Problem Addressed

• Communication problems, leading to reduced access and effectiveness: Patients with limited English proficiency are less likely to use health care services and to adhere to recommended treatments when they do access care. Problems with patient–provider communication, shared decisionmaking, and trust disproportionately affect these vulnerable populations, leading to worse health outcomes for these patients than for their English-speaking peers.^1,2
• Driven in part by lack of provider training: Fifty-six percent of providers report having received no language or cultural competency training.²
• Unrealized potential of language services: Small practices can effectively serve patients with limited English proficiency if language services are available to help facilitate communication,² but relatively few practices have such resources available.

Description of the Innovative Activity

• Linguistically appropriate staff: As of March 2012, BIAS has staff members who speak Albanian, Bosnian, Russian, English, Vietnamese, Korean, Chinese (Mandarin), Hindi, Pashto, Urdu, and Spanish. As a result, agency staff can provide services in a client's native language and help with interpretation and translation of English documents. Because some consumers speak other primary languages, BIAS allocates an annual budget for interpreter needs and contracts with a large number of trained professional interpreters to ensure that no senior is denied services due to language barriers.
• Identification and initial assessment of participants: Clients hear of BIAS through word of mouth and referrals from physicians, health agencies, insurers, and other social work/community agencies. BIAS therapists screen and assess new clients to evaluate functional abilities, identify deficits and prioritize service needs. Using the evidence-based model of Assertive Community Treatment,³ cognitive behavioral therapy, and other biopsychosocial models, the initial focus is to meet clients' basic needs for housing and food. As these needs are met, staff members move on to provide mental health and other social support services (as described below).
• Counseling and psychotherapy services: BIAS staff provide mental health assessments, psychotherapy, psychiatric home visits and various support services that address symptoms of Adjustment or Post Traumatic Stress Disorders.
• Social support services: BIAS staff provide a variety of social support services to clients, including interpretation, translation, and assistance understanding and completing applications for government benefits (e.g., Medicare, Medicaid, food stamps, etc.) and community services; limited transportation to appointments; and provision of free medical equipment and supplies not covered by Medicaid (e.g., bathroom rails and commodes). According to information provided in March 2010, BIAS also assists older adults obtain home care aides and other consumer-directed service. Additionally, consumers who recently attained U.S. citizenship receive assistance to obtain naturalization benefits, including Medicare coverage. Since 2010, BIAS has been awarded a contract with CLAIM to ensure foreign born clients equal access to Medicare counseling services and provide staff with training and updates related to ongoing changes in Medicare coverage. 
• Citizenship program: BIAS staff provide free services to support elderly and disabled individuals prepare for and obtain U.S. citizenship. Included are assistance completing applications; one-on-one tutoring for required examinations (civics, U.S. history and English as a Second Language); and after citizenship has been attained, enrollment for Medicare. The agency contracts with an attorney to ensure appropriate legal services and timely interventions are attained as needed. Funded through appropriations by the State of Missouri, the citizenship program recently received a Citizenship for Frail Elders award. As of March 2012, the program has expanded statewide to service 225 individuals annually through a satellite office in Sedalia and trained partners in the Kansas City area. The naturalization success rate among BIAS' Limited English Proficient applicants is at 97 percent or higher.
• Information and referral: BIAS staff provide clients with information about and referrals to other organizations that can offer financial assistance, home care, medical treatment, psychiatric care, and medical supplies. Because seniors often are reluctant to initiate contact, staff members offer a "warm referral" (e.g., proactive link to targeted service agencies), to ensure the connection is made and services become available.
• Professional training and interpreter seminars: BIAS staff offers social workers and other professionals workshops and seminars related to social service and mental health service delivery for elderly, new Americans. Training topics include cultural competency, translation, and interpretation; accessing social services and community resources; the citizenship education and application process; and recognizing and treating problems such as posttraumatic stress disorder, depression, and substance abuse. In March, 2011 Julia Ostropolsky, BIAS CEO, participated in NASW visit to Habana, Cuba, and is now offering seminars that include the information on lessons learned.
• Interpretation in medical settings: In late 2007, BIAS launched the Culturally and Linguistically Appropriate Services (CLAS) Standards at Work program, with funding from the Missouri Foundation for Health. Now funded through the Daughters of Charity Foundation, the program provides 400 hours of interpretation to community medical professionals serving elderly and disabled patients. With the goal of educating providers on both the importance of CLAS standards and the benefits of professional interpretation, the program is a key to providers' buy-in for future budgeting for said services.
• Advocacy-related work: Since March 2010, BIAS has actively educated providers on adherence to access-to-care provisions of Title VI of The Civil Rights Act of 1964, which mandates nondiscrimination in federal assistance programs. BIAS also created a local Refugee Immigrant Consortium Advocacy Task Force to focus on strategies for adhering to Title VI. Additionally, as an offshoot of the CLAS Standards at Work program, BIAS formed a task force to advocate for the inclusion of medical interpretation as a Medicaid-covered service in Missouri.
• Steps to Better Health Program: Information provided in March 2012 indicates that, recognizing the relationship between mental health and physical health, BIAS launched an Obesity and Diabetes prevention program funded by the Mental Health Board of Saint Louis. This program provides a 16-week treatment and focuses on consumers' individual needs. The program involves pharmacist assessments, registered nurse visits, and education and counseling by trained mental health professionals. The program also offers one gift card to a grocer and a trip to a grocery store to help consumers learn to read food labels and choose healthy inexpensive foods for daily diet. The program budget allows for interpreter support, thus making the program available to all.

References/Related Articles

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Results

• Facilitating access to services: Information provided in March 2012 indicates that, since its inception, the agency has served almost 2500 clients. BIAS currently provides services to more than 600 individuals, and access to health care coverage is provided to an estimated 250 individuals annually.
• Tangible benefits delivered: Information provided in March 2012 indicates that BIAS services have helped at least 380 clients become naturalized U.S. citizens. In addition, more than 200 individuals have gained access to Medicare and other benefits coverage (as of March 2012), and at least 200 clients have received medical supplies not paid for by Medicare or Medicaid thanks to the financial assistance program offered by BIAS.
• Influenced State legislature: BIAS played an instrumental role in alerting state legislators to the needs of the frail elderly who are not capable of attending classroom instruction related to becoming a U.S. citizen. As a result, Missouri appropriated new funds to assist these individuals through home-based instruction and assistance.
• Positive impact on communities: By outreach into new communities of the foreign born, BIAS is able to estimate the quality of its services and positive results to consumers. For instance, the Korean Community of Saint Louis was established over 20 years ago. Since then, the majority of seniors continued to lack naturalization, did not know their rights to interpreters, had not for the most part enrolled in Medicare, and were unaware of financial assistance available to them via SSI. Each new community outreached by staff exhibits similar patters of lack of access and lack of awareness, both of which are resolved usually by active engagement with services within the first year. Information provided in March 2012 indicates that BIAS is now also working with Albanian and Nepali communities of foreign-born seniors.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Securing preliminary funding: BIAS initially failed in securing preliminary funding; during the initial startup phase, the program's chief executive officer and chief financial officer volunteered much of their time as they worked to secure funding to provide psychological education, support groups, monthly social gatherings, and supplies.
• Outreach to communities: Program developers built solid relationships with existing service providers and assessed community needs by interviewing resettlement workers, attending gatherings, and engaging in other activities designed to help them learn about the local culture. Information provided in March 2012 indicates that once community assessments were complete, the CEO reached out to the seniors with speaking engagements and educational seminars, thus beginning the second phase—engagement.
• Hiring and training staff: Each member of BIAS' staff is unique and possesses the language skill and cultural background to conduct successful outreach and education of communities; each possesses a holistic tool kit of expertise. For instance, each staff member is trained to provide Medicare/Medicaid/Food stamp counseling and to fill out pertinent forms. Each staff is educated on Medicare Part D benefits and on Medicare Fraud Prevention. Each staff person is a trained interpreter offering a non-advocacy interpretation when in this role. Each is expected to be extremely familiar with the naturalization process, forms to be completed, and the educational components of the naturalization preparation. Each person is trained to conduct mental health assessment and memory testing in his/her own language and is also able to provide a myriad other answers, ranging from housing assistance to financial assistance, and even filling out simple tax forms.

Resources Used and Skills Needed

• Staffing: Information provided in March 2012 indicates that in late 2011, BIAS changed its organizational structure by appointing Social Services and Mental Health Team leads. All of the 14 projects currently offered by the agency fall into one of these categories. BIAS now employs one full-time Bosnian medical assistant (counseling); one full-time Vietnamese Master's of Social Work (MSW); one full-time Korean licensed medical social worker (LMSW); one full-time medical assistant (education) to help with citizenship issues; and one part-time MSW, one part-time licensed clinical social worker (LCSW) (Spanish), and a full-time CEO. A Chief Financial Officer works part time and a consultant is currently contracted to focus on internal needs of the agency as it prepares to go paperless. In addition, a full-time staff member now focuses on volunteer and interpreter coordination, as much of citizenship educational work is conducted by volunteers. BIAS also relies on language assistance from MSW students.
• Costs: BIAS was able to secure increasing amounts of revenue through grant writing and increased recognition of its contribution to the social and mental health needs of indigent seniors of Missouri. The secured budget for 2011 to 2012 reflects $630,000; however, $665,000 is budgeted for the fiscal year, which ends in May 2012. BIAS also conducts annual fundraisers and works with board members on fiscal responsibility and fundraising.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Assemble task force: Create a task force of community leaders (e.g., healers, doctors, religious leaders) interested in becoming involved in this kind of program.
• Research target population(s): Identify and understand the unique needs of the community of individuals to be served by the program. Needs will vary based on cultural and family backgrounds.
• Hire linguistically appropriate staff: Once needs are identified, hire a bilingual professional with prior experience or training, along with a paraprofessional who can be trained as needed to address community needs.
• Ensure adequate training: Provide necessary training to staff and volunteers on available resources and systems of care. 
• Acknowledge that staff members "go the extra mile": Staff members' level of expertise and knowledge is hardly matched by available financial resources; this attests to workers' dedication to the cause; they are willing to take less pay to ensure that the seniors within their communities receive respect and assistance they cannot do without.
• Build on what already works: Use existing strengths and mechanisms while aiming to fill the gaps in care.

Sustaining This Innovation

• Utilize reimbursement sources: Tap into existing payment sources for services provided, including Medicare and other insurance programs.
• Search broadly for funding: Seek additional funding, including grants from local and national organizations, to offset program costs.
• Tap into volunteers: Use volunteers as much as possible, including bilingual students from local universities.
• Expand infrastructure as needed: In the beginning, BIAS relied primarily on a small number of volunteers to provide services to clients. However, as the number of clients grew and their needs increased, the program expanded and BIAS leaders discovered the need for more supervisory staff and other centralized support.
• Use volunteers: Information provided in March 2012 indicates that program developers should tap into communities of professional volunteers (e.g., AmeriCorps VISTA), some of whom may be representatives of minority communities.
• Budget: Information provided in March 2012 notes that agencies and providers budget for office supplies, rents, and other expenses. Program developers suggest that interpreter expense must also be budgeted so that anyone who seeks professional services may receive them, regardless of language needs. Never ask untrained bilingual speakers to interpret (e.g., family members), even if the consumer should request it.