Meaningful Communication Access for Deaf People In ... - MHIT
Meaningful Communication Access for Deaf People In Behavioral Health: WHAT IT IS AND HOW TO ACHIEVE IT Steve Hamerdinger, MA 2016 Failure to Assess Leads to Arrest In June, 2014, a 30-year old deaf woman, Kate*, with a known history of severe mental illness was brought to the
emergency room by her group home staff following a violent outburst. No attempt was made by the ER staff to locate a Qualified Interpreter. The psychiatric resident on duty assessed and released her without having communication access. Less then 24 hours later she was incarcerated in Shelby County jail. In what ways does this incident violate her legal rights? Among the more obvious violations: Joint Commission Standards. DHHS CLAS standards. ADA Title III (and maybe Title II).
Title VI of Civil Rights Act. * Not her real name, of course Depressingly Common Kates experience is extremely common. August 2014 Board meeting of Alabama Association of the Deaf, 100% of the board members (12 present) were able to recount a recent time when they or someone they knew were denied interpreter access at a health care facility. At least half were specifically hospitals and were first hand experience.
Procedural safeguards are not working. A well-known deaf professional was scheduled to have a heart procedure at one of the largest healthcare facilities in the state in January, 2014. The procedure was to be scheduled around interpreter availability and a request was put in by the surgeon several weeks prior to the surgery date. On the day of the surgery, no interpreter was available. An ad hoc arrangement was finally put in place more than 5 hours after the scheduled start of the procedure. Its Nerve-Wracking and Traumatizing
Why Am I Dying? Alfred Weinrib died of cancer but never knew his diagnosis after 3 Long Island hospitals allegedly did not have sign language interpreters on staff. Three Long Island medical facilities failed to get him sign-language interpreters for seven months. Alfred Weinrib, 82, even attempted suicide after nurses at one geriatric rehab facility ignored his desperate pleas for help getting to the bathroom because they
couldnt understand him, his children claim in a Brooklyn federal court lawsuit. How Many Deaf People in AZ? Based on 2015 data, there are at least 11,625 deaf people. Somewhere around 10% of the population of AZ does not use English very well. (Only CA and TX have a larger percentage) Of that, something like 81% speak Spanish. ASL is likely the third most common language in Arizona. Implicaciones de los datos.
A high number of bilingual people, which is a blessing and a curse. Forget that conversational fluency interpreting skill. An Aside Arizona has a high percentage of seniors which means a large number of people with hearing loss. Usually not tracked exactly how many people with significant hearing loss? Quality of treatment can be effected if not addressed. So Whats the Big Deal
Failure establish effective communication opens the provider to significant risk. Consider the case of Willie Ramirez: In 1980, 18-year-old Willie Ramirez was admitted to a Florida hospital in a comatose state. His friends and family tried to describe his condition to the paramedics and doctors who treated him, but they only spoke Spanish. Translation was provided by a bilingual staff member who translated "intoxicado" as "intoxicated." A professional interpreter would have known that "intoxicado" is closer to "poisoned" and doesn't carry the same connotations of drug or alcohol use that "intoxicated" does. Ramirez's family believed he was suffering from food poisoning. He was actually suffering from an intracerebral hemorrhage, but the doctors proceeded as if he were suffering from an
intentional drug overdose, which can lead to some of the symptoms he displayed. Because of the delay in treatment, Ramirez was left quadriplegic. He received a malpractice settlement of $71 million. But That Never Happens Today, Right? Bryce Accused Of Using Unqualified Interpreters During Mental Evaluation In Capital Murder Case. Dominguez's attorneys on Friday filed a motion requesting a hearing be held to determine the competency and reliability of an interpreter who has translated conversations between Dominguez and doctors at Bryce Hospital Pulliam granted the defense attorneys' motion on Monday morning.
According to the motion, the interpreter "lacks the qualifications and training necessary to render a true, clear and accurate interpretation of the communications with Ms. Dominguez. "Discussions with a psychiatrist and notes from him that were translated by the interpreter do not appear to be correct on a variety of issues," Lentine told the judge. "Doctors are relying on information that is being directly misinterpreted." But That Never Happens Today, Right? Use of unqualified interpreters is endemic in Arizona hospitals and nationwide. http://www.modernhealthcare.com/article/20140830/MAGAZINE/3
08309945 Most organizations advise against the use of a patient's family or friends, who can potentially do more harm than good. Bilingual clinical staffers also are discouraged from stepping in if they have not been certified as medical interpreters. But physicians and hospital staff often ignore these policies, typically because of time pressures, lack of knowledge about the availability of professional interpreters, or procedural difficulties in arranging for interpreters. We Will Get a Signer ASL interpreters are well regulated in some states but
safeguards are ignored and procedures/acquisition becomes ad hoc. MUST be licensed at a generalist level to practice at the behavioral/medical health level in Arizona (A.R.S 12-242), but: No special training required in Arizona for behavioral health or medical interpreting. Legal interpreters have higher requirements. Special certification for court interpreting in all languages. Implications for forensic psychiatry. Clinicians are not trained to work with interpreters. This is especially critical in mental health.
So Whats the Big Deal? Its not a theoretical concern: There have been numerous lawsuits against all levels of service from local clinics to state mental health authorities. Dekalb Regional Crisis Center, (2015). The Heart Center of Memphis, (2013). A specialty clinic. Virginia Psychiatric Company, Inc. d/b/a Dominion Hospital , (2013). Northshore University Healthsystems, (2012) Trinity Regional Medical Center and Trinity Health Systems , (2012)
Old Problem Gets New Attention Barrier Free Health Care Initiative The Department of Justices Barrier-Free Health Care Initiative is a partnership of the Civil Rights Division and U.S. Attorneys offices across the nation to target enforcement efforts on a critical area for individuals with disabilities. The initiative, launched on the 22 nd anniversary of the ADA in July 2012, includes the participation of more than 40 U.S. Attorneys offices. What Is Effective Communication? Effective Communication is consumer-defined.
In Maine, DeVinney checked herself into Maine Medical Center because she was suicidal. MMC did not provide requested interpreters for a variety of reasons, including that DeVinney (late-Deafened but ASL fluent) could speak so well she didnt need them. She was referred for anger management sessions when she became upset over a hospitals refusal to provide auxiliary aids and services in its psychiatric facility. In a bitter irony, the hospital refused to provide auxiliary aids and services for the anger management sessions. Part of settlement, which became a model, was the communication preferences were consumer driven and not the providers choice of convenience.
Individuals Not Familiar with Deaf Consumers Will often: Confuse poor English with poor language. Underestimate the incidence of general language dysfluency. Have no frame of reference to understand language deprivation. Confused about interpreter role. Cannot separate the interpreter /interpreting process from the Deaf person.
Adapted from Roger Williams, 2015 DHHS CLAS Standards In 2000, President Clinton signed executive order 13166 which extended civil right protections to non-English speaking people. Specifically includes deaf people who prefer ASL. DHHS has published standards for Culturally and Linguistically Appropriate Services
CLAS CLAS standards Provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs. CLAS
Burden of ensuring competence (and appropriateness) of communication access or interpreters on the healthcare provider. You must vet your interpreters. Simply contracting out to a third party is NOT adequate (See Joint Commission HR.01.02.01) But We Use VRI
https://nad.org/issues/technology/vri/position-statement-hospit als But We Use VRI VRI has a tool, not a panacea Is controversial in the deaf community with strong passions being common Must not be first resort Has technical limitations, particularly when applied to deaf people Adapted from Rosenblum, 2015
But We Use VRI Considerations for appropriateness Can the patient 1. Understand the interpreter? 2. See the screen without discomfort? 3. Does the patient have intellectual or behavioral contraindications? 4. Are there cultural considerations? Adapted from Rosenblum, 2015
But We Use VRI Regulatory Considerations VRI service minimum standards: (1) Real-time, full-motion video and audio over a dedicated high-speed, wide bandwidth video connection or wireless connection that delivers high quality video images that do not produce lags, choppy, blurry, or grainy images, or irregular pauses in communication (28 CFR 35.160(d)(1)) Adapted from Rosenblum, 2015
But We Use VRI Regulatory Considerations VRI service minimum standards: (2) A sharply delineated image that is large enough to display the interpreters face, arms, hands and fingers, and the participating individuals face, arms, hands and fingers, regardless of his or her body position (28 CFR 35.160(d)(2)) Adapted from Rosenblum, 2015 But We Use VRI
Other Considerations Need to be prepared to address all VRI technological and personnel challenges (including back up equipment and 24/7 staff) Need to ensure quality of interpreters match specialized language and regional signs Adapted from Rosenblum, 2015 Why Should I worry About Vetting? Why Should I worry About Vetting?
The Joint Commission will not be impressed if you simple contract it out! Danger is real for all languages. Cutting corners is a fact of life. Late nights on weekends are especially troubling. Behavioral Health raises additional considerations. Interpreters Are Not Enough The use of interpreters does not achieve equal communication between
the States mental health care providers and deaf consumers as that between the States providers and hearing consumers. U.S. District Judge Richard Story, Northern District of Georgia The Case of Pablo Oldest son in non-English speaking family, has no
functional language skills except very rudimentary ASL Moved from Puerto Rico 10 years ago Neighborhood nuisance Can be scary when confronted Now placed in the psych ward of a large metro area hospital for evaluation Mental Health Care Requires More How do you sort out what is psychosis from what is language/information deprivation? Communication assessments are critical Who will your trust to do it?
Communication Assessments Required by The Joint Commission, but little directi0n as to how. Some states have specific requirements for behavioral health. Alabama. Required for all clients who are Deaf. Georgia. Required for all clients with a communication disability. South Carolina.
Required for all new clients. Pennsylvania. For all clients who are Deaf and DD. Communication Assessments Communication Skills Assessment is state of the art Assess an individuals relative strengths and weaknesses across a continuum of communication modalities. Identify individual strengths and weaknesses in addition to assisting in identifying an individuals most effective communication strategies.
Permit those with severe language deficits to demonstrate skills, thus the definition of competence does not necessarily reflect a high degree of fluency or skill. It does not allow for meaningful comparisons between individuals, nor does it compare one individual to a group norm. Does give specific recommendations. Communication Assessments Communication Skills Assessment is state of the art Assess an individuals relative strengths and weaknesses across a continuum of communication modalities.
Identify individual strengths and weaknesses in addition to assisting in identifying an individuals most effective communication strategies. Permit those with severe language deficits to demonstrate skills, thus the definition of competence does not necessarily reflect a high degree of fluency or skill. It does not allow for meaningful comparisons between individuals, nor does it compare one individual to a group norm. Does give specific recommendations. Communication Assessments
Expectations for Rater: Communication Skills: Must be ASL-fluent. How can you assess dysfluent language if you are not fluent in the target language? Knowledge: Deafness (culture). Language development. Disability: Hearing loss & additional. Experience of the Evaluators: Behavioral observation & writing skills.
Inter-rater reliability: Alabama uses Its Deaf Services Office for training and monitoring of fidelity. Mental Health Care Requires More Who is being treated, the consumer or the interpreter? Remember this statement: Cannot separate the interpreter /interpreting process from the Deaf person? Interpreters are often poorly trained in working in behavioral health Afraid of making mistakes so will avoid it. Lack of professional mentors and clinical supervisors.
Clinicians are frequently not aware of the above. Mental Health Care Requires More If interpreters are considered less than equal access, then what is failure to provide interpreters? Brings us back to Kate A misdiagnosis without an interpreter is possible (probable?), predictable and preventable. The residents treatment of Kate could (should?) be ruled malpractice. What is the legal exposure of the hospital in that case?
Behavioral Health systems must make this a priority writing a generic policy does not put a qualified interpreter in the treatment setting. Whats Needed to Achieve Meaningful Access? Attention to the issue healthcare providers must take communication access seriously. They must convince the deaf community that they do take it seriously. Policy that is appropriate and enforced by the providers. There need to be clear consequences for violations. Are there any deaf people on citizen advisory boards at any
level of the behavioral health system? Make the system more hospitable to deaf practitioners. Most healthcare systems discriminate against deaf clinicians Lauren Searls case. Whats Needed to Achieve Meaningful Access? Mandatory training related to CLAS repeated as needed. One focus usually neglected is the effect of an interpreter on the clinical interaction.
Large systems should consider full-time staff interpreters. Whats Needed to Achieve Meaningful Access? Development of statewide interpreter (and clinical) resources that are able to be tapped systematically rather than current ad hoc processes. Tighten interpreter qualifications for both behavioral health and medical interpreters. Statewide coordination of behavioral health for deaf people can be effective.
Establish regional centers for psychiatric acute care. Professional Development Opportunity Alabama Mental Health Interpreter Training Project Montgomery, Alabama Full details at www.mhit.org Contact: [email protected]
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