Empowering Leaders: Building the Business Case for Language Access

IMIA Tri-Symposia

Oct. 3rd, 2014

Douglas E. Green

© International Medical Interpreters Association

Why Healthcare Reform• Historical Challenges• Comparison• The ACA and Reimbursement

The LEP Opportunity Under the ACA• Increasingly Diverse• Understanding the LEP patient experience• Ensuring Comprehensive Access

Best Practices Aligning to Organizational Goals

• Organizational Solutions• Community Solutions• Future Models

The Neurosurgeon and the sink basin1

•Dr. Guy Clifton, leading surgeon and chief of neurosurgery at a leading Texas Hospital.•Called upon administrators to address the safety concerns of his staff.•Not enough sink basins, drew up blue prints to fix 3x•Push to digitize x-rays to eliminate the need to perform duplicate x-rays, ‘No business case for’•Core issue, disjointed culture and high turnover leading to post surgical complication, developed plan to address and was refused. •Study: $10,000 per patient per surgical complication

1 ‘Unaccountable’, Marty Makary, MD, pg 30-33, 2013

An example of a systemic flaw

The Case for Healthcare Reform• The Case for Healthcare Reform

• Size of the healthcare industry• 17% of the Gross Domestic Product

• .17 cents of every dollar produced in the US• Number of deaths per year

• America's healthcare-system-induced deaths are the third leading cause of death in the U.S., after heart disease and cancer.

• 12,000 deaths per year due to unnecessary surgery• 7,000 deaths per year due to medication errors• 20,000 deaths per year due to other errors in hospitals• 80,000 deaths per year due to infections in hospitals• 106,000 dues to negative effects of drugs

• Global ranking(s)• The US Healthcare system is ranked 37th globally by the World Health

Organization• 14th in preventable deaths• 24th in life expectancy• 72nd in level of health• 2nd in Total Health Expenditures as a percent of GDP

The Case for Healthcare Reform

The Case for Healthcare Reform• Medical Errors

Medical errors kill enough Americans to fill over 390 Boeing 747 Airplanes every year.

• Poor communicationThe HC Industry loses 12B a year due to poor communication (about $1.2B for LEPs)

• TJC Sentinel Events3rd leading cause of all sentinel events is errors of poor communication, found as a root cause in 59% of all sentinel events

• Willie Ramirez caseThe $72M word

• Cost: The US HC system costs $8.2K a year per capita, 2.5Xs other developed nations

The Case for Healthcare Reform

The Case for Healthcare Reform• Waste of the US healthcare System

The US Healthcare system wastes over $750B a year, or 30% of all medical procedures on unnecessary and inefficient services.

* 2012 Institute of Medicine Study

0

10

20

30

40

50

60

$26 billion

$50 billion

$30 billion

$42 billion

Opportunity: Language access eliminates waste

Before Healthcare Reform Language Access Was Seen as an Expense

How does your organization view language access?

New Rules Under the ACA: Beyond Coverage

• Greater resources and commitment to primary and preventive care• Greater focus on community health centers• Formation of ACO’s

• 30-day readmission penalties• 2,217 Hospitals have been penalized $280 million in 20131

• Patient satisfaction and reimbursement bonuses• Focus on quality of care versus ‘amount’ of care

The ultimate goal of the Affordable Care Act is to reduce healthcare costs by increasing the health and wellness of the US Population.

1A Path Forward on Medicare ReadmissionsKaren E. Joynt, M.D., M.P.H., and Ashish K. Jha, M.D., M.P.H.N Engl J Med 2013; 368:1175-1177March 28, 2013

Readmissions Penalties Under the ACA

Under the ACA hospitals will be penalized up to a 2% reduction in Medicare payments for all procedures for high 30 day re-admissions for Congestive Heart Failure, Heart Attacks, and Pneumonia (chronic Pulmonary Disease, and Hip Replacement 2015).

In addition, CMS will not reimburse for the cost of the readmissions.1

169 Texas Hospitals penalized in 20132

1 Hospitals work to keep patients from being readmitted, USA Today, Shari Rudavsky, March 18 th,20132 Texas Tribune, Interactive: Hospitals Penalized for Readmission Rates, Becca Aaronson, August 16, 2013

Case Study: Readmissions at Memorial Healthcare

1 Hospitals work to keep patients from being readmitted, USA Today, Shari Rudavsky, March 18 th,2013

Example: Memorial Healthcare, Broward County, Florida

2011:•35% of patients spoke a language other than English in the home.•1,430 readmissions within 30 days•10,041 days of care that cost the system $114.8 million. •Average cost per episode was $80,279.•Readmissions ranked in the bottom quartile with a rate of 14%•Estimated penalty for 2014 at 2% would have been $3.8 million. •Total Loss: $118.6 million

Patient Satisfaction Penalties Under the ACA

What affects Patient Satisfaction?

1U.S. Ties Hospital Payments to Making Patients Happy, The Wall Street Journal, Janet Adamy, Oct. 14, 2012

Nearly $1 billion in payments to hospitals over the next year(2012) will be based in part on patient satisfaction, determined by a 27-question government survey administered to patients. Hospitals with high scores will get a bonus payment. Those with low ones will lose money.1

The HCAHPS Survey

Topic

Questions Involving

CommunicationTotal

Questions PercentNurse Care 2 4 50%Doctor Care 2 3 67%Hospital Environment 2 10 20%After You Left the Hospital 2 3 67%Overall Rating 0 2 0%Understanding Your Care 2 3 67%About You 3 7 43%

Total 13 32 41%

The intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care.1

1www.hcahpsonline.org

Readmissions, Patient Satisfaction and LEPs

1. Heart disease is the leading cause of death among minorities in the United States, according to the U.S. Department of Health and Human Services' Office of Minority Health.

Hispanics and Latinos are at greater risk. Due to: 1.High Blood Pressure2.Obesity3.Diabetes1

2. LEPs are going to have lower patient satisfaction scores than English speakers.

1The American Heart Association

English LEP

Satisfied 71% 52%Would not return 9.50% 14%

LEPs are 36% more likely to be dissatisfied with care and 47% more likely to not return. The study also showed that LEPs are more likely to report overall problems with care,

communication, and testing.2

Why Healthcare Reform• Historical Challenges• Comparison• The ACA and Reimbursement

The LEP Opportunity Under the ACA• Increasingly Diverse• Understanding the LEP patient experience• Ensuring Comprehensive Access

Best Practices Aligning to Organizational Goals

• Organizational Solutions• Community Solutions• Future Models

The Future of Healthcare: America in 2050

Increasing Diversity: The US in 2050*• 1 in 5 will be immigrants (1 in 12 2005)• Latino population will triple by 2050 and will be the largest ethnic

group comprising 29% of the population (14% in 2005)• The non-Hispanic white population will be a minority at 47% in 2050• Population growth will continue to occur in immigrant populations• The dependency ratio will increase from 59 children and adults per

100 adults of working age to 72

*Pew Research Projections: US Population Projections 2005 – 2050, February 11 th, 2008

"My great-grandfather did not travel across four thousand miles of the Atlantic Ocean to see this nation overrun by immigrants,"

The US is Historically Diverse

What happens when LEPs enter the US HC system?

What Happens When LEPs Enter the HC System?

Patient Safety, Quality, and Cost DriversQuality and cost drivers are emerging in support of work in this area:• Longer length of hospital stays for LEP patients when professional interpreters were not used at admissions and/or discharge.• Greater risk of line infections, surgical infections, falls, and pressure ulcers due to LEP patients’ longer hospital stays compared to English-speaking patients with the same clinical condition.• Greater risk of surgical delays and readmission due to LEP patients’ greater difficulty understanding instructions, including how to prepare for a procedure, manage their condition, and take their medications, as well as which symptoms should prompt a return to care or when to follow up.• Greater chance of readmissions for certain chronic conditions among racial and ethnic minorities compared to their white counterparts.

Improving Patient Safety Systems for Patients With Limited English Proficiency A Guide for Hospitals, AHRQ Publication No. 12-0041,September 2012

What Happens When LEPs Enter the HC System?

Risk ManagementRisk management remains a critical concern .• Patient comprehension of medical condition, treatment plan, discharge instructions, complications, and follow up• Inaccurate and incomplete medical history;• Ineffective or improper use of medications or serious medication errors;• Improper preparation for tests and procedures;

Improving Patient Safety Systems for Patients With Limited English Proficiency A Guide for Hospitals, AHRQ Publication No. 12-0041,September 2012

20

Triage Registration MD Tests DischargeED

Front Desk

RN MDRegular Appt

Triage RegistrationMD

SurgicalMD

Anesthesia DischargeProcedure

Technician Test

MD Rounds

RN 2 or 3XAdmin of

Medication Consults DischargeInpatient/Med/

1 day

Front Desk

Front Desk

Mapping the Patient Experience

Lulu Sanchez, Director Implementation Services, Languageline Solutions

21

Mapping Patient Encounters

UtilizationNumber of Encounters

LEP %

LEP Encounters

Avg. Hospital Stay

Avg. Encounters per day

Total Encounters

In-Patient 100,000 20% 20,000 5 4 400000

Out Patient 200,000 20% 40,000 1 4 160000Emergency Department 30,000 20% 6,000 1 5 30000

590,000

NOTE: It is estimated that even the most advanced language access programs only meet about 20-30% of LEP encounters.

Interpreter neededFor Patient Family

Use SBAVRIAvailable?

Use VRIUse Language Line

YesNo

SBAAvailable?

LASInterpreterNeeded?

LAS Interpreter Sent

Call Dispatcher

Language Line NotAvailable

YesNo

Interpreter needed for outpatient

*Edgardo Garcia, Manager Language Access Services, Childrens Medical Center Dallas

Out Patient

Type Modality Encounters

Front Desk SBA/VRI/OPI 40,000

RN SBA/VRI/OPI 40,000

MD SBA/VRI/OPI 40,000

Front Desk SBA/VRI/OPI 40,000

Interpreter NeededFor Patient Family

Call Dispatcher

LAS InterpreterAvailable?

Send LAS InterpreterVRIAvailable?

Use VRIIUse Language Line

Yes

Yes

No

No

Interpreter needed for inpatient

*Edgardo Garcia, Manager Language Access Services, Childrens Medical Center Dallas

In Patient

Type Modality Encounters

MD Rounds Staff/Video/OPI 100,000

RN SBA/VRI/OPI 100,000

Medication SBA/VRI/OPI 100,000

Consults Staff/Video/OPI 100,000

Interpreter Needed for Emergency/First Care/Arch ED Patient Family

Interpreter NeededFor Patient Family

Call Dispatcher

ER InterpreterAvailable?

Send ER InterpreterOther InterpreterAvailable?

Send Other InterpreterSBAAvailable?

Use SBAVRIAvailable?

Use VRIIUse Language Line

Yes

Yes

Yes

Yes

No

No

No

No *Edgardo Garcia, Manager Language Access Services, Childrens Medical Center Dallas

Emergency Department

Triage Modality Encounters

Registration SBA/Over the phone 6,000

MD Staff/Video/OPI 6,000

Tests Staff/Video/OPI 6,000

Front Desk SBA/Over the phone 6,000

Discharge Staff 6,000

Modalities by encounter type

OutpatientIn

PatientEmergency Department Total

SBA/Over the Phone 160,000 200,000 12,000 372,000

Staff/Video/OPI 0 200,000 12,000 212,000

Staff 0 0 6,000 6,000

Total 160,000 400,000 30,000 590,000

OutpatientIn

PatientEmergency Department Total

SBA/Over the Phone 27% 34% 2% 63%

Staff/Video/OPI 0% 34% 2% 36%

Staff 0% 0% 1% 1%

Total 27% 68% 5% 100%

Emergency Room Inpatient OutpatientTriage Typically no Paperwork

Admitting

Permission to Treat

Admitting

Permission to Treat

Admitting

Permission to Treat Insurance Insurance

Insurance Notice of Patient Rights Notice of Patient Rights

Notice of Patient Rights HIPAA Notification HIPAA Notification

HIPAA Notification Financial Documents Financial Documents

Financial Documents RoundsDisease

Education/Treatment Testing Informational Brochures

Testing

Informational Brochures Rounds Medication Education Specific Consents

Specific Consents Procedure Consent FormConsult

Informed consent

Consult Informed consent

Discharge

Discharge Instructions Referrals to aftercareReferrals to aftercare Medication Information

Discharge

Discharge Instructions

Discharge

Discharge Instructions Information for Transfer Medication Information

Medication Information Patient Education Information for transfer

Information for transfer Patient Education

Patient Education

Localized marketing and support content-Web-Education campaigns

Bilingual Staff-Fluency testing

-Training- Medical interpreter testing

- Call center monitoring

Inbound LEP calls

-Customized greeting-Call routing

Over the phone interpreting

-Language diversity-Data capture

-speed of answer-connect time

Video Remote Interpreting-Critical encounters-Quick connect-Smart phones, tablets, PC

Translation Solutions-Vital documents-Consent forms-Discharge InstructionsOnsite Interpretation-Extended critical encounters

Comprehensive Language Access Solutions

Why Healthcare Reform• Historical Challenges• Comparison• The ACA and Reimbursement

The LEP Opportunity Under the ACA• Increasingly Diverse• Understanding the LEP patient experience• Ensuring Comprehensive Access

Best Practices Aligning to Organizational Goals

• Organizational Solutions• Community Solutions• Future Models

© International Medical Interpreters Association

dherence

afety

roductivity

mage

evenue

xpense

Aligning to Organizational Goals

Organizational goals and priorities will shift based upon the environment in which we work.

It is important to identify the focus of your internal champions.

Position Area of concern

Risk Management Safety/Adherence

CNO Productivity/Safety

Patient/Guest Services Image/Safety

Manager/CFO Revenue/Expense

CEO ASPIRE

30

Organizational Initiative: Referral to primary care

Historic Metric: Significant non-critical care being treated in the ER

Resolution: During triage referred to primary care physician

New Metric: Significant reduction in re-admissions, uncompensated care, and increases in efficiency and wait times.

Organizational Solutions: Referral to Primary care

Productivity and Expense

31

Organizational Initiative: Reduce/eliminate no show appointments

Historic Metric: $250 loss per no show

Resolution: Proactive in language outbound campaign

New Metric: Significant reduction in no-Shows

Organizational solutions: Reduce/Eliminate no Show Appointments

LEPs are perceived to have a higher rate of no shows to appointments due to a

lack of understanding

Productivity, Revenue, Expense

Organizational Initiative: Reduce discharge time

Historic Metric: 1 hour 23 minutes

Resolution: Integration into EPIC

New Metric: 20 Minutes

Organizational Solutions: Reducing Discharge Time

NOTE: Translation of discharge materials seen as contributing to

reduced readmissions and treatment plan compliance, but most hospitals

only sight translate.Adherence, Safety, Productivity, Image, Revenue, Expense

Future Models of Healthcare: Texas Health Resources

What other innovations are Health Care providers utilizing?

Texas Health Resources: Meeting needs through education

Image, Productivity, Revenue, and Expense

Future Models of Healthcare: Kaiser Permanente

What other innovations are Health Care providers utilizing?

Kaiser Permanente: Communicating through culture

Image, Productivity, Revenue, and Expense

Representative Solution: St. Luke’s Episcopal Hospital

6 Hospitals (Acute + Specialty Acute) 5 Urgent Care or Freestanding ER3 Clinic/Physicians-Primary Care 2 Disease Mgmt/Health Mgmt2 Rehab/PT/sports Clinic

ASPIRE

© International Medical Interpreters Association

Questions?