Limited English Proficiency (LEP) Patient Hospital Toolkit

The Effective Communications in Hospitals Committee from the Kentucky Hospital Association (KHA) is pleased to announce an Intranet Resource Toolkit to help you better serve those patients who are limited-English proficient (LEP).

The Intranet Resource Toolkit is better defined as an internal hospital resource kit designed to share resources to address best practices concerning effective communications with patients and families.

This toolkit includes many resources to help you better communicate with LEP patients. The kit includes a history and demographics of difference cultures and languages represented in Kentucky, standards for compliance and accreditation, how and why to work with interpreters, as well as the tools and resources needed to effectively establish a language services program in your organization.

What is a Refugee?
By the United Nations definition, a refugee is a person who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership in a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country.” 

What is the Difference Between an Immigrant and a Refugee?
An immigrant is a foreign-born individual who voluntarily leaves his/her country of origin and has been admitted to reside permanently in the U.S. as a Lawful Permanent Resident. The key difference is that an immigrant chooses to leave his/her country of origin. A refugee, on the other hand, is compelled to seek asylum in another country.

Asylees and refugees must meet the same legal definition of a refugee: that they have been persecuted in the past and/or have a “well-founded” fear of persecution in the future because of their race, religion, nationality, political opinion, or membership in a particular social group, by their government or by persons the government cannot or does not wish to control. The difference between refugees and asylees is where the determination that a person fits this definition is made. Refugee status is granted to people who are outside the United States, while asylum status is granted to people who enter the United States on their own and then apply for asylum from within the U.S.

Who Determines Refugee Status?
The United Nations High Commissioner for Refugees (UNHCR) interviews those who believe they are refugees to decide whether they qualify for UNHCR protection and to determine whether the permanent solution in their case is resettlement in a third country, such as the United States. If a refugee is referred by UNHCR for resettlement in the U.S. or if a refugee appears to be eligible on other grounds listed, he/she will be interviewed by an officer of the U.S. Citizenship and Immigration Services (formerly the U.S. Immigration Naturalization Service or INS) who will decide whether a person qualifies as a refugee under U.S. law, and thus is eligible for resettlement.

What are a Refugee’s Options for Resettlement?
Uprooted people have historically had three options available to them:

  • Voluntary Repatriation
    While this is often the most desired outcome of the uprooted, returning to former homes can be very difficult due to the devastation visited on their communities. For example, in less than five months after the UNHCR began its repatriation program, more than 1.3 million Afghan refugees in Pakistan and Iran opted to go home following the fall of the Taliban. Over the same period, another 200,000 internally displaced people also returned home. They found their communities destroyed, fields littered with landmines, orchards uprooted, and the prospects for restarting their lives daunting indeed. U.N. High Commissioner for Refugees (UNHCR)
  • Local Integration into the Country of Asylum
    Like Tibetans in India or Cubans in the U.S., many who flee to another country then seek asylum there. In the U.S., applicants must meet the same legal test as refugees, but asylum can be denied by an immigration judge or the Bureau of Citizenship and Immigration Services. Some 28,000 uprooted people were granted asylum in the U.S. in 2001, but 396,000 applicants are still pending. United States Committee on Refugees (USCR)
  • Resettlement to a Third Country
    If a refugee cannot return home or find asylum in the country to which he or she has fled, the third option is resettlement in another country. But less than 1% of the world’s refugees are resettled in a third country. For example, the U.S. admitted 68,500 refugees for resettlement in 2001 and only 27,000 in 2002. USCR

Are There Other Groups of Uprooted People?
Other groups of uprooted people include internally displaced persons who are forced to flee their homes due to armed conflict, internal strife and systematic violations of human rights, but who do not cross an international border; stateless persons who are not recognized by any country as citizens, and whose access to national or international legal protection or to basic rights such as health and education is severely restricted as a result; and others in refugee-like situations who do not meet the narrow definition of refugee, or who do not have access to credible refugee determination procedures. Included in this last category are those who are tolerated or ignored by host governments or those regarded as illegal aliens.

How Many Refugees Enter the Country Each Year?
A refugee admissions ceiling is set on a yearly basis. The President establishes the ceilings each year in consultation with Congress and the State Department. Various organizations, including Church World Service and Episcopal Migration Ministries, are invited to present testimony supporting specific admissions levels and their rationale.

Who Pays for the Refugee’s Travel?
Each refugee receives an interest-free travel loan from the U.S. government. Prior to their departure, the head of the refugee family signs a promissory note to repay their loan. Approximately three months after their arrival, CWS or EMM will send the refugee family their first bill to begin repayment of their loan. It is very important that refugees repay their travel loans as these funds are made available for other refugee’s travel through a revolving loan fund.

Do Refugees Receive Welfare Benefits?
There are several cash and medical assistance programs in place for newly-arrived refugees to try to stem the use of state-administered public assistance. Case workers help determine for which program a refugee is eligible and which program would bring the most benefits.

  • TANF (Temporary Assistance to Needy Families): This means of income support is for parents with minor children who are unlikely to be self-sufficient in 90 days.
  • The Matching Grant Program: Funded by Congress since 1979, provides an alternative to the state-administered programs and is funded by the Office of Refugee Resettlement (ORR). Federal funds of up to $2,000 per refugee are provided on a dollar for dollar matching basis to voluntary agencies participating in the program. The program’s goal is to help refugees attain self-sufficiency within four months after arrival in the U.S. without access to public assistance.
  • The Wilson Fish Cash and Medical Assistance Program: This is available to refugees without children over 18 who do not qualify for another cash assistance program.
  • Social Security Insurance: This form of assistance is available to refugees over the age of 65.

Are Refugees Considered “Aliens”?
Under U.S. law, any person who is not a U.S. citizen (including refugees) and resides in the U.S. is considered an “alien.” Most aliens have some form of legal status in the U.S. and can be documented or undocumented.

Can a Refugee Become a U.S. Citizen?
A refugee is eligible for permanent resident status after living in the U.S. for one year. After five years of residence in the U.S. and gaining Permanent Resident Status, he or she may apply for citizenship.

Information adapted from “Kentucky Refugee Ministries, Inc.”, retrieved May 18, 2011, from

Hospitals are always working on compliance, whether it be compliance towards federal and state laws or to your accreditation body. This section will guide you toward resources and will also help explain the processes/justifications from a language services point of view. 

Federal Law
Title VI of the Civil Right Act of 1964
If your facility accepts federal funds, chances are you are obligated to provide language appropriate and effective services for limited-English proficient (LEP) patients and their families/caretakers.

State Law
There is currently no Kentucky state law regarding language and culture in the health care setting.

Accreditation – The Joint Commission (TJC)

What is the Difference Between Interpretation and Translation? 
Interpreting takes a spoken message in one language and relays that message in a different language (ex: English into Spanish). In interpreting, the interpreter takes a complex message from one language, and then chooses the most appropriate vocabulary in the target language to accurately deliver the message. This is done with linguistic, emotional, tonal, and cultural equivalence.

Translation is relaying meaning from text in one language to another. Translators have time and access to resources in order to produce an accurate document.

How is an Interpreter Used?
The interpreter’s job is to be an “invisible” connection between the patient and provider. There are a few simple things to remember when you are using an interpreter.

  1. They speak in the first person and interpret everything that is said exactly as it is said including tone and body language.
  2. The patient and provider should always be looking at one another and not at the interpreter; they should speak directly to one another not saying, “Tell her/him…”
  3. It is important for the patient and provider to speak clearly and pause frequently to allow for an accurate interpretation.
  4. If the interpreter needs you to pause in order to interpret they will signal you most likely by raising their hand.

When appropriate the interpreter may intervene and ask for / provide clarification for vocabulary or cultural barriers. In these situations the interpreter will say something to the effect of “as the interpreter I would like to clarify…”

When is it Appropriate to Use a Face-to-Face Interpreter?
Face to face interpreters need to be used in situations where it is critical to be able to see the patient’s facial expressions and body language, or when the patient is having a procedure or a treatment where holding a phone would be very difficult. Another time when a face to face interpreter would be appropriate would be when there are multiple people in the room and it would be very difficult for an OPI (Over the Phone Interpreter) to know who is speaking.

When is an OPI Appropriate?
An over the phone interpreter is helpful for giving instructions or answering questions. The over the phone interpreter is helpful for inpatients that have rounding sessions with their doctors and routine checks by the nurses. These situations are conducive to phone use because in most cases the patient and provider are familiar with one another and reading facial expressions is not as crucial and the patient generally is able to hold a phone.

When Should a VRI be Used?

The VRI or Video Remote Interpreting uses a computer with a wireless internet connection and two cameras to allow a patient to communicate with an interpreter. The patient and interpreter can see one another which provides a distinct advantage over phone interpretation where body language cannot be observed. The VRI allows interpreters to be anywhere when they connect and the process is almost instantaneous so it saves time in situations where someone is needed right away.

The following resources can be helpful for members of the hospital staff when working with patients/families who have limited English proficiency (LEP).