Mind the Gap: Identifying and Addressing Communication Barriers with Non-English-Speaking Caregivers for Medically Complex Children

We know our patient communication can suffer with language barriers, even with the use of interpreters. As our patients become more complex, so does the communication of their care. While many studies have investigated existing communication techniques with caregivers for children with medical complexity (CMC),^1–3 and studies have examined best practices for communicating with patients with a different preferred language,^4–6 a new study recently published in Hospital Pediatrics, entitled “Improving Hospital-to-Home for Medically Complex Children: Views from Spanish-Speaking Caregivers,” addresses the overlap between those two queries (10.1542/hpeds.2024-007925).

The transition to home is a time rife with potential missteps and setbacks. Readmission rates are even higher for CMC, as we can all intuit when we remember patients re-admitted for medication errors, supply issues, or exacerbations of underlying conditions.⁷ Caregivers with non-English preferred languages (languages other than English [LOE]) face language discordance in their interactions with pharmacies, home health, and written instructions. How can we narrow the gap of our language discordance for this specific patient population?

This study examined this question through semi-structured interviews with caregivers of CMC with a primary preferred language of Spanish, conducted 1–3 days after discharge. Spanish-speaking caregivers were chosen because Spanish is the number one non-English language spoken in the US, and because of the availability of interpretation services for Spanish in this and many other institutions.

Fourteen physician interviews and 14 paired caregiver interviews were conducted with a bilingual research assistant for the caregivers and a physician team member for the physicians, following submission of self-reported questionnaires by the study participants. Interviews were transcribed, professionally translated as needed, and then reviewed and coded by 2 members of the research team.

Challenges were identified from these interviews, including the language discordant care that can be provided by other key stakeholders for CMC, such as supply vendors and insurance companies. Families reported difficulties not so much with large discussions or rounds, but with small questions and interactions, like the findings of prior research for LOE families.^4–6 Similar to those prior studies, caregivers also reported feeling that they were burdening their care team with their questions or needs for interpretation.

This paper goes further by interviewing caregivers and physicians on not just existing challenges, but possible mitigating strategies. Physicians should use interpretation services (which other studies suggest are best in person, followed by video and then phone)⁵ for all interactions, including extemporaneous interactions. Perhaps think of blocking out interpretation time leading up to patient discharge, so that the ins-and-outs of the care team can be relayed in real time. And when communicating in writing (patient portals, prescription administration information, patient instruction), write in the caregiver’s preferred language whenever possible.

Of note, DME providers do not consistently use interpreters for education, and as many readmissions can be caused by technological complications, this offers a clear opportunity for improvement.

This study showed similar themes as prior qualitative studies with LOE families for non-CMC patients, perhaps exacerbated by the volume and intricacy of the communication for CMC patients. As our care for CMC advances, we can continue to advance our communication techniques and aim to provide the same level of care to our LOE patients and caregivers that we provide to their language-concordant counterparts.

"We can learn an extraordinary amount about improving the hospital discharge experience for all children by listening to the perspectives of some of the most vulnerable families, including LOE  caregivers of CMC."

References

1. Desai AD, Zhou C, Simon TD, Mangione-Smith R, Britto MT. Validation of a parent-reported hospital-to-home transition experience measure. Pediatrics. 2020;145(2). doi:10.1542/peds.2019-2150
2. Coller RJ, Klitzner TS, Lerner CF, et al. Complex care hospital use and postdischarge coaching: A randomized controlled trial. Pediatrics. 2018;142(2). doi:10.1542/peds.2017-4278
3. Coller RJ, Nelson BB, Sklansky DJ, et al. Preventing hospitalizations in children with medical complexity: A systematic review. Pediatrics. 2014;134(6):e1628-e1647. doi:10.1542/peds.2014-1956
4. Cheng JH, Wang C, Jhaveri V, Morrow E, Li STT, Rosenthal JL. Health Care Provider Practices and Perceptions During Family-Centered Rounds With Limited English-Proficient Families. Acad Pediatr. 2021;21(7):1223-1229. doi:10.1016/j.acap.2020.12.010
5. Velez T, Gati S, Batista CA, de Rivera JN, Banker SL. Facilitating Engagement on Family-Centered Rounds for Families With Limited Comfort With English. Hosp Pediatr. 2022;12(5):439-446. doi:10.1542/hpeds.2021-006403
6. Ju A, Sedano S, Mackin K, Koh J, Lakshmanan A, Wu S. Variation in Family Involvement on Rounds Between English-Speaking and Spanish-Speaking Families. Hosp Pediatr. 2022;12(2):132-141. doi:10.1542/hpeds.2021-006221
7. Glick AF, Farkas JS, Magro J. Management of Discharge Instructions for Children With Medical Complexity: A Systematic Review. Pediatrics. 2023;152(5). doi: 10.1542/peds.2023-061572