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Home Visiting with Language Interpreters
Kaying Vang-Lor, PHN, RNMarsha Milgrom, MPA
October 19, 2016
Learning Objectives
1. Case study of a Healthy Families America (HFA) site startup working with refugee families via language interpreters
2. Discussion of modifications to HFA home visitor activities
3. Practical tips for home visitors or supervisors
4. Sustainability: billing resources, administrative considerations
National Trends & Projections
1900: the US currently looks like the year 1900
13% of the population is foreign-born
19% nearly 1 in 5, will be foreign-born in
2050
U.S. Population Projections: 2005-2050 | Pew Research Center
Need for the most culturally competent services,
with the best outcomes.
The bottom lineHFA standards 1, 3, 5 most directly impacted by use of language interpreters and cultural competency in materials, training, services.
Brief State and Local History
• Ramsey County is 2nd largest in MN (pop.= 538,133)• Metro urban/suburban area; 300,851 City of St. Paul• Local Public Health Department home visiting since 1906 • NFP 2007, HFA in 2012
Context for Saint Paul-Ramsey County Public Health
Where we are on the map...Minneapolis' twin city, St. Paul. Minnesota's most diverse county, Ramsey. Urban/suburban mix.
MN History:40 years+ of refugee resettlementState capitol marks major contribution to the community from
Southeast Asia's refugees; a large part of community fabric in St. Paul.
MN: Land of Ice and Snow• HFA home visitors work with interpreters of 15 languages• SPRCPH home visitors work with interpreters of 30 languages• St. Paul Public Schools’ students speak a combined 100 languages
Some of our newest arriving families speak
The Newest Families: Karen [kəˈren]
• 12,000 now in MN• From Burma (Myanmar)• Long history of war, trauma, refugee camps• Largest concentration in the United States• Most too new to US to understand English
MIECHV Initial HFA Targeting• 40 Karen families• HFA services for at least 3 yearsSPRCPH began working with community partners, building on cultural strengths. Quickly exceeded capacity for HFA families with this target group.
Our HFA Program Outcomes
HFA Best Practice Standard Rate
Home Visit Completion – 1 year 75% or more
Home Visit Retention – 1 year 85%
What I liked best about my home visits:
the joy I found.
As a new mother in a new country, I didn’t know about raising babies. My home visitor taught me that you don’t need to scold your children. You don’t need to raise your voice, hit or anything.
- Quote from a Karen HFA mom after 3 years in program – as interpreted by Karen interpreter
Assumptions We Had…
• Confidentiality
• Lengthy home visits
• Working with unknown interpreters
• Coordinating/scheduling home visits among 3 individuals
It’s fairly common for home visitors to share these uncertainties
The joy of having a home visitor
Tar, Thaw, and AnneVideo clip
Establishing Trust
The importance of developing a supportive, engaging triangular relationship with your family
Make that initial phone call matter
Facilitating trust with the use of an Interpreter
Make every attempts to have 1-2 consistent interpreters for each family
Always ask for gender preference, NEVER assume she wants a female interpreter
Maintaining Relationships
Maintain relationship with interpreter
• Develop a relationship with most commonly used interpreters
• Select interpreters who resemble some of the characteristics of the nurse
• Allow opportunity for family to meet a few interpreters at onset of home visiting
“When I chose an interpreter, I find a balance. A balance means that I look at their personality, tone of voice, and how they carry themselves during the home visit.” – Mai Nou
Maintaining Relationships with families
Maintain these relationships like your other English speaking families
Have honest conversations around family function needs
Consistent use of interpreters
Involving extended family particularly if it is a multi-generational household
Acknowledge their own cultural competency AND independency (ATP..ATP..ATP)
Tailoring Materials to Meet Linguistic and Cultural Needs
Program
• Use of smart phone
• Monthly group consultation during the first 6-9 months of implementation
Individual
• Made cultural adaption to the GGK/GGF
• Shortening GGK/GGF activities to accommodate for interpreting and family
• Paraphrase activities in the modules to convey appropriate messages
Logistical Challenges
and Cultural Adaptation
used
Competency and professionalism of
interpreters
Family choosing their own interpreter
New Community
• Switch to new interpreter• Have open discussion with
interpreter
• If professional relationship is maintain, will accommodate to request
• If boundary a concern, will discuss with interpreter
• Treat a new community like you would with any new population you’re working with
• Usually will have 1 or 2 interpreters available
Unknown relationship with interpreter and very close
community
Language conundrum with family satisfaction
Interpreters’ understanding of the evidence-based model and
its curriculum
• Initial conversation with interpreter and reinforce confidentially at beginning of services
• May place a call to family
• Have phone conversation to verified understandings from home visit
• Use a different interpreter
• Have discussion prior to home visit
• Do not provide an overview of our model program to interpreters
Home visiting is feasible with the use of interpreters
• Looking through the lens of health equity
• Family does want and need home visiting services
• Supportive and trusting relationship can be established with the use of interpreters
Funding For
•Important Qualifiers• County commitment for PHNs in home visiting• Long history in MN of managed care (PMAP) reimbursing for
PHN home visiting to Medical Assistance clients• State supports PMAP interpreter reimbursement • Information today doesn’t represent entire business model
Managerial/Administrative Considerations:
1.3rd-Party (Medical Assistance) Billing 2.Contract Versus In-House3.Legal Requirements
State Intent: Health Equity Framework CLAS=Culturally and Linguistically Appropriate Services
Interpreter Billing
• Billed to Prepaid Medical Assistance Plan-PMAP • PMAPs contract with County, selected by State • Public Health Nurses don’t see this part
Two Types of Language Interpreters• Contracted • In-House
County goes through interpreter agency contracting process. Similarly, for PMAP-paid interpreters, each PMAP has selection; usually at least a few language interpreter agencies.
Ideally, of course, home visitor staff are bilingual. We do have bilingual PHN’s/home visitors.
We use in-person interpretation on all home visits requiring language interpretation.
• 2004 US HHS issued Guidance to Federal Financial Assistance Recipients Re: Title VI
• “Additional” guidance for other programs• 4-factor analysis as a tool
Legal - Federal
1. # and % served/encountered in eligible population
2. Frequency of contact
3. Nature and importance of program
4. Resources available and costs
“Reasonable Steps to Assure Meaningful Access to Programs”
Legal - State
MN Statute 145A.17 Family Home Visiting Programs
- Identify appropriate targets (12)- Services to Limited English Proficient (LEP)
families not mandated- “Soft” guidance, such as MN Dept. of Human Services’ LEP Planning Tool
Non-direct uses for interpreters in HFA programming example: HFA Advisory Council
When working with language interpreters it is important to include the non-direct functions. We did an interview panel with graduating (3 year completion) HFA families. Keep in mind written surveys may not be the best method.
Resources: Culture and Linguistic Standards
1. Stratishealth.orghttp://culturecareconnection.org/navigating/assessment.html
2. United States Department of Health and Human Services, Office of Minority Health http://www.minorityhealth.hhs.gov
Resources: MN Health Care Programs
Legal References
Minnesota Statutes 256B.0625, subd. 18a(d) Covered Services, Access to medical servicesMinnesota Rules 9505.0140 Payment for Access to Medically Necessary Services, Access to medically necessary servicesMinnesota Rules 9505.2175 Health Service Records, Language interpreter services
Questions:
• To what extent is it important to use language interpreters in home visiting with LEP families?
• To what extent is it practical?
• How can we be the change we want to see?
1.eq·ui·ty2.[ˈekwədē]3.NOUN4.the quality of being fair and impartial: 5."equity of treatment"6.synonyms: fairness · justness · impartiality · egalitarianism · [more]
