Best practices in care management: Engaging the ESL population · 2018-12-17 · ESL population...

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Best practices incare management:

Engaging the ESL population

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[ Best practices in care management : Engaging the ESL population ]

Immigrants will drive U.S. population growth over the next 50 years,1 and the number of non-native English speakers is already significant. As recent as 2013, a record 61.8 million U.S. residents reported that they speak a native language other than English at home.2 While this shifting demographic will likely affect all industries to some degree, it is especially notable to the health insurance and care management industries. While many members of the ESL population were previously uninsured, the Affordable Care Act (ACA) mandate is drastically increasing the percentage of insured ESL speakers.

According to the Kaiser Family Foundation,

by 2019 about one in four exchange

enrollees will speak a language other than

English at home.3

Care management (including care

coordination; case, disease management

and maternity management; and wellness

coaching) is challenging by nature.

It takes a tremendous amount of work and

dedication for clinical staff in healthcare

organizations to engage members,

help them sustain behavioral change,

and drive positive clinical and financial

outcomes. These challenges increase

significantly when dealing with members

who speak English as a second language,

as interventions take longer and positive

outcomes can be far more difficult to

achieve. What’s more, the relevance

of providing high-quality care to this

population has increased significantly

given the transformation to value based

payments and the continued scarcity of

clinical resources.

In regards to Medicare members, as of

2007, 14% of the over-65 population spoke

a foreign language at home.4 That means

addressing the ESL population is a pressing

need for healthcare companies that are

striving to attain high Star ratings and

qualify for substantial bonuses and rebates.

Knowing your patients’ psychosocial

drivers and communication preferences,



These difficulties often go beyond a simple

language barrier, as differences in ethnicity

can create additional clinical challenges in

care coordination. For example, Hispanics

are 50% more likely to die from diabetes or

chronic liver disease than non-Hispanics

due to lifestyle and diet, according to the

CDC.5 The health risks for this population

and others also vary depending on whether

or not they were born in the US or in

another county.

The traditional care management approach

has been to treat the ESL population much

like the rest of the population: Health plans

have focused their primary attention and

care to the top 3% of chronic care patients,

who essentially drive the majority of their

expenses. Such a strategy is simply not an

option in the new era of healthcare for a

variety of reasons.

The state of healthcare in the U.S.

From a strictly practical standpoint, the

ongoing decline of the overall health of

the total population is causing the cost of

chronic care to increase. Illness rates are

on the rise, with nearly half of all working

adults being diagnosed with a chronic

disease or condition such as heart disease,

stroke, diabetes, or asthma.

From a healthcare reform perspective,

focusing on the unhealthiest members is

no longer an option since providers and

strategically aligning them with the right

providers, and effectively measuring

members’ processes and outcomes is

challenging in itself. The language barrier

can make this task even more difficult. For

example, translation, socioeconomic, and

cultural considerations can make phone

calls between nurses and ESL members

much longer than conversations with

members whose primary language is

English.



payers are now incented to expand their

focus to the total population. To maximize

reimbursements, revenue, and rebates,

plans must maintain a high quality of care

and outcomes as measured through Star

and HEDIS metrics. To drive those results,

payers are moving provider contracts

towards value-based reimbursement

structures and away from the traditional

fee-for-service approach. Achieving high

quality ratings and optimizing outcome-

based payments requires a shift to Total

Population Health Management (TPHM),

rather than simply caring for those with the

greatest illness burden.

Considerations in managing ESL communicationsFrom a regulatory standpoint, the ACA

Verbal communications: Lost in translation

Just because a nurse or coach is

bilingual, he or she may not be qualified

to engage all ESL members across all

care management areas for different

situations or diagnoses. For example, an

oncology nurse would not typically work

with a diabetic patient. The same principle

holds true for English-speaking nurses

and patients. However, when it comes to

working with ESL populations who are

already disproportionately at risk, language

is often the only factor that is used to

match patients to medical personnel.

mandates interpretation and translation

services if 10 percent or more of the

population living in the consumer’s county

are literate only in the same non-English

language. This threshold affects 23 states

and 255 counties nationwide,6 meaning it

is now virtually impossible for any major

health payer to keep their current strategy

for dealing with ESL members unchanged.

Current solutions for communicating

with ESL populations often start and

stop with translation services and/or

matching the ESL speaker with a nurse or

coach who speaks their language. These

oversimplified solutions are ineffective at

producing the best outcomes, and do little

to maximize the insurer’s investment in ESL

communications.



It’s not always easy finding a bilingual

nurse in a specific specialty. Hence, a

common solution is to pair the member

with a qualified nurse and use a translation

service to bridge the language gap.

Unfortunately, engaging an interpreter

does not always result in the most effective

communication. While an interpreter may

speak the language, he or she likely lacks

the necessary background information to

understand the nuances of the situation.

To improve the communication process,

a few minutes prepping the interpreter

with key information, including what the

nurse intends to be the outcome of the

conversation, can greatly increase the

probability of a positive outcome.

When working with non-English speaking

populations, there are additional cultural

barriers to consider. In one recent example

involving a major carrier, a woman called

in with questions related to her pregnancy.

The woman spoke Arabic and was

provided with an interpreter. However,

the interpreter was male and the woman

refused to speak to him. Cultural diversity

training and educating care managers can

help bridge these gaps.



A recent survey by the Institute for Diversity

in Health Management, an affiliate of the

American Hospital Association, found that

81% of hospitals educate all clinical staff

on how to address unique cultural and

linguistic factors.7 Health care plans would

do well to follow suit, but limited resources

often cause difficulties when choosing the

most effective areas to focus their efforts.

One solution to this issue is working with

partners and internal staff to segment the

member population in ways that promote

effective engagement. Plans frequently

identify and stratify those members who

can most benefit from additional clinical

support. Adding flags to this data to

call out ESL members and their primary

language enables plans to approach the

ESL care delivery model in a more strategic

manner. If, for example, data demonstrates

that a large number of ESL members

are Vietnamese women of childbearing

age, care managers can educate any

Vietnamese-speaking nurses in obstetrics

and gynecology.

Solving the challenges involved with nurse-

to-member communications can result

in significant savings. For example, if the

average number of calls a nurse of coach

conducts per day increased from 11 to 12

calls per day, this results in an immediate

9% improvement in productivity. Assuming

a $90,000 benefits loaded salary, this

equates to an $810,000 productivity gain

per 100 nurses. Additionally, the gain in

productivity would give the health plan the

option to potentially hire more nurses or

reduce their staffing costs.

Written communications : More than just tag lines

According to DHHS Regulation 45 CFR

§ 155.205(c), exchanges must include

“taglines” that will inform individuals

of the availability of translation and

interpretation services. For many health

plans, this has resulted in a “minimum

requirement” approach, such as adding a

short disclaimer at the bottom of health

communications that encourages the ESL



member to call for a complete translation

of the letter’s contents.

While this disclaimer technically fulfills

DHHS Regulation 45 CFR § 155.205(c)

requirements, this practice rarely achieves

the desired results. It’s not unusual for

recipients to misunderstand the disclaimer

or to even overlook it entirely. In many

cases, these communications are treated

as junk mail and result in ESL members

missing important healthcare information.

Although a fully translated letter would be

ideal, it may not be possible in every case.

However, a full translation may not be

necessary. Adding a more robust statement

in the member’s primary language that

summarizes the letter’s key points can

greatly increase the probability that the

recipient will actually call to request a full

translation.

Texting brings its own set of issues.

Something as innocuous as an ESL

member signing up for texts can cause

confusion if the texts are all provided in

English. The member would need to be

flagged and contacted regarding their

preference to ensure he or she was not

missing key information.

Even enrollment communications are no

longer as straightforward as they used

to be. Studies indicate that employer-

sponsored insurance will decrease almost

30% over the next few years.8 For insurance

companies, that means a shift from B2B

marketing plans to B2C. This change

requires providing enrollment information

in multiple languages throughout the year

and addressing potential enrollees with

vastly different levels of understanding

of insurance. Consumers who have been

without insurance for a while, or have never

been enrolled in a health plan before,

will likely have questions regarding the

process or their specific benefits. This

Of course, effective written communication encompasses more than just taglines.



need for education can be compounded

by language barriers that may impact the

frequency and tone of communication

from the plan to the member.

Alternative primary care delivery models It’s important to remember that the end

goal of any ESL communication is to ensure

that non-English speaking patients get the

care they need. Partnering with the right

providers can be essential for boosting

quality of care, improving a member’s

clinical status, identifying and supporting

at-risk members, as well as maintaining the

status of healthy members.

Among ESL populations, new delivery

models such as Patient-Centered Medical

Homes (PCMH) are gaining popularity

in the medical community and among

the government, employers, and third-

party payers. PCMHs house primary and

specialty care physicians under a single

roof, which can reduce the communication

gaps, errors in medication, and repeated

tests that often occur when multiple

physicians, nurses, medical assistants,

insurance, and billing offices coordinate

from separate offices. For the ESL

population, this solution can be particularly

helpful in bridging communication gaps,

as the PCMH may be able to provide

an onsite native-language speaker to

assist in translations. If not, face-to-face

communication will often be more effective

than using a telephonic translator.

To improve their Star ratings and realize

positive outcomes, companies should

ensure their PCMH relationships accept

all of their available plans, especially the

narrow network plans where the majority of

ESL members may reside.



Potential payoffsThe potential payoffs when addressing

the growing ESL population in the US can

include benefits to the plan’s productivity,

improved clinical outcomes, and ultimately

better Star ratings based on higher quality

of care and customer satisfaction rates

within this market segment.

The difference between a 3.5 star and 4

star could mean receiving tens of millions

of dollars for most plans. In order to receive

the best possible reimbursements from the

Centers for Medicare & Medicaid Services

(CMS), plans have to achieve a rating of 4.0

or higher. Currently, the majority of health

plans have a Star rating below 4.0 and the

bonus payment in 2015 dropped from 5% to

0%, with rebate percentages also dropping.

Because of these factors, the larger

the ESL population is within a plan, the

greater the need for plans to work with this

population to meet their specific needs.



References

1. Immigrants will drive U.S. population

growth in next five decades: Pew,

Reuters, http://www.reuters.com/

article/us-usa-immigration-study-

idUSKCN0RS08V20150928

2. One in Five U.S. Residents Speaks

Foreign Language at Home, Record

61.8 million, Center For Immigration

Studies, http://cis.org/record-one-in-

five-us-residents-speaks-language-

other-than-english-at-home

3. Focus on Health Reform, The Henry

J. Kaiser Family Foundation, https://

kaiserfamilyfoundation.files.wordpress.

com/2013/01/8147.pdf

4. English Language Proficiency,

Family Economic Security, and Child

Development, National Center for

Children in Poverty, http://www.nccp.

org/publications/pub_948.html

5. Hispanic Health, Centers for Disease

Control and Prevention, http://www.

cdc.gov/vitalsigns/hispanic-health/

6. Good for Business: How US

Healthcare Reform Is Driving

Translation Demand, SLATOR

Language Industry Intelligence,

https://slator.com/demand-

drivers/good-for-business-how-

us-healthcare-reform-is-driving-

translation-demand/

7. Becoming a Culturally Competent

Health Care Organization, Equity

of Care, http://www.hpoe.org/

Reports-HPOE/becoming_culturally_

competent_health_care_organization.

PDF

8. Impact of the ACA on Health Plan Chief

Medical Officers, Dr. Gerald Osband,

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Best practices in care management: Engaging the ESL population · 2018-12-17 · ESL population...

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