AltaMed and Large-Scale Linguistic Interpretation Services for Patients with Limited English Proficiency (LEP) in California

Linguistic equity in healthcare refers to the principle that all patients - regardless of their language proficiency or the language they speak - should have equal access to high-quality and culturally appropriate healthcare. Healthcare providers and systems have an added responsibility to address language barriers and ensure that patients with Limited English Proficiency (LEP) can navigate the healthcare system effectively, comprehensively understand their health information and engage constructively with their healthcare provider when questions arise, and be able to participate in medical decision-making to the same extent as English-proficient patients. 

Achieving linguistic equity requires more than just providing interpreter services. It also involves collecting data on patients' language needs, training staff in cultural sensitivity and the appropriate use of interpretation services, developing culturally and linguistically appropriate health materials, and creating an organizational culture that values diversity and equity. The organizational responsibilities and means to both achieve and maintain high standards of linguistic equity for LEP populations is a critical need across the United States. Cultural understanding in the provisioning of healthcare facilitates transparent and impactful clinician-patient communication. Past research has shown that older people from Culturally and Linguistically Diverse (CALD) backgrounds benefit from and are open to using technological interpretation services to reduce communication barriers. Older Latino patients reported poor experiences related to inability to effectively communicate with their provider-simultaneously impacting their willingness to access healthcare services as well as their satisfaction with the quality of care received [1]. Key components to a positive interpretation experience include the accuracy of the interpretation and ease of using the technology [2]. 

Linguistic equity is important because language barriers can lead to disparities in health care access, quality, and outcomes for LEP patients. These patients may experience higher rates of medical errors, poorer health status, and lower satisfaction with their healthcare compared to English-proficient patients. By addressing language barriers and promoting linguistic equity, healthcare providers can help to reduce these disparities and improve health equity for diverse patient populations. Research has shown that patients who speak a non-dominant language are more likely to not only have an unanticipated Emergency Room (ER) visit but moreover, children whose parents do not speak a dominant language are more likely to go to the ER [3]. Language is also a critical social determinant of health. Fewer resources for patients speaking a non-dominant language was associated with lower COVID-19 vaccination rates and delays in care that impacted COVID-19 mortality and hospitalizations [4,5]. A study combining 2013 American Hospital Association and Hospital Compare data found that hospitals that had standardized protocols identifying language needs at the time of a patient’s hospital admission also had lower median hospital Length-of-Stay (LOS). This impact on hospital courses was likewise found in hospitals that, in advance, accommodated patient cultural and dietary needs [6]. 

For patients with Limited English Proficiency (LEP), healthcare practitioners can lessen inequities, enhance health outcomes, and advance linguistic equity by using these measures. Leading the charge to become a true language equity leader is AltaMed, the largest Federally Qualified Health Center (FQHC) in the United States of America. Originally known as the East LA Barrio Free Clinic, AltaMed was founded on Whittier Boulevard in 1970. It has more than 55 years of experience serving the people of Southern California. Under the direction of its CEO, Cástulo de la Rocha, AltaMed has grown to become one of the biggest healthcare systems in the region, employing 5,500+ professionals across 60 locations and providing annual care to almost 889,000 patients. 

Due to AltaMed’s diverse patient population, it became evident that to deliver care in ways their patients understand; they needed to create a department that could strategize and collaborate with physicians and stakeholders to ensure that AltaMed was providing culturally and linguistically appropriate services to their communities. As a result, the Department of Cultural and Linguistic Competency was created over 15 years ago. Recently, in the year 2024, the Cultural and Linguistic Competency department changed its name to Cultural and Linguistic Equity, highlighting the importance of aligning to best practices of incorporating linguistic equity within healthcare. The department's primary focus is ensuring compliance, training physicians and staff on the importance of language justice, and overseeing language access programs within the organization.

The volume of calls and segregation by language was completed using Microsoft Excel and evaluated call volume from January 2023 to December 2023. Descriptive statistics were obtained for the number of total calls by language alongside of percent of calls by language relative to all language calls. The data was extracted from the language vendors' dashboard, providing comprehensive insights into interpretation service usage. Raw data from vendor dashboards was consolidated and processed using Microsoft Excel. The data was cleaned to remove duplicate entries and standardize language categorizations. The segregation of calls by language was completed using Excel's pivot table and filtering functions to enable detailed analysis of usage patterns. 

The AltaMed protocols for language services are derived from the standard operating procedures and policies of the AltaMed Department of Cultural and Linguistic Equity. All language access protocols followed AltaMed's standard operating procedures, which align with Title VI of the Civil Rights Act requirements, Section 1557 of the Affordable Care Act, National CLAS (Culturally and Linguistically Appropriate Services) Standards, and the Joint Commission standards for patient-centered communication. 

These protocols were implemented under the supervision of AltaMed's Department of Cultural and Linguistic Equity, with regular reviews to ensure compliance with organizational policies and regulatory requirements. 

Data 

Figure 1 shows the linguistic interpretation services clinical workflow. AltaMed has refined and streamlined the process of accessing interpreter services within our organization. When patients walk into our office, they are met by bilingual front office staff. Once the patient is in the check window, a language services flyer allows patients to point to their preferred language so that AltaMed can provide interpreter services upon request. AltaMed offers over 45 languages via Video Remote Interpretation (VRI) and over 200 languages via Over-the-Phone Interpretation (OPI) and On-Site Interpretation (OSI) (Table 1). 

 Figure 1: Office-based interpretation services patient protocol. 

Table 1: Number of calls and percent of total calls by linguistic interpretation service for AltaMed (January-December 2023). 

Figure 2 shows a bar graph representation of the total calls by language serviced during the dates of January 2023 to December 2023. 

 Figure 2: Total number of calls by language serviced (bar graph).

The analysis reveals two essential aspects of linguistic equity. The first is the implementation, which consists of staff training, multilingual resources, and interpreting services. The second, possibly more complex, is the cultural shift that healthcare institutions must undergo to accept linguistic diversity fully. Both elements are necessary to establish a setting in which linguistic barriers do not prevent high-quality care. Our results show that 54 different languages had interpretation services employed during the study period. Of these, 92.8% of all interpretation services used at AltaMed during the study period were Spanish language-representing 52,217 distinct calls. The next highest was Mandarin language services at 1.70% or 956 distinct calls and then Russian at 1.04% or 589 distinct calls. There is a heavy skew with a left-sided tail wherein the remainder 51 languages were interpreted at less than 0.50% or fewer than 300 distinct calls. 

The wide linguistic diversity among the patient population is evidenced by the interpretation calls that were recorded during the study period, with services rendered in 54 different languages. Spanish accounted for 92.82% (n=52,217) of all requested interpretation services, making it the most requested language. This conclusion matches the demographic makeup of AltaMed's service region and is consistent with the organization's historical beginnings servicing Southern California's largely Hispanic neighborhoods. Mandarin (1.70%, n=956), Russian (1.05%, n=589), Cantonese (0.56%, n=315), ASL (0.49%, n=273), and Korean (0.55%, n=255) were the top five most requested languages after Spanish. 

These six languages, along with Spanish, accounted for 97.07% of all requests for interpretation, indicating Following Spanish, Mandarin (1.70%, n=956), Russian (1.05%, n=589), Cantonese (0.56%, n=315), ASL (0.49%, n=273), and Korean (0.45%, n=255) were the top five languages requested. These six languages accounted for 97.07% of all interpretation requests, including Spanish, indicating a concentrated need for these particular language services. Even in cases where usage patterns are heavily biased toward a primary language, these findings emphasize the difficulty of delivering linguistically appropriate healthcare services in a multicultural urban environment and the significance of preserving strong interpretation services across a wide range of languages. 

When a patient requests interpreter services, AltaMed has cutting-edge technology that allows staff and patients to communicate effectively in their preferred language in the check-in windows, exam rooms, or any other setting within the healthcare center. There are three ways patients could receive interpreter services: Video Remote Interpretation (VRI), On-Site Interpretation (OSI), and Over-the-Phone Interpretation (OPI). The more accessible and cost-effective modalities are VRI and OPI. AltaMed can also provide On-Site Interpretation (OSI) on special occasions and upon request. On-site interpretation allows the most personal approach but is the most expensive modality. The VRI device has over 45 video languages you can click, connecting you to an interpreter in less than 30 seconds for languages that are not of lesser diffusion. However, the standard is less than 2 minutes. AltaMed monitors connection times to ensure vendors staff accordingly based on our needs. 

If the patient's language is unavailable via video, AltaMed can access over 200 languages available via OPI. To access over-the-phone interpretation, each site is equipped with its own site-specific 800 number, which allows for easy cost allocation. The caller will need to dial the 800 number, and they will be connected to an “Interactive Voice Response,” a system that allows you to quickly select the language desired for interpretation and be connected immediately to an interpreter without interaction with a live attendant. If the language you need is not listed, the caller can press 0, and they will be connected to the remaining audio languages. AltaMed has put in place three standard questions that the interpreter asks for quality assurance and accurate cost allocation. When the interpreter picks up the phone, they ask the caller to provide their employee ID, location, and MRN. Cultural and Linguistic Equity works across the enterprise to ensure that providers and support are trained, and vendor oversight, and quality is measured to ensure that all patients receive access in their preferred language. 

On-Site Interpretation (OSI) services are particularly critical in specialty care settings, where complex medical discussions, diagnostic procedures, and treatment plans require nuanced communication and comprehension. These specialized medical encounters often involve detailed explanations of conditions, treatment options, and potential risks - conversations that benefit significantly from the presence of a qualified medical interpreter. Recognizing this necessity, AltaMed has extended its OSI services beyond its network, offering interpretation support to non-affiliated specialty providers who serve AltaMed patients. This extension ensures linguistic continuity throughout the patient's healthcare journey, even when specialty care necessitates treatment outside the AltaMed system. 

AltaMed's interpretation services protocol implements a sophisticated, three-tiered approach utilizing On-Site Interpretation (OSI), Over-the-Phone Interpretation (OPI), and Video Remote Interpretation (VRI). This comprehensive system allows for dynamic allocation of interpretation resources based on several key factors: the clinical complexity of the appointment, the patient's linguistic needs, the availability of technology at the point of care, and the urgency of the medical situation. The protocol establishes clear decision pathways for determining the most appropriate interpretation modality, ensuring consistent service delivery across all facilities. 

This examination suggests that achieving accurate linguistic equity requires a systemic approach. Healthcare organizations must move beyond viewing language services as merely a compliance requirement and instead recognize them as integral to delivering equitable, patient-centered care. Future research might explore how emerging technologies and innovative approaches could enhance linguistic equity in healthcare settings. 

There are a range of practices that will effectively support linguistic equity provisioning in a healthcare system: 1) Provides professional interpreter services in the patient's preferred language for all healthcare encounters, 2) Uses bilingual/bicultural staff and community health workers to facilitate communication and navigation of the healthcare system, 3) Develops health education materials and informed consent documents in the languages spoken by the patient population, 4) Includes language data in electronic health records and uses this data to identify language needs and track disparities, 5) Provides cultural competency training for all staff on the importance of language access and how to work effectively with interpreters, and 6) Has a written language access policy and a plan for implementing the national standards for culturally and linguistically appropriate services (CLAS).

All authors discussed the results and contributed to the final manuscript. J.G., C.G., and M.V.R., collected the data and helped draft the manuscript. Y.C. helped write the manuscript and provided supervision over data collection. V.S. completed the data analysis and helped write the manuscript.

Not applicable.

There was no funding received for this work.

There are no conflicts of interest

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