VA Health Care
Facilities Have Taken Action to Provide Language Access Services and Culturally Appropriate Care to a Diverse Veteran Population Gao ID: GAO-08-535 May 28, 2008The Department of Veterans Affairs (VA) faces challenges in bridging language and cultural barriers as it seeks to provide quality health care services to an increasingly diverse veteran population in terms of race, ethnicity, sex, and age. To meet the needs of veterans with limited English proficiency (LEP), VA issued an LEP Directive that provides guidance for medical centers in assessing language needs and, if needed, developing language access services designed to ensure effective communication between English-speaking providers and those with LEP. In addition, VA is also challenged to deliver health care services in ways that are culturally appropriate--that is, respectful of and responsive to the cultural values of a diverse veteran population. In light of these challenges, GAO was asked to discuss the (1) actions VA has taken to implement its LEP Directive and the status of veterans' utilization of language access services, and (2) efforts VA has made to provide culturally appropriate health care services. GAO reviewed VA's policies and the LEP Directive, interviewed VA officials and reviewed efforts by 6 VA medical centers and 10 other VA facilities to implement VA's LEP Directive and to provide culturally appropriate health care services. GAO also reviewed documents from 17 other VA medical centers related to implementation of the LEP Directive.
VA reported that as of June 2007, all of its medical centers had taken action to implement the guidance in VA's LEP Directive. Specifically, medical center officials told VA that they had assessed the language needs of their veteran service populations, and, if necessary, developed language assistance policies and offered language access services, including providing translated materials and interpretation services. The VA medical centers GAO reviewed provided translated materials to meet the various language needs of their veteran service populations and offered interpretation services as well. For example, VA medical centers maintained a list of bilingual medical center staff who can provide interpretation services during a clinical encounter between a provider and a veteran with LEP. In addition, five of the six VA medical centers GAO reviewed can access telephone interpretation services that are provided through a contract to help ensure that medical staff can communicate with veterans and their families with LEP. According to officials at medical centers GAO reviewed, utilization of language access services is low. However, VA officials told GAO that they expect the demand for language access services to grow as the increasingly diverse military servicemember population transitions to veteran status. VA medical centers are addressing the need for culturally appropriate health care services through staff training and tailoring health care services. Medical centers provide training for medical center staff to facilitate the delivery of culturally appropriate health care services including an annual mandatory training on the health care needs of veterans in various age groups. VA medical centers and other VA facilities GAO reviewed have implemented a variety of measures to meet the needs of their culturally diverse veteran populations. For example, three VA facilities GAO reviewed offer spiritual services, such as the use of medicine men and traditional healing rituals, in order to meet the needs of Native American veterans. Also, VA has minority veterans program coordinators at each medical center to identify barriers to health care for minorities and advise medical center officials in developing services to make health care more accessible and culturally appropriate for minority veteran populations. VA medical centers GAO reviewed have also initiated outreach efforts to promote the availability of culturally appropriate care. In commenting on a draft of this report, VA stated that it agreed with the information presented as it pertained to VA.
GAO-08-535, VA Health Care: Facilities Have Taken Action to Provide Language Access Services and Culturally Appropriate Care to a Diverse Veteran Population
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
May 2008:
VA Health Care:
Facilities Have Taken Action to Provide Language Access Services and
Culturally Appropriate Care to a Diverse Veteran Population:
This report includes a Spanish translation of the Highlights page,
[hyperlink, http://www.gao.gov/highlights/d08535high.pdf].
Para ver la versión de "Highlights" en inglés e español, [hyperlink,
http://www.gao.gov/highlights/d08535high.pdf], oprima aquí.
GAO-08-535:
GAO Highlights:
Highlights of GAO-08-535, a report to congressional requesters.
Why GAO Did This Study:
The Department of Veterans Affairs (VA) faces challenges in bridging
language and cultural barriers as it seeks to provide quality health
care services to an increasingly diverse veteran population in terms of
race, ethnicity, sex, and age. To meet the needs of veterans with
limited English proficiency (LEP), VA issued an LEP Directive that
provides guidance for medical centers in assessing language needs and,
if needed, developing language access services designed to ensure
effective communication between English-speaking providers and those
with LEP. In addition, VA is also challenged to deliver health care
services in ways that are culturally appropriate”that is, respectful of
and responsive to the cultural values of a diverse veteran population.
In light of these challenges, GAO was asked to discuss the (1) actions
VA has taken to implement its LEP Directive and the status of veterans‘
utilization of language access services, and (2) efforts VA has made to
provide culturally appropriate health care services.
GAO reviewed VA‘s policies and the LEP Directive, interviewed VA
officials and reviewed efforts by 6 VA medical centers and 10 other VA
facilities to implement VA‘s LEP Directive and to provide culturally
appropriate health care services. GAO also reviewed documents from 17
other VA medical centers related to implementation of the LEP
Directive.
What GAO Found:
VA reported that as of June 2007, all of its medical centers had taken
action to implement the guidance in VA‘s LEP Directive. Specifically,
medical center officials told VA that they had assessed the language
needs of their veteran service populations, and, if necessary,
developed language assistance policies and offered language access
services, including providing translated materials and interpretation
services. The VA medical centers GAO reviewed provided translated
materials to meet the various language needs of their veteran service
populations and offered interpretation services as well. For example,
VA medical centers maintained a list of bilingual medical center staff
who can provide interpretation services during a clinical encounter
between a provider and a veteran with LEP. In addition, five of the six
VA medical centers GAO reviewed can access telephone interpretation
services that are provided through a contract to help ensure that
medical staff can communicate with veterans and their families with
LEP. According to officials at medical centers GAO reviewed,
utilization of language access services is low. However, VA officials
told GAO that they expect the demand for language access services to
grow as the increasingly diverse military servicemember population
transitions to veteran status.
VA medical centers are addressing the need for culturally appropriate
health care services through staff training and tailoring health care
services. Medical centers provide training for medical center staff to
facilitate the delivery of culturally appropriate health care services
including an annual mandatory training on the health care needs of
veterans in various age groups. VA medical centers and other VA
facilities GAO reviewed have implemented a variety of measures to meet
the needs of their culturally diverse veteran populations. For example,
three VA facilities GAO reviewed offer spiritual services, such as the
use of medicine men and traditional healing rituals, in order to meet
the needs of Native American veterans. Also, VA has minority veterans
program coordinators at each medical center to identify barriers to
health care for minorities and advise medical center officials in
developing services to make health care more accessible and culturally
appropriate for minority veteran populations. VA medical centers GAO
reviewed have also initiated outreach efforts to promote the
availability of culturally appropriate care.
In commenting on a draft of this report, VA stated that it agreed with
the information presented as it pertained to VA.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-535]. For more
information, contact Randall B. Williamson, (202) 512-7114,
williamsonr@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
VA Medical Centers Are Implementing VA's LEP Directive; However,
Utilization of Language Access Services Is Low:
VA Medical Centers Are Addressing the Need for Culturally Appropriate
Health Care Services through Staff Training and Tailoring Health Care
Services:
Agency Comments and Our Evaluation:
Appendix I: GAO Contact and Staff Acknowledgments:
Abbreviations:
CBOC: community-based outpatient clinic
CMV: Center for Minority Veterans:
DOJ: Department of Justice:
EEO: Equal Employment Opportunity:
EO: executive order:
HHS: Department of Health and Human Services:
LEP: limited English proficiency:
NDAA: National Defense Authorization Act:
VA: Department of Veterans Affairs:
VHA: Veterans Health Administration:
VISN: Veterans Integrated Service Network:
[End of section]
United States Government Accountability Office: Washington, DC 20548:
May 28, 2008:
The Honorable Michael H. Michaud:
Chairman:
Subcommittee on Health:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable John T. Salazar:
House of Representatives:
The Honorable Hilda L. Solis:
House of Representatives:
The veteran population served by the Department of Veterans Affairs
(VA) will become more diverse in terms of race, ethnicity, sex, and
age. VA data show that racial and ethnic minorities account for about
20 percent of the veteran population and that about 7 percent of
veterans are women.[Footnote 1] We reported in 2005 that racial and
ethnic minorities accounted for about 33 percent of servicemembers in
the military; about 16 percent of servicemembers were women.[Footnote
2] Based on the higher diversity among servicemembers in the military
compared to veterans, VA officials anticipate that the veteran
population eligible to receive health care services from VA will become
more diverse as current members of the military are discharged or
released from active duty and transition to veteran status. In addition
to racial and ethnic diversity, VA has seen an increase in the number
of younger Operation Enduring Freedom and Operation Iraqi Freedom
veterans using VA health care services and officials expect this number
to continue to grow.
As its veteran population becomes more diverse, VA faces challenges in
bridging language and cultural barriers as it seeks to provide quality
health care services to its veteran population. For example, a study
commissioned by the California Endowment and the Robert Wood Johnson
Foundation found that to help meet the needs of a diverse patient
population, health care institutions, such as VA medical facilities,
should provide language access services.[Footnote 3] Language access
services are designed to ensure effective communication between English
speakers and those with limited English proficiency (LEP). This may
include providing translated versions of informational brochures or
consent forms and making staff available who can interpret providers'
instructions for patients or their family members with LEP. Several
studies have found that the implementation of language access services
in health care settings can increase access to care, quality of care,
and health outcomes.[Footnote 4]
Research suggests that providing culturally appropriate health care
services is an integral part of quality health care, and that cultural
factors can have a significant influence on the delivery of health care
services and can compromise access for culturally diverse
populations.[Footnote 5] At the federal level, HHS has published a set
of standards for medical facilities that state that health care
services should be delivered in ways that are culturally appropriate--
that is, respectful of and responsive to the cultural values of a
diverse population.[Footnote 6] This can mean, for example, recognizing
the role of the extended family in medical decisions for a particular
ethnic group and including these individuals in discussions of a
patient's medical care and treatment. According to HHS's standards,
providing culturally appropriate services to culturally diverse
patients has the potential to improve access to care, quality of care,
and ultimately, health outcomes. Prior to the enactment of the National
Defense Authorization Act (NDAA) for Fiscal Year 2008, there was no
specific statutory requirement for VA to provide culturally appropriate
care. However, several provisions in the 2008 NDAA require the
consideration of the gender-, ethnic group-, or age-specific needs of
veterans, including a direction to provide age-appropriate nursing home
care.[Footnote 7]
To meet the needs of persons with LEP, the President issued an
executive order[Footnote 8] in August 2000 that required all federal
agencies to develop and implement a system by which persons with LEP
can have meaningful access to the services provided by the agency. The
order also instructs federal agencies to work to ensure that recipients
of federal financial assistance provide meaningful access to their LEP
applicants and beneficiaries. According to the order, each agency must
develop a plan that outlines the steps the agency will take to ensure
that persons with LEP have meaningful access to the programs and
services it provides.[Footnote 9] In response to this order, in January
2002, VA issued a directive of its own--referred to in this report as
the LEP Directive[Footnote 10] --to assist VA programs, including its
medical centers, in providing appropriate language access services for
veterans with LEP. The LEP directive provides guidance to medical
centers and other facilities within VA to help them comply with EO
13166; medical centers and other facilities that do not adopt all of
the specific practices outlined in the directive are not necessarily
out of compliance with the executive order as long as medical center
officials take reasonable steps to assess and meet the language needs
of the veteran service population. Additionally, because the diversity
of the veteran service population varies across VA medical centers,
some medical centers may not have a need to take all the actions
identified in VA's LEP Directive.
In light of the increasing diversity of the veteran population in terms
of race, ethnicity, sex, and age, you asked for information about the
steps VA has taken to provide language access services for veterans and
its efforts to deliver health care services in ways that are culturally
appropriate for veterans' diverse cultural values. This report
discusses the (1) actions VA has taken to implement its LEP Directive
and the status of veterans' utilization of available language access
services, and (2) efforts VA has made to provide culturally appropriate
health care services. We did not assess VA's compliance with EO 13166
and instead describe actions taken under VA's LEP Directive in response
to EO 13166.
To describe the actions VA has taken to implement its LEP Directive as
well as veterans' utilization of available language access services and
the efforts VA has made to provide culturally appropriate health care
services, we reviewed an executive order, federal guidance, and VA
policy and procedures. We also selected five Veterans Integrated
Service Networks (VISN) to review.[Footnote 11] We selected these five
VISNs based on the number of racial and ethnic minority veterans living
in each VISN and geographic variation.[Footnote 12] Within these five
VISNs we selected a judgmental sample of 16 VA facilities, including
six VA medical centers, five community-based outpatient clinics (CBOC),
and five Vet Centers, to include in our review.[Footnote 13] From our
sample of VA facilities, we conducted site visits to medical centers
and associated CBOCs, and Vet Centers, located in Chicago, Illinois;
Durham, North Carolina; and Los Angeles, California. For the remainder
of VA facilities in our sample, we conducted in-depth telephone
interviews with medical center, CBOC, and Vet Center officials in Bath,
New York; Prescott, Arizona; and Richmond, Virginia.[Footnote 14] We
conducted in-depth interviews with VA officials and staff from each of
the 16 VA facilities to learn about actions taken at their facility to
provide language access services for veterans with LEP, the utilization
of these services, and the efforts the facility has made to provide
culturally appropriate health care services. At the six VA medical
centers we reviewed in depth, we examined documents related to efforts
by the centers to assess the language needs of their service population
and, if necessary, provide language access services. In addition, we
interviewed officials in each of the five VISNs we selected for review.
The information we collected from the six medical centers and five
VISNs we reviewed is not generalizable to all VISNs and VA medical
centers.
Additionally, in order to obtain information on the steps VA has taken
through its medical centers to provide language access services under
its LEP Directive, we selected a random sample of 20 VA medical centers
and requested copies of language needs assessments conducted by medical
center officials and language assistance policies.[Footnote 15] We
received documentation from 17 of the 20 medical centers. We conducted
follow-up with the three medical centers that did not provide
documentation but did not receive the requested materials from them. We
did not evaluate the quality of the language needs assessments or
language access policies provided by the 17 medical centers or from the
6 medical centers we visited or reviewed in depth. The information we
collected from our sample of 17 medical centers is not generalizable to
all VA medical centers. In addition to interviews we conducted with VA
officials, we also interviewed officials from the Department of Justice
(DOJ), as well as experts in the field of language access services and
the provision of culturally competent health care services.[Footnote
16] We conducted this performance audit from February 2007 through
March 2008, in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings based on our audit objectives.
Results in Brief:
As of June 2007, all VA medical centers had taken actions to implement
VA's LEP Directive, according to VA. Specifically, all medical centers
had assessed the language needs of their veteran service populations,
and if necessary developed language assistance policies, and offered
language access services. These language access services mainly involve
providing translated materials and interpretation services. In
addition, we found that all VA medical centers have computer software
that generates medical treatment consent forms in Spanish and
additional software that allows VA staff to access patient education
materials in languages other than English. Medical centers offered
interpretation services as well. For example, the six medical centers
we reviewed maintained a list of bilingual medical center staff who
volunteered to provide interpretation services during a clinical
encounter between a provider and a veteran with LEP. In addition, five
of the six medical centers included in our in-depth review can access
telephone interpretation services that are provided through a contract
to ensure that medical staff can communicate with veterans with LEP and
their families. VA medical center officials reported to us that current
utilization of language access services is low. However, VA officials
told us that they expect the demand for language access services to
grow as the increasingly diverse military servicemember population
transitions to veteran status.
We found that the six VA medical centers we reviewed in depth are
addressing the need for culturally appropriate health care services
through staff training and tailoring health care services. The six
medical centers we reviewed provided training for medical center staff
to facilitate the delivery of culturally appropriate health care
services, including a mandatory training on the health care needs of
veterans in various age groups. We found that VA medical centers and
other VA facilities we reviewed in depth implemented a variety of
measures to meet the needs of their culturally diverse veteran
populations. For example, some locations offered spiritual services to
meet the needs of Native American veterans, including the use of
medicine men and traditional healing rituals. Another offered a
counseling group exclusively for African American veterans; another
offered counseling groups specifically for women veterans. Also,
minority veterans program coordinators at all VA medical centers are
charged with identifying barriers to health care for minorities and
advising medical center officials in developing services to make health
care more accessible and culturally appropriate for minority veteran
populations. Some VA medical centers have also initiated outreach
efforts to promote the availability of culturally appropriate care. For
example, at two VA medical centers we reviewed in depth, staff told us
that they worked closely with military and National Guard bases located
near the medical center to increase the awareness of VA health benefits
among younger veterans and their families. According to VA officials,
these outreach efforts helped younger veterans understand that VA
serves veterans of all ages and from all military conflicts.
In commenting on a draft of this report, VA stated that it agreed with
the information presented as it pertained to VA.
Background:
EO 13166, Improving Access to Services for Persons with Limited English
Proficiency, requires that all federal agencies take reasonable steps
to ensure meaningful access to their programs and services for people
with LEP. DOJ has issued guidance that spells out four factors agencies
need to consider in determining whether they are taking reasonable
steps in this regard: (1) the number or proportion of LEP persons in
the eligible service population; (2) the frequency with which LEP
individuals come in contact with the program; (3) the importance of the
services provided by the program; and (4) the resources available.
[Footnote 17] Reasonable steps to ensure meaningful access could
include developing language access services and guidance for
implementing these services. The EO required that each federal agency
create a plan outlining steps it will take consistent with DOJ guidance
to ensure meaningful access to its services by LEP individuals. The EO
did not require DOJ to evaluate the plans or to monitor the
implementation of these plans.
In 2002, in response to EO 13166, VA created and implemented VHA
Directive 2002-006. It provided a framework for VA medical centers to
assess and determine if there was a need to develop language assistance
policies and language access services. The medical centers retain
flexibility to determine exactly how they will comply with the EO, but
they must do so in accordance with the four factors as outlined by DOJ
and reiterated in the LEP Directive. In February 2007, VA issued VHA
Directive 2007-009, which renewed VA's guidance on language assistance
policies.[Footnote 18] In its LEP Directive, VA outlined the steps that
constitute an effective language assistance program at its medical
centers, including an assessment of the language needs of the veteran
population served and identification of the non-English languages
encountered by medical center staff. If a VA medical center identifies
a specific language need among its veteran service population, VA's LEP
Directive also indicated that the medical center should develop and
implement a language assistance policy to ensure meaningful
communication. According to the directive, the policy should describe
how the medical center plans to provide language access services and
ensure that all veterans receive meaningful access to VA health care
services, regardless of the veterans' level of English proficiency.
VA's LEP Directive also provided medical centers with examples of ways
to provide language access services--including, translating written
materials,[Footnote 19] hiring bilingual staff, and contracting with
interpreter services.
VA's Equal Employment Opportunity (EEO) office is responsible for
overseeing the implementation of VA's LEP Directive. As such, this
office conducted surveys of VA medical centers to assess whether
medical center officials were following the steps outlined in the LEP
Directive, such as conducting an assessment of language needs, or
otherwise taking reasonable steps to provide language access services
for veterans being served. VA's Center for Minority Veterans (CMV)
[Footnote 20] is also involved in helping medical centers meet the
language and cultural needs of the veteran population. CMV is
responsible for ensuring that eligible minority veterans receive VA
benefits and services.
Culturally appropriate health care is care that is respectful of and
responsive to the cultural needs of patients. According to HHS,
providing culturally appropriate services to culturally diverse
patients has the potential to improve access to care, quality of care,
and ultimately, health outcomes. HHS has published a set of standards
[Footnote 21] for all medical facilities regarding the delivery of
culturally appropriate care. Other national organizations also
recognize the importance of culturally appropriate care and have
established standards or recommendations for its provision. For
example, the Joint Commission has standards related to culturally
appropriate health care that must be met by hospitals, including VA
medical centers, to receive accreditation.[Footnote 22]
VA Medical Centers Are Implementing VA's LEP Directive; However,
Utilization of Language Access Services Is Low:
VA medical centers are implementing VA's LEP Directive in terms of
assessing the language needs of its veteran service population, and, if
necessary, developing language assistance policies. VA medical centers
and facilities have offered language access services that include
providing translated materials and interpretation services to meet the
needs of veterans with LEP. VA medical center officials reported a low
utilization of these language access services. However, VA and medical
center officials told us that they expect the demand for language
access services to grow as the increasingly diverse servicemember
population transitions to veteran status.
VA Medical Centers Have Implemented the LEP Directive:
VA stated that by June 2007 all of its medical centers had taken
actions to implement the guidance in VA's LEP Directive. According to
VA, all of its medical centers have assessed the language needs of its
veteran service population, and, as necessary, developed language
assistance policies. Our visits to three VA medical centers and in-
depth telephone interviews with staff at three VA medical centers
provided a more detailed account of the variety of language access
services being offered at VA medical centers.
VA first surveyed each of VA's medical center directors in December
2005 to assess if medical centers were following the guidance in VA's
LEP Directive.[Footnote 23] The survey contained 10 "yes" or "no"
questions to gauge the extent of medical centers' efforts to implement
the LEP Directive. The questions ranged from issues such as overall
language assistance policies to efforts to provide language access
services. If a "no" response was provided for any question, the medical
center directors completing the survey were instructed to indicate a
tentative date by which they would take action to address the item. VA
required medical center directors and VISN directors to ensure that the
responses for individual medical centers were completed. However, VA
did not require that VISN or medical center directors provide
documentation to support their "yes" responses to the survey.
The results of the 2005 survey showed that 65 percent of VA medical
centers had assessed the language needs of their veteran service
population and that 60 percent of the centers had developed a language
assistance policy.[Footnote 24] While completing the survey, VA medical
center directors reported information about other medical center
efforts to meet the needs of LEP veterans, including efforts to
translate documents and hire bilingual interpreters. For example, 87
percent of VA medical center directors reported establishing a list of
staff available for interpretation services and that 24 percent of VA
medical centers had translated written documents into languages other
than English.
After conducting its initial survey, VA took several steps to help
medical centers improve their efforts to implement the LEP Directive,
according to a VA official. VA staff made follow-up calls to VA
officials from the medical centers that did not respond to the survey
or that were identified by the survey as not conducting efforts
consistent with the LEP Directive.[Footnote 25] During these follow-up
efforts, VA staff offered guidance to medical center officials on
conducting language needs assessments and developing language
assistance policies in ways that were consistent with the LEP
Directive. According to officials we interviewed at two VA medical
centers, the guidance was helpful in their facilities' assessment of
language needs among their service population and development of
language assistance policies.
According to VA, the follow-up efforts proved successful, as all
medical centers reported that they had assessed the language needs of
their veteran service population, and, as necessary, developed language
assistance policies. In July 2007, VA reported that as a result of its
follow-up efforts, all of VA's medical centers, in accordance with the
LEP Directive, had assessed the language needs of their veteran service
population and developed language assistance policies as needed. VA
concluded that because of the progress and efforts made by its medical
centers to implement the LEP Directive, VA would not conduct any
additional evaluations of medical center implementation of the LEP
Directive. Instead, VA said it would rely on the medical centers to
monitor their own LEP language access needs and programs.
VA Medical Centers and Facilities Offer a Variety of Language Access
Services for Veterans with LEP:
VA medical centers and other VA facilities have access to a variety of
translation services. At the national level, VA has translated its
widely distributed benefits publication into Spanish and makes
information from this publication available in Spanish on its Web site.
[Footnote 26] All VA medical centers have computer software that offers
medical treatment consent forms in Spanish and additional software that
allows VA staff to access patient education materials in several
languages other than English, such as Spanish and Korean.[Footnote 27]
The VA medical centers and facilities included in our in-depth review
also provide translated materials to meet the various language needs of
their veteran service populations. We found that all six medical
centers in our in-depth review translate written materials on their
own. For example, staff at one medical center we interviewed told us
that they translated educational materials on traumatic brain injuries
into Spanish. However, staff at the medical centers reported that they
primarily rely on publicly available translated documents rather than
translating written materials on their own because of the cost of
independently translating documents. The sources of these publicly
available materials range from other federal agencies to results of an
Internet search. For example, according to VA officials, patient
educators at some medical centers use patient education materials on a
range of topics including heart disease and diabetes that have been
translated into Spanish by HHS's Food and Drug Administration. VA
medical center staff can also use materials translated by staff at
other medical centers. For example, staff at one medical facility we
reviewed reported that the VA medical center located in San Juan,
Puerto Rico, has shared patient education materials they have
translated into Spanish with other VA medical centers. Medical center
staff we interviewed also reported using professional groups within VA,
such as EEO managers or patient educators, to identify and share
existing translated materials. However, these groups are limited in
their membership and, as such, might not be aware of all translated
materials available at VA medical centers. Additionally, VA medical
facilities included in our review generally offer translated materials
specific to the services they provide, when needed. For example, one
Vet Center we reviewed translated a pamphlet on post-traumatic stress
disorder into Spanish for its largely Hispanic veteran service
population.
As part of language access services, VA medical centers we reviewed in
depth provide language interpretation services to help address the
language needs of veterans with LEP. Staff we interviewed at all six
medical centers we reviewed had the ability to provide interpretation
services to veterans with LEP and were doing so in several different
ways. For example, staff members at all six of these medical centers
maintained a list of bilingual medical center staff who volunteered to
provide interpretation services during a clinical encounter between a
provider and a veteran with LEP. Medical center staff primarily used
people from this list to provide needed interpretation services. In
addition, staff at five of the six VA medical centers had contract
telephone interpretation services available as a means to help
effectively communicate with veterans and their families with LEP.
Moreover, two of the three medical centers we visited advertised within
the medical center, in languages other than English, the availability
of language interpretation services to veterans and their families with
LEP. In these medical centers, we observed signs posted near entrances
and elevators that advertised, in multiple languages, free language
interpretation services for veterans and their family members.
In addition to efforts made by VA's medical centers to provide language
access services, some of VA's Vet Centers have also made efforts to
provide language access services to ensure that veterans with LEP have
meaningful access to counseling and other services. Vet Centers provide
language access services to veterans' family members with LEP to ensure
that they are able to participate in counseling sessions, such as
marital and family counseling. For example, at one Vet Center we
visited, the entire staff was bilingual to help accommodate the needs
of its mostly Hispanic veteran service population. In cases where
bilingual staff were not available, four of the five Vet Centers where
we conducted interviews had agreements with the local VA medical center
to access its list of bilingual staff available for interpretation
services.
VA Medical Center Officials Report Low Utilization of Language Access
Services; However, Officials Expect the Demand for These Services to
Grow:
Officials at the VA medical centers and facilities included in our in-
depth review reported that veterans seldom use VA's language access
services. For example, officials and staff we interviewed from five of
the six medical centers in our review stated that their facility had a
contract in place for telephone interpretation services but only one
medical center reported ever utilizing these services. Staff at the
medical center that reported utilizing the interpretation service
stated that the use was infrequent. Moreover, staff we interviewed at
the six VA medical centers we reviewed reported that most veterans
speak English and staff at one medical center reported that veterans
prefer to receive written materials in English. Staff at one medical
center told us that they stopped routinely offering translated
materials after veterans--for whom English was not their primary
language--stated their preference for materials in English. However,
translated documents were made available upon request. Despite the low
utilization of interpretation services, such as the use of a contracted
telephone interpretation service, officials at all six medical centers
in our in-depth review reported using bilingual staff to serve as
volunteer interpreters when needed.[Footnote 28] In addition, in our
review of 17 other medical centers' language needs assessments,
officials from one medical center volunteered utilizing telephone
interpretation services four times in the 2 years prior to our request
in July 2007, while another medical center volunteered in its
assessment that veterans at the facility never used the facility's
contracted telephone interpretation service.
VA medical center officials told us that they expect the demand for
language access services to grow as the increasingly diverse
servicemember population transitions to veteran status. The
servicemember population is more diverse--in terms of race, and
ethnicity--than the current veteran population.[Footnote 29] VA
officials we interviewed projected that the increased diversity of the
military servicemember population will directly translate to an
increased level of diversity in the veteran population as these
servicemembers end their military careers and become veterans who may
be eligible for VA health care services. Staff from several VA
facilities told us that they have recently witnessed demographic
changes in their service population. For example, two Vet Centers we
visited told us that they have experienced an increase in the number of
veterans and family members needing language access services in Spanish
to facilitate marital and family counseling sessions.
VA Medical Centers Are Addressing the Need for Culturally Appropriate
Health Care Services through Staff Training and Tailoring Health Care
Services:
In an effort to address the cultural differences represented in its
veteran service population, VA medical centers have conducted training
programs to increase staff awareness about cultural diversity and the
need for culturally appropriate health care services. Additionally, VA
medical centers and facilities tailored a variety of health care
services to different segments of the veteran population and promoted
the availability of culturally appropriate health care services by
targeting outreach efforts to different segments of the veteran
population.
VA Medical Centers Provided Training to Staff to Increase Awareness
about the Need for Culturally Appropriate Health Care Services:
VA medical centers have provided a variety of training programs for
staff to both raise cultural awareness and to assist medical center
staff in providing culturally appropriate health care services.
According to VA medical center officials we interviewed, medical center
staff are required to annually complete one mandatory VA-developed
training course on the health care needs of veterans of various age
groups.[Footnote 30] The six VA medical centers we reviewed have
offered training to help staff understand cultural diversity as well as
appreciate the need for culturally appropriate health care. These
training efforts included locally-developed training on diversity given
to new staff during orientation and on-line diversity training that is
available to all staff. One of the six medical centers we reviewed in
depth also developed training to help staff better understand what it
was like for a veteran in general to serve in the military, as well as
what it was like for a veteran who served during a particular military
service era, such as the Vietnam War. The training materials also
provided information on the types of medical diagnoses that may be
related to a veteran's service, such as exposure to environmental
hazards. Additionally, individual medical centers developed programs
designed to increase awareness of veteran diversity and different
cultural practices. For example, four VA medical centers we reviewed
reported using celebrations and events in conjunction with heritage
months (e.g., African American Heritage Month and Women's History
Month) as educational opportunities to increase medical center staff
awareness of veteran cultures and diversity. Programs included
speakers, cultural fairs, and presentations open to staff and veterans
at the individual VA medical centers.
VA Medical Centers and Facilities Have Provided Health Care Services
Tailored to Meet the Needs of a Culturally Diverse Veteran Population:
VA medical centers and facilities have provided numerous health care
services designed to meet the needs of the culturally diverse veteran
population that differs in terms of race, ethnicity, sex, as well as
age. According to VA officials, these services have varied across VA
medical centers, CBOCs, and Vet Centers, depending on the needs of the
veteran populations served. During our in-depth review of 16 VA medical
centers and facilities, officials identified a number of health care
services that are provided in a culturally appropriate manner:
* Two medical centers and one Vet Center offer spiritual services,
which include the use of medicine men and traditional healing rituals,
in order to meet the needs of Native American veterans.
* Three medical centers and one CBOC have increased the use of modern
technology, such as text-messaging appointment reminders, to
communicate more effectively with younger veterans, who are typically
accustomed to such means of communication.
* One Vet Center offered a counseling group exclusively for African
American veterans and one Vet Center offered counseling groups for
women veterans.
According to staff we interviewed, services tailored to different
segments of the population are often designed using information gained
from specific veteran requests, veteran focus groups, or through
recommendations of special-emphasis population groups.[Footnote 31]
To facilitate the delivery of culturally appropriate health care
services, all VA medical centers have a minority veterans program
coordinator.[Footnote 32] The role of the minority veterans program
coordinator is to identify barriers to health care and advise medical
center officials in developing services to make health care more
accessible and culturally appropriate for minority veteran populations.
Minority veterans program coordinators also work directly with minority
veterans in an effort to facilitate access to and use of VA health care
services.
To promote the availability of culturally appropriate care, the six VA
medical centers included in our in-depth review have implemented a
variety of targeted outreach efforts to different veteran populations.
For example, officials at two of the six medical centers we reviewed
reported working closely with military and National Guard bases located
near the medical center to increase awareness of VA health benefits
among younger veterans and their families. According to VA staff, these
outreach efforts helped younger veterans understand that VA was not
just "their grandfather's VA" and that VA medical centers serve
veterans from all military conflicts. At one medical center, officials
we interviewed reported outreach efforts to help Hispanic, younger, and
female veterans recognize when they might need medical services, for
example treatment for post-traumatic stress disorder or depression.
These outreach efforts included participating in community health fairs
and ceremonies held to welcome home servicemembers from the combat
theaters. VA staff said they tailored these efforts to different
communities, and staff at one medical center reported including
materials in Spanish.
Agency Comments and Our Evaluation:
VA reviewed a draft of this report and sent us comments by email. VA
agreed with the information presented as it pertained to VA. In
commenting on the development of resources and education to help
facilitate the delivery of culturally competent care, VA noted that
there are different solutions based on local needs and supports a
multimodality strategy as opposed to a "one module fits all" approach.
We agree and as we discussed in our report, VA medical facilities do
conduct training for staff and tailor health care services in an effort
to address the differing needs for culturally appropriate health care
services in particular locations. These efforts and services are often
locally developed in response to the characteristics and needs of the
veteran population served.
As arranged with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
after its issuance date. At that time, we will send copies of this
report to the Secretary of Veterans Affairs. We will also provide
copies to others upon request. In addition, the report is available at
no charge on the GAO Web site at [hyperlink, http://www.gao.gov]. If
you or your staff have any questions about this report, please contact
me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff that made major contributions
to this report are listed in appendix I.
Signed by:
Randall B. Williamson:
Director, Health Care:
[End of section]
Appendix I: GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov:
Acknowledgments:
In addition to the contact above, Marcia Mann, Assistant Director;
Melanie Anne Egorin; Krister Friday; Adrienne Griffin; Samantha Poppe;
and James Walker made contributions to this report.
[End of section]
Footnotes:
[1] See Department of Veterans Affairs, VA Benefits & Health Care
Utilization (Washington, D.C., 2007), and Department of Veterans
Affairs, Women Veterans: Past, Present and Future (Washington, D.C.,
May 2005). VA data from 2007 show that about 80 percent of veterans are
white, non-Hispanic; 11 percent are African American; 6 percent are
Hispanic; and 4 percent are other racial groups.
[2] See GAO, Military Personnel: Reporting Additional Servicemember
Demographics Could Enhance Congressional Oversight, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-05-952] (Washington, D.C.: Sept.
22, 2005). We reported that 67 percent of military servicemembers were
white, non-Hispanic; 9 percent were Hispanic, 17 percent were African
American; and 3 percent were Asian American/Pacific Islander.
[3] See Grantmakers in Health, In the Right Words: Addressing Language
and Culture in Providing Care (San Francisco, Calif., August 2003).
[4] See Department of Health and Human Services (HHS), A Patient-
Centered Guide to Implementing Language Access Services in Healthcare
Organizations (Washington, D.C., September 2005); B. D. Smedley, A. Y.
Stith, and A. R. Nelson, Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care, Institute of Medicine Report
(Washington, D.C., 2003); Grantmakers in Health, In the Right Words;
and Edward L. Martinez, Steve Hitov, and Mara Youdelman, Language
Access in Health Care Statement of Principles: Explanatory Guide
(Washington, D.C., October 2006, reissued November 2007).
[5] See Institute of Medicine, Speaking of Health: Assessing Health
Communication Strategies for Diverse Populations (Washington, D.C.,
2002), and The Henry J. Kaiser Family Foundation, Compendium of
Cultural Competence Initiatives in Health Care (Washington, D.C., and
Menlo Park, Calif., 2003).
[6] HHS, Office of Minority Health, National Standards for Culturally
and Linguistically Appropriate Services in Health Care (Washington,
D.C., 2001).
[7] See, for example, Pub. L. No. 110-181, §§ 1603, 1661, 1706, 122
Stat. 3.
[8] Exec. Order (EO) No. 13166, Improving Access to Services for
Persons with Limited English Proficiency, 65 Fed. Reg. 50121 (Aug. 11,
2000).
[9] EO 13166 further states that these plans are to be consistent with
the standards set forth in the Department of Justice (DOJ) guidance
that was issued at the same time as the EO. See 65 Fed. Reg. 50123
(Aug. 16, 2000). The steps outlined in the plans are required to be
consistent with, and not unduly burdensome to, the fundamental mission
of the agency. DOJ serves as the central repository for materials
related to implementation of EO 13166, including agency plans.
[10] In this report, the term "LEP Directive" refers to Veterans Health
Administration (VHA) Directive 2002-006, Limited English Proficiency
(LEP) Title VI Prohibition Against National Origin Discrimination in
Federally-Conducted Programs and Activities and in Federal Financial
Assisted Programs, renewed as VHA Directive 2007-009, unless otherwise
noted.
[11] VA organizes its medical facilities into 21 regional networks,
called Veterans Integrated Service Networks (VISN). For this report, we
focus exclusively on health care services provided by VA in its medical
centers, community-based outpatient clinics (CBOC), and Vet Centers,
which are federally-conducted programs. The scope of this report does
not include recipients of financial assistance from VA.
[12] There is geographic variation in this group of VISNs: VISN 2
includes upstate New York; VISN 6 includes Richmond, Virginia, and
Raleigh-Durham, North Carolina; VISN 12 includes Chicago, Illinois;
VISN 18 includes northern Arizona; and VISN 22 includes the greater Los
Angeles, California, area. There is also variation in the racial and
ethnic composition of veteran service populations in each VISN. For
example, VISN 22 has significant Hispanic, African American, Asian/
Pacific Islander, and Native American populations whereas the majority
of veterans served in VISN 12 is Caucasian with smaller percentages of
African American veterans.
[13] VA's health care system includes different types of health care
facilities, including medical centers and community-based outpatient
clinics (CBOC). VA medical centers offer services that range from
primary care to complex specialty care, such as cardiac or spinal cord
injury. VA's CBOCs are an extension of VA medical centers and mainly
provide primary care services. VA also operates Vet Centers, which
offer counseling services, including psychological counseling and
psychotherapy, to combat veterans and their family members. Vet Centers
are the only VA medical facilities authorized to provide services to
family members. Vet Centers operate outside of the VISN structure but
coordinate veterans' services and outreach with nearby VA medical
centers.
[14] Specifically, we conducted site visits to Jesse Brown VA Medical
Center, Auburn Gresham CBOC, and Chicago Vet Center in Illinois; Durham
VA Medical Center, Raleigh CBOC, and Raleigh Vet Center in North
Carolina; and West Los Angeles VA Medical Center, East Los Angeles
CBOC, and East Los Angeles Vet Center in California. We conducted in-
depth interviews with officials from Bath VA Medical Center, Rochester
CBOC, and Rochester Vet Center in New York; Prescott VA Medical Center,
Anthem CBOC, and Prescott Vet Center in Arizona; and Hunter Holmes
McGuire Medical Center in Virginia. We conducted interviews with
officials from the medical center in Richmond, Virginia, because the
medical center operates one of four VA polytrauma centers that provide
care to active duty servicemembers as well as veterans. We did not
interview CBOC or Vet Center officials from the Richmond area.
[15] This sample did not include the six medical centers that we
visited or reviewed in depth.
[16] We interviewed experts in the field including staff from HHS's
Office of Minority Health; the National Health Law Program; and the
National Center for Cultural Competence.
[17] See 65 Fed. Reg. 50123 (Aug. 16, 2000). EO 13166 indicated that
the agency plans for their own programs should be consistent with this
DOJ guidance.
[18] VHA Directive 2002-006 expired in January 2007. The current VHA
Directive 2007-009, which contains the same guidance as the 2002
directive, expires in February 2012.
[19] VA's LEP Directive prescribes standards for written translations
that, if implemented by medical centers, would constitute a "safe
harbor" for the center. That is, VA will consider those facilities that
adopt the LEP Directive's standards to be in compliance with EO 13166.
For example, if a medical facility has a population of at least 3,000
veterans with LEP who speak the same primary language that facility
will be considered in compliance with the EO if it provides translated
written materials including vital documents in that primary language.
[20] The Veterans Benefits Improvement Act of 1994 required VA to
create the CMV, which is organizationally aligned to VA's Office of the
Secretary. See Pub. L. No. 103-446, § 509, 108 Stat. 4645, 4665-66
(codified as amended at 38 U.S.C. § 317). As required by law, CMV's
primary emphasis is on minority veterans, specifically veterans in the
following groups: Pacific Islander, Asian American, African American,
Hispanic/Latino, and Native American, including American Indian, Alaska
Native, and Native Hawaiian.
[21] HHS, Office of Minority Health, National Standards for Culturally
and Linguistically Appropriate Services in Health Care (Washington,
D.C., 2001).
[22] The Joint Commission, previously known as the Joint Commission on
Accreditation of Healthcare Organizations, is a not-for-profit
organization that evaluates and accredits health care organizations
throughout the United States to help assure the quality of care
provided to patients. Accreditation is an assessment process by which
an organization's performance is measured against certain standards
defined by industry experts. VA requires its medical centers to obtain
and maintain accreditation from the Joint Commission.
[23] VA initiated its survey in response to a November 2005 letter from
members of Congress to VA's Secretary, which requested that VA monitor
the implementation of VA's LEP Directive to help ensure that medical
center's actions were consistent with the steps outlined in the
directive.
[24] This survey showed that four of the medical centers we reviewed in
depth assessed the language needs of their veteran service population
and that three of the medical centers we reviewed in depth developed a
language assistance policy.
[25] Staff from VA's EEO office conducted the follow-up calls to VA
medical centers.
[26] Department of Veterans Affairs, Federal Benefits for Veterans and
Dependents (Washington, D.C., 2008). This publication is available in
Spanish at [hyperlink, http://www.va.gov/opa/vadocs/fedbensp.pdf]
(accessed May 27, 2008).
[27] The iMed Consent application allows VA medical center staff to
create medical consent forms in Spanish. Similarly, the KRAMES-on-
Demand program allows medical center staff to provide patient education
materials in several languages other than English. KRAMES-on-demand
provides all its education materials and drug information sheets in
English and Spanish. Additionally, education materials covering 10
critical health topics are available in 10 languages: English, Spanish,
Armenian, Chinese, Farsi, Hmong, Korean, Russian, Tagalog, and
Vietnamese.
[28] According to VA medical center staff we interviewed, the use of
volunteer staff interpreters is often not reported to medical center
officials and as a result may be undercounted.
[29] See [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-952] and
Department of Veterans Affairs, VA Benefits & Health Utilization
(Washington, D.C., 2007).
[30] Training of medical center staff on the health care needs of
various age groups is an accreditation requirement from The Joint
Commission. VA established a Cultural Competency Taskforce to identify
and provide resources and training materials to medical centers to help
facilitate the delivery of culturally appropriate health care. The
taskforce is reviewing training modules on culturally appropriate
health care in an effort to find a module that can be distributed to
all VA medical centers for use in their efforts to provide culturally
appropriate health care to veterans. The taskforce began work in spring
2006.
[31] Special-emphasis population groups are advocacy groups comprised
of VA staff and focus on understanding the needs and promoting
awareness of certain groups including Native Americans, Asian Pacific/
Islanders, African Americans, Hispanics, women, and people with
disabilities.
[32] Minority veterans program coordinators have been placed at each VA
medical center by CMV as part of its systemwide effort to improve
services for minority veterans.
[End of section]
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