Language Access Basics

11/17/2014

Language Access BasicsUpdated ACA, CLAS and Joint Commission standards have changed the game for hospitals

Eliana Lobo for InDemand


Language Access BasicsUpdated ACA, CLAS and Joint Commission standards have changed the game for hospitals

How to comply with updated language access standards

A Language Access Plan is required by law. Entities enforcing penalties include:

The Federal government via the ADA Americans with Disabilities Act or ADA prohibits discrimination on the

basis of disability in employment, State and local government, public accommodations, commercial facilities, transportation, and telecommunications. It also applies to the United States Congress.

To be protected by the ADA, one must have a disability or have a relationship or association with an individual with a disability. An individual with a disability is defined by the ADA as a person who hasa physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such animpairment, or a person who is perceived by others as having such an impairment. The ADA does not specifically name all of the impairments that are covered

o Deaf, Deaf-Blind, Blind, Disabled (physically and mentally) all fall under the ADA

The Federal government via Title VI 1964 Federal mandate signed by President Johnson, prohibiting

discrimination based on race, religion, and country of origin. Title VI is part of the Civil Rights Act, which is administered by the Office of Civil Rights

o Denial of language access (i.e., access to an interpreter) is a civil rights violation. Any judgments awarded on behalf of plaintiff are NOT covered by malpractice insurance

The Joint Commission

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o Accreditation for hospitals hinges on following Joint Commission protocols. Increasingly, they have focused on LEP patients and their family’s experience of care, in the weighting of their onsite assessment, performed yearly at all major hospitals.

Recipients of Federal Funds are required, to take reasonable steps to ensure meaningful access to LEP persons. To comply with the law, you need to satisfy the 4 factor analysis.

What are the 4 Factors?

1. The number/proportion of LEP persons served or encountered in the eligible service population

2. The frequency with which LEP persons come into contact with the program 3. The nature and importance of the program, activity, or service provided

by the program4. The resources available and costs to the recipient

Are you providing MEANINGFUL language access, is the question you mustask at every step.

A Language Access Plan is good for LEP patients.

Poor patient–provider communication due to limited English proficiency (LEP) costs healthcare providers; hospitals; healthcare facilities; payers and everyone with a health insurance policy; money.

LEP patients traditionally exhibit Higher readmission rates Increased hospital and emergency room admissions

o No primary care provider, which leads too Overutilization of the Emergency Room for primary care

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More misdiagnoses, Increase in the number of diagnostic tests ordered Poor patient compliance,

o Leads to higher risk of medication errors o Difficulty linking to and following up with referrals

Longer LOS (length of stay)o Higher number of associated complications and higher

fall rateso Higher rates of no-shows for appointments

Scarcity of bilingual healthcare professionals and interpretation costs have hindered full implementation of language services despite federal and state laws requiring their provision.

For organizations seeking to initiate or expand their language services, the Internet provides access to guidelines, promising practices as well as best practice, planning tools, and research briefs. Such recent technological advances make provision of language services—to respond to federal and state mandates and improve access and quality of care to LEP persons more feasible than is widely believed. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2992399

LEP patients tend to be at greater risk for negative health outcomes. Over time, LEP individuals will also represent a disproportionately large percentage of the remaining uninsured; patients who regularly access services through emergency departments.

Given the incentives and penalties associated with the ACA, serving both insured and uninsured LEP patients will become more expensive. The cumulative effect should be a major incentive for healthcare organizations to provide the most effective services possible for LEP patients before, during, and after treatment. (Cyracom ACA 2013 white paper version 1, pg.2)

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2992399


ACA tightening standards and imposes progressively increasing fines

The ACA will be reducing reimbursement rates for failure to meet specific goals. As of October 2012, the government started cutting Medicare reimbursement for hospitals with readmission rates consideredexcessive. In 2015, hospitals that still have high rates of hospital-acquired infections will see a further reimbursement rate cut. With nearly one in five Medicare patients returning to the hospital within a month — about two million people a year — readmissions cost the government more than $17 billion annually. (http://www.nytimes.com/2012/11/27/health/hospitals-face-pressure-from-medicare-to-avert-readmissions.html?_r=0)

3% decrease in pay-outs for higher readmission rates, (rates thatare significantly higher among LEP patients)

o This is the third year the industry faces these penalties, which were created by the Affordable Care Act. This year potential fines are the highest: up to 3 percent of Medicare bills.

o The penalties aren't just getting increasingly harsh; they're also affecting more hospitals. Half of the hospitals in 29 states and the District of Columbia will be losing money. Those states include CA, FL, GA, IL, MA, NJ, NY, OH, PA, TN and TX, according to a Kaiser Health Newsanalysis of the penalties.

o One reason the punishments are expanding is that Medicare is tracking more conditions. In addition to patients suffering from heart failure, heart attacks and pneumonia, this year Medicare analyzed readmissions ofpatients with elective hip and knee replacements and lung ailments such as chronic bronchitis. As a result, some hospitals that never faced fines are now on Medicare's list.

Using an interpreter for conversations, and translations for written documents, helps organizations

o Reduce risko Reduce harm to patientso Improve patient satisfaction

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http://capsules.kaiserhealthnews.org/wp-content/uploads/2014/10/Readmissions-Year-3.csv

http://www.kaiserhealthnews.org/Stories/2014/October/02/Medicare-readmissions-penalties-2015.aspx

http://www.kaiserhealthnews.org/Stories/2014/October/02/Medicare-readmissions-penalties-2015.aspx

http://www.nytimes.com/2012/11/27/health/hospitals-face-pressure-from-medicare-to-avert-readmissions.html?_r=0

http://www.nytimes.com/2012/11/27/health/hospitals-face-pressure-from-medicare-to-avert-readmissions.html?_r=0


o Improve health outcomes Improved language access links directly to Patient Safety Other benefits include

o Improved efficiencyo Lower hospital costso Better outcomeso Reduced health disparities

For detailed information and resources to assist you as you create your LAP, please see:

http://portal.hud.gov/hudportal/HUD?src=/program_offices/fair_housing_equal_opp/promotingfh/lep-faq

http://www.in.gov/ocra/files/Civil_Rights_Form_10_-_Community_Sample_LAP_for_LEP_2010-10-06.pdf

FAQsWHAT DO I NEED TO INCLUDE IN MY LAP IN ORDER TO BUILD A SUCCESSFUL LANGUAGE ACCESS PROGRAM?

a. Language preference collection protocolsb. Provision of service to those spoken language populations in

excess of 5% of the local demographic, in at least one of the following modalitiesi. In-person interpreterii. Video interpreteriii. Telephonic interpreter

c. Provision of service to all Deaf, Hard of Hearing and Deaf-Blind clients without exception, at all times

What are common pitfalls when implementing a language access program?

THE NUMBER ONE ANSWER TO THAT QUESTION IS: NOT KNOWING YOUR DEMOGRAPHIC!

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Know the answers to the following two questions, right off the top of your head

o What are the top five languages needed for your service or location?

o How are you currently collecting these data?

IF I DON’T KNOW THE ANSWER TO THE TWO QUESTIONS ABOVE, HOW DO I REMEDY THAT?

At Registration, ASK patient for their preferred language

o Do NOT ask, “Do you speak English?”

Many LEP will answer “yes” if you ask the question this way out of fear of being turned away if they don’t speak English

Sadly, many institutions are reluctant to provide language access as mandated by law. Although their numbers are fewer today, the impact has been to cause fear of disclosing their language limitations by LEP patient and their families

o Ask instead, “What language would you prefer to use when discussing your medical concerns?”

Update your languages list (no more Yugoslavia/Czechoslovakia please!)

o Have a poster, notebook or reference where all languages are listed in English and in their native alphabet. Sometimes these lists also include a picture of the country’s flag. This helps the LEP patient point out which language they speak, which will assist you in locating an interpreter

Make sure the preferred language a “stop field” in the software program! If it

isn’t, ask I.T. for help

Track your interpreter requests and

Compare your interpreter request numbers to the Information Desk and/or

Registration numbers

Note any discrepancies because

o Discrepancies often mean inappropriate use of friends and family members as

interpreter

o Discrepancies can point to patients going without language access which is

a violation of the law

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Know the number of requests for your top languages and

o Track daily/monthly requests

o Track requests by location

IC-patient

clinics

Rehab

It is common for patterns of usage to show which will help you staff

accordingly

o For example, Mondays is traditionally a heavy interpreter use day

o Fridays tend to be lighter in volume

Facilitate the documentation on the EMR (electronic medical record) so

providers can accurately document the language and the fact that an

interpreter was used for the encounter

SOURCING

What is your plan to provide language access?o Assessed bi-lingual providers?

o Medical interpreter staff?

o Independently contracted interpreters?

o Interpreter agency contracts?

o Remote interpreting services?

What is your fallback position?o What is the protocol if the agency interpreter fails to show up on time or

at all?

o What is the protocol if the staff interpreter or bilingual provider calls out sick that day?

o What is the protocol for when you cannot source an available interpreter for a rarer language, (known as LLD, or language of limited diffusion)?

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o What is the protocol for when you can’t source a tactile interpreter for a Deaf-Blind patient?

SCHEDULING: HOW DO YOU ARRANGE FOR SERVICE? In advance, and for

Same day requests

GOOD METRICS LEADS TO BETTER SCHEDULING

Having good language preference collection means better outcomes when pairing clients with interpreters. You want to avoid mismatches, e.g.,wrong dialects, wrong language.

Consistently asking the question, “In what language would you prefer to discuss you medical concerns?” makes all the difference. The language field within your admitting form or registration software should be a “stop field”. A blank field should not lead to the assumption that the patient speaks English. A blank field indicates that the question was not asked, and it needs to be. Ask I.T. to make sure your language field is a “stop field”.

This way, you can ensure the question is asked of everyone regardless of appearance or the ability to say hello and state their name. Often,when asked a yes/no question, LEP will nod “yes”, because they want toshow they are cooperative. It should not be inferred that the patient actually understood the question itself.

Matching preferred interpreters with patients and clients leads to better outcomes and clearer exchanges of information as it avoids issues, which can often escalate, surrounding

o Differences in dialects

o Gender preference

o Clan or religious affiliations

Matching preferred ASL interpreters with Deaf patients also leads to better outcomes and greater patient satisfaction. Can you answer this question? What the difference is between a Certified Deaf interpretersand a Certified ASL interpreter?

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o Certified ASL interpreter is hearing and speaks English as well as sign language (ASL)

o Certified Deaf interpreters are Deaf, and assist Deaf patients who do not know ASL to communicate, in effect, forming a bridge between the Deaf client and the ASL interpreter

LANGUAGES OF LIMITED DIFFUSION (LLD)- HOW DO I PROVIDE LANGUAGE ACCESS FOR LLD PATIENTS AND THEIR FAMILIES?

o For a Central American agricultural migrant worker, whose first language isMixteco, providing a Spanish interpreter is not helpful. The same applies for other industries such as fishing, logging, fish processing plants, lumber mills, any and all agricultural jobs such as pickers and packers. All of these sectors attract a higher percentage of indigenous language speakers who are also LEP

o Do you know which indigenous languages come to your clinic or hospital in significant numbers?

Often when they come to your facility for the first time, it is via the Emergency room, due to an on the job accident

Are you ready for these patients?

o Sourcing interpreters for languages of limited diffusion is challenging but possible

Sometimes the solution is to find an indigenous Central American interpreter who speaks Spanish, sourced remotely, with your staff or agency interpreter who speaks English/Spanish available onsite to partner with the remote interpreter

ASL and Certified Deaf interpreters always partner to provide service

What are the must-haves for a language access plan?

The easiest and most cost effective way to source an interpreter, particularly at a moment’s notice, is via the telephone. However, the telephone will never be able to satisfy ADA requirements for the Deaf.Video remote interpreting can. Video remote interpreting can also help

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you locate interpreters for LLD patients with far greater ease than you can via your local pool of contractors.

If you have the budget to hire or contract in-person interpreters, video is an excellent back-up strategy. There are always times when demand exceeds capacity for a particular language. You can lose staff to illness or long-term leave, retirement and recruitment from anotheremployer. Sometime budget cuts don’t allow you to backfill vacated positions.

Have your strategy in place. Most institutions require a process for approving vendors. You need to have completed this process prior to the appointment where the patient is LEP.

o Availability must be 24/7, 365 days of the year

o This is the most basic, most affordable way, to provide language access to your LEP and Deaf patients.

CLAS standards require provision of meaningful language access to services. What exactly does that mean? It means for example, that the telephone doesn’t work for these scenarios:

Deaf patients Hard of hearing patients Patients in ICU Confused or elderly patients Mental health patients

For certain other scenarios, you will always want to use an onsite interpreter. Situations requiring complex cultural brokering often do best with an onsite interpreter such as:

Giving the patient bad news, best practice is to do this in person End of life/ Last rites Spiritual counseling Conscious sedation procedures Mental health encounters Family conferences ICU First visit by the patient to the facility

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Who is the Joint Commission and what do they do? Why do they matter?

An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 20,500 health care organizations andprograms in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

The onsite hospital inspection, undertaken yearly by the Joint Commission, has increasingly focused on the LEP patient experience. Successful accreditation depends on their scrutiny.

According to the Joint Commission Language barriers appear to increase the risks to patient safety It is important for patients with language barriers to have ready

access to competent language services Providers need to collect reliable language data at the patient

point of entry and Providers need to document the language services provided during

the patient–provider encounter

Remember, one size does NOT fit all! Different scenarios require different approaches.

IF YOU DON’T MEASURE IT, YOU DON’T KNOW HOW BIG IT IS!

HOW DO I KNOW WHAT KIND OF BUDGET AND RESOURCES I WILL NEED TO COMPLY WITH THESE LANGUAGE ACCESS REQUIREMENTS?

Have a SYSTEM for collecting language preference from clients and patients so you can adequately plan for your needs

What are your most frequently requested languages?11


You should plan for your top five at least, if not the top ten

What is the monthly frequency of interpreter requests for those languages?

How can you budget if you don’t know what you need?

Most hospitals use EPIC at registration

What does your organization use?

What are you doing about translated information for your patients? Many of our English-speaking patients are not getting good care becausethey cannot decode health care their information adequately, particularly discharge instructions and follow-up referrals. Health literacy is a problem for all of us. Our English-speaking patients share this problem with our LEP patients and with our Deaf and differently-abled patients.

Have a FALL BACK position for when your agency interpreter fails to show, or when an in-person interpreter for a particular language is not available such as

Telephonic interpreter serviceo Less popular with clients due to lower customer satisfaction

rates, but fulfills the Title VI requirement for basic language access provision.

o Again, assess for meaningful access! Video interpreter service

o Much higher user satisfaction rates than video for both patient and provider

o Users can see each othero Provides body language cues to interpretero Patients can display prescriptions bottles which are visible

to both the interpreter and the provider, leading to less

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time wasted trying to pin down medications names, needed refills, etc.

o Video works for both spoken language and ASL

Video trumps telephone in terms of both provider and patient satisfaction. Plan to use a MIX of services (in-person, video and telephone) to satisfy the variety of needs your LEP and disabled patients, and clients will have.

Once I have implemented my LAP, how do I ensure it’s working well?

Now that you’ve set up your language access plan, there are still steps you need to take to make sure it is well utilized by clients, providers, patients and their families.

Train all staff on how to work with interpreters

o Include in new employee orientation

o Include in volunteer orientation

o Include in spiritual care orientation

o Include in resident/intern/nurse and critical care staff

orientation

o Require this training as part of the annual competencies for

all staff

Collect language preference data at ALL points of entry

o Emergency Room

o Out-patient Clinics

o Referrals

o Transfers from other hospitals

o Transfers from one unit or floor to another unit or floor13


Collect LEP patient satisfaction via surveys

o Interpreters can assist filling out short surveys together

with your LEP patients

Translate signage into your top languages instructing patients

and families on how to request an interpreter

Translate patient education materials and instructions into your

top languages

o Develop enterprise-wide standards such as requiring all

patient education materials to be written at 6th grade

reading level and central archiving

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Best Practice for Working with Interpreters

IT’S MY FIRST TIME WORKING WITH AN INTERPRETER, WHAT DO I NEED TO KNOW?

Shorten what you have to say, by pausing frequently and SPEAK IN FIRSTPERSON. Don’t say, “Ask her, to tell you, how her pain level is today”. Say instead, “How is your pain today?”

WORKING WITH AN IN-PERSON INTERPRETER

Introduction, make sure everyone knows each other’s name, this isvery important to most cultures, and shows respect to patients. It also helps build trust

Review any time constraints upfront and inform the interpreter about the general nature of the visit. This is called the pre-session. One or two sentences will do, e.g.,

This is a first visit This is a referral for _____ care I need to give this patient a diagnosis We’re going to review pre-procedural preparation, etc.

Remember to document interpreter use in EMR During the encounter

o Look at the patient while they speak or you will miss valuable body language indicators

o Avoid asking questions that can be answered with a yes or no, use teach-back to confirm understanding

o Speak plainly. Avoid idiomatic expressions like ‘Feeling blue’ or ‘down in the dumps’ say “depressed” instead

‘Acting up’ or ‘Acting out’ say “misbehaving”15


In short, boring is better, plain direct language is best

WORKING WITH A VIDEO INTERPRETER FOR THE FIRST TIME, WHAT SHOULD I DO DIFFERENTLY?

NOT A THING!

Just make sure the volume and picture are satisfactory at the beginning of the interpreted session. Both end users have controls right on the screen, to increase or diminish their respective volumes,brightness and contrast.

SummaryTO COMPLY WITH THE LAW, YOUR FACILITY NEEDS TO SATISFY A FOUR -FACTOR ANALYSIS

1. The number or proportion of LEP persons served in the eligible service population

a. usually once a demographic hits 5% of the local population, it qualifies as one of the languages you should plan to offer with the assistance of in-house or contracted staff

2. The frequency with which LEP persons come into contact with your program

a. sometimes, due to the nature of the services offered, peoplewill travel from outside local city limits to seek services,or,

b. if they know they can access an interpreter at your facility, they will travel quite far in order to avail themselves of that service. So their numbers may not be reflected in local demographics based on residence

3. The nature and importance of the program, activity, or service provided

4. The resources available and costs to the recipient

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ASK YOURSELF ON A REGULAR BASIS, ARE YOU PROVIDING MEANINGFUL LANGUAGE ACCESS TO THOSE WHO NEED IT? This is the question you will be asked by the Joint Commission. Meaningful access is one of the CLAS standards.

“The key to providing meaningful access for LEP persons is to ensure effective communication between the entity and the LEP person.” (For complete details on compliance with these requirements, consult the HHS guidance on Title VI with respect to services for LEP individuals (65 Fed. Reg. 52762-52774, August 30, 2000) www.hhs.gov/ocr/lep.

What is effective for an LEP patient, may not effective for a Deaf patient, e.g., using a telephonic interpreter. Deaf-Blind patients’ needs differ significantly from other patients requiring assistance with language access. Again, there is no one solution for everyone. One size does not fit all.

Overall,o Video trumps telephone in terms of both provider and patient

satisfaction.o Meaningful access requires using a MIX of services

Patient safetyo Improved access leads to

Improved efficiency Lower hospital costs Better outcomes Reduction in health disparities

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Definition of Terms

1. ACA Affordable Care Act

2. ADA American with Disabilities Act

3. ASL American Sign Language

4. CLAS Culturally & Linguistically Appropriate Services

5. Deaf Needs ASL interpreter

6. Deaf-Blind Needs tactile interpreter

7. EMR Electronic Medical Record

8. Forms of access In-Person Interpreter

a. Telephonic Interpreter

b. Video Interpreter

c. Translated Forms and Documents

9. Hard of Hearing Needs technological assistance, amplification

10. Joint Commission published findings

a. Divi C, Koss RG, Schmaltz SP, Loeb JM. Language Proficiency and Adverse

Events in U.S. Hospitals: A Pilot Study. International Journal for

Quality in Health Care 2007; 19: 60-67.

b.

11. LAP Language Access Plan

12. LEP Limited English Proficient, needs spoken language interpreter

13. LLD Language of limited diffusion. Can be an indigenous language or a

foreign language that is underrepresented in the local population. Examples

include Mixteco and Zapoteco from Mexico, Tongan and Marshallese from the

Pacific Islands.

14. Title VI Federal mandate signed into law by President Johnson as part of

the Civil Rights Act, prohibiting discrimination on race, religion and country

of origin (which is where language access and language barriers come into

consideration)

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Certifying Bodies for Medical Interpreters

CCIE national accreditation (ASL)

o RID however, no medical specialization currently available for ASL

NCIHC national accreditation process (spoken language)

o CCHI - Medical

IMIA national accreditation process (spoken language)

o NBCMI - Medical

DSHS Washington state accreditation process (spoken language)

o Medical

o Social Service

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Web Links for Additional Detailed Information

1. About Deaf Culture

http://www.gallaudet.edu/clerc_center/information_and_resources/info_to_go/

educate_children_%283_to_21%29/resources_for_mainstream_programs/

effective_inclusion/including_deaf_culture/about_american_deaf_culture.html

2. ACA Affordable Care Act. Specifically, about the law.

http://www.hhs.gov/healthcare/rights/index.html

3. ACA Penalties for higher readmission rates

http://www.npr.org/blogs/health/2014/10/02/353306337/medicare-fines-record-

number-of-hospitals-for-excessive-readmissions

4. ADA American with Disabilities Act

http://www.ada.gov

5. ADA Guide to Disability Rights Law

www.ada.gov/cguide.htm

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http://www.ada.gov/cguide.htm

http://www.ada.gov/

http://www.npr.org/blogs/health/2014/10/02/353306337/medicare-fines-record-number-of-hospitals-for-excessive-readmissions


http://www.hhs.gov/healthcare/rights/index.html

http://www.gallaudet.edu/clerc_center/information_and_resources/info_to_go/educate_children_(3_to_21)/resources_for_mainstream_programs/effective_inclusion/including_deaf_culture/about_american_deaf_culture.html




6. ASL American Sign Language

http://www.nidcd.nih.gov/health/hearing/pages/asl.aspx

7. CLAS Culturally & Linguistically Appropriate Services

http://clas.uiuc.edu and

http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf

8. Deaf-Blind FAQs

http://www.aadb.org/FAQ/faq_DeafBlindness.html

9. Joint Commission

a. Language Proficiency and Adverse Events in U.S. Hospitals

http://www.jointcommission.org/limited_english_proficiency

b. Language Access and the Law

http://www.jointcommission.org/assets/1/6/Lang%20Access%20and%20Law%20Jan

%202008%20%2817%29.pdf

c. Advancing Effective Communication, Cultural Competence, and Patient-

and Family-Centered Care

http://www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727

.pdf

10. LEP FAQs

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http://www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727.pdf

http://www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727.pdf

http://www.jointcommission.org/assets/1/6/Lang%20Access%20and%20Law%20Jan%202008%20(17).pdf

http://www.jointcommission.org/assets/1/6/Lang%20Access%20and%20Law%20Jan%202008%20(17).pdf

http://www.jointcommission.org/limited_english_proficiency

http://www.aadb.org/FAQ/faq_DeafBlindness.html

http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf

http://clas.uiuc.edu/

http://www.nidcd.nih.gov/health/hearing/pages/asl.aspx


http://portal.hud.gov/hudportal/HUD?src=/program_offices/

fair_housing_equal_opp/promotingfh/lep-faq#q7

11. Medicare Fines Related to High Readmission Rates

http://www.npr.org/blogs/health/2014/10/02/353306337/medicare-fines-record-

number-of-hospitals-for-excessive-readmissions

12. Robert Wood Johnson - Interpreter Satisfaction Survey

http://www.rwjf.org/en/research-publications/find-rwjf-research/2007/03/

interpreter-satisfaction-survey.html

13. Tactile Interpreting

http://rid.org/UserFiles/File/pdfs/Standard_Practice_Papers/Drafts_June_2006/

Deaf-Blind_SPP%281%29.pdf

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http://rid.org/UserFiles/File/pdfs/Standard_Practice_Papers/Drafts_June_2006/Deaf-Blind_SPP(1).pdf

http://rid.org/UserFiles/File/pdfs/Standard_Practice_Papers/Drafts_June_2006/Deaf-Blind_SPP(1).pdf

http://www.rwjf.org/en/research-publications/find-rwjf-research/2007/03/interpreter-satisfaction-survey.html

http://www.rwjf.org/en/research-publications/find-rwjf-research/2007/03/interpreter-satisfaction-survey.html



http://portal.hud.gov/hudportal/HUD?src=/program_offices/fair_housing_equal_opp/promotingfh/lep-faq#q7

http://portal.hud.gov/hudportal/HUD?src=/program_offices/fair_housing_equal_opp/promotingfh/lep-faq#q7