For visits that require language services, the most requested languages at NYC Health & Hospitals are Spanish, 44%, followed by Bengali, 13%, and Mandarin Chinese, 10%.
The public health system also tries to proactively prepare for events that could change that composition.
In anticipation of Ukrainian refugees who could be coming to New York, Wallach reached out to the mayor's Office of Immigrant Affairs to offer support.
NYC Health & Hospitals also reached out to language service vendors to warn that requests for Ukrainian interpreters could rise, said Margarita Larios, the system's director of operations and language services. She hasn't seen a spike in requests yet, but wants to know those services will be available.
Lack of language services could affect care quality for patients who need them. Nearly half of clinicians in a Rand survey said they thought the quality of telehealth care for patients with limited English skills was lower than for those who spoke English.
The Affordable Care Act and Civil Rights Act of 1964 are the main federal laws that have been interpreted to require language services for non-English speaking patients, said Mara Youdelman, a managing attorney at the National Health Law Program, a civil rights advocacy group based in Washington, D.C.
Both laws apply generally to health programs that accept federal funds or are federally administered and aren't specific to telehealth.
"I would love to see more explicit guidance—and even a 'how-to' guide—be put together for specific programs and activities," Youdelman said.
She suggested the Health and Human Services Department's Office for Civil Rights or Office of Minority Health could provide guidance on the responsibilities for telehealth companies and healthcare providers delivering care via telehealth under existing laws and what they can do to comply.
Youdelman added that insurers often don't pay for the cost of language services.
UCSF's Khoong suggested the federal government could set minimum standards for telehealth software, like the ability to integrate interpreters and be translated into different languages.
Having staffers at a healthcare organization who speak a patient's preferred language and can help navigate telehealth has proven helpful, said Denise Payán, an assistant professor in the public health program at the University of California, Irvine, and co-author on a study investigating the experiences of patients with limited English skills at community health centers.
"Often, it was the administrative staffers or non-healthcare providers who were the ones who were helping people to set up the call or helping them to set up the video," Payán said.
Researchers, who interviewed clinic staff and patients for the study, also found it was difficult to integrate third-party language services into video visits, and that patients receiving language services via phone call could be confused when an interpreter called them directly from an unknown number.
Columbia, Maryland-based MedStar Health started using a platform from company Bluestream Health for at-home video visits in March 2020. Bluestream, which MedStar had already been using in a limited capacity in the emergency department, lets providers request an interpreter on-demand from within a video visit.
Bluestream also sends messages to patients, such as invitations with a link to sign on to the telehealth visit, in their preferred language.
The system had to enter the pandemic with "humility," said Dr. Ethan Booker, medical director of the MedStar Telehealth Innovation Center. "The humility of being able to understand what your patients' needs are—including hearing when they don't have the best possible experience and listening carefully to that and trying to respond to it in a way that is agile."
That included feedback that sign-on instructions could be difficult to parse for patients who speak other languages or patients who find the print is too small, among other barriers.
The telehealth platform used at Miami-based Nicklaus Children's Health System is available in English and will be available in Spanish across the system by the end of May, said Evelyn Terrell, director of telehealth and special projects at Nicklaus Children's Hospital. The system is working to translate the platform into Haitian Creole, which will roll out by August.
Roughly 83% of patients who need language services for treatment at Nicklaus Children's ask for Spanish, followed by Haitian Creole at 12%, according to Terrell.
The language update is part of a broader expansion to the telehealth program that the system is rolling out, after testing changes over the past few months.
SameSky Health, a healthcare engagement and navigation company that provides support tailored to patients' cultural backgrounds, experienced a rise in patients needing help connecting to telehealth visits during the pandemic, said Abner Mason, the company's CEO and founder.
SameSky Health contracts with health plans and provider organizations, whose patients get access to its community health guide workers and care navigation resources.
Many health centers the company works with hadn't used telehealth before the COVID-19 crisis, and needed help making patients aware of the service, Mason said. So, the company developed information on what telehealth is and instructions for how to access a telehealth platform—which previously might have only been available in English—in patients' preferred languages.
To make a new approach to healthcare delivery like telehealth accessible, "you've got to have the ability for [patients] to engage within the language and culture that they're comfortable with," Mason said. "If we can't talk to people in a language that they're comfortable with, it's going to make it much harder to build trust."
