC Staff/Advisor: Corinne Abraham, RN, DNP, Saeed Raees, Gulshan Harjee, MD, Lynne Moody, MD, Keyur Patel, MD Contact: Lacey Gleason & Julia Schiff

lacey.patricia.gleason@emory.edu julia.schiff@emory.edu

Figure 5. The IHI Language QI Team ran three rapid PDSA cycles concurrently in each of the three intervention areas starting in Spring 2017

Table 1. Number of tele-interpreters by language

Figure 7. Percentage of patients who received adequate interpretative services before and after implementation

Language # Interpreters Amharic 4

Arabic 8

Bengal 3

Bosnian 2

Burmese 5

Chinese 9

Farsi 1

French 4

Gujarati 1

Haitian Creole 1

Hindi/Urdu 16

Kurdish 1

Marathi 1

Moore 1

Nepali 2

Pashto 1

Russian 3

Sinhala 1

Somali 1

Spanish 4

Swahili 1

Vietnamese 2

Increased use of providers,

trained volunteer

interpreters, or phone

interpreters during patient

clinic visits

Trained volunteer

interpreters are

available in the clinic

Providers are able to

utilize phone

interpreters when

needed

Frequently used

materials are

available in most

languages

Review current volunteer list to review accuracy and recruit new volunteers

Make dual headset available for providers to use during phone calls

Create monthly volunteer schedule to indicate volunteer availability

Work with clinic to determine key languages, interview process, training strategy, and other logistics

Recruit community volunteers to serve as interpreters

Enlist vendor to train volunteer interpreters

Identify resources to be translated

Develop physical resources and make them available to providers

Enlist translation services to translate materials

Figure 2. Driver Diagram

Provider Factors

Patient Factors

Community Barriers

Clinic Factors

Interpreter Factors

System Factors

Decreased medical

effectiveness and

understanding in the refugee clinic without the use

of trained interpreters

Effect

No access to interpreters

Incorrect utilization

Not using when

available

Use of ad-hoc interpreters

No phone line for tele-

interpreters

Large number of languages

Volunteer status

Limited finances

Many non-English languages spoken

Unfamiliar with system

Difficulty with communication

No access to interpreters

Difficulty integrating into

clinic

Informal training

Lack of incentives

Lack of funding for

training

Do not have ability to volunteer

Variety of languages, cultures,

and practices

Lack of social structure due to refugee nature

Novelty of US healthcare system

Distrust of system

Interpreter training resources

Poor chart documentation

Lack of available interpreters

Lack of network with refugee resources

Time constraints

Figure 3. Cause and Effect Fishbone Diagram

Phones New language sticker implementation Trained interpreters

Figure 4. Spaghetti Diagram of Clinic Flow

Figure 1. Interpretative Services Received – March 2017

Figure 6. Percentage of CCHC patients who received adequate interpretative services over time

Act Plan

Do Study

Act Plan

Do Study

Act Plan

Do Study

1. Phone line added & “dual-handset” telephones purchased for each provider room

2. -Vetted list of tele-interpreters -Recruited new interpreters, schedule creation, implementation

3. Spread the new tele-interpreter list/system to all clinic areas

Staff feedback included 1) balancing need to receive incoming calls on phone line vs. using line for tele-interpretation and 2) lack of communication of the locations of the phones to all staff/volunteers

Those who were aware of the list and used it viewed it as a significant improvement, and they suggested making copies of the list for all clinic areas

Continued lack of awareness of the phones and the new tele-interpretation list system due to flux of new staff/volunteers

Act Plan

Do Study

Act Plan

Do Study

Act Plan

Do Study

3. Reformatted language checklist into simplified language checklist stickers (for patient charts)

1. Created stakeholder survey to assess perspectives regarding interpretation system

2. Created language checklist (for staff to easily view on front of patient charts)

Worked well in flagging patients who may need interpretative services early on → making the list more permanent would minimize work for staff filling out the form for same information

Positive response by staff → continue to integrate language checklist process as a part of check-in

-Confidentiality - Clarkston is a small, well-connected town -Unreliable on-call interpreters -Discomfort relying on family members/friends to interpret -80% needs not being met

1.  Language sticker impl. 2.  Phone implementation

Tele-interpreter list implementation

Language checklist implementation

Baseline

Goal

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Amharic Arabic Burmese Hindi/Urdu Nepali

Tele-Interpreter Implementation by language

In-Person Interpreter Implementation by language Table 2. Number of in-

person interpreters by language

Language # Interpreters Amharic 1

Arabic 3

Burmese 1

Nepali 2

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Amharic Arabic Burmese Nepali

Act Plan

Do Study

Act Plan

Do Study

Act Plan

Do Study

1. Developed and advertised medical interpreter certification training program

2. Interviewed applicants → 8 finalists completed professional medical interpreter certification program

3. Integrated trained medical interpreters into clinic as in-house medical interpreters

Unintended benefit included being able to connect &

network with other community organizations in Clarkston

Development of rapport & sense of community among

participants

- Extremely positive and enthusiastic response among staff - Smooth incorporation of interpreters into clinic flow