Purpose of This Tool
The U.S. is made up of diverse multicultural populations.1 Cross-cultural health care encounters involving a broad array of patients with diverse health beliefs, language preferences, cultural norms, and health-seeking behaviors occur everyday across the country. While many providers provide excellent cross-cultural care, language barriers and cultural diversity are still associated with worse care and preventable rehospitalization in many organizations.
The delivery of culturally and linguistically appropriate services is addressed throughout the Re-Engineered Discharge (RED) toolkit, but this tool specifically aims to:
- Explain why it is important to address patients' cultural and linguistic needs as part of the RED.
- Describe the infrastructure needed to deliver the RED in a culturally and linguistically competent manner.
- Describe how discharge educators (DEs) can deliver the RED to patients with a diversity of language, culture, race, ethnicity, education, or health literacy.
- Provide DEs with practical strategies to ensure the successful delivery of the RED to patients with cultural and language assistance needs, using effective cross-cultural communication and educational strategies.
This RED tool is meant to be used in concert with the other tools in the RED toolkit.
Role of Culture, Language, and Health Literacy in Readmissions
Improving the discharge process for people who experience language barriers, cultural differences, and limited health literacy is a critical component of improving the quality of care and avoiding preventable readmissions.2
Culture and Its Relationship to Readmissions
Culture is the learned, shared patterns of beliefs, values, attitudes, and behaviors characteristic of a society or population.3 From this cultural context emerges the patient's health belief system and explanatory models of illness.4 Patients' explanatory models for their health and well-being include their understanding of the causes, treatment options, and outcomes associated with their ailments. The case example below shows how failing to address patients' beliefs can lead to readmission.
The Case of Asthma Beliefs An asthmatic patient of Chinese ancestry was prescribed a course of systemic steroids. The patient returned to the hospital shortly after discharge with a severe asthma attack. When asked about adherence to the discharge plan, the patient reported that he had not taken the systemic steroids and had instead received "cupping" therapy from a practitioner of Chinese medicine. Cupping therapy is a treatment to enhance and improve the immune system. Had the DE elicited and discussed the patient鈥檚 health beliefs regarding what he thought caused and would cure his illness, she might have discovered that the patient thought asthma was the result of a weak immune system and would resist taking medicine that suppresses the immune system. At that point the DE would have had the opportunity to discuss how the medicine could be taken along with cupping therapy and could even have brought in a cupping therapist to help negotiate a discharge plan that would be acceptable to the patient. |
In cross-cultural clinical encounters, multiple cultural influences and health belief systems come into play, such as the culture of the provider, the culture of the patient, and the culture of the health care system. When these cultures clash, misunderstandings about the nature of an illness, its remedies, and appropriate health behaviors are more likely to occur. Cross-cultural communication, which requires an exchange of shared meaning, can occur even when both parties speak the same language.5
Aside from the potential for deteriorating health or readmission as a result of the patient's not understanding the discharge plan, communication barriers can lead to a sense of not being understood as a person. This can lead to mistrust and treatment nonadherence, which can threaten the successful transition from hospital to home.6 Thus, failing to address culture and language in the discharge planning process may expose patients to otherwise preventable adverse events and readmissions.
Language and Its Relationship to Readmissions and Patient Safety
Limited English proficiency (LEP), the limited ability to speak English, can prevent people from interacting effectively with health care providers. More than 20 million people, or 8.6 percent of the U.S. population, have LEP.7 People with LEP are 40 percent more likely to experience physical harm associated with an adverse event than English-speaking patients, and adverse events reported by LEP patients are more likely to be due to communication errors.8 However, patients who used professional interpreters at the time of hospital admission had a shorter length of stay and were less likely to be readmitted to the hospital in the next 30 days than those who did not have professional language interpreters at admission.9
Without appropriate language assistance for LEP patients (i.e., interpretation and translation services), DEs will face challenges in teaching patients how to take care of themselves when they get home, including how to take their medicines. Arrangements for appropriate language assistance after discharge (e.g., postdischarge followup phone call, subsequent laboratory tests, followup appointments) are also needed.
Health Literacy and Its Relationship to Readmissions
Health literacy refers to a patient's ability "to obtain, process, and understand basic health information and services needed to make appropriate health decisions."10 It is estimated that 77 million adults in the United States have limited health literacy and that health literacy barriers are more common among minority adults and those who did not speak English before going to school. Sickness and the stress of hospitalization can lower health literacy, so all patients are at risk of misunderstanding important information.11
Limited health literacy has been linked to more frequent hospitalization and readmissions.12,13 The Joint Commission, in its report What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety, recommends practices to avoid miscommunication that could lead to readmission.14 These practices are part of the RED and are described in detail in the following sections.
Preparations for Providing the RED to Diverse Populations
As part of preparing to provide the RED to diverse populations, consult the National Standards on Culturally and Linguistically Appropriate Services,15 a set of recommendations from the Department of Health and Human Services' Office of Minority Health. This section applies some of the standards to the implementation of the RED.
Hiring Bilingual, Bicultural Discharge Educators
Staff who share the language and cultural background of the community a hospital serves help create a welcoming environment that facilitates clear communication.16 If you have a concentration of LEP patients who prefer to use a particular language, consider hiring a DE who is bilingual and bicultural. If you hire a bilingual DE, you must ensure he or she is proficient in both languages.
If you expect bilingual DEs to interpret for other medical team members, you must make sure they are trained in medical interpreting and are qualified to fill that role. It can be tempting to try to "get by" with staff members who do not possess proficient language skills or by asking bilingual staff who do not have proper training to interpret. Professional development may be needed to avoid significant patient safety risks that can result from inadequate skills.
Providing Cultural and Linguistic Competence Training
All DEs should participate in formal training in cross-cultural health care to gain a full appreciation of how culture and language influence health care. Even bicultural and bilingual DEs will be asked to provide services to patients with cultural and language preferences that differ from their own. DEs should strive to cultivate cultural self-awareness, avoid making assumptions about patients' needs, and be open to learning from patients themselves.16
Ensuring Availability of Interpreter and Translation Services
All recipients of Federal funds, such as Medicare or Medicaid providers, must offer language assistance to any person requiring such services in a health care setting.17 Language assistance includes the provision of both interpreter services (for oral communication) and translation services (for written communication). Access to language services facilitates patient participation in care. Investing in language services can help prevent costly readmissions and reduce the cost of providing high-quality health care.18
Qualified medical interpreters, defined in the text box below, should assist in all in-person and phone encounters with LEP patients. Even if a patient speaks English fluently, it may be necessary to employ interpreter services to help teach the discharge plan to supportive caregivers. Qualified translators are also needed to make written information available in the patient's preferred language.
What Is a Qualified Medical Interpreter? A qualified medical interpreter is fluent in English and in the language of a non-English speaker, is trained and proficient in the skill and ethics of interpreting, and is knowledgeable about specialized medical terms and concepts. The National Council on Interpreting in Health Care ( ) has published a code of ethics and standards of practice for interpreters in health care. Currently two organizations, the National Board of Certification for Medical Interpreters ( ) and the Certification Commission for Healthcare Interpreters ( and the Speaking Together Toolkit.20 Overview of Delivering the RED to Diverse Patient PopulationsPatients can benefit from a linguistically and culturally appropriate approach to implementing RED components. Some of the ways this can be done are listed in Table 1. Table 1. RED Components and DE Responsibilities for Diverse Patients
Note: The rest of this tool addresses the DE directly. Getting Started With the RED for Diverse PopulationsStrategies that assist health professionals to anticipate, identify, and address cultural and linguistic communication barriers can significantly improve the hospital discharge experience and reduce unnecessary readmissions. Your awareness of the potential for cross-cultural communication barriers and use of strategies to anticipate and address these barriers can help avert mishaps. It is therefore essential for you to know how to assess communication and cultural needs and implement strategies to address barriers when providing the RED. Assessing Communication NeedsTo provide culturally and linguistically appropriate services, you first need to assess your patient's communication and cultural needs.
Using Nonverbal Communication Styles While Teaching the REDWhile language is often the most commonly examined aspect of communication, nonverbal communication is a powerful and culturally rooted form of interaction. Nonverbal communication includes not only facial expressions and gestures, but also personal distance and time references. Here are some examples of how nonverbal communication can affect your conversation with patients.
Understanding Health Beliefs, Alternative Healers, and Attitudes About MedicinesPeople's sociocultural background influences their approach to health care and shapes their world view and values regarding health and illness.6 Patients and their families and health professionals may not share the same health beliefs, such as what causes a disease or the benefits of traditional medicine. This diversity in health perspectives can heighten the risk of communication errors. To ensure the success of a discharge plan, you should elicit the patient's understanding of his or her illness and explore how the individual wishes to address treatment. The Kleinman Questions in Table 2 have been used to integrate a cross-cultural perspective into clinical medicine.6,24 These questions can be asked during your first meeting with the patient. You should practice them in simulation to get accustomed to cross-cultural inquiry. Table 2. The Kleinman Questions
Reassure your patient that his or her answers to these questions will help you in developing a comprehensive and effective treatment plan. If a treatment plan is not congruent with the patient and family's health beliefs, it is unlikely to be followed. In the discharge summary, you should inform the clinicians taking care of the patient about health beliefs and other cultural considerations. You can encourage this discussion by asking such questions as:
Understanding Patients and Communicating Across DifferencesStrive to overcome barriers to effective communication by approaching all patients with positive regard and an ethic of caring.25,26 This can be done by being:
In addition to the techniques listed in Tool 3, "How To Deliver the RED at Your Hospital," the following are important:
Teaching the AHCP to Patients With Limited English ProficiencyPrint the AHCP in the patient's preferred language, if possible. The RED Workstation can print the AHCP in English, Chinese, and Spanish. Provide the AHCP in the patient's preferred language, as well as in English for the benefit of health care providers and caregivers who read English. AHCPs that are not printed in the patient's preferred language should have a space in each section for a medical translator to write the translated discharge instructions in the patient's own language. Be sure that this is legible in the space provided. Some tips for teaching the AHCP to patients with LEP are listed below:
The AHCP includes a color-coded calendar to help patients learn how to take medicines and to help them remember the correct dates of their followup appointments. When printed using the Workstation, the calendar will offer to record major religious observances for a wide array of faiths. When helping patients arrange followup appointments, you can reference the calendar to determine whether any special religious observances will occur in the 30-day period following discharge. This information may be important when scheduling followup appointments or to determine whether the occasion involves special foods or fasting that might require additional education or a change in the treatment plan. Using Qualified Medical Interpreters To Create and Teach the After Hospital Care PlanIf your patient speaks English less than proficiently and you are not a documented bilingual provider in your patient's preferred language, arrange for a qualified medical interpreter. It may be tempting to "get by" if your patient speaks some English or if you speak your patient's language well enough to have a conversation. "Getting by," however, can lead to medical errors. If an in-person interpreter is not immediately available and the need to talk with your patient is urgent, engage a telephone interpreter while you are waiting. Do not use family or friends or others who are not qualified medical interpreters to interpret. Medical interpreting requires specialized skill and training. Further, patients have a legal right to determine whether they want family and friends to know their private medical information. Even if the patient prefers having a family member or friend interpret, also have a qualified medical interpreter present to correct any errors in interpretation. Never use a child under the age of 18 to interpret. Family members can be encouraged to support the patient and treatment plan rather than to serve as interpreters. Familiarize yourself with the language assistance programs at your hospital. Learn the proper procedures for requesting language assistance and be aware if advance notice is needed. When arranging for language assistance for the final interaction when the AHCP is taught, be sure to inform the medical interpreter that up to 1 hour of assistance might be required. If you have little or no experience working with medical interpreters, find out what training is available to help you work more effectively and efficiently with interpreters. Working With Qualified Medical InterpretersA few tips for working with qualified medical interpreters are included here as an introduction. This is not a substitute for formal training on working with interpreters. More information about working with people with limited English proficiency is available in AHRQ's Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS庐) training module, Enhancing Safety for Patients With Limited English Proficiency, available at http://www.ahrq.gov/teamstepps-program/.
Accessing Interpreters by Phone and VideoTraining in both the use of the language assistance devices and working effectively with a remote interpreter is essential. If you lack experience with language assistance devices, it is strongly recommended that you conduct a practice session before the initial patient meeting. For example, when using a telephone interpreter service, find out if there is a speakerphone or a dual handset so that both you and the patient have individual telephone handsets for use during your session. Practice connecting to the telephone and video interpreters and make sure the phone numbers, video links, and access codes are operational. Handling Patient Refusal of Language AssistanceOccasionally, a patient with LEP will decline the assistance of an interpreter, believing that his or her English skills are sufficient, or will ask to use a friend or family member for interpretation. You should:
Understanding the Role of Family and CommunityFamily and community support is often essential to a patient's safe transition from hospital to home. In some cultures, the role of family members, and even members of the broader community (e.g., religious or spiritual leaders, traditional healers), is instrumental in the treatment of illness and medical decisionmaking. Neglecting to assess the presence and influence of family and community members before hospital discharge could lead to nonadherence to the discharge plan, dissatisfaction with the medical care received, and hospital readmission for relapse of symptoms or other adverse events following discharge. It is important, therefore, that you inquire and assess family and community involvement in a patient's care early in the hospital course. The following are some ways cultural differences can influence your interactions with family and community members.
It is a good idea to ask the medical team if you have any concerns about the family or community members' role as you prepare the patient for discharge.
Additional ConsiderationsYou may ask questions to assess other culturally influenced factors that can relate to readmissions. These factors include dietary patterns, religious observance, gender preferences for caregivers, sexual orientation and gender identity, and mental health. Dietary PatternsConflicts with the dietary recommendations in the discharge plan can lead to setbacks in the transition from the hospital to home. You can ask the patient to review the dietary recommendations and assess whether the patient anticipates a problem adhering to the nutrition plan. If so, you can consult with the hospital dietitian to receive more information about how to assist the patient.
Religious ObservancesIt is not uncommon for patients to adjust medication regimens and dietary patterns as part of religious observances. Such observances may include fasting or consuming special meals prepared for the occasion or may prohibit the use of certain treatments during periods of observance. Sometimes, these changes can jeopardize the success of the discharge plan. Try the following:
Mental HealthMental health disorders, though common among hospitalized patients, are frequently undiagnosed and untreated and become important risk factors for rehospitalization.29 The populations below are at particular risk of unmanaged mental health difficulties:
To start exploring the possibility of mental health symptoms, you might ask the following:
You can also investigate specific circumstances that lead to mental health disorders. For example, when working with foreign-born patients, find out where they are from and when they left. It is quite useful to know some of the basic social and political history for your patient's country of origin. Sources such as the are easy to use to learn information about countries and give you a sense of some of the challenges your patients may have faced.33 To learn if your patient was likely to have been dislocated due to war, famine, or natural or political disaster, you might ask the following:
Report any suspected mental health issues to the medical team for them to investigate and plan for treatment if needed. |
