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Health Plan's Comprehensive Strategy Involving Physician Incentives and Targeted Recruitment Enhances Patient Access to Language-Concordant Physicians


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Snapshot

Summary

Kaiser Permanente Southern California’s Language Concordance Program involves a comprehensive strategy to ensure that patients have access to primary care physicians who have been certified as speaking their preferred language. The program provides fluency certification, incentives and educational benefits to physicians who speak or wish to become fluent in another language, and actively recruits bilingual providers. The program significantly increased language-concordant visits among patients with limited English proficiency, particularly among those who prefer a Spanish-speaking physician. Additionally, a pre-post evaluation found that higher rates of language-concordance between provider and patient led to better control rates among Spanish-speaking patients who had diabetes and/or hypertension.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the percentage of language-concordant visits for 14 languages, use of physicians certified in these languages, and percent of limited English proficient patients in these physicians' practices. It also includes pre- and post-implementation comparisons of clinical data on hypertension rates for Spanish-speaking and non–Spanish-speaking patients with diabetes; a measure of quality for the language concordance program.
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Developing Organizations

Southern California Permanente Medical Group (SCPMG)
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Use By Other Organizations

In late 2009, Southern California Permanente Medical Group began expanding the program to clinic-based specialty departments to match limited-English-proficient patients with a language concordant specialist within a 14 day period, when possible. After 1 year of operation, results showed that the language-concordant specialty visit rate increased from 11.7 percent in 2009 to 15 percent in 2010. In the future, the program may also be implemented at Kaiser Permanente locations in other parts of the country.

Date First Implemented

2008
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Patient Population

Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Immigrants; Non-english speaking/limited english proficiencyend pp

Problem Addressed

Language barriers between physicians and the increasing number of patients with limited English proficiency can have negative consequences for access to and quality of care. Many organizations offer interpretation services, which are helpful but not sufficient. Matching patients to physicians who speak their preferred language—i.e., "language-concordant" physicians—can improve the health care experience, but often such physicians are not available.
  • More patients with limited English proficiency: Approximately 30 million individuals in the United States are classified as limited English proficient, which has doubled from an estimated 14 million in 1990.1 On average, 12 percent of Kaiser Permanente Southern California's members prefer to speak a language other than English. Spanish is the second highest language need, comprising 90 percent of interpretation requests.
  • Language barriers, leading to negative health care experiences: Language barriers between patients and providers can have a negative impact on health care access and quality of care.2,3 Patients with limited English proficiency are less likely to develop a rapport with physicians, receive adequate information, and participate in medical decisionmaking.4
  • Inadequacies of interpreter services, need for language-concordant physicians: Although many medical settings provide interpreters, communication errors during the interpretation process remain common and can lead to serious clinical consequences.5 Patients who have access to language-concordant physicians, however, are more likely to report that their concerns and needs were addressed, more likely to bond with their providers, and more likely to be satisfied with the health care experience.3,6 Many patients, however, do not have access to physicians who speak their preferred language.

What They Did

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Description of the Innovative Activity

Kaiser Permanente Southern California’s Language Concordance Program created a comprehensive strategy to ensure that patients have access to primary care physicians who have been certified as speaking their preferred language. The program provides fluency certification to physicians who speak any of 14 designated languages. To ensure the availability of such physicians, the program offers incentives and educational benefits for physicians who speak or wish to become fluent in another language, and actively recruits bilingual providers. Key program elements include:
  • Fluency certification for physicians: Physicians who speak any of 14 designated languages can take a 40-minute assessment test called the Clinician Cultural and Linguistic Assessment (CCLA) developed by Kaiser Permanente National Diversity Program Office. This test ensures verifiable linguistic proficiency in clinical encounters whereby the clinician is deemed to have a qualifying level of proficiency in communicating directly with patients independent of an interpreter. Those who pass are certified as fluent and are entered into a registry of participants in the language concordance program. Since the program's inception, more than 1,100 physicians have been certified (updated August 2013). Languages that were initially covered by the program included Arabic, Armenian, Cantonese, Farsi, Khmer, Korean, Mandarin, Russian, Spanish, Tagalog, and Vietnamese. At the end of 2009, French, Japanese, and Portuguese were added to the program.
  • Programs to build capacity among language-concordant physicians: The program uses financial incentives and special recruitment efforts to maximize the number of physicians certified in the designated languages, as outlined below:
    • Incentives and educational benefits: Physicians receive financial incentives for passing the fluency certification test and for taking on a predetermined number of language-concordant patients in their practices. Physicians who have not yet achieved language fluency, but wish to do so, can receive educational benefits, including funding to take college classes, participate in the Rosetta Stone program (as of 2011), or participate in a language immersion program.
    • Recruiting physicians who speak languages other than English: The program works closely with Kaiser Permanente’s physician recruitment department to promote outreach to physicians fluent in languages other than English. In addition, service chiefs who identify particular fluency needs or gaps in their departments can request that physician recruitment focus their efforts on applicants who speak that language. Since 2010, these efforts have been enhanced by the ability to post job listings with a required or preferred language need with the service chiefs’ approval. In addition, a signing bonus is offered if the physician is able to pass the fluency test.
  • Matching patients with language-concordant physicians: At the patient's request, the program assigns patients with limited English proficiency to a primary care physician certified as fluent in his or her preferred language; a patient with an existing physician is never removed from that provider’s care without the patient’s expressed consent. Scheduling staff and panel managers assign limited English proficiency patients to language-concordant physicians as follows:
    • New patients: All new patients seeking a primary care provider who self-identify as preferring a language other than English are assigned to the first available language-concordant physician, provided one is available.
    • Existing patients: Existing patients who wish to switch to a physician fluent in their preferred language are assigned to the first available language-concordant physician. â—¦Appointment scheduling: In addition, limited English proficiency patients whose existing primary care provider is unavailable for a needed appointment are scheduled with the first available language-concordant physician.

Context of the Innovation

Kaiser Permanente Southern California is a nonprofit, integrated health plan serving almost 3.3 million members. Comprised of 12 medical centers and 145 medical offices, the Southern California Permanente Medical Group provides medical services for the Kaiser Permanente Southern California Region. Due to its location, the group serves a large, growing Hispanic population. Members of a regionwide Kaiser team focusing on providing more culturally responsive care identified a need to address the language barriers experienced by these patients when accessing medical services.

Did It Work?

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Results

The program significantly increased language-concordant visits among patients with limited English proficiency, particularly for those who prefer a Spanish-speaking physician. Additionally, a pre-post evaluation found that higher rates of language concordance between provider and patient led to better controlled hypertension among Spanish-speaking patients who had diabetes and hypertension.
  • More bilingual Spanish-speaking physicians: The enhanced recruitment efforts resulted in a 78 percent increase in the number of bilingual Spanish-speaking physicians employed within one year of program implementation (updated August 2013).
  • Rise in language-concordant visits: The percentage of language-concordant visits, or all visits by patients with limited English proficiency where physicians spoke the patient's preferred language (now in 1 of 14 languages) increased from 24.6 to 37.8 percent since program implementation in 2008 (updated August 2013). This increase means that over 430,000 concordant visits occurred in primary care departments in which patients with limited English proficiency saw physicians fluent in their preferred spoken language during just one program year.  An average of 100,000 specialty departments are provided each year with a concordant physician since the implementation of the specialty program in 2009-2010.
  • Increased use of Spanish-speaking physicians: Physicians certified as being fluent in Spanish experienced a 6 percent increase in the number of Spanish-speaking patients in their practice during the first year after program implementation, while the number of Spanish-language concordant appointments increased 8 percent during the same time period.
  • Improved hypertension rates: As a measure of quality associated with language concordant care, the program examined how well hypertension was being managed among diabetic patients both before the program was launched in 2007 and again after the program was implemented in 2009. Before the implementation of the Language Concordant Program, patient chronic disease registry data showed that Spanish-speaking patients with diabetes were 1.4 percent more likely to have uncontrolled hypertension than were non–Spanish-speaking patients. Post-implementation data gathered in 2009 found that trend to have reversed, with Spanish-speaking patients now 0.5 percent less likely than non–Spanish-speaking patients to have uncontrolled hypertension, representing an overall improvement of 1.9 percent. The trend in improved language concordant care for Spanish-speaking patients over the same period indicates a positive association between increased language concordance and a better control of hypertension for this population.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the percentage of language-concordant visits for 14 languages, use of physicians certified in these languages, and percent of limited English proficient patients in these physicians' practices. It also includes pre- and post-implementation comparisons of clinical data on hypertension rates for Spanish-speaking and non–Spanish-speaking patients with diabetes; a measure of quality for the language concordance program.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Developing language assessment test: Kaiser Permanente National Diversity Program Office contracted with an outside academic institution to validate its language assessment tool, which determines the fluency level of physicians who report that they speak a language other than English. Southern California Permanente Medical Group physicians participated in the design and evaluation of this tool.
  • Forming task force: The medical group formed a task force of stakeholders involved or interested in providing language-concordant care to Spanish-speaking patients, including medical directors, administrators, regional chiefs of various departments (such as family medicine, pediatrics, and internal medicine), and 16 Spanish-speaking physicians representing their respective centers. The task force met regularly over the course of 6 months.
  • Examining patient data: To determine the needs and concerns of Spanish-speaking patients, the task force examined data collected from six focus groups of Spanish-speaking Kaiser Permanente Southern California patients that had been held in 2004, along with 2006 electronic patient data on a number of indicators related to language concordance and patient care. This analysis found that only 25 percent of the demand for Spanish-speaking primary care physician appointments was being met. The focus groups also found that patients matched with language-concordant physicians were more likely to bond with their providers and felt more satisfied with their care.
  • Expanding program to additional languages: Believing that language-concordant physicians could similarly benefit limited English proficiency patients who speak languages other than Spanish, the task force expanded the program to 10 additional languages spoken by a significant number of the region’s patients. At the end of 2009, three additional languages were made available for testing (French, Japanese, and Portuguese) and were added to the Language Concordant Program.
  • Training for staff: The program provided training to receptionists and medical staff to ensure identification of patients with language preferences other than English. In addition, scheduling staff received training on assigning patients to language-concordant physicians, and chiefs of service, department administrators, and panel managers received training on the importance of language-concordant services for patients with limited English proficiency.

Resources Used and Skills Needed

  • Staffing: Southern California Permanente Medical Group physician and administrative leaders oversaw the program’s implementation, interfacing with primary care departments, call center agents, panel managers, and regional offices. A program manager and project analyst also supported implementation. Physicians and other staff participate in the program on an ongoing basis as part of their regular responsibilities.
  • Costs: According to information provided in July 2011, the total cost for the program was $1.394 million, which was offset by the savings of not using a telephonic or staff interpreter for the 164,000 language-concordant visits added. (The cost for a staff member to interpret a 15-minute appointment is $6.72, while a telephone interpreter costs $1.29 per minute.)
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Funding Sources

Southern California Permanente Medical Group (SCPMG)
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Adoption Considerations

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Getting Started with This Innovation

  • Determine current rate of concordance: Collect the language preferences of patients and include this information in patient demographic data. Test physicians for fluency in languages other than English, and use this information to calculate the current level of physician–patient language concordance in their practice. Documenting the magnitude of the problem can help promote internal buy-in for the program and stimulate development of a plan of action.
  • Obtain commitment from senior leadership: Convincing senior leaders and administrators to prioritize language concordance as a quality issue can have a trickle-down effect on other staff, thus building wider support for the initiative.
  • Emphasize importance of process changes to staff: Ensure that schedulers, panel managers, and other staff involved in assigning patients to providers recognize and understand the organization’s commitment to language concordance.
  • Encourage physicians to gain additional language proficiency: Would-be adopters should identify educational opportunities for physicians to increase their language proficiency. As previously mentioned, these can include funding of college courses and participation in language immersion programs (updated July 2011).

Sustaining This Innovation

  • Keep language concordance as integral component of scheduling: Instituting language concordance as a standard part of appointment scheduling and assigning new patients ensures that it becomes part of the organizational culture. This approach also helps to keep language concordance a priority even as leadership changes occur over time.
  • Consider pairing with health literacy efforts: To more fully address the needs of patients with limited English proficiency, consider pairing language-concordance initiatives with health literacy outreach to patients and/or with provider training on foreign language medical terminology.

Use By Other Organizations

In late 2009, Southern California Permanente Medical Group began expanding the program to clinic-based specialty departments to match limited-English-proficient patients with a language concordant specialist within a 14 day period, when possible. After 1 year of operation, results showed that the language-concordant specialty visit rate increased from 11.7 percent in 2009 to 15 percent in 2010. In the future, the program may also be implemented at Kaiser Permanente locations in other parts of the country.

More Information

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Contact the Innovator

Michael Kanter, MD
Medical Director, Quality & Clinical Analysis
Kaiser Permanente Southern California
Permanente Medical Group
393 East Walnut Street, 7th Floor
Pasadena, CA 91188
Phone: (626) 405-5707
E-mail: Michael.H.Kanter@kp.org

Michael Morris, MD
Assistant Executive Medical Director, Care Experience
Kaiser Permanente Southern California
Permanente Medical Group
393 East Walnut Street, 7th Floor
Pasadena, CA 91188
Phone: (626) 405-3120
E-mail: Michael.E.Morris@kp.org

Innovator Disclosures

Dr. Kanter and Dr. Morris have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Kanter MH, Abrams KM, Carrasco MR, et al. Patient-physician language concordance: a strategy for meeting the needs of Spanish-speaking patients in primary care. Permanente Journal. 2009;13(4):79-83.

Footnotes

1 Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005;62(3):255-99. [PubMed]
2 Hampers LC, McNulty JE. Professional interpreters and bilingual physicians in a pediatric emergency department. Arch Pediatr Adolesc Med. 2002;156(11):1108-13. [PubMed]
3 Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med. 2007;22 Suppl 2:324-30. [PubMed]
4 Ferguson W, Candib LM. Culture, language, and the doctor-patient relationship. Fam Med. 2002;34(5):353-61. [PubMed]
5 Flores G, Laws MB, Mayo SJ, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;111(1):6-19. [PubMed]
6 Fernandez A, Schillinger D, Grumbach K, et al. Physician language ability and cultural competence: an exploratory study of communication with Spanish-speaking patients. J Gen Intern Med. 2004;19(2):167-74. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 11, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: September 11, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 09, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Back Story
Mrs. Ramirez* is a 70-year-old Latina woman who has been a Kaiser Permanente Southern California member for more than 10 years. She speaks limited English and prefers to communicate in Spanish, but in the past had been reluctant to request a Spanish-speaking primary care physician.

In early November she...

Read more