Patients Who Are Deaf or Hearing Impaired
The federal government requires appropriate auxiliary aids and services when necessary to ensure effective communication with individuals with disabilities.
Title III (Public Accommodations) of the Americans with Disabilities Act (ADA) prohibits private places of public accommodation from discriminating against individuals with disabilities. Examples of public accommodations include privately-owned, leased or operated facilities like doctor's offices. This title directs businesses to make "reasonable modifications" to their usual ways of doing things when serving people with disabilities. It also requires that they take steps necessary to communicate effectively with customers with vision, hearing, and speech disabilities.
The Texas Medical Association (TMA) Office of the General Counsel has prepared a whitepaper Americans with Disabilities Act and the Hearing Impaired (members only) that provides guidance on the statutory and regulatory provisions, penalties, and more.
The whitepaper states that, according to the U.S. Department of Justice (DOJ), the type of auxiliary aid or service necessary to ensure effective communication will vary in accordance with the length and complexity of the communication involved. The regulations include providing qualified interpreters to be available to individuals with hearing impairments.
TMA also has some tips in Communicating With Patients Who Are Deaf or Hard of Hearing.
The DOJ Civil Rights Division provides information on the ADA requirements for effective communication with people with hearing, vision or speech disabilities.
The U.S. Department of Health and Human Services (HHS) Office of Civil Rights discusses Effective Communication for Persons Who Are Deaf or Hard of Hearing.
Interpreter Resources and Guidance
A list of Interpreters for the Hearing Impaired (pdf) in the Houston area.
Is an interpreter the only kind of auxiliary aid a physician's office may use?
The federal government provides the following example of an appropriate accommodation: The hearing impaired patient goes to the doctor for a bi-weekly check-up, during which the nurse records the patient's blood pressure and weight. Exchanging notes and using gestures are likely to provide an effective means of communication at this type of
check-up.
However, when the ailment is of sufficient complexity that an interpreter is necessary to ensure effective communications, then the physician must provide a qualified interpreter. Note that a certified interpreter does not need to be provided and is not required by the ADA - it requires only a qualified interpreter. This is potentially a cost saving distinction.
Can a patient's family member be used as the interpreter?
Impartiality is one of the elements necessary for an interpreter to be considered qualified. Using a family member entails risk because the lack of impartiality may cause the patient to avoid sharing important, but very personal, facts. Indeed, the federal government prevents physicians from requiring or coercing a family member, companion, case manager, advocate or friend of a hearing impaired individual to be an interpreter.
Who pays for the interpreter?
The physician responsible for the care must pay for the cost of the interpreter and may not impose a surcharge on an individual with a disability directly or indirectly to offset the cost of the interpreter, as it is considered to be an overhead expense. Under certain circumstances, Texas Medicaid will reimburse the physician for some of the costs. Refer to the TMHP Provider Manual for details. For commercial health plans, check with the patient's plan to determine if it provides reimbursement.
Who gets to choose the appropriate accommodation?
The physician, not the hearing impaired person, chooses the appropriate accommodation, and if an interpreter is needed, the physician chooses the interpreter. The TMA whitepaper states that a physician need not accept and pay for the services of a sign-language interpreter who is unilaterally retained by the hearing impaired patient, when the physician has had no opportunity to make his or her own arrangements. However, the practice would want to consult with the patient since the goal is to provide an aid or service that will be effective, given the nature of what is being communicated and the person's method of communicating.
Staff Training
To avoid any problems, practices should teach staff, especially front line staff, about the practice's policies and the ADA's requirements for communicating effectively with people who have communication disabilities.
Patients With Limited English Proficiency (LEP)
Under the Affordable Care Act and accompanying federal rules, certain medical practices must take "reasonable steps" to provide meaningful access to people with limited English proficiency (LEP).
The Texas Medical Association (TMA) Office of the General Counsel has a whitepaper Accommodation of Persons With Limited English Proficiency (LEP) (members only) that provides guidance on the U.S. Department of Health and Human Services (HHS) requirements. It explains that most physicians are likely subject to the HHS LEP rules, as most physicians participate in at least one federal, state, or local health program that receives federal financial assistance. Many physicians, for instance, participate in Medicaid or receive "meaningful use" payments (or the successor to meaningful use payments). The rules make no distinction between entities who receive financial assistance directly or indirectly.
The whitepaper discusses which entities are subject to the rules with some example situations. It also states that language services that are required as "reasonable steps to provide meaningful access" should be free of charge, be accurate and timely, and protect the privacy and independence of the LEP person.
Additional information covered in the whitepaper includes:
- The four factors used under federal rules to determine whether a practice has taken reasonable steps to provide meaningful access;
- The definitions of a "qualified interpreter" or "qualified translator" that may be required for meaningful access;
- Restrictions the rules place on providing language services; and
- When notices and taglines are required.
Interpreter-Translator (LEP) Resources and Guidance
A list of Limited English Proficiency (LEP) Interpreter-Translator Services (pdf).
Medical Directions, Inc. provides Tips for Working with Health Care Interpreters (pdf).
HHS Section 1557 Resources
The Department of Health and Human Services (HHS) has many resources when treating a patient with Limited English Proficiency (LEP), including guidance on Section 1557, and answers to some frequently asked questions.
Also, see the HHS site for some sample notices and other resources translated into different languages, as well as a table showing the top 15 languages spoken by individuals with LEP in each state.
Dealing With Some Difficult Patient Situations
What qualifies as a "service animal"? Is it ever okay to exclude a service animal? What about an "emotional support animal"?
Under Title III of the ADA, a service animal is a dog that has been individually trained to perform work or tasks that assist an individual with a disability. Some examples of tasks that service animals can perform are pulling a wheelchair, assisting a person who is blind, assisting an individual during a seizure, alerting a person with diabetes of dangerous changes in his blood sugar level, and helping with psychiatric or neurological disabilities by preventing or interrupting impulsive or destructive behaviors. For more information, what accommodations should be made, and when is it okay to exclude a service animal, see Service Animals, Small Business, and Other Public Accommodations. (ADA National Network)
Emotional support animals, comfort animals, and therapy dogs are not service animals under Title III of the ADA. The ADA does not require business owners to permit these types of animals in their premises. That would be a decision by the business owner. Read more at Service Animal or Emotional Support Animal: What's the Difference? (ADA National Network)
Any advice when uncomfortable discussions arise involving topics like vaccinations, firearm safety, religious objections to medical treatments, and concerns about discrimination?
The Texas Medical Association (TMA) provides guidance on working with patients through these demanding interactions in Countering controversy: How to have difficult conversations with patients (TMA)
How should we deal with a patient who is becoming difficult and disruptive?
The Texas Medical Liability Trust (TMLT) provides assistance in From Difficult to Dangerous: How to Handle Disruptive Patients. (TMLT, The Reporter, Q2 2019)
Any advice on how my staff and I should handle an angry or complaining patient?
TMA has recommendations in How to handle patient confrontations (TMA) and How to handle patient complaints. (TMA)
I have a patient who is showing signs of becoming suicidal. What should I do?
TMLT provides guidance in the article Evaluating and Treating the Suicidal Patient. (TMLT, The Reporter, Q1 2019)
How should we deal with a patient who refuses to take No for an answer?
Physicians Practice has some tips in the article How to say No to unreasonable patient requests. (Physicians Practice)
How should I respond to patients who regularly go online to try to self-diagnose their symptoms?
Before responding, TMA recommends first determining what kind of patient he is. See When patients consult Google... (TMA)
Looking for additional help?
TMA has more patient/customer service resources. (TMA)
Electronic Communications with Patients
Electronic communications, such as email or text messaging, can be useful tools in the practice of medicine and can facilitate communication between patients and the physician, but these channels can raise special concerns about privacy and confidentiality.
However, communicating with a patient via a secure patient portal that meets HIPAA requirements provides not only the necessary confidentiality, it also acts as a "firewall" between the patient and the physician.
Any electronic encounters that involve patient care must be documented in the patient's medical record.
The AMA Code of Medical Ethics provides guidance for physicians engaged in electronic communications with patients under Consent, Communication and Decision Making, Opinion 2.3.1 Electronic
Communication With Patients.
The Texas Medical Association (TMA) provides helpful information on the TMA Health Information Technology (HIT) page.
Refer to the HCMS Health Information Technology (HIT) page for guidance on remote patient monitoring, telemedicine, preventing information blocking, etc.