Appointment Scheduling Fixes Needed for LEP Patient Access

The appointment scheduling process is proving not ideal, especially for Spanish-speaking or limited English proficiency (LEP) patients, according to data from RAND.

The study, published in Health Affairs Scholar, showed that it’s harder for Spanish-speaking patients to get to the appointment scheduling process with front office staff in safety-net behavioral health clinics, let alone book the spot.

Instead, Spanish-speaking patients are more likely than their White peers to be hung up on or told that nobody in the clinic could help them, posing serious barriers to treatment, the secret shopper survey showed.

Despite federal regulations calling on safety-net providers (or any provider receiving federal funding) to support language-concordant care access and treatment, data has shown barriers for LEP patients. According to the RAND researchers, Spanish-speaking patients with LEP don’t receive as many healthcare services, have greater unmet mental and behavioral health needs, and have poorer quality of care than their White counterparts.

Previous studies have shown that challenges to healthcare navigation have driven those treatment barriers, and this latest study corroborated that.

In a secret shopper-style survey of safety-net behavioral health clinics in California, the RAND researchers found that it was harder for Spanish-speaking patients with LEP to get someone on the phone to book an appointment.

The team enlisted secret shoppers to pose as English- and Spanish-speaking patients looking for an appointment to get medication for depression. Overall, Spanish-speaking patients had more trouble getting an operator on the line and getting to the point of booking the appointment.

For starters, only 62 percent of callers could connect with a scheduler who spoke one or both languages, with a total of 149 calls happening in English and the remaining 97 happening in Spanish. Additionally, English speakers were more likely to speak with a live person (90 percent versus 72 percent) and more likely to get to the scheduling process in their preferred language (62 versus 41 percent).

What’s more, a whopping one in five Spanish-speaking callers were either hung up on or told nobody could help them in their preferred language. Spanish speakers were also more likely to be placed on hold for longer than five minutes (48 percent versus 28 percent).

Once Spanish-speaking callers did get to the point where they’d schedule an appointment, patient experiences were about the same. Although Spanish speakers were slightly more likely to be asked about their insurance status, the researchers observed about equal rates of “gatekeeping,” or being told patients needed to complete an intake visit.

Wait times, too, were similar across language preferences. The time to a prescribing visit was around 36 days, regardless of caller language preference. Although there is some equity here, the researchers did point out that 36 days is beyond established targets.

That said, Spanish speakers tended to have more options once they got to the appointment scheduling part of the call. For example, 71 percent were given a choice of visit modality—telehealth versus in-person—while only 48 percent of English speakers were given the same.

This comes as more than half (64 percent) of the clinics included in the experiment offered both in-person and telehealth appointments. For Spanish-speaking patients asking about language services, the researchers noted language-concordant care being more available for telehealth (50 percent) than in-person visits (46 percent).

Moving forward, it’d incumbent upon healthcare organizations to hire bilingual front office staff and simplify workflows so it is easier to bring in language interpreters during the appointment scheduling and intake process. Online appointment scheduling systems hosted in multiple languages could also help fill in some blanks.

Still, the researchers noted that these solutions are not always simple.

“It is important to recognize that there is a cost to providing language assistance in every interaction, and laws requiring meaningful access are commonly criticized as unfunded mandates,” they wrote. “Hiring multilingual front office staff may not be a feasible solution to communication barriers in safety-net settings where many languages are spoken and workforce shortages are common. Broader efforts at the payer or state level, however, could generate economies of scale.”

Although this study focused more on the patient access experience, the researchers did point out some issues with language-concordant patient-provider communication. Around half of the clinics in the sample had Spanish-speaking clinicians, but separate secret shopper experiments have shown that less than half (between 9 and 43 percent) of visits with Spanish-speaking patients were led by Spanish-speaking providers.

There’s some untapped potential for telehealth here, the researchers said. Organizations that cannot meet the demand for healthcare delivered in Spanish may consider hiring Spanish-speaking clinicians from outside the community to meet with patients virtually via telehealth.

Moreover, payers, providers, and policymakers should also work to boost the number of in-person behavioral health services offered in safety-net settings. Data has shown that Spanish-speaking patients and those visiting safety-net clinics are less likely to be interested in telehealth. A dearth of in-person appointments shouldn’t be a barrier to care, the researchers concluded.