Chapter 5. Patient Centeredness

The Institute of Medicine identifies patient centeredness as a core component of quality health care (Institute of Medicine, 2001a). Patient centeredness is defined as:

[H]ealth care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.(Institute of Medicine, 2001b)

Patient centeredness "encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient" (Institute of Medicine, 2001a). In addition, translation and interpretation services facilitate communication between the provider and the patient and are often a legal requirement.ⁱ The patient-centered approach includes viewing the patient as a unique person, rather than focusing strictly on the illness, building a therapeutic alliance based on the patient's and the provider's perspectives.

Patient-centered care is supported by good provider-patient communication so that patients' needs and wants are understood and addressed and patients understand and participate in their own care (Institute of Medicine, 2001b). This approach to care has been shown to improve patients' health and health care (DiMatteo, 1998; Stewart, et al., 2000; Little, et al., 2001; Anderson, 2002; Beck, et al., 2002). Unfortunately, many barriers exist to good communication.

Providers also differ in communication proficiency, including varied listening skills and different views from their patients of symptoms and treatment effectiveness (Rhoades, et al., 2001). Additional factors influencing patient centeredness and provider-patient communication include:

• Language barriers.
• Racial and ethnic concordance between the patient and provider.
• Effects of disabilities on patients' health care experiences.
• Providers' cultural competency.

Efforts to remove these possible impediments to patient centeredness are underway within the Department of Health and Human Services (HHS). For example, the Office of Minority Health has developed a set of Cultural Competency Curriculum Modules that aim to equip providers with cultural and linguistic competencies to help promote patient-centered care.(HHS)ⁱⁱ These modules are based on the National Standards on Culturally and Linguistically Appropriate Services. The standards are directed at health care organizations and aim to improve the patient centeredness of care for people with limited English proficiency (LEP). Another example, which is being administered by the Health Resources and Services Administration, is Unified Health Communication, a Web-based course for providers that integrates concepts related to health literacy with cultural competency and LEP.ⁱⁱⁱ

Similarly, the HHS Office for Civil Rights, in partnership with 18 medical schools in the National Consortium for Multicultural Education, funded by the National Institutes of Health, provides a course on cultural competency in medicine that focuses on Title VI compliance, "Stopping Discrimination Before It Starts: The Impact of Civil Rights Laws on Health Care Disparities."^iv This course discusses, in part, the HHS Office for Civil Rights' Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. This guidance explains that recipients of Federal financial assistance must take reasonable steps to provide LEP people with a meaningful opportunity to participate in HHS-funded programs. Failure to do so may violate the prohibition under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq., against national origin discrimination (HHS, 2008).

In addition, the HHS Office for Civil Rights is responsible for the enforcement of Section 1557 of the Affordable Care Act, 42 U.S.C. 18116, which provides that an individual shall not be excluded from participation in, be denied the benefits of, or be subjected to discrimination on the grounds prohibited under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq. (race, color, national origin), Title IX of the Education Amendments of 1972, 20 U.S.C. 1681 et seq. (sex), the Age Discrimination Act of 1975, 42 U.S.C. 6101 et seq. (age), or Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794 (disability), under any health program or activity, any part of which is receiving Federal financial assistance, or under any program or activity that is administered by an executive agency or any entity established under Title I of the Affordable Care Act or its amendments.

Importance

Morbidity and Mortality

• Patient-centered approaches to care have been shown to improve patients' health status. These approaches rely on building a provider-patient relationship, improving communication, fostering a positive atmosphere, and encouraging patients to actively participate in provider-patient interactions (Stewart, et al., 2000; Anderson, 2002).
• A patient-centered approach has been shown to lessen patients' symptom burden (Little, et al., 2001).
• Patient-centered care encourages patients to comply with treatment regimens (Beck, et al., 2002).
• Patient-centered care can reduce the chance of misdiagnosis due to poor communication.(DiMatteo, 1998).

Cost

• Patient centeredness has been shown to reduce underuse and overuse of medical care (Berry, et al., 2003).
• Patient centeredness can reduce the strain on system resources and save money by reducing the number of diagnostic tests and referrals (Little, et al., 2001).
• Although some studies have shown that being patient centered reduces medical costs and use of health service resources, others have shown that patient centeredness increases providers' costs, especially in the short run (Bechel, et al., 2000).

Measures

The National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR) track several measures of patients' experience of care. The reports also address the priority of ensuring that each person and family are engaged as partners in their care, found in the National Strategy for Quality Improvement in Health Care.^v The rationale is that "[h]ealth care should give each individual patient and family an active role in their care. Care should adapt readily to individual and family circumstances, as well as to differing cultures, languages, disabilities, health literacy levels, and social backgrounds." Examples of person-centered care could be ensuring that patients' feedback on their preferences, desired outcomes, and experiences of care is integrated into care delivery and enabling patients to effectively manage their care.

The NHDR has tracked a growing number of patient centeredness measures. Organized around the National Strategy for Quality Improvement in Health Care (National Quality Strategy), the 2011 NHDR presents the following measures that relate to the goal to provide patient-centered care:

• Adults and children who reported poor communication at the doctor's office (composite).
• Adults who reported poor communication with nurses and doctors at the hospital.
• Provider's involvement of the patient in making treatment decisions.

This year, the NHDR includes an expanded section that deals with language and includes some contextual data on primary language spoken at hospitals in California and New Jersey. In addition, this chapter includes two supporting measures: whether language assistance was provided by the usual source of care and need for a translator.

The last supporting measure deals with whether a provider sometimes or never asked for the patient's help in making treatment decisions. This measure relates to the National Quality Strategy goal of patient engagement.

Findings

Patients' Experience of Care—Adults

Optimal health care requires good communication between patients and providers, yet barriers to provider-patient communication are common. To provide all patients with the best possible care, providers must be able to understand patients' diverse health care needs and preferences and communicate clearly with patients about their care.

Figure 5.1. Adults who had a doctor's office or clinic visit in the last 12 months who reported poor communication with health providers, by race and education, 2002-2008

Key: AI/AN = American Indian or Alaska Native.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: Civilian noninstitutionalized population age 18 and over who had a doctor's office or clinic visit in the last 12 months.
Note:For this measure, lower rates are better. Patients who report that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication. Data for AI/ANs were insufficient for analysis in 2004, 2005, 2007, and 2008.

[D] Select for Text Description.

• Between 2002 and 2008, the percentage of White and Asian adults who reported poor communication with their health providers significantly decreased (Figure 5.1). During the same period, the percentage of Hispanics reporting poor communication also decreased significantly (data not shown). In addition, the percentage of adults with less than a high school education and those with any college who reported poor communication decreased during the period.
• In all measured years, Hispanics were significantly more likely than non-Hispanic Whites to report poor communication. In 2008, the percentage who reported poor communication was significantly higher for Black and Hispanic adults than for White adults.
• In 2008, adults with less than a high school education and those with a high school education were more likely than those with any college education to report poor communication with health providers.

Also, in the NHQR:

• In 2008, a significantly lower percentage of adults ages 45-64 and age 65 and over reported poor communication with their health providers compared with adults ages 18-44.
• From 2002 through 2008, the percentage of people reporting poor communication with their health providers was significantly higher for those with basic and complex activity limitations than for those with no activity limitations.
  

Racial and ethnic minorities are disproportionately of lower education levels. To distinguish the effects of race, ethnicity, and income on provider-patient communication, this measure is stratified by income.

Figure 5.2. Adult ambulatory patients who reported poor communication with health providers, by race and ethnicity, stratified by income, 2007

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2008.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: For this measure, lower rates are better. Sample sizes were too small to provide estimates for poor and low-income Asians. Patients who report that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

[D] Select for Text Description.

• Income explains some of the racial and ethnic differences in provider-patient communication for patients age 18 and over. A significantly higher percentage of poor and middle-income Blacks reported poor communication with their health provider compared with poor and middle-income Whites (Figure 5.2).
• A higher percentage of low-income Hispanics reported poor communication compared with low-income non-Hispanic Whites (15% compared with 11%).

Patients' Experience of Care—Children

Communication in children's health care can be challenging since the child's experiences are interpreted through the eyes of a parent or guardian. During a health care encounter, a responsible adult caregiver will be involved in communicating with the provider and interpreting decisions in an age-appropriate manner to the patient. Optimal communication in children's health care can therefore have a significant impact on receipt of high-quality care and subsequent health status. This is especially true for children with special health care needs.

Figure 5.3. Children who had a doctor's office or clinic visit in the last 12 months whose parents reported poor communication with health providers: Overall composite, by race and insurance status, 2002-2008

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008.
Denominator: Civilian noninstitutionalized population under age 18.
Note: For this measure, lower rates are better. Data for Asians in 2005 and 2007 and multiple-race children in 2006 did not meet criteria for statistical reliability. Parents who report that their child's health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

[D] Select for Text Description.

• From 2002 to 2008, significant decreases in the percentage of children whose parents or guardians reported poor communication were seen in children who were White, Black, Asian, multiple race, non-Hispanic White, and Hispanic. Significant decreases were also seen in children who had any private insurance or had public insurance only (Figure 5.3).
• The only group to not improve from 2002 to 2008 was children who were uninsured.
• In 2002, the percentage of Asian and multiple-race children whose parents or guardians reported poor communication with their health providers was significantly higher than for Whites; however, by 2008 there was no gap for either group compared with White children.
• In all years, a higher percentage of poor communication was reported for uninsured children compared with those with any private insurance (in 2008, 6% compared with 3%). In 2004, 2005, 2007, and 2008, a higher percentage of children with public insurance only reported poor communication compared with those with private insurance.

Also, in the NHQR:

• From 2002 to 2008, there was a statistically significant decrease for children ages 0-5 and ages 6-17 whose parents reported poor communication. During the same period, there was a statistically significant decrease for both gender groups as well.

Racial and ethnic minorities have disproportionately lower incomes. To distinguish the effects of race, ethnicity, and income on provider-patient communication, this measure is stratified by income level.

Figure 5.4. Composite measure: Children with ambulatory visits whose parents reported poor communication with health providers, by race and ethnicity, stratified by income, 2008

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2008.
Denominator: Civilian noninstitutionalized population under age 18.
Note: For this measure, lower rates are better. Data were not available for high-income Blacks. Parents who report that their child's health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

[D] Select for Text Description.

• There were no statistically significant differences between Whites and Blacks who reported poor communication with their health providers when stratified by income.
• There were no statistically significant differences between non-Hispanic Whites and Hispanics who reported poor communication with their health providers when stratified by income.

Patients' Experience of Care—Hospital

Using methods developed for the CAHPS® (Consumer Assessment of Healthcare Providers and Systems) survey (Hargraves, et al., 2003), the NHQR and NHDR use a composite measure that combines three measures of provider-patient communication into a single core measure. The three measures are: providers who sometimes or never listen carefully, explain things clearly, and respect what patients say. These data are presented separately for communication with doctors and communication with nurses.

Figure 5.5. Adult hospital patients who reported poor communication with nurses and with doctors, by race, ethnicity, education, and language, 2008

Key: NHOPI = Native Hawaiian or Other Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: Agency for Healthcare Research and Quality, CAHPS® (Consumer Assessment of Healthcare Providers and Systems), 2008.
Note: For this measure, lower rates are better. Poor communication is defined as responded "sometimes" or "never" to the set of survey questions: "During this hospital stay, how often did doctors/nurses treat you with courtesy and respect?" "During this hospital stay, how often did doctors/nurses listen carefully to you?" and "During this hospital stay, how often did doctors/nurses explain things in a way you could understand?"

[D] Select for Text Description.

• In 2008, overall, 6% of adult hospital patients reported poor communication with nurses during their hospital stay, and 5% reported poor communication with doctors (data not shown).
• Compared with Whites, all minority groups were more likely to report poor communication with nurses (Figure 5.5). Blacks, American Indians and Alaska Natives, and patients of more than one race were more likely to report poor communication with doctors.
• Also in 2008, Hispanics were less likely to report poor communication with nurses but not with doctors compared with non-Hispanic Whites (5% compared with 7% with nurses).
• Patients with less than a high school education were more likely to report poor communication with both nurses and doctors compared with patients with any college education (7% compared with 5% with nurses, 6% compared with 5% with doctors, respectively).
• Patients who speak Spanish at home were more likely to report poor communication with nurses compared with patients who speak English at home (7% and 5%, respectively), while patients who speak some other language at home were more likely to report poor communication with both nurses and doctors (7% for nurses and 6% for doctors).

Also, in the NHQR:

• Patients ages 45-64 were more likely to report poor communication with doctors compared with patients ages 18-44.
• Patients age 65 and over were less likely to report poor communication with nurses compared with patients ages 18-44.

Patient and Family Engagement: Enabling Effective Patient Navigation and Management of Care

To effectively navigate the complicated health care system, health care providers need to provide patients with access to culturally and linguistically appropriate tools to support patient engagement. Clear communication is an important component of effective health care delivery. It is vital for providers to understand patients' health care needs and for patients to understand providers' diagnoses and treatment recommendations. Communication barriers can relate to language, culture, and health literacy. This year, we provide data on language diversity.

For people with limited English proficiency, having language assistance is of particular importance, so they may choose a usual source of care in part based on language concordance. Not having a language-concordant provider may limit or discourage some patients from establishing a usual source of care.

To fill the data gap that currently exists, we examined subnational data-gathering activities and identified the California Health Interview Survey (CHIS) as a unique source of this type of information. CHIS is conducted by the UCLA Center for Health Policy Research in collaboration with the California Department of Public Health, the Department of Health Care Services, and the Public Health Institute.

Every 2 years, CHIS involves random-dial telephone interviews with up to 50,000 California households. The people included in CHIS are a statistically representative sample of the entire State's diverse population. With each survey cycle, new households are selected to participate. Beginning in 2007, CHIS also includes a sample of cell-phone-only households, which are often younger and more mobile Californians frequently overlooked in land-line surveys.

Patient Language Diversity at Hospitals

The overall percentage of Americans that belong to minority groups is increasing, and the total number of minorities in the United States surpassed 100 million in 2007 (U.S. Bureau of the Census, 2007.). A large number of these groups are made up of recent immigrants and groups that may not speak English as their primary language (Shin & Kominski, 2010). When members of these groups seek health care, language barriers may present significant challenges to communication with their providers and caregivers.

The ability to capture the variety and numbers of patients who speak languages other than English is a recent new development, and two States (California and New Jersey) seem to have data that are robust enough to be reported at present. The following figures present some of these new State-level data that allow more insight into this topic.

Table 5.1. Top 10 most widely spoken languages in California and New Jersey

California's Top 10 Leading Languages

New Jersey's Top 10 Leading Languages

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Databases.
Note: California and New Jersey only.

Figure 5.6. California and New Jersey hospitals with a high number of patients for whom English was not their primary language, by ownership, teaching status, occupancy load, and geographic location, 2009

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Databases.
Note: Data are from 42 hospitals and 229,394 discharges. High-percentage Spanish hospitals represent the top 10% of facilities with the highest percentages of patients for whom English is not their primary language. California and New Jersey only.

[D] Select for Text Description.

• Only 7% of privately owned, for-profit hospitals were in the group with a high percentage of non-English-speaking patients (top 10%), whereas 9% of private, not-for-profit hospitals had a high percentage of non-English-speaking patients (Figure 5.6). About 16% of public hospitals had a high percentage of non-English-speaking patients.
• Almost a quarter (23%) of teaching hospitals had a high percentage of non-English-speaking patients, but only 6% of non-teaching hospitals had a high percentage of non-English-speaking patients.
• Based on occupancy rates, 18% of high-occupancy hospitals had a high percentage of non-English-speaking patients. Only 8% of medium-occupancy hospitals had a high percentage of non-English-speaking patients, and just 3% of low-occupancy hospitals had a high percentage of non-English-speaking patients.
• Geographic location also seems to be associated with the percentage of hospitals that have a large percentage of patients whose primary language is not English. Thirteen percent of large metropolitan hospitals had a high percentage of non-English-speaking patients, and only 4% of small metropolitan hospitals had a high percentage of non-English-speaking patients. No micropolitan or noncore hospitals had a high percentage of non-English-speaking patients.

Information about hospitals that served a high percentage of Spanish speakers and their patients was also gathered:

• The top 10% of hospitals serving Spanish speakers were predominantly in large metropolitan areas (84%), moderately sized (had 100-299 beds, 56%), private, not for profit (51%), teaching (53%), and high occupancy (51%).
• Approximately 60% of patients at hospitals with a high percentage of Hispanic patients were insured by Medicaid, while 7% were uninsured. About 43% of these patients were from very low-income communities, while 24% were from low-income communities.

Language Assistance

Language barriers in health care are associated with decreases in quality of care, safety, and patient and clinician satisfaction and contribute to health disparities, even among people with insurance. The Federal Government has issued 14 culturally and linguistically appropriate services (CLAS) standards. These standards, which are directed at health care organizations, are also encouraged for individual providers to improve accessibility of their practices. The 14 standards are organized by themes: Culturally Competent Care (Standards 1-3), Language Access Services (Standards 4-7), and Organizational Supports for Cultural Competence (Standards 8-14). For people with limited English proficiency, having CLAS is of particular importance and may influence the patient's choice of a usual source of care.

Figure 5.7. Adults with limited English proficiency, by whether they had a usual source of care with or without language assistance, by race, ethnicity, income, and education, 2008

Key: USC = usual source of care.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2008.
Note: For this measure, lower rates are better. Hispanic and non-Hispanic include all races. Data were not available for those in the high-income group

[D] Select for Text Description.

• In 2008, Hispanic adults were significantly more likely than non-Hispanic adults to have a usual source of care with language assistance (Figure 5.7).
• In 2008, White adults with limited English proficiency were significantly more likely than Asians to have a usual source of care with language assistance.

Need for a Translator

The ability of providers and patients to communicate clearly with each other can be compromised if they do not speak the same language. Quality may suffer if patients with limited English proficiency cannot express their care needs to providers who speak English only or who do not have an interpreter's assistance. Communication problems between the patient and provider can lead to lower patient adherence to medication regimens and decreased participation in medical decisionmaking. It also can exacerbate cultural differences that impair the delivery of quality health care.

Figure 5.8. Adults age 18 and over who needed a translator during last doctor visit, California, by race/ethnicity, income, and education, 2008

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2008.

[D] Select for Text Description.

• In 2008, non-Hispanic White patients in California were significantly less likely than Hispanic patients to need a translator during their last doctor visit (0.5% compared with 10%; Figure 5.8). Non-Hispanic Whites also were less likely than Mexicans and Central Americans to need a translator. Asians were significantly more likely than non-Hispanic Whites to need a translator during their last doctor visit (3% compared with 0.5%). There were, however, no statistically significant differences between the overall Asian population and Chinese or Vietnamese patients. There also were no statistically significant differences between Chinese and Vietnamese patients.
• Also in 2008, poor (12%), low-income (7%), and middle-income (2%) patients were significantly more likely than high-income (0.7%) patients to need a translator.
• Patients in California with less than a high school education and high school graduates were significantly more likely to need a translator than patients with any college education (14% and 3%, respectively, compared with 1%).

Also, in the NHQR:

• In 2008, patients age 65 and over with Medicare and public insurance were significantly more likely than patients with Medicare and private insurance to have a usual source of care not ask for their help in making treatment decisions.

Providers Asking Patients To Assist in Making Treatment Decisions

The increasing prevalence of chronic diseases has placed more responsibility on patients, since conditions such as diabetes and hypertension require self-management. Patients need to be provided with information that allows them to make educated decisions and feel engaged in their treatment. Treatment plans also need to incorporate their values and preferences.

Figure 5.9. Adults with a usual source of care whose health providers sometimes or never asked for the patient's help to make treatment decisions, by race, ethnicity, income, education, and English proficiency, 2008

Key: AI/AN = American Indian or Alaska Native.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2008.
Note:For this measure, lower rates are better.

[D] Select for Text Description.

• In 2008, Whites were significantly less likely than Blacks, Asians, and people of more than one race to have a usual source of care who sometimes or never asked for the patient's help to make treatment decisions (15% compared with 18%, 24%, and 16%, respectively; Figure 5.9). In 2008, non-Hispanic White patients were significantly less likely than Hispanics to have a usual source of care who sometimes or never asked for the patient's help to make treatment decisions (14% compared with 18%).
• In 2008, patients with any college education were significantly less likely than patients with less than a high school education to have a usual source of care who sometimes or never asked for the patient's help to make treatment decisions (15% compared with 19%).
• In 2008, patients who usually spoke English at home were significantly less likely than patients who mostly spoke another language at home to have a usual source of care who sometimes or never asked for the patient's help to make treatment decisions (15% compared with 19%).

Also, in the NHQR:

• In 2008, patients age 65 and over with Medicare and public insurance were significantly more likely than patients with Medicare and private insurance to have a usual source of care not ask for their help in making treatment decisions.

References

Anderson EB. Patient-centeredness: a new approach. Nephrol News Issues 2002 Nov;16(12):80-82.

Bechel DL, Myers WA, Smith DG. Does patient-centered care pay off? Jt Comm J Qual Improv 2000 Jul;26(7):400-9.

Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract 2002 Jan-Feb;15(1):25-38.

Berry LL, Seiders K, Wilder SS. Innovations in access to care: a patient-centered approach. Ann Intern Med 2003 Oct 7;139(7):568-74.

DiMatteo MR. The role of the physician in the emerging health care environment. West J Med 1998 May;168(5):328-33.

Hargraves JL, Hays RD, Cleary PD. Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS®) 2.0 adult core survey. Health Serv Res 2003 Dec;38(6 Pt 1):1509-27.

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001a.

Institute of Medicine. Envisioning the National Health Care Quality Report. Washington, DC: National Academies Press; 2001b.

Little P, Everitt H, Williamson I, et al. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ 2001 Oct 20;323(7318):908-11.

Rhoades DR, McFarland KF, Finch WH, et al. Speaking and interruptions during primary care office visits. Fam Med 2001 Jul-Aug;33(7):528-32.

Shin H, Kominski R. Language use in the United States: 2007. American Community Survey Reports. Suitland, MD: U.S. Census Bureau; 2010. Available at: http://www.census.gov/hhes/socdemo/language/data/acs/ACS-12.pdf [Plugin Software Help].

Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000 Sep;49(9):796-804.

U.S. Census Bureau. Minority population tops 100 million. Suitland, MD: May 17, 2007. Available at: http://www.census.gov/newsroom/releases/archives/population/cb07-70.html.

U.S. Department of Health and Human Services, Office for Civil Rights. Guidance to federal financial assistance recipients regarding Title VI prohibition against national origin discrimination affecting limited English proficient persons. 68 Fed. Reg. 47311-02; August 2, 2008. Available at: http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/factsheetguidanceforlep.html. Accessed April 24, 2009.

U.S. Department of Health and Human Services, Office of Minority Health. Think Cultural Health: bridging the health care gap through cultural competency continuing education programs. Available at: http://www.thinkculturalhealth.hhs.gov.

^i. For example, Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, may require the practitioner or hospital to provide language interpreters and translate vital documents for limited-English-proficient persons. Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794, may require the practitioner or hospital to provide sign language interpreters, materials in Braille, and/or accessible electronic formats for individuals with disabilities.
^ii. This online program (available at http://www.thinkculturalhealth.org ) is accredited for Continuing Medical Education credits for physicians and Continuing Education Units for nurses and pharmacists.
^iii. This online program (available at http://www.hrsa.gov/publichealth/healthliteracy/) is accredited for Continuing Medical Education credits for physicians and Continuing Education Units for nurses, physician assistants, pharmacists, and Certified Health Education Specialists.
^iv. This course (available in the Association of American Medical Colleges' MedEdPORTAL, https://www.mededportal.org/publication/7740 ) has been presented at five national medical schools. For the 2011-2012 academic year, "Stopping Discrimination Before It Starts" has been incorporated into the fourth year curriculum at Emory University School of Medicine and the University of Colorado School of Medicine.
^v. Available at www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf [Plugin Software Help].

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