Counseling Medications to Patients with Limited English Proficiency

FEBRUARY 07, 2017
Larry Calemine RpH, worked with Jared Lapkowicz PharmD WVU Medicine, and  Rajesh R. Nair, Assistant Professor, Department of Microbiology to develop this article. 

The number of families residing in the United States that speak a language other than English has dramatically grown in the past decade. Indeed, the US Census survey shows that approximately 25 million US residents have limited English proficiency (LEP).1  

It is not surprising then, that about 63% of all hospitals surveyed encountered LEP patients on a daily or weekly basis.Unfortunately, an increasing barrier in providing quality healthcare to these individuals/families with LEP, is language access. For example, LEP patients; (i) are more likely to experience adverse medical reactions,(ii) have increased length of stay in hospitals,and, (iii) are at higher risk of return visit for admissions5compared to proficient English-speaking patients. Realizing this shortcoming, language access is mandated for healthcare organizations that receive federal funding by Title VI of the 1964 Civil Rights Act.6  To address this mandate, the most common practice for providing language access is (i) telephone interpreter, (ii) onsite professional language interpreters, (iii) bilingual volunteers or (iv) software with accurate translation capacity.  Even though language barriers can have major adverse consequences in health care, little is known about whether pharmacies provide adequate care to patients with LEP. 

From a pharmacist’s point-of-view, medication counseling and instructions are necessities that need to be addressed when dispensing medicines to LEP patients. Additionally, pharmacists must ensure compliance in these patients, which can be achieved by a thorough medication reconciliation. Providing this service can ensure a seamless discharge and provide an additional step to avoiding medication errors. 

Medication reconciliation can identify inconsistencies with medication not only prior to admission but also during the length of the hospital stay and upon discharge to home. The process involves informing the medical teams of any therapeutic issues such as; therapeutic duplications, incorrect dosing, and drug interactions. Counseling at discharge using the “teach back method” provides a way the pharmacist can ensure the patient or caregiver (especially individuals with LEP), understands the current drug regimen and the importance of adhering to their current therapy.

In addition, the “Show and Tell” method, when appropriate, had been a great tool in education patient with many drug delivery systems.  These can include syringe demonstration, lovenox teaching kits, meter dose inhalers, and more.

We at WVU Medicine Ruby Memorial Hospital have developed a unique protocol to communicate with LEP patients.  WVU Medicine Ruby Memorial Hospital, which also includes the WVU Medicine Children’s, is a 500+ bed academic teaching hospital located in Morgantown, West Virginia. The Appalachian state has a diverse cultural background and is home to West Virginia University, which hosts a large contingent of international students with LEP.  Not unlike the national demographics, the WVU Medicine Ruby Memorial Hospital patients encompass foreign-born individuals that have LEP.  Our hospital has an outpatient pharmacy on site, which in 2012, launched a Transition of Care (TOC) Pharmacy to offer bedside consulting service and post-discharge prescription service to all patients within our facility. Since inception, our program has reached over 40,000 patients in 4 years and has had up to a 62% capture rate7.  

The outpatient pharmacy staff is a part of the multidisciplinary team that works with the healthcare staff, including the nursing department and discharge teams to focus on improving the transitions home for patients admitted at this institution.

Although the "meds to beds" discharge pharmacy service targets specific disease states that have been identified for high risk for readmission, all patients are eligible for the service. Having a seamless discharge with discharge counseling on the medications helps patients remain compliant and drastically lowers readmission rates. 

The TOC in developing a translation protocol looked at their own pharmacy software to be able to translate the prescription instructions and medication leaflet information. Although few languages were available, the existing software database on languages was limited. The TOC pharmacy utilized Google translate to have the pharmacy type the English version of the directions which is converted on its opposing screen to the patient’s root language. 

The translated directions are copied and pasted into the (sig) directions field of the pharmacy software.  A printed information sheet with the medications and directions is made with both the English and the patients root language for the pharmacy and nursing staff to utilize upon the patient’s discharge.
  
A copy of both directions is printed and affixed to the prescription hard copy for record keeping, the second copy is used for patient counseling not only with the patient but is available to any healthcare team member as a tool for the discharge process. 

Below is the protocol being used at WVU Medicines TOC pharmacy:
To Speak with a Patient who Speaks a Foreign Language
1. We locate our STRATUS iPad by asking at each floor.  Every floor contains a Stratus Ipad for translation to our patients.
2. Follow the easy directions on the attached, laminated instruction card.
3. Opening the stratus App > Press the Login button > Select the desired language > Meet the interpreter
4. The username and login for each machine should be attached to the instruction card.
5. Begin the conversation between your patient and the interpreter.
 
Once the prescription is ready, the TOC pharmacy delivers the medication to bedside when the patient is discharged.  The pharmacist uses the hospitals translator service (Stratus Translator) to provide medication education in their root language. Any additional questions are answered at the time of discharge and the pharmacy phone number is provided.

Our experience has taught us that empowering the patients is a positive way to facilitate the best outcome.  Once the patients realize that their needs would be heard and correctly interpreted, they engage better with the pharmacists and this two-way communication ensures that medications are consumed correctly and prescriptions are refilled in a timely manner.  This in turn restores the patients’ health and decreases adverse reactions and re-admittance to the hospital.  Indeed, studies have shown that convenient access to interpretation for LEP patients resulted in significant expenditure savings even after accounting for interpreter services costs.8

In conclusion, we have observed in our hospital that counseling LEP patients with readily available internet resources in combination with a software app greatly increased patient’s participation and understanding of their diagnosis and treatment regimen. 
 
 
References
1.     US Census Bureau.  Detailed languages spoken at home and ability to speak English for the population 5 years and over: 2009-2013. www.census.gov/data/tables/2013/demo/2009-2013-lang-tables.html.
2.     Hasnain-Wynia R, Yonek J, Pierce D et al. Hospital language services for patients with limited English proficiency: results from a national survey: Health Research & Educational Trust and National Health Law Program. 2006; 20. www.hret.org/resources/1550998119.
3.     Divi C, Koss RG, Schmaltz SP et al. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007; 19:60-67.
4.     John-Baptiste A, Naglie G, Tomlinson G et al. The effect of English language proficiency on the length of stay and in-hospital mortality. J Gen Inter Med. 2004; 19:221-228.
5.     Gallagher RA, Porter S, Monuteaux MC et al. Unscheduled return visits to the emergency department: The impact of language. Ped Emergency Care. 2013; 29:579-583.
6.     OPHS US Department of Health and Human Services.  National standards for culturally and linguistically appropriate services in health care. Washington DC: Office of Minority Health; 2001.
7.     Calemine L, Stinehart A. Reduction in 30-day readmissions through implementation of medication to beds and reconciliation at discharge. Poster presented at: ASHP Midyear 2014: The 49th ASHP Midyear Clinical Meeting and Exhibition; December 6-10, 2014; Anaheim, CA.
8.     Karliner LS, Perez-Stable EJ and Gregorich SE. Convinient  access to professional interpreters in the hospital decreases readmission rates and estimated hospital expenditures for patients with limited English proficiency. Medical Care. 2016.
 



 
 


Larry Calemine, RPh, BS Pharm
Larry Calemine, RPh, BS Pharm
Larry Calemine, RPh, obtained his BS Pharm degree at West Virginia University in 1992 and has spent most of his career focused on ambulatory pharmacy. In 1999, he trained at PCCA's compounding center to increase his knowledge and worked for a compounding pharmacy specialized in altered dosage forms. He obtained certifications in Diabetes, Immunizing, Cardiovascular Risk Management, and MTM through APhA. He developed a discharge pharmacy in 2012 at WVU Medicine's outpatient pharmacy to aid in lowing readmission rates for all causes at Ruby Memorial Hospitals. Larry also started an APPE program with 6 schools of pharmacy to increase clinical outcomes.
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