2024 MIPS IA_EPA_6: Create and Implement a Language Access Plan

Activity ID

Activity Weighting

Subcategory Name

Activity Description

Create and implement a language access plan to address communication barriers for individuals with limited English proficiency. The language access plan must align with standards for communication and language assistance defined in the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (https://thinkculturalhealth.hhs.go v/clas).

Objective

Improve quality of care and patient outcomes by ensuring clear and culturally relevant communication with patients with limited English proficiency.

Suggested Documentation

Evidence of a practice-wide review and implementation of a plan to language access. Include all of the following elements:

1) Review - Documentation of a practice-wide review of existing tools and policies; AND

2) Gap analysis memo - Completion of a memo comparing the results of the above review with the four standards on communication and language assistance stipulated in the National CLAS Standards; AND

3) Plan to improve language access - A new or updated plan, which includes information on patient needs (i.e., common languages spoken, percent of practice’s population that has low English proficiency), defines how interpretation will be provided, outlines how patients and families will be notified about interpretation services, and specifies staff training; AND

4) Plan Implementation - Report comparing the results from implementing the new or updated language access plan with the four standards on communication and language assistance stipulated in the National CLAS Standards and documenting where gaps have been closed or still remain.

Examples of Additional Activities that Qualify for Attestation

A practice-wide review and gap analysis indicated that a practice's signage and website is predominantly in English only and that clinicians often rely on family members to communicate with patients with limited English proficiency. The practice updated its signage and website to include common languages other than English and make patients aware that interpretation services are available at no cost. The clinic trained clinicians on use of professional interpreter services.

Example/Information

• The U.S. Department of Health and Human Services publishes the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. Four of these standards address communication and language assistance. Free, continuing education e-learning programs are available for clinicians, allied health workers, and administrators. National Standards for Culturally and Linguistically Appropriate Services. (https://thinkculturalhealth.hhs.gov/clas)
• CMS has issued a Guide to Developing a Language Access Plan that identifies ways that providers can assess their programs and develop language access plans to ensure persons with limited English proficiency have meaningful access to their programs: Guide to Developing a Language Access Plan. (https://www.cms.gov/About-CMS/AgencyInformation/OMH/Downloads/Language-A...)
• This 2017 article by Alexander R. Green and Chijioke Nze uses a case vignette to illustrate the potentially serious consequences of language barriers for the care of patients with limited English proficiency, and suggests actions that can be taken to improve patient care: Language-Based Inequity in Health Care: Who Is the “Poor Historian”?. AMA J Ethics. 2017;19(3):263- 271. doi: 10.1001/journalofethics.2017.19.3.medu1- 1703. (https://journalofethics.amaassn.org/article/language-based-inequity-health-carewho-poor-historian/2017-03)