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How to Establish Effective Communication Procedures
for Persons with Limited English Proficiency
and for Persons with Impaired Hearing, Vision, or Speech
(Attachment B)

The Department of Health and Human Services has issued regulations to notify health care and social service providers who are recipients of Federal financial assistance from the Department of their civil rights obligations under Title VI of the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973. Regulations at Title 45 Code of Federal Regulations Part 80, issued pursuant to Title VI, prohibit recipients from conducting any program, activity or service in a manner that excludes, denies, or otherwise discriminates on the basis of race, color, or national origin. Regulations at Title 45 Code of Federal Regulations Part 84, issued pursuant to Section 504, prohibit similar discrimination on the basis of disability. Health care and social service providers may also be subject to Title II or Title III of the Americans with Disabilities Act (ADA). Title II of the ADA prohibits discrimination against individuals with a disability in public services and Title III of the ADA prohibits discrimination in public accommodations against individuals with a disability.

A frequent cause of discrimination on the basis of national origin in a health care setting that may violate Title VI is a provider's method of communicating with patients and other persons who, because of their national origin, have limited proficiency in speaking or understanding English ¹. A similar cause of disability discrimination is a provider's ineffective communication with patients and other persons who have sensory or speech impairments.

Providers have an obligation under 45 C.F.R. Part 80 to ensure that persons with limited proficiency in English because of their national origin have a meaningful opportunity to apply for, receive or participate in, or benefit from the services offered. Under 45 C.F.R. Part 84, for providers with 15 or more employees, individuals with sensory or speech impairments must have an opportunity equal to, or as effective as, that afforded others, to apply for, receive or participate in, or benefit from the services offered. One way for providers to meet these obligations is to establish written procedures and train staff on how to obtain assistance in communicating with patients who are:

• limited English proficient (LEP), and
• who have sensory or speech impairments.

Providers have the obligation to provide communication aids and interpreters at no cost to the LEP/sensory impaired person.

The following list provides guidance for developing a formal written communication procedure. The procedure should reflect the specific kinds of services provided and the particular administrative practices of each provider.

Steps in Developing an Effective Communication Procedure

1. Write down the kinds of services provided, who provides them, and what methods are used (e.g., in writing, by telephone, by face-to-face contact, in group or individual settings).

2. Estimate the frequency of staff contact with Limited English Proficient (LEP) or sensory or speech impaired individuals. Base the estimates on the person's primary language, degree of impairment, and probable need for different types of communication aids.

   Methods of obtaining such estimates include taking a census of contacts with patients and community members over a given period of time or using demographic data on the service area (the U.S. Census information may be found at your local library or on the Internet). Combining these methods will probably result in the most realistic estimates.

3. Consult with persons with LEP, sensory impairments, and speech impairments, or community groups or organizations that represent them, to discuss:
   • unique communication needs
   • problems experienced in seeking and receiving services
   • recommendations on how to meet communication needs
   • situations in which only qualified bilingual or sign language interpreters are appropriate (for reasons of confidentiality and assurance of quality interpretation, especially in a medical setting, family members and/or friends are not recommended as interpreters)
   • sources of qualified bilingual and sign language interpreters
   • effective methods of notifying persons of the communication procedures and options available at no additional cost
   • how to provide an equal opportunity for persons with sensory or speech impairments, and for LEP persons to be aware of your programs, activities, and services.

4. Determine how staff will identify the communication needs of individuals at the initial point of contact. Community groups may suggest and assist in translating key phrases, such as: "What language are you speaking?" or "Where does it hurt?" (which can be read or shown to the client). Voice tapes of key phrases can be helpful. Persons with sensory or speech disabilities should be asked which communication methods and auxiliary aids they prefer. This may involve different methods depending on the nature, length, or complexity of the communication.

5. Identify staff who are truly bilingual, i.e., persons who with a high degree of accuracy and fluency can communicate (speak and write) with equal skill in English and a non-English language concerning the subject matter of the health care services or information to be provided. If indicated by the probable demand, make arrangements in workload or job functions so that these bilingual staff can be released for interpreter duties as necessary without adversely affecting their job performance or career advancement. The method of assessing bilingual staff should be part of the procedure.

6. Make formal arrangements with individuals or organizations to obtain the services of qualified interpreters when needed. This may take whatever form is agreeable to both parties, such as a contract, a written agreement, or a memorandum of understanding ². Possible ways of providing interpreter services are to use a telephone interpreter service or local educational institution. It is important to provide a qualified interpreter, especially in situations requiring medical terminology and explanations, and in situations of stress for the patients. Unqualified interpreters should not be used by providers before the LEP person or hearing-impaired person has been fully informed of the availability of qualified interpreters and communication options at no cost to the person. Having been so informed, the person may elect to rely on an unqualified interpreter (children, family members, friends) in a particular situation.

7. Develop, maintain, and routinely update a list of all bilingual persons, organizations, and staff members providing bilingual services including telephone numbers, addresses, languages available, conditions under which the person(s) are available, hours of availability, etc.

8. Identify staff who will be responsible for implementing effective communication with LEP and sensory-impaired persons. This may be a single coordinator with back-ups, or all staff members, depending upon the organization.

9. Write down the procedure or method to be used by staff to ensure effective communication, including such topics as:
   • how staff can identify the language used or the communication needs of individuals on the telephone and in person;
   • how bilingual/sign language interpreters will be provided during all hours of operation (existing staff, formal arrangements, etc.);
   • how appropriate information about a person's communication needs and use of interpreters or other aids will be recorded and shared;
   • how effective initial and continuing notice can be given to LEP persons and to persons with impaired hearing, vision, or speech, regarding programs, services, and activities, including the availability of interpreters and other communication facilitating aids (without charge to the client). Note that the regulation implementing Section 504 requires that an agency/facility "that provides notice concerning benefits or services or written material concerning waivers of rights and consent to treatment shall take such steps as are necessary to ensure that qualified disabled persons, including those with impaired sensory or speaking skills, are not denied effective notice because of their disability" (45 C.F.R. §84.52(b)).
   • how a clear understanding of written materials relating to admission, treatment, or other aspects of informed consent, including all documents requiring a signature, can be reached with persons who have sensory or speech impairments or who are not proficient in English.

10. Regularly notify and train all staff on the written communication procedure. Such a procedure will be effective only if they understand the reason for it and how to use it. Management's task is to bring this about through training and direction.

11. In planning for the costs of providing interpreter services, be advised that recipients of Federal financial assistance from the Department of Health and Human Services (this includes Medicare, Part A providers) are responsible for providing communication-facilitating auxiliary aids without cost to those needing them.

    Providers must not imply that clients or prospective clients must furnish their own interpreters or bring a family member or friend to interpret as a convenience or a condition of receiving services.

    With respect to reimbursement of interpreter expenses, the Health Care Financing Administration's Medicare Provider Reimbursement Manual states in Section 2147:

    The costs incurred for bilingual services are allowable provider costs to the extent that the costs are reasonable both as to the amount and in relationship to the extent of need for the services. They include, but are not limited to, the costs of translators for communication between the provider and patients, printed provider informational materials distributed to patients, and special personnel recruitment efforts designed to recruit bilingual employees. For purposes of Medicare reimbursement, the term bilingual includes the ability to communicate with the deaf through sign language. Providers are encouraged to make bilingual services available to patients wherever the services are necessary to adequately serve a multilingual patient population.

Procedure for Communicating Information to Persons with Sensory Impairments

The following is a sample procedure for effective communication with persons with sensory impairments.

(Name of provider) will take such steps as are necessary to ensure that qualified persons with disabilities, including those with impaired sensory or speaking skills, receive effective notice--written material or other communication--concerning benefits or services. Effective notice should cover for example, consent to treatment, waiver of rights, authorization to dispense medical information, handling of personal valubles, financial agreement(s), financial obligations, assignment of insurance benefits, Medicare patient certification and payment request.

For Persons With Hearing Impairments: Qualified sign-language interpreter -- For persons who are deaf/hearing impaired and who use sign-language as their primary means of communication, the following procedure has been developed and resources identified for obtaining the services of a qualified sign-language interpreter to communicate both verbal and written information:

(Insert the information for obtaining the services of a qualified sign-language interpreter. The information should identify the staff person authorized to obtain the interpreter, the information on the agency that has agreed to provide the service, telephone numbers and hours of availability and/or a list of qualified staff interpreters. Methods used to train patient contact staff in the use of effective methods of communication with Sensory Impaired persons should also be included. Note: Family members and friends should not be used as interpreters. The only case when this is acceptable is when the patient/client has been made aware of the availability of qualified sign-language interpreters at no additional charge and, without any coercion whatsoever, chooses the services of family members or friends).

If your agency/facility utilizes a Telecommunication Device for the Deaf (TDD), give an explanation of where it is located, how to operate it, and the telephone number. If there is an arrangement for sharing a TDD, give an explanation of the sharing arrangement, the telephone number and the procedures for borrowing the device. If you are using your State Relay Service, give an explanation of how this is used.

For Persons With Visual Impairments: Reader -- Staff will communicate the content of written materials concerning benefits, services, waivers of rights, and consent to treatment forms by reading them out loud to visually impaired persons.

Large print, taped, and braille materials -- (If any of these aids are chosen, in addition to reading, this section should tell what other aids are available, where they are located, and how they are used.)

For Persons With Speech Impairments: Writing materials, typewriters, TDD, and computers are available to facilitate communication concerning program services and benefits, waivers of rights, and consent to treatment forms.


Procedure for Communication with Persons of Limited English Proficiency

The following is a sample procedure for effective communication with persons of limited English Proficiency.

Policy:

It is the policy of (name of provider) to provide communication aids (at no cost to the person being served) to Limited English Proficient (LEP) persons, including current and prospective patients, clients, family members, interested persons, et al., to ensure them a meaningful opportunity to apply for, receive or participate in, or benefit from the services offered. The procedures outlined below will reasonably ensure necessary steps that persons with Limited English Proficiency or impaired speaking skills receive effective notice--written material or other communication--concerning benefits or services. Effective notice should for example cover consent to treatment, waiver of rights, authorization to dispense medical information, handling of personal valubles, financial agreement(s), financial obligations, assignment of insurance benefits, Medicare patient certification and payment request. This information is communicated to LEP persons in a language which they understand. Also, they will provide for an effective exchange of information between staff/employees and patients/clients and/or families while services are being provided.

Procedure:

1. The (provider) will designate (employee name and/or title) to be responsible for implementing methods of effective communication with LEP persons.

2. (employee name and/or title) will:
   • maintain, and routinely update a list of all bilingual persons, organizations, and staff members who are available to provide bilingual services, and
   • develop written instructions on how to gain access to these services, i.e., contact persons, telephone numbers, addresses, languages available, hours available, fees and conditions under which the person(s) are available.

3. In order to ensure effective communication and to protect the confidentiality of (client/patient) information and privacy, the (client/patient) will be informed that the services of a qualified interpreter are available to him/her at no additional charge. Only after having been so informed, the (client/patient) may choose to rely on a family member or friend in a particular situation. The choice of the (client/patient) and presence of an interpreter will be documented after every visit.

1. See the current LEP Guidance, also available in Spanish and Chinese, issued August 30, 2000.

2. If no interpreters are available in your community, you may want to try Certified Languages International at 1-800-237-8434, the AT&T Language Line at 1-800-752-6096 or your local community college language department for help. OCR does not endorse any particular organization, product, or service mentioned hereinbefore.
   
   
        

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   Date revised: November 22, 2000