DEAF ADVOCACYHCS 330

Christopher Chavez

The deaf culture, infused with its own language and heritage, this must be represented with responsibility.

We identify ourselves as deaf or hard of hearing.

Phrases such as “deaf-mute”, “deaf and dumb”, and “hearing impaired” are inaccurate and not acceptable.Audiences have the right to portrayals of deaf and hard of hearing people that show us as we are so that there is increased understanding, acceptance.

Our unique identities are forged by our lifelong experiences, and no amount of research and training can prepare a hearing actor to approximate what it is like to be or to sign or speak like a deaf or hard of hearing person.

Most medical training programs fail to adequately prepare medical staff to effectively communicate with deaf individuals.

The first step to ensuring better health care access for deaf individuals is the establishment of a strong relationship between the primary care provider and the patient.

A strong primary care provider-patient relationship has been demonstrated to be critical to improving chronic disease management while reducing inappropriate and unnecessary health care services.

However, due to communication barriers, many individuals who are deaf are unable to establish a strong relationship with their primary care providers. This frequently results in inadequate comprehension of disease management and poor treatment adherence.

Anecdotal evidence suggests that because of language and communication barriers, deaf individuals are more likely to over-utilize the emergency room and urgent care services for routine health care matters.

Research demonstrates that in hospital settings, effective communication can result in:

• Shorter lengths of stay (LOS)

• Fewer hospital readmissions

• Fewer emergency room visits

• Better treatment adherence

• Better medical follow-up

• Fewer unnecessary diagnostic tests

• Better healthcare outcomes

• Better patient health care satisfaction

Guidelines for the Health Care Provider

1. Clearly identify at-risk individuals for poor communication

Flag records to recognize those who need language and communication assistance. This can potentially be done through a pop-up window in the patient’s chart in the electronic medical record or by labeling a patient chart with a universally recognized icon to indicate that the patient is deaf.

2. Visual Medical Aids Where necessary to facilitate patient education and

communication use charts, diagrams, models and aids in the office to help explain certain concepts and basic anatomy. In addition, provide a list of online resources to reinforce teaching and understanding.

3. Providers who know basic sign language

a. Be aware of your limits: having basic sign language skills can certainly make a deaf patient more comfortable. However, this does not meet the level of fluency required for effective communication, especially in regards to complex health care discussions. Language fluency often requires years of training, which is true of any language including ASL. Consequently, using basic sign language skills should only be used as a last resort in an emergency situation such as when an interpreter is not readily available and even then should only be used until a professional interpreter arrives. It is important that providers be honest with their assessment of their ASL fluency, in addition to be receptive to any potential patient communication issues.

b. If bilingual staff members are used as interpreters, their sign language fluency should be assessed by a an accredited certifying body, such as the Registry Interpreter for the Deaf (RID) prior to providing services,

4. Establish an effective communication office policy

It is recommended that the frontline staff should ask deaf patients what their communication needs are and document this in the patient’s medical records to facilitate any future requests. Documentation should be clear on how any language or communication needs were addressed with each patient at each visit. This should also include any reason why accommodations were declined by the patient.

To provide qualified interpreting services, it is recommended that medical providers and/or centers build a database of qualified sign language interpreters with expertise in medical settings. This database should be used as a reference for all medical situations that may come up in the future. Medical centers, including health care providers can contact any of the following organizations to learn about potential listings of certified sign language interpreters: the a deaf and hard of hearing state commission, if one exists, the state association of the deaf, the National Association for the Deaf (www.nad.org), as well as local chapters of the Registry of Interpreters for the Deaf (RID) (www.rid.org). The listing of interpreter agencies and certified interpreters should be freely available to any health care staff that is responsible for coordinating language and communication services for deaf patients.

5. Provide qualified sign language interpreters

a. Interpreters should be familiar with medical terminology and medical context in order to effectively interpret in the healthcare setting. While there is no medical certification for sign language interpreters at the present time, medical interpreting requires training and experience that is not routinely integrated into most interpreter training programs. This is usually obtained through continuing educational opportunities and collaborating closely with skilled medical interpreters.

b. Deaf individuals may vary with their preferences for types of sign languages and signing styles. For example, some deaf individuals may prefer an English-based sign language or ASL. Individuals who are deaf-blind or experience low vision (e.g. Usher’s syndrome) may require a tactile sign language or they may need an interpreter to stand at close proximity.

c. Certain individuals may require the addition of a Certified Deaf Interpreter (CDI). A CDI is a certified interpreter who is also deaf or hard of hearing who works in tandem with the sign language interpreter. This type of an interpreter is specially trained to facilitate communication between the medical provider and individuals who are deaf with poor communication skills secondary to language deprivation or use a foreign or home-based sign language unfamiliar to the medical interpreter (refer to www.rid.org)

5. Provide qualified sign language interpreters

d. Health providers and staff should understand the patient’s specific language and communication needs. This is best done by finding out directly from the patient as to his or her needs. The patient will have the best ability to assess their needs and what tools are needed to ensure effective communication. Language and communication needs should be determined upon enrollment as a new patient or visit and should be done prior to each appointment or encounter. The individual should be asked about the quality of their health communication and accommodations they receive to ensure that effective communication is being provided.

e. When applicable or requested, certified interpreters familiar with medical interpreting should be provided at all times. If face-to-face interpreters are not available, then video remote interpreting services should be offered. Need link here to NAD’s position paper on VRI services.

f. The use of friends and family members, especially children of deaf individuals, as interpreters, should be avoided due to lack of impartiality, unfamiliarity with medical terminology and interpreting strategies, and difficulty in communication during times of highly sensitive medical topics or duress.

5. Provide qualified sign language interpreters

g. The use of qualified interpreters leads to fewer clinical errors, higher patient satisfaction, and better clinical outcomes.

h. Health care providers and staff should make every effort to inform and assist interpreters in understanding clinical information that is to be presented. Avoidance of medical jargon or acronyms should be minimized to enhance effective communication.

i. Health care providers and staff should make every effort to look at the patient directly, not the interpreter, to both engage the deaf patient and to improve patient-provider alliance. This also helps establish a therapeutic alliance.

j. Speak in the first person to the deaf patient even if the patient is looking at the interpreter. Do not assume talking loudly will help increase understanding.

6. Ineffective methods of communication

a. Lip/speech reading is frequently ineffective. Many factors reduce lip reading abilities (e.g. lighting, facial hair, foreign or regional accents). Many sounds cannot easily be read on the lips. Additionally, patients who are anxious, scared, fatigued, affected by medication, may all hinder the patient’s ability to effectively lip/speech read. Many deaf people, particularly in medical settings, will feign to understand and nod their heads in agreement. This is usually not an indication that they are understanding but as a result of feeling reticent to inform the health care professional that they are NOT able to understand. Teach-back is extremely important in assessing and ensuring patient’s understanding.

b. Do not assume note writing is an effective communication tool. American Sign Language is not based on written or spoken English. The syntax and grammatical structure are very different from English. English is often a second language for many deaf people just as it is for people coming from other countries. Writing is also labor intensive and for many deaf people as well as health care providers, writing may be found to be cumbersome and inefficient in a medical setting.

7. Effective Communication

7. Effective Communication Approaches: Resources

a. Patient education programs such as AskMe3 . See: www.npsf.org/for-healthcare-professionals/programs/ask-me-3/

b. Teach-Back method to improve communication between patient and health care provider. See: www.nchealthliteracy.org/toolkit/tool5.pdf

c. Joint Commission See:(http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf)

d. American Academy of Family Physicians for further information on effective communication with deaf individuals.

Criminal laws and lawyers

Recent NAD Action Highlights ◦Robertson v. Los Animas County Sheriff’s Department – A deaf man

alleged that he could not make a phone call from jail or participate in a televised advisory hearing that had no captions. A federal trial court dismissed the case. The NAD joined the case on appeal and won reinstatement of the deaf man’s disability discrimination claims. The case later settled.

◦Cuevas v. City of Hialeah, Florida – A deaf couple alleged that the police failed to provide qualified interpreters and involuntarily committed the wife to a hospital on two separate occasions because she was deaf. This matter was resolved.

◦Mosier v. Commonwealth of Kentucky – A deaf attorney alleged that the Kentucky state courts have a policy of not providing interpreters to ensure effective communication with deaf attorneys when they appear in court. This case is pending.

Movies

The Americans with Disabilities Act (ADA) makes it clear that movie theaters are a place of public accommodation and should provide the accommodations needed by people with disabilities, including people with hearing loss. Theaters are required to provide assistive listening devices and have worked to comply with that regulation for many years. However, until recently theater owners have successfully contended they were not required to provide captioned movies.

In April, 2010, the Ninth Circuit Court of Appeals ruled that the Americans with Disabilities Act does require movie theaters to show closed-captioned movies unless doing so would constitute an "undue burden." Then in July, 2010, the US Department of Justice (DOJ) released an Advanced Notice of Proposed Rulemaking that made it clear closed captioning of movies would be considered a reasonable accommodation

Hearing Aides 80% of people who could benefit from hearing aids do not get them.

There are many reasons why people do not seek help for their hearing loss but we should not underestimate the impact of the cost of hearing aids. The number one inquiry that comes into the HLAA office is about affording hearing aids and the number one page visited on the HLAA website is the information fact sheet on financial aid for hearing technology.

To overcome the barrier that cost presents and to encourage more people to take action to treat their hearing loss HLAA has been focusing on ways to improve access to affordable hearing health care. There is no one silver bullet and so we are working on several fronts:

• Educating about itemization of professional services & price transparency

• Supporting Hearing Aid Tax Credit legislation: H.R. 1479 & S 905 • Advocating for insurance coverage & tax relief in the states • Supporting lower cost options for consumers

• Supporting Direct Access for Medicare Recipients

• Insurance coverage under employer plans • HLAA member discounts for hearing aids • Essential Health Benefit in the Affordable

Care Act • Supporting innovative approaches to

entering the hearing health care system ◦ Mobile apps

◦ Telemedicine ◦ Software to program hearing aids/implants