Navigating Older Adults Service Provision during the COVID-19 Pandemic: A Qualitative Study of Bicultural and Bilingual Asian Human Service Workers

The pandemic has spotlighted multiple long-standing inequities among marginalized populations. Of particular concern is the population of older Asian adults with limited English proficiency, who rely heavily on bicultural and bilingual Asian human service workers for culturally and linguistically appropriate service provision. With ever-evolving public health measures implemented during the COVID-19 pandemic, new challenges arose for bicultural and bilingual Asian human service workers to provide timely and appropriate care. To better understand the challenges among bicultural and bilingual Asian human service workers, this qualitative study explores how these workers changed their service provision in assisting older adults with limited English proficiency. Using the purposive sampling strategy, ten bicultural and bilingual Asian human service workers participated in the study that employed a phenomenological approach. Findings suggest that the workers need additional support to create a more comprehensive system of care for their older Asian clients who carry dual cultures and systems during the time of public health emergencies. Implications for social work and human service practice are offered.

The Use of Interpreters in Health Centers: A Mixed-Methods Analysis

Health centers serve millions of patients with limited English proficiency (LEP) through highly variable language services programs that reflect patient language preferences, the availability of bilingual staff, and very limited sources of third-party funding for interpreters. We conducted a mixed-methods study to understand interpreter services delivery in federally qualified health centers during 2009–2019. Using the Uniform Data System database, we conducted a quantitative analysis to determine characteristics of centers with and without interpreters, defined as staff whose time is devoted to translation and/or interpreter services. We also analyzed Medicaid-relevant policies' association with health centers' interpreter use. The qualitative component used a sample of 28 health centers to identify interpreter services models. We found that the use of interpreters, as measured by the ratio of interpreter full-time equivalents per patients with LEP, decreased between 2009 and 2019. We did not find statistically significant relationships between interpreter staffing and number of patients with LEP served, or in our examination of Medicaid-relevant policies. Our qualitative analysis uncovered homegrown models with varying program characteristics. Key themes included the critical role of bilingual staff, inconsistent interpreter training, and the reasonably smooth transition to virtual interpretation during COVID-19.

Stress among Korean immigrant parents of children with diagnosed needs amid the COVID-19 pandemic

This study examines difficulties amid the COVID-19 pandemic in raising children and meeting their educational needs among Korean immigrant parents of children with disabilities, giftedness, and/or limited English proficiency living in the U.S. The Ordinary Least Squares (OLS) regression analysis examined the associations between the 48 participants' perceived difficulties meeting their children's educational needs, parental stress, and parents' resilience and social support. Additionally, basic interpretive qualitative analysis was conducted for the 18 survey participants who provided data via an open-ended survey response. Results determined that participant difficulties in assisting with their children's educational needs were associated with increased parental stress. Participants also described lack of resources and support, language and communication barriers, internal family conflicts, and developmental concerns about the child. Implications for practice and future research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Strategies Used by Healthcare Systems to Communicate with Hospitalized Patients and Families with Limited English Proficiency During the COVID-19 Pandemic: A Narrative Review.

The COVID-19 pandemic disproportionately affected racial and ethnic minorities in the United States, including many with limited English proficiency (LEP). These patients face various communication barriers, including a shortage of available interpreters and the need for masks that exacerbated communication barriers. It is not known how hospitals responded to these unique challenges to providing language services for the large number of patients with LEP during COVID-19. This narrative review assessed literature and lay media to identify strategies utilized by hospitals to communicate with patients with LEP hospitalized during the COVID-19 pandemic. A search of APA PsychInfo, EBM Reviews, Embase, Ovid MEDLINE, Epub Ahead of Print, and Ebsco Megafile initially yielded 61 articles, 6 of which were ultimately included after reviewing abstracts and full texts. The identified interventions, which sought to increase accessibility of language-concordant care, increase accessibility of professional interpretation, and improve family communication and understanding, were described positively, though only one was tested for effectiveness.

A systematic review and meta-analysis of psychosocial interventions for immigrant and limited English proficient cancer patients.

OBJECTIVE: Immigrants, particularly those who are less acculturated and limited English proficient (LEP), often lack access to culturally and linguistically appropriate psychosocial care in cancer survivorship. We sought to determine what psychosocial interventions are available for immigrant and/or LEP cancer patients and to assess treatment and patient factors that may correlate with better psychosocial outcomes for this population. METHODS: We conducted a systematic review and meta-analysis of studies published through August 2022 of interventions conducted with immigrant and/or LEP cancer patients aimed at improving psychosocial outcomes (i.e., quality of life, depression, cancer-related distress, and anxiety). Using Covidence, a software program for systematic review management, four independent raters screened 16,123 records with a systematic process for reconciling disagreement, yielding 48 articles (45 studies) for systematic review and 21 studies for meta-analysis. RESULTS: Most studies were conducted with Spanish-speaking patients with breast cancer. Study participants (N = 5400) were primarily middle-aged (mean = 53 years old), female (90.0%), and Hispanic (67.0%). The weighted average effect size (g) across studies was 0.14 (95% CI 0.03-0.26) for quality of life (18 studies), 0.04 (95% CI -0.08 to 0.17) for depression (8 studies), 0.14 (95% CI -0.03 to 0.31) for cancer-related distress (6 studies), and 0.03 (95% CI -0.11 to 0.16) for anxiety (5 studies). CONCLUSION: The interventions under review had small but beneficial effects on psychosocial outcomes for immigrant and LEP cancer patients. Notably, effect sizes were smaller than those found in previous meta-analyses of psychosocial interventions conducted in majority U.S.-born, non-Hispanic White, English-speaking cancer patient samples. More research is needed to identify key components and adaptations of interventions that benefit immigrant and LEP cancer patients to strengthen their effects for this growing yet underserved population.

Neighborhood-level COVID vaccination and booster disparities: A population-level analysis across California.

Objectives: To describe vaccine and booster uptake by neighborhood-level factors in California. Methods: We examined trends in COVID-19 vaccination up to September 21, 2021, and boosters up to March 29, 2022 using data from the California Department of Public Health. Quasi-Poisson regression was used to model the association between neighborhood-level factors and fully vaccinated and boosted among ZIP codes. Sub-analyses on booster rates were compared among the 10 census regions. Results: In a minimally adjusted model, a higher proportion of Black residents was associated with lower vaccination (HR = 0.97; 95%CI: 0.96-0.98). However, in a fully adjusted model, proportion of Black, Hispanic/Latinx, and Asian residents were associated with higher vaccination rates (HR = 1.02; 95%CI: 1.01-1.03 for all). The strongest predictor of low vaccine coverage was disability (HR = 0.89; 95%CI: 0.86-0.91). Similar trends persisted for booster doses. Factors associated with booster coverage varied by region. Conclusions: Examining neighborhood-level factors associated with COVID-19 vaccination and booster rates uncovered significant variation within the large and geographically and demographically diverse state of California. Equity-based approaches to vaccination must ensure a robust consideration of multiple social determinants of health.

Interpreter use in sustained nurse home visiting: interpreter experience and support.

BACKGROUND: The aim of this study was to explore the experiences of healthcare interpreters working with child and family health nurses (CFHNs) in providing child and family health nursing (CFHN) services and sustained nurse home visiting (SNHV) programs to culturally and linguistically diverse (CALD) families with limited English proficiency. METHODS: A mixed methods longitudinal research design was conducted to develop, implement and evaluate a training and practice support model for healthcare interpreters working with nurses and CALD families in providing CFHN services and SNHV programs in three major local health services in Sydney, Australia. One pre-training survey with 24 healthcare interpreters was conducted; field notes were recorded during training and implementation; and a post-implementation focus group with six healthcare interpreters was conducted. Quantitative survey data were analysed descriptively using Alchemer. The focus group was audio-recorded for transcription purposes, and this and the field notes were thematically analysed applying a socioecological framework. RESULTS: Three themes were identified from the initial, pre-training survey: facilitate communication and delivery accurately; a bridge linking the clients and the healthcare practitioners; and make everybody feel comfortable. Practice support implementation was negatively impact by system and COVID-19 related barriers. Four themes were developed from evaluative phase of the study including: system-related issues; interpreters' challenges; working with nurses; and client session related issues. CONCLUSION: Quality interpreting was favourably influenced by adequate time for interpreting the session including a pre- and post-briefing session with CFHNs, an appropriate mode of interpretation, allocation of female interpreters and the same interpreters with CALD mothers and clarity about interpreter role and cultural comfort. These strategies support the quality of communication and relationships in delivery of CFHN services and SNHV programs to CALD mothers with limited English proficiency.

Meeting them where they are on the web: addressing structural barriers for Latinos in telehealth care.

As we enter an era of health care that incorporates telehealth for routine provision of care, we can build a system that consciously and proactively includes vulnerable patients, thereby avoiding further exacerbation of health disparities. A practical way to reach out to Latino patients is to use media they already widely use. Rather than expect patients to adapt to suboptimal systems of telehealth care, we can improve telehealth for Latinos by using platforms already familiar to them and thereby refocus telehealth delivery systems to provide patient-centered care. Such care is responsive to patients' needs and preferences; for Latinos, this includes using digital devices that they actually own (ie, smartphones). Equity-centered telehealth is accessible for all, regardless of linguistic, literacy, and socioeconomic barriers.

Stress among Korean immigrant parents of children with diagnosed needs amid the COVID-19 pandemic

This study examines difficulties amid the COVID-19 pandemic in raising children and meeting their educational needs among Korean immigrant parents of children with disabilities, giftedness, and/or limited English proficiency living in the U.S. The Ordinary Least Squares (OLS) regression analysis examined the associations between the 48 participants' perceived difficulties meeting their children's educational needs, parental stress, and parents' resilience and social support. Additionally, basic interpretive qualitative analysis was conducted for the 18 survey participants who provided data via an open-ended survey response. Results determined that participant difficulties in assisting with their children's educational needs were associated with increased parental stress. Participants also described lack of resources and support, language and communication barriers, internal family conflicts, and developmental concerns about the child. Implications for practice and future research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Spanish-Language Communication of COVID-19 Information Across US Local Health Department Websites.

The COVID-19 pandemic has brought new urgency to a longstanding problem: the US health system is not well-equipped to accommodate the country's large limited English proficient (LEP) population in times of national emergency. We examined the landscape of Spanish-language COVID-19 website information compared to information in English provided by health departments of the top 10 cities by population in the USA. For each city, coders evaluated three score measures (amount of information, presentation quality, and ease of navigation) for six content types (general information, symptoms, testing, prevention, vaccines, and live statistics) across six delivery modes (print resources, website text, videos, external links, data visualization, and media toolkits). We then calculated a grand average, combining all cities' values per score measure for each content type-delivery mode combination, to understand the landscape of Spanish-language information across the country. Overall, we found that, for all cities combined, nearly all content types and delivery modes in Spanish were inferior or non-existent compared to English resources. Our findings also showed much variability and spread concerning content type and delivery mode of information. Finally, our findings uncovered three main clusters of content type and delivery mode combinations for Spanish-language information, ranging from similar to worse, compared to information in English. Our findings suggest that COVID-19 information was not equivalently provided in Spanish, despite federal guidance regarding language access during times of national emergency. These results can inform ongoing and future emergency communication plans for Spanish-preferring LEP and other LEP populations in the USA.

Analysis of Language Translations of State Governments' Coronavirus Disease 2019 Vaccine Websites.

Introduction: During the coronavirus disease 2019 (COVID-19) vaccination campaign, non-English-communicating individuals have faced inequities in access to resources for vaccine education and uptake. We characterized the language translation status of states' COVID-19 vaccine websites to inform discussion on the sufficiency of translated information and strategies for expanding the availability of multilingual vaccine information. Methods: We identified the primary COVID-19 vaccine website for all 50 states, the District of Columbia, and the federal government ("jurisdictions") and determined the languages into which information about obtaining the vaccine (access) and vaccine safety and efficacy had been translated, as of October 2021. We compared these findings with data from the American Community Survey to determine how many individuals had these online resources available in their primary language. Results: Only 56% of jurisdictions provided professionally translated information about COVID-19 vaccine safety and efficacy, and only 50% provided professionally translated information about how to register for or obtain the COVID-19 vaccine, in at least one language. Consequently, ∼26 million Americans may not have accurate vaccine safety and efficacy information available, and ∼29 million Americans may not have vaccine access information available, from their jurisdiction in their primary language. Furthermore, translated information often was limited in scope and/or number of languages provided. Conclusion: Translation of COVID-19 vaccine information on state government websites currently is insufficient to meet the needs of non-English-communicating populations. This analysis can inform discussions about resource needs and operational considerations for adequate provision of multilingual, critical health information.

The Use of Automated Machine Translation to Translate Figurative Language in a Clinical Setting: Analysis of a Convenience Sample of Patients Drawn From a Randomized Controlled Trial.

BACKGROUND: Patients with limited English proficiency frequently receive substandard health care. Asynchronous telepsychiatry (ATP) has been established as a clinically valid method for psychiatric assessments. The addition of automated speech recognition (ASR) and automated machine translation (AMT) technologies to asynchronous telepsychiatry may be a viable artificial intelligence (AI)-language interpretation option. OBJECTIVE: This project measures the frequency and accuracy of the translation of figurative language devices (FLDs) and patient word count per minute, in a subset of psychiatric interviews from a larger trial, as an approximation to patient speech complexity and quantity in clinical encounters that require interpretation. METHODS: A total of 6 patients were selected from the original trial, where they had undergone 2 assessments, once by an English-speaking psychiatrist through a Spanish-speaking human interpreter and once in Spanish by a trained mental health interviewer-researcher with AI interpretation. 3 (50%) of the 6 selected patients were interviewed via videoconferencing because of the COVID-19 pandemic. Interview transcripts were created by automated speech recognition with manual corrections for transcriptional accuracy and assessment for translational accuracy of FLDs. RESULTS: AI-interpreted interviews were found to have a significant increase in the use of FLDs and patient word count per minute. Both human and AI-interpreted FLDs were frequently translated inaccurately, however FLD translation may be more accurate on videoconferencing. CONCLUSIONS: AI interpretation is currently not sufficiently accurate for use in clinical settings. However, this study suggests that alternatives to human interpretation are needed to circumvent modifications to patients' speech. While AI interpretation technologies are being further developed, using videoconferencing for human interpreting may be more accurate than in-person interpreting. TRIAL REGISTRATION: ClinicalTrials.gov NCT03538860; https://clinicaltrials.gov/ct2/show/NCT03538860.

A high-touch outreach model to re-engage patients in mammogram screening

Background: Disparities in cancer screening have been well documented during the Covid-19 pandemic. However, there are limited patient-reported data describing the prevalence and drivers of patient hesitancy towards cancer screening and willingness to resume screening. As health systems continue to experience pandemic-related capacity strain, there is an urgent need for innovative models of re-engaging patients in preventive screening. To address this issue, we developed a medical student-led, high-touch outreach model to re-engage primary care patients at Brookside Community Health Center in cancer screening. Methods: We iteratively optimized semi-structured call scripts and surveys in English and Spanish to contact patients overdue for mammography screening. Student callers included medical and pre-medical students with native Spanish fluency. Using the call script, students identified patient-reported barriers and facilitated mammogram scheduling for consenting patients. For consenting patients, student callers placed a telephone encounter with a pended screening mammogram order in the electronic medical record. PCP confirmation of the order triggered outreach by the radiology department for mammogram scheduling. Patients also received reminder calls from students the week of their appointment. Primary outcomes include screening consent rates, mammogram scheduling and completion rates, and screening results. Patient survey responses were securely recorded using the REDCap survey platform. Results: 198 patients were eligible for the intervention. 60% are primarily Spanish-speaking and 81% are insured by Medicaid. 145 patients (73%) have successfully been contacted, of which 129 (89%) consented for mammogram screening. 74 (57%) of the consenting patients have scheduled their mammogram and 38 (29%) have completed their mammogram. 36% of consenting Spanish-speaking patients with active mammogram orders did not have a mammogram scheduled, compared to 9% of consenting English-speaking. To date, 6 patients had abnormal mammograms requiring subsequent diagnostic imaging, and 1 patient was diagnosed with ductal carcinoma in situ requiring oncologic care. Qualitative analysis of patient surveys found that primary barriers to screening included factors associated with the Covid-19 pandemic (32.9% of contacted patients), lack of awareness of overdue status (25.9%) and patient unavailability (e.g. outside of country) (20%). Conclusions: In this single-center quality improvement study, we found that patients had a high willingness to engage in cancer screening during the pandemic and that trainees can play a vital role in re-engaging patients in preventative care. The disparity between Spanish and English-speaking patients' ability to schedule a mammogram after the consent process suggests that patients with limited English proficiency face additional challenges in accessing screenings.

Improving Language Access for Patients with Limited English Proficiency (LEP) During Emergency Room Care

Purpose/Objectives: Patients with Limited English proficiency (LEP) are at greater risk for hospital admissions and representations to the emergency department (ED) in comparison to patients with English proficiency (EP). Improved communication with language services has been shown to decrease these health disparities. In our free-standing Children's Hospital yearly ED representation rates for patients with LEP (4.6%) are over 20% higher than for our patients with EP (3.7%). We aimed to decrease the 7-day representation rate for patients with LEP in the emergency department by 20% over 18 months using the Plan Do Study Act (PDSA) method for quality improvement. Design/Methods: Our first cycle was the deployment of video remote interpretation (VRI). Second and third cycles included focused teaching for Faculty, House staff and staff on VRI use. PDSA cycles were interrupted with the unexpected event of Covid-19 and issues obtaining Cerner data. We evaluated outcomes quantitatively based on data from our language service provider and electronic medical record (EMR). We also conducted an electronic survey of Faculty and Staff to evaluate quantitatively over time VRI reception and frequency of obtaining preferred language. Results: LEP representation rates initially increased followed by a decreasing trend with the Covid19 pandemic and opening of an ED observation unit but this trend was not sustained and average representation rates after PDSA cycles increased to 6.1%. EP representation rates overall remained unchanged at 3.7%. Utilization of interpretation carts increased from 0 to >250 total calls made per month over the course of 18 months. The monthly average number of identified patients with LEP decreased after changes were made to the recording system in the EMR. Monthly rates of interpretation carts used for un-identified patients with LEP were found to range from 27% to 78%, signifying significant under identification in the EMR. 75% of ED Faculty and staff reported that they only ask preferred language or offer interpretation services for medical discussions infrequently when patients appear to speak English well but is clearly not their native language. Total ED visit numbers decreased after March of 2020 to 30-50% of expected due to Covid-19 pandemic. Conclusion/Discussion: ED Patients with LEP had an unexpectedly high rate of un-identification in addition to ED faculty and staff reporting not asking preferred language if the patient seems to speak English well. This has likely led to an underestimation of our LEP representation rate and lack of representative change during our PDSA cycles. Without identifying this vulnerable population, we will always be lacking in providing care in the preferred language which is critical for improving outcomes for our patients with LEP. Our next steps are to develop interventions to increase the identification of patients with LEP to provide safe and comprehensive care for this vulnerable population.

The Effect of Primary Household Language on Well Child Care Utilization During the COVID-19 Pandemic

Background: The COVID-19 pandemic disrupted well child care nationally, leading to decreased primary care visits and routine childhood vaccinations. Children in limited English proficiency (LEP) households experience disparities in access to well child care;however, little is known about the impact of the COVID-19 pandemic on these disparities. We aimed to assess if patients' primary household language was associated with 1.) changes in well child care utilization after the pandemic onset;and 2.) the rate of recovery towards pre-pandemic utilization. Methods: Secondary analysis was conducted on medical records data from 4 clinics in a large urban university health system to determine the number of 1.) well child visits;2.) vaccines administered;3.) developmental delay diagnoses;and 4.) audiology referrals (proxy for developmental screening/referral) in patients 9-36 months old between January 2019-December 2020. Data was aggregated monthly by household primary language: limited English proficiency, Spanish (LEP-Spanish) vs. English. Differences between the pre-pandemic and pandemic periods (onset defined as March 2020) in 1.) well child care utilization and 2.) rate of recovery towards pre-pandemic utilization by primary household language were analyzed using Poisson linear regression. Results: 8504 well child encounters occurred during this time period: 6615 in English-speaking patients, 1747 in LEPSpanish speaking patients, and 142 in patients with other primary languages. After the pandemic onset, there was a decrease in well visits per month in both English (46% decrease, p<.001) and LEP-Spanish (61% decrease, p<.001) speaking patients (Fig. 1, Table 1). This decrease was significantly greater in the LEP-Spanish group (p<.001). Average number of vaccines administered per month also decreased in both English (44% decrease, p<.001) and LEP-Spanish (56% decrease, p<.001) speaking patients;the decrease was significantly greater in the LEP-Spanish group (p<.001). There was no evidence of recovery in either language group during the pandemic period for well child visits or vaccines administered. Between the pre-pandemic and pandemic periods, there was a significant increase in developmental delay diagnoses in LEP-Spanish speaking patients only (p=.001);both the English (p<.001) and LEP-Spanish (p=.02) groups had significant decreases in audiology referrals. Conclusion: While well child care utilization decreased after the onset of the COVID-19 pandemic in all patients, LEP-Spanish speaking patients had disproportionately larger decreases in total number of well child visits and vaccines administered, as well as significantly higher diagnoses of developmental delay compared to primarily English-speaking patients. These findings suggest the need to focus outreach efforts and resources on patients with LEP to reduce healthcare disparities amplified by the COVID-19 pandemic. Further research is needed to identify barriers facing LEP patients in accessing well child care, as well as to evaluate the impact of the pandemic on other language groups.

A Folk Remedy for a Bellyache

Introduction: This case describes a curious cutaneous finding with a unique etiology from a cultural remedy. Case Description: A 19-month-old female was brought in by ambulance for an acutely progressive abdominal rash. Three days prior to presentation, she had a febrile seizure. The next day, she continued to have low grade temperatures and developed a faint red rash on the abdomen. On the day of presentation, the mother found a dark violaceous rash on the abdomen and called 911. The patient's presenting vital signs were unremarkable except for tachycardia to 133 and lower blood pressure for age of 86/67. She was tired and irritable. She had a large welldemarcated dusky and dark plaque with central denudation over the whole abdomen and right lateral back [Figures]. She was exquisitely tender to light palpation and guarding her abdomen. The remainder of her exam was unremarkable. Given the extent of her skin injuries, differential included intra-abdominal injury, intra-abdominal hemorrhage, burn or bruise from accidental and non-accidental cause, allergic dermatitis and disseminated intravascular coagulation in the setting of sepsis. Laboratory evaluation revealed mildly low hemoglobin for age at 10.5 g/dl with low MCV 74.2fL and a leukocytosis with WBC of 18.41 x10-3 πl with neutrophil predominance. Coagulation factors were normal. CMP revealed mild acidosis with CO2 of 17 mmol/L. Imaging studies included normal: CT head and CT abdomen with mild subcutaneous edema in the anterior abdomen near the umbilicus. Additional infectious studies were negative including nasal SARS-CoV-2 PCR, blood culture and urine culture. After the work-up, findings were consistent with a second-degree burn confirmed by Dermatology and Plastic Surgery. Suspected Child Abuse and Neglect team conducted additional social history with maternal grandmother because she is the caretaker when parents are at work, given parental denial of witnessing or causing the burn. Grandmother had limited English proficiency, so history was taken using a Medical Spanish interpreter. Grandmother explained that one day prior to presentation, she used an Oaxacan folk remedy to alleviate abdominal pain in which green tomato pulp was applied like a salve. Final diagnosis was second degree burn from phytophotodermatitis. Patient's skin improved with daily dressing changes and application of silver sulfadiazine, and she was discharged home to parents. Discussion: The use of tomato salve is a unique etiology of phytophotodermatitis that has not been well-characterized. Typical vegetation that causes burn injuries include figs, lemons and common wildflowers. Tomatillos or green tomatoes contain plant psoralens that can induce a strong phototoxic reaction to ultraviolet A radiation exposure after cutaneous contact. Conclusion: We present this case to highlight the importance of conducting thorough social history in the family's preferred language and to share a unique folk practice that can present as a severe burn and mimic child abuse.

Promoting Telehealth Equity Through Strategiesto Address Social Determinants of Health

Background: Due to the COVID-19 pandemic, health systems rapidly embraced telemedicine for a range of health services. Prior to COVID, approximately 15% of physicians offered telehealth services and less than 10% of patients utilized it. By Spring 2020, 85% of physicians and 46% of patients reported using telehealth, encouraged by federal and state emergency actions. However, without explicit efforts to ensure equity, broad reliance on telemedicine can perpetuate and increase disparities in health care access for vulnerable populations such as patients with Limited English Proficiency (LEP). Methods: We leveraged an implementation sciences framework to improve telehealth equity for patient families whose preferred language was not English. Our project included 1) pre-intervention planning to define the problem, summarization of the organizational evidence-practice gap and involvement of stakeholders;2) implementation of change interventions;and 3) postimplementation evaluation at quarterly intervals (Q1, Q2 and Q3). Our project team assembled Health Information Technology (HIT) solutions to support redesigned clinical workflows that included universal screening for self-reported English proficiency and on-demand integrated video interpretation services. The package of interventions included decision supports to recommend language services utilization, an interpretation platform integrated with our video software, and analytic reports to monitor performance metrics. Data were collected at baseline and for 9 months post-intervention defined as implementation of the HIT intervention package. We calculated a “Telemedicine Care Gap” by comparing the proportion of non-English-speaking telemedicine encounters to the proportion of non-Englishspeaking in-person encounters. We tracked the percentage of non-English-speaking patient telemedicine encounters with receipt of documented language services as well as the percentage of non-English-speaking patients with an activated patient portal, which is a prerequisite to conducting a telemedicine visit at our institution. Results: Shortly after implementation of telemedicine throughout the health system, use of telemedicine favored English-speaking families. At baseline, our “Telemedicine Care Gap” was 2.9%. Overall, the introduction of integrated telemedicine interpretation services did not significantly increase adoption of telemedicine for nonEnglish-speaking patients. However, significant progress was made in the uptake of integrated interpretation services for eligible encounters, which steadily increased from 0% at baseline to 23.9% by the end of Q3. Despite outreach efforts, the percentage of non-English-speaking patients with an active patient portal is much lower at 51.9% than patients who are English-speaking at 69.4%. Conclusion: The promotion of telehealth equity requires deliberate attention and a commitment to iterative problem-solving by healthcare organizations. Identifying populations at risk of poor access to telemedicine and monitoring access disparities are both critical to overcoming societal and systems barriers to care. We plan to eliminate the patient portal requirement for telemedicine which disproportionately burdens non-English speaking patient families.

Qualitative Evaluation of an Innovative Home Health care Delivery Model for Children with Medical Complexity

Background: Family caregivers of children with medical complexity (CMC) report financial problems, job loss due to caregiver responsibilities, fragmented care coordination, and difficulty accessing social services. Home health care services (such as certified nursing assistants or CNAs) provide critical support for these families but are often underfunded and understaffed. Parents also worry about the erratic availability and quality of care offered by external CNAs. These issues led to development of an innovative home care delivery model in Colorado which allows parents or family members of CMC to be paid as their child's CNA. This family certified nursing assistant (fCNA) program has been operating for 20 years, but little is known or published to inform communities and policymakers in other states of the benefits and challenges of this home healthcare model. Methods: We assessed stakeholders' perceptions of the fCNA program by interviewing 25 English- and Spanish-speaking family caregivers (FCs), 10 home health providers (HHPs), and 10 primary care providers (PCPs) of CMC who receive fCNA services. Semi-structured interviews explored perceptions of the program focusing on specific factors such as caregiver self-efficacy, caregiver burden, and implications for QOL. Qualitative content analysis methods were used to generate themes to characterize the fCNA model's benefits and challenges. Results: FCs and HHPs were very knowledgeable about the fCNA program, whereas PCPs had variable knowledge depending on the proportion of CMC in their practice. The three groups aligned around 6 major themes to characterize the program: Financial impact, emotional impact, physical impact, self-efficacy, respite, and access. In general, the program was perceived to be very popular among families of CMC. Major strengths included the financial and employment benefits, the ability to have reliable/high quality services (with added protection during Covid-19), and improved FC confidence and self-efficacy (via the training and the work). There were mixed perceptions of the emotional and physical impact. Stakeholders reported added fulfillment, joy, and bonding time in the FC caring directly for the child, but also reduced attention to other family members, decrease FC self-care/respite, and potential for injury as the child ages. Several challenges were identified regarding program access and health equity. These included training requirements, limited English-proficiency, lower health literacy, immigration status, and rural resources. Conclusion: The fCNA program is seen as extremely popular and beneficial for families of CMC. However, improvements could be directed towards equitable access, and increasing respite for FCs already in the program.

Socio-economic Barriers to Care and Medical Complexity Leading to a 5-year Diagnostic Delay of Untreated Chronic Diabetes Insipidus and Rapidly Progressive Puberty in a 10-year-old Venezuelan Immigrant

Introduction: Germ cell tumors, including germinomas, account for 10% of pediatric chronic Diabetes Insipidus (DI) cases. Delays in diagnosis of germinomas are generally longer than six months, however, no reported cases of suprasellar germinomas causing chronic DI and precocious puberty have been known to exceed a 5-year delay in both treatment of DI symptoms and a definitive diagnosis. Case Description: A 10-year-old Hispanic male presented with a 5-year history of polydipsia and polyuria. He underwent evaluation in Venezuela, where DI was reportedly 'ruled out';however, no head MRI was performed. After two years in the US struggling to acquire insurance, he presented to his pediatrician with worsening symptoms. A head MRI, ordered to evaluate dilute high-volume urine output, revealed a suprasellar mass. He was admitted for diagnostic evaluation and met the criteria for DI. Notably, he had an elevated Beta-Human Chorionic Gonadotropin (B-HCG) level. Biopsy confirmed the diagnosis of a Central Nervous System (CNS) germinoma. He was treated with DDAVP and proton therapy with subsequent remission of his tumor. Discussion: Throughout the patient's disease course, there were multiple delays in seeking and receiving care. These include a 5-year delay in seeking care despite worsening symptoms, a one-month delay in completing a 24-hour urine collection, a one-month delay in consulting pediatric nephrology, and another month delay before completing a retroperitoneal ultrasound. Multiple medical and socio-economic factors led to these delays. The patient did not present with symptoms more typical of CNS Germinomas like headaches, nausea, and vomiting. He had no visual disturbances despite mass effect on his optic chiasm. His increased stretched penis length and Tanner staging, which were identified later in his disease course, were contradicted by his pre-pubertal testicular volume and bone age. The patient is from a Spanishspeaking/Limited English Proficiency (SSLEP) household. While Spanish interpreters were present at each appointment, the language barrier proved to be a consistent issue. Initially, the child's mother indicated that the diagnosis of DI was 'ruled out' in Venezuela. In reality, the recommended imaging was never performed. Mychart messages left by his father further highlighted communication difficulties. Without access to an interpreter, he was forced to use broken English to relay his concerns. These frantic messages indicated misunderstandings regarding scheduling with various services and completing vital labs. Care only proceeded after significant physician intervention. Poverty in Venezuela, lack of insurance, and anxiety regarding COVID-19 also contributed to these delays. Conclusion: To our knowledge, this is the first case report of a pediatric patient presenting with a 5-year history of untreated polyuria and polydipsia due to undiagnosed DI with a B-HCG secreting CNS germinoma, without spinal metastasis. This study also illustrates the importance of supporting SSLEP families as they grapple with the complicated process of navigating our healthcare system. Sagittal T1 post gadolinium contrast image (A) and axial T2 FLAIR image (B) show an enigmatic, homogeneous, briskly enhancing mass in the suprasellar cistern (red arrow) with mass effect on the optic chiasm which is displaced upward and anteriorly (green arrow).