Not all caregivers are interpreters

Limited English proficiency is much more widespread than interpreter access.

Even if patients have limited English proficiency, clinicians might assume that their caregivers understand English. However, a recent study found that they often do not.

Researchers interviewed 158 caregivers for Chinese- and Spanish-speaking patients with limited English proficiency who had been discharged from the University of California, San Francisco (UCSF), Medical Center's orthopedic surgery, general surgery, and cardiovascular inpatient floors from June 2012 to August 2013. About 69% of caregivers were adults caring for parents or grandparents, and about 21% were spouses or partners.

Photo courtesy of Dr Semere
Photo courtesy of Dr. Semere

Overall, about 44% of caregivers had limited English proficiency, yet only 12% of patients reported having access to professional interpreters when receiving discharge instructions, according to results published online in June by the Journal of General Internal Medicine. These results suggest that at discharge, clinicians were relying on communicating with caregivers, many of whom had limited English proficiency themselves, said lead author Wagahta Semere, MD, MHS.

Dr. Semere, who is an assistant professor of medicine at UCSF and a primary care physician at the Richard H. Fine People's Clinic at Zuckerberg San Francisco General Hospital, recently spoke with ACP Hospitalist about how hospitals and physicians can better support caregivers of patients with limited English proficiency.

Q: Did the findings of your study surprise you?

A: I think some of these findings were surprising, probably most notable that so many of these caregivers had limited English proficiency themselves. I think there is a tendency in the hospital discharge setting, and also probably in other settings, to presume that caregivers have higher levels of health literacy and more English proficiency than the patients that they're caring for. That can be a problematic assumption to make. . . . We also found that caregivers for patients with limited English proficiency are experiencing burden. . . . This seemed to be particularly prevalent among those caregivers for Chinese-speaking patients. In national surveys, Asian caregivers are more likely than other ethnic groups to report that they are working full-time while providing care. They also are more likely to report having multiple care recipients. I think many of these things could be coming into play in terms of the level of burden that they're experiencing.

Q: What are the potential clinical implications of your findings?

A: Many of these caregivers had limited English proficiency, and if they were being relied upon, as they were in many cases, to understand hospital discharge instructions, that creates the potential for medical errors and adverse events to happen upon leaving the hospital. These are challenges in communication that can be avoided.

Q: How might hospitals better support these caregivers?

A: Using professional interpreters is key. We need to have interpreters on board, ideally throughout the hospital stay, but very much so at the time of hospital discharge. Some of the most convenient options, especially in the hospital where there can be delays and people might need to quickly access an interpreter, are telephones with professional interpreters immediately accessible, even if not in person. Dual handsets are quick ways where you can directly, automatically dial a professional interpreter who will be able to interpret on the spot. That's something that happens very frequently for our inpatients and can be a really important resource.

It's also important to think about ways in which these caregivers and the patients they're caring for might benefit from focused postdischarge check-ins that include the caregiver, making sure that they truly did understand the discharge instructions. And ideally, if caregiver burden or stress was picked up on, then there might be a way to navigate caregivers towards resources that are in place. . . . We've really just started to begin to explore the differences in terms of caregiving experiences for culturally and linguistically diverse populations, and now that we're starting to see that caregiving in these groups looks different than it does for our general population, we need to start thinking about interventions to better support these patients and their caregivers.

Q: What can individual hospitalists do to help at discharge?

A: I think that the first and most important question to ask is whether the caregiver and patient prefer to speak a language other than English and in which language do they prefer to receive their medical care. I think that is very often overlooked. . . . Even if someone might speak English, receiving medical care and instructions in English may be challenging for them and would highlight the need for an interpreter. Asking those questions early on and up front during the hospital stay is really key. And once the need for another language is identified, making sure that there is access to an interpreter and that access is convenient and that it's there throughout the hospital stay, including at the time of discharge.

I think it's also important for hospitalists to recognize that it may take more time at discharge for these patients and for their caregivers, so planning for that time is key. This is not a population that you can always rush out of the hospital quickly, so having a plan in place to accommodate for the extra time that it's going to take is very important. It's also helpful to ask about what support the patient will have at home in addition to their primary caregiver, so finding out what the home situation looks like, as we do with all of our patients, but perhaps trying to pay a little bit more attention to this population as we're able, since they have a tougher time navigating the resources that they can have access to.