Healthcare administrators and staff may complain about regulatory requirements. But many regulations result in much better care for non-English-speaking patients. Language Program Managers can use these requirements as a platform to drive more attention to patients’ need for effective communication.
The Medicare Readmissions Reduction Program serves this purpose brilliantly. This program is designed as a cost-cutting measure, to interrupt the cycle of patients being admitted over and over for the same condition when that condition could and should be managed more effectively by the care team. Think of a child with asthma being re-admitted several times a year. Or think of a diabetic patient who is re-admitted for recurrent infections in the feet.
Most healthcare actually takes place at home. People take their medicines, tend their wounds, recover from infections, and monitor their body functions on a daily basis with the help of their family members. An admission to the hospital marks a failure of the patient to manage his condition at home.
When a patient is admitted, the first job of the hospital providers and staff is to stabilize the patient so that he does not get worse. The next job is to implement a program of care for the patient which will improve his condition so that he can go home (or at least step down to a less intense level of care). The expectation under the Medicare rule is to teach the patient and family how to achieve good enough control over symptoms to stay home and be managed as an outpatient.
Communication is key to educating patients and families in self-care. First, there must be understanding of the medical condition. Second, there must be understanding of all of the steps required of the patient at home: nutrition, monitoring of body functions, taking of medications, exercise, avoidance of risky behavior. Third, patients must know who to contact if there are questions or a worsening of condition.
There are many ways that an active language support program can help the hospital reduce preventable re-admissions. First we will mention techniques to boost the effectiveness of patient education by nurses, doctors, pharmacists, therapists, and others while the patient is still in the hospital. Then we will address the follow-up period after the patient has gone home.
As is true of many English-speaking patients, immigrant patients and Deaf patients may have trouble understanding all of the information that pours over them from their care team. They may understand it, but then forget it very soon. Or they may not understand it, and be missing chunks of necessary information. Or they may mis-understand what their condition is, or what they are supposed to do.
The key to good patient education is to present the information at the level that the patient can understand it, then reinforce that by illustrations, diagrams, practice, stories, and examples. Every provider should ask the patient for a teach-back of important information each time things are discussed. The interpreter can play an important role by suggesting to the provider that the provider ask the patient for a teach-back, particularly after lots of information has been discussed. The interpreter can say that he or she hopes that interpretation has been effective, NOT making any mention of whether the patient has understood. This is done transparently: the interpreter tells the patient what he or she has just suggested to the provider.
Licensed providers in every discipline want their patients to understand their condition and their care plan and their self-care instructions. The Language Program Manager’s offer to assist in developing culturally competent materials OR translations of existing materials will be welcomed. Audio recordings of standard teaching topics, in the needed languages, can be presented to patients on iPads on the inpatient floors, and can be emailed to the patient for use later at home.
Because of how expensive it is for a hospital to have too many preventable re-admits, nurses have been asked to take on a new work flow. In-patient nurses round by phone on patients that were recently discharged from their hospital. These nurses are tasked because they have expertise in the type of care that the patient received on the unit. In some hospitals, Triage Nurses are tasked with this job. The nurses call the patients at home within two to three days of discharge to see how they are doing and to advise them if they are not doing well. The idea is to identify any decline in the patient’s clinical condition and to intervene before the patient needs to be re-admitted.
This task of calling patients at home is outside of the comfort level of many inpatient nurses. When the additional requirement of involving an interpreter for the call is added, it is an unfortunate fact that nurses may avoid making the calls to non-English-speaking patients. Many inpatient nurses have no idea how to get a telephonic interpreter on the line to help them make a phone call to a patient at home.
This is where support and training from Language Program departments makes the difference. They can in-service the nurses on how to access and work with a phone interpreter. Headphones at the noisy nurse’s station may help them focus on the conversation.
Nurses should be coached to put the interpreter in the picture by explaining that they are the inpatient nurse checking up on a patient at home who was recently discharged. Part of this pre-session with their phone interpreter should address what the interpreter will do if a family member or an answering machine picks up. And nurses should be reminded to document in their nursing note that they had an interpreter on the call.
A final note on how the Language Program Manager can support the hospital in minimizing preventable re-admissions: Data drives improvement. Each inpatient floor and high administrators are now provided with detailed reports on how many patients are re-admitted. If language need is added to these reports, all of a sudden it becomes clear whether non-English-speaking patients are being re-admitted at a higher rate. If so, extra attention will then be focused on providing more effective communication for those patients. A win for all involved!