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Can you Say that in Chuukeese? David Lane, Ph.D.Chief Compliance and Privacy OfficerHawaii Health Systems Corporation

HHSC…

�Where are we located?

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Ka’u HospitalKona Community Hospital & Ali’i Health Center (Affiliate)

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Hilo Medical Center & Yukio Okutsu VA State Home

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Hale Ho’ola Hamakua

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Kula Hospital

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Maui Memorial Medical Center

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Roselani Place (Affiliate)

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Lanai Community

Hospital

MAUI, LANAI, BIG ISLANDKohala Hospital

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KAUAI and OAHU

Kahuku Medical Center (Affiliate)

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Samuel Mahelona Memorial Hospital

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West Kauai Medical Center Maluhia

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Who are we? � “Safety Net” for neighbor island acute care

� “Safety Net” for Hawaii’s long-term care (LTC)

� Only option for primary care in many communities

� 1275 licensed beds including 800 LTC beds

� 21,168 acute care admissions

� 1,396 LTC admissions

� Approximately 4000 employees

� $533 million in revenue projected

Who is a “LEP”?

� A limited English proficient (LEP) individual is a person who does not speak English as their primary language and who has a limited ability to read, write, speak, or understand English.

� Source: OCR, September 20, 2013

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Hawaii’s LEP Profile � Out of Hawaii’s total population of 1,361,628, more than 24% or 329,827 speak a language other than English at home.

� Out of those who speak a language other than English at home, 151,187 or 46% are LEP.

� Out of the total LEP population, 125,602 or 83% live on Oahu.

� Out of the total LEP population, 80% are Asian language speakers while more than 13% being Native Hawaiian and Pacific Island language speakers.

� Source: Hawaii State Office of Language Access –September, 2013

LEP patients come from all ages….

Age Group # LEP

19 years old and below 14,245

20 to 39 years old 35,239

40 to 59 years old 50,056

60 to 79 years old 39,207

(48% are Ilokano and Tagalog; 16% Japanese; and 14% Chinese)

80 years old and above 12,440

(38% are Japanese; 38% are Ilokano and Tagalog; 11% Chinese)

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Top LEP Languages

(1,000 or more speakers)

1. Ilokano2. Tagalog3. Japanese4. Chinese (Cantonese and Mandarin)5. Korean6. Vietnamese7. Spanish8. Hawaiian9. Samoan10.Marshallese11.Chuukese12.Tongan13.Bisaya (Cebuano)

Language is a barrier…

Patients:

�Multi-lingual

� English not always first language

�Multicultural

� Resistance to “western” medicine practices

Staff:

�Multi-lingual

� English not always first language

�Multicultural

� Variety of training backgrounds

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With Other Challenges…� Limited resources

� Patients bring in family member for interpretation and “don’t” require services

� Staff training on language access requirements

� Cultural barriers to accessing services

� “isms” that exist for non-English speaking patients

� Finding qualified medical interpreters on neighbor islands (especially ASL)

….and of course COMPLIANCE….

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Federal Compliance

� Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Section 1557 of the Patient Protection and Affordable Care Act, and Regulations of the U.S. Department of Health and Human Services issued pursuant to these statues at Title 45 Code of Federal Regulations Parts 80, 84 and 91.

Title VI of the Civil Rights Act

� “No person in the United States shall on the ground of race, color or national origin, be excluded form participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”

� Section 601 of Title VI of Civil Rights Act of 1964

� 42 USC, Section 2000d et. Seq.

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Supreme Court Decision

� “Title VI prohibits conduct that has a disproportionate effect on LEP persons because such conduct constitutes national-origin discrimination.”

� Lau v Nichols, 1974

Federal Guidance for Title VI Compliance � “The U.S. Department of Justice has issued a Policy Guidance Document, "Enforcement of Title VI of the Civil Rights Act of 1964 - National Origin Discrimination Against Persons With Limited English Proficiency" (LEP Guidance). This LEP Guidance sets forth the compliance standards that recipients of Federal financial assistance must follow to ensure that their programs and activities normally provided in English are accessible to LEP persons and thus do not discriminate on the basis of national origin in violation of Title VI's prohibition against national origin discrimination. “

� Federal Register, 68, 103, 5/29/03, pp. 32290-32305

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Federal Guidance….Recipients and federal agencies are required to take reasonable steps to ensure meaningful access to their programs and activities by LEP persons. While designed to be a flexible and fact-dependent standard, the starting point is an individualized assessment that balances the following four factors:� The number or proportion of LEP persons eligible to be served or likely to be encountered by the program or grantee;

� the frequency with which LEP individuals come in contact with the program;

� the nature and importance of the program, activity, or service provided by the program to people's lives; and

� the resources available to the grantee/recipient or agency, and costs. As indicated above, the intent of this guidance is to find a balance that ensures meaningful access by LEP persons to critical services while not imposing undue burdens on small business, or small nonprofits

� http://www.lep.gov/faqs/faqs.html#OneQ7

Who is covered by HHS?

� All recipients of HHS Federal financial assistance, either directly or indirectly through a grant, contract, or subcontract

� Yes! Medicare and Medicaid

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Recipient Responsibilities under Title VI

�OCR: “Under Title VI and its implementing regulations, recipients must take reasonable steps to ensure meaningful access to their programs, activities, and services for LEP persons.”

And even Meaningful Use…

� “Preferred Language” documentation is required in core objectives

�Must be charted for every patient

� Implication that appropriate language services provided throughout the patient’s stay or service

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Remember….

�Service to LEP individuals requires:

�INTERPRETATION: Oral

�TRANSLATION: Written

Ways to Provide Cost-Effective Language Services

� Information sharing

� Training bilingual staff

� Telephone and video conferencing services

� Standardizing documents

� Using qualified translators and interpreters

�Centralizing services

� Formalized use of qualified volunteers� Source: OCR Seminar—September 20, 2013

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And …

�State Law…. Act 290, Session Laws of Hawaii, 2006 (Chapter 321C, Hawaii Revised Statutes).

Hawaii’s Language Access Law� Passed in 2006; amended in 2008, 2009, 2012 and 2013

� Purpose is to affirmatively address, on account of national origin, the language needs of LEP persons to ensure equal access to state services, programs and activities

� Applies to all state agencies (executive, legislative and judicial branches) and covered entities (receive state funding and provide services to the public – counties, non-profits)

Source: Hawaii Office of Language Access

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State Law applies to…..� "Covered entity" means a person or organization receiving state financial assistance, includinggrants, purchase-of-service contracts, or any other arrangement by which the State provides or otherwise makes available assistance in the form of funds to the person or organization for the purpose of rendering services to the public. It shall not include procurement contracts, state insurance or guaranty contracts, licenses, tax credits, or loan guarantees to private businesses of general concern that do not render services on behalf of the State.

State Law….[§321C-3] Oral and written language services. (a) Each state agency and all covered entities shall take reasonable steps to ensure meaningful access to services, programs, and activities by limited English proficient persons, which will be determined by a totality of circumstances, including the following factors:� (1) The number or proportion of limited English proficient persons served or encountered in the

eligible service population;� (2) The frequency with which limited English proficient persons come in contact with the services,

programs, or activities;� (3) The nature and importance of the services, programs, or activities; and� (4) The resources available to the State or covered entity and the costs.� (b) Subject to subsection (a), each state agency and covered entity shall provide competent,

timely oral language services to limited English proficient persons who seek to access services, programs, or activities.

� (c) Subject to subsection (a), each state agency and covered entity shall provide written translations of vital documents to limited English proficient persons who seek to access services, programs, or activities, as follows:

� (1) Written translations of vital documents for each eligible limited English proficient group that constitutes five per cent or one thousand, whichever is less, of the population of persons eligible to be served or likely to be affected or encountered; or

� (2) If there are fewer than fifty persons in a limited English proficient group that reaches the five per cent threshold in paragraph (1), written notice in the primary language to the limited English proficient language group of the right to receive competent oral interpretation of those written materials, free of cost.

� (d) To the extent that the State requires additional personnel to provide language services based on the determination set forth in this section, the State shall hire qualified personnel who are bilingual to fill existing, budgeted vacant public contact positions. [L 2012, c 201, pt of §2]

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Law requires agencies to….� Assess the need for providing language services and take reasonable steps to ensure meaningful access to state services, programs and activities

� Provide oral language services in a timely and competent manner

� Provide written translations of vital documents (5% rule)

� Establish a language access plan� Designate a language access coordinator� Hire bilingual personnel for existing, budgeted, vacant public contact positions

Source: Summary from Hawaii Office of Language Access

Hawaii and Federal Guidance:

Four Factor Test

� Number or proportion of LEP persons served or encountered in the eligible service population

� Frequency of contact with services, programs or activities

� Nature and importance of services, programs or activities

� Resources available and the costs

Note: Agencies must consider the totality of circumstances; no one factor is determinative.

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Historically, HHSC has ….� Devoted resources devoted to language interpretation (limited due to budget constraints and low utilization)

� Used Staff interpreters� Contracted with telephonic vendor; however, low utilization can lead to assumption that language interpretation and translations services not needed

� Tracked language access requests (which have been low—less than 5% for any one language).

Flash forward to 2013….

� New Office of Civil Rights “sheriff” in town…

� Stronger Federal and State Guidance and Mandates

� Stronger interest from State Legislature and the Hawaii Office of Language Access

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For example…..

�On April 30, 2013, the Office of Civil Rights (OCR) announced a new compliance initiative called “Advancing Effective Communication in Critical Access Hospitals” to support language access programs in hospitals

Compliance Reviews by OCR

� Random Compliance Review by OCR of HHSC facility– Four Month Interaction

�Only facility in Hawaii selected

�OCR wanted a Critical Access Hospital

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What we learned from OCR….

�Mandated policies on access and grievance process.

� Posting of policies and signs

�Website language

� Procedures for tracking and notifying staff when patient requests interpretation

We also learned….

� Interpretation NOT the same as translation

� Staff “interpretation” not always advisable or sufficient

� Need to document training and certification that staff interpreters have received

� Family members are not acceptable as automatic interpreters

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OCR requested language….Non-Discrimination Policy� As a recipient of Federal financial assistance, the Kauai Region does not exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, age, sex, sexual orientation, gender identity, religion, arrest, court record, or marital status in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out directly by the Kauai Region facilities or though a contractor or any other entity with which the Kauai Region arranges to carry out its programs and activities. This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Section 1557 of the Patient Protection and Affordable Care Act, and Regulations of the U.S. Department of Health and Human Services issued pursuant to these statues at Title 45 Code of Federal Regulations Parts 80, 84 and 91.

More OCR Suggestions….Notice to Limited English Proficiency Individualsof the Availability of Free Language Access� The Kauai Region facilities will take reasonable steps to ensure that persons with Limited English

Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits. Our policy is to ensure meaningful communication with LEP patient/residents and their authorized representatives involving their medical condition and treatment. The policy also provides for communication of information contained in vital documents, including but not limited to, waivers of rights, consent to treatment forms, financial and insurance benefit forms, discharge instructions and follow up appointments. All interpreters, translators, and other aids needed to comply with this policy shall be provided without cost to the person being served and patient/residents and their families will be informed of the availability of such assistance free of charge.

Language assistance will be provided through use of a contract or formal arrangement with qualified businesses providing interpretation or translation service, or technology and telephonic interpretation services. All staff has been provided a notice of this policy and procedure, and staff that may have direct contact with LEP individuals have been trained in effective communication techniques, including the effective use of an interpreter. Sign language services for the deaf are included in these services.

The Kauai Region facilities will conduct a regular review of the language access needs of our patient population, as well as update and monitor the implementation of this polices and these procedures, as necessary.

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And still more….Grievance/Complaint Procedure� The Kauai Region has adopted and implemented a grievance process to address concerns raised by persons who feel that they have been denied access to appropriate services based on their race, color, national origin, disability, age and sex. All complaints will be investigated and a response provided within 30 days. In case of questions or to file a complaint, please contact:

Dani Kroll, Compliance & Privacy OfficerKVMH: (808) 240-2754

SMMH: (808) 823-4155

dkroll@hhsc.org

Filing a grievance with the Kauai Regiondoes not prevent filing with the: Office for Civil Rights U.S. Department of Health and Human Services 907th Street, Suite 4-100San Francisco, CA

Main Line: (425) 437-8324 Toll-Free Hotline: (800) 368-1019 Website: www.hhs.gov/ocr/

….New Forms…..

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…new signage….

And finally new posting….

TagalogPasyente nagsasalita Tagalog mangyaring tawag KVMH (808) 338-9431 SMMH (808) 822-4961 at humingi Nursing superbisor

Japanese日本語を話す患者はKVMH（808）338から9413またはSMMH（808）822から4961を呼び出し、看護スーパーバイザはお問い合わせください。SpanishLos pacientes que hablan español, por favor llame KVMH (808) 338-9413 o SMMH (808) 822-4961 y pregunte por el Supervisor de Enfermería.

IlocanoNo makasarita ka ti Ilocano, mabalin mo nga tawagan ti KVMH iti numero (808) 338-9431 wenno ti SMMH (808) 822-4961 ken saludsudem ti Nursing Supervisor.

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2013: How HHSC is Responding to the Challenges� New contracts for vendors for language interpretation and translation services including Micronesian and Hawaiian languages

� ASL video-based services� Translating critical documents into multiple languages

� Tracking language access requests in EMR� Tracking language requests, offers, and refusals.

� Staff training

Resources:

�www.hhs.gov/ocr

�www.lep.gov

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Questions?