Trust in Translation: Rural Providers Cross Language Barriers with Training, Outreach

by Gretel Kauffman

Looking back, Joelle Ashley describes the listening sessions as painful but necessary.

For hours, Ashley and her fellow hospital administrators at Gunnison Valley Health listened to members of their small Colorado community list the ways the local health system had let them down: "Story after story," Ashley recalled, "of how we'd failed people."

One woman, following a miscarriage, had left the hospital without realizing she was no longer pregnant. Another described her fear while she was held in isolation with her 12-year-old daughter during the COVID-19 pandemic, not knowing why they were being kept in a room alone with the doors closed and having no way to ask.

A third woman who'd given birth at the hospital didn't understand that her newborn was facing serious medical complications; when doctors tried to transfer the infant to another hospital for treatment she refused to let him go, afraid that the doctors were trying to take her baby away from her.

Together, the stories painted a picture of a health system unable to communicate with a large share of its patients — and told Ashley and her colleagues that something needed to change.

In the two years since they first heard these stories, Gunnison Valley Health leaders have overhauled the hospital's approach to caring for patients with limited English proficiency (LEP), implementing new measures to ensure clear communication and build trust in the community. Over that time, the health system has seen a significant increase in the number of Hispanic patients using its services.

Hispanics and Latinos are the fastest-growing demographic in rural America, with roughly one in ten rural Americans identifying as such. A survey of rural counties with Critical Access Hospitals found close to 200 counties with "significant language diversity," meaning that at least 5% of that county's residents had limited English proficiency. And among the approximately 2.9 million agricultural workers in the U.S., a majority — 62% — are most comfortable conversing in Spanish, according to the National Center for Farmworker Health.

For some rural providers, caring for LEP patients in their preferred language with a small clinic or hospital's limited resources can be "a huge challenge," said Modjulie Moore, an assistant professor of family medicine at the University of North Carolina (UNC) School of Medicine and Medical Director of the North Carolina Farmworker Health Program. Overextended rural providers, a national shortage of medical interpreters, and the cost and broadband requirements of virtual translation technology can all exacerbate this challenge.

But rural health systems like Gunnison Valley Health are figuring out how to meet the needs of their LEP patients with the resources at hand, using community feedback to shape uniquely local initiatives. Meanwhile, some medical training programs have begun to prioritize LEP patient care, equipping future rural providers with the tools they'll need to communicate with any patient they might meet.

"We [rural health professionals] have to be open to listening," Moore said, "and if there's a trend where we're seeing new languages come into our area, to make sure we're responding."

Finding the Gaps

At Gunnison Valley Health, opening up a dialogue with the community — through listening sessions, patient surveys, and meetings with local leaders and organizations — was a turning point for administrators.

That's really when the change came: when we started getting out in the community and saying, 'Tell me more. What are we missing? What are the gaps?'

"That's really when the change came: when we started getting out in the community and saying, 'Tell me more. What are we missing? What are the gaps?'" said Nicole Huff, Chief Nursing Officer for Gunnison Valley Health. "And really hearing those hard things."

The process of actually affecting change — of implementing new policies with support from the nonprofit Colorado Health Innovation Community initiative, and of gaining the trust of LEP community members — is ongoing.

After the listening sessions, Huff "dove in and did some homework here at the organization to better understand what we were doing," she said. "I started asking questions at the points of access, like: Do you have an iPad? Do you offer care in a patient's preferred language? Do you ask them what their preferred language is?"

Some changes were quick and easy, such as purchasing additional iPads with virtual on-call interpretation services for each of the hospital's 12 access points; previously, the hospital had only had three iPads available, two of which were in the emergency department. The hospital also put additional processes into place for answering phone calls from LEP patients: in the listening sessions, it had come to light that hospital employees were accidentally hanging up on patients while attempting to connect them to a three-way call with an interpreter.

Other changes have required more time and creativity. The iPads provide access to round-the-clock on-call virtual interpreters for Spanish-speaking patients, but not for patients who speak Cora, an indigenous Mexican language commonly spoken in Gunnison. The Colorado town is believed to have the largest population of Cora people outside of Mexico.

Gunnison Valley Health has one part-time Cora interpreter on staff, but not on call 24 hours a day — and additional interpreters who speak the language are hard to come by, Ashley said. The Cora interpreter also works with the hospital's new bilingual Spanish-speaking patient navigator to follow up with LEP patients after visits, ensuring that people understand what was discussed during the visit and what their next steps should be, and helping them to schedule additional appointments or access financial assistance if needed.

The patient navigator "helps people do the thing that we all kind of need help with sometimes, which is just work their way through the health system," Ashley said. "She's able to sit down with them and help them move through that process in a much less confusing and scary way."

Still, barriers remain: Hiring and scheduling staff interpreters — in both Spanish and Cora — is an ongoing challenge, Huff and Ashley said, though expanding the number of providers who speak Spanish has helped reduce the need for Spanish interpreters. Developing resources for Cora patients has been particularly tricky, they noted, due to a lack of existing Cora-focused infrastructure or organizations to work with. How, for instance, do you certify the proficiency of a Cora interpreter when no official test or certification exists? Going forward, the hospital is also looking into how to provide written translation for discharge instructions.

"We'll get there," Huff said. "We've just got to spend the time to do it."

'Preparing to Meet a Need'

In nearby Idaho, Latinos are the fastest-growing demographic in the state, including in rural areas: Some of Idaho's least-populated counties have some of the highest shares of Hispanic residents, according to data from the Idaho Commission on Hispanic Affairs. Idaho also boasts one of the highest concentrations of refugees per capita in the U.S., welcoming more than 1,100 refugees in the last year, most of whom come from African or Middle Eastern countries.

H. Cathleen Tarp, a medical Spanish interpreter and professor of Spanish, is the director of Idaho State University's (ISU) Spanish for Health Professions program and an adjunct professor in the university's department of Physician Assistant (PA) Studies. Tarp spends her Fridays interpreting at a clinic in American Falls, a town of 4,000 in southeastern Idaho. Her pro bono services there are in high demand, she says: "I can tell you that I'm busy the entire time." Even with up to three interpreters working at the small clinic at a time, Tarp typically interprets for about five patients a day.

Meanwhile, Tarp and her colleagues in the PA Studies program are preparing their students for the multilingual landscape they'll graduate into. The optional Hispanic Health Track trains PA students to communicate with Spanish-speaking patients through a mix of medical Spanish language instruction, rotations at clinics serving large Hispanic populations, and immersive medical mission trips to Spanish-speaking countries. To prepare students to care for refugee and other non-Spanish-speaking LEP populations, the program includes hands-on training working with virtual and in-person interpreters.

There's a need, and we're trying to prepare our students to be able to meet that need.

"There's a need, and we're trying to prepare our students to be able to meet that need," Tarp said.

While the Hispanic Health Track officially launched with funding from a Health Resources and Services Administration (HRSA) grant in 2023, it's the latest evolution of a longer effort by ISU's PA program to produce and recruit bilingual providers through similar grant-funded programs developed over the past decade. Students in the Hispanic Health Track's first graduating class went on to be hired by the LEP-serving clinics where they completed rotations; one was also certified as a medical interpreter.

Christine Hall, a practicing PA and co-principal investigator of the grant behind the Hispanic Health Track, oversees community and clinical partnerships for the track, in which students complete 10-week rotations at a clinical site serving primarily Spanish-speaking patients.

"I'm trying to cultivate those relationships with clinics in areas where the provider need will be greatest," Hall said. "And so with hope, we can get our students ready and kind of have a pipeline to work for them when they graduate."

Clinics have generally been "super enthusiastic" about working with students in the track, Hall said, and feedback has been positive. One physician preceptor shared that having a student in the clinic had "inspired her to be a better provider, and to continue advancing her own Spanish vocabulary and skills," Hall said. "And so that expands our impact to the patients of those preceptors as well."

The Hispanic Health Track grant allows for nine students in the track per graduating class, but students outside of the track — and students in other tracks, such as the rural-focused PACARE program — are encouraged to incorporate Spanish language and interpretation training into their learning as well. Any PA student can earn a graduate certificate in Spanish for Health Professions (SHP), take individual SHP courses, or participate in medical mission trips to Spanish-speaking countries.

"While there are these specific tracks where specific students get to do things, we've also been able to incorporate elements of the tracks into the curriculum as a whole," said Jared Papa, program director and chair of the PA Studies program. "So all the students get to be engaged and involved, and have some training and experiences that they wouldn't otherwise have."

Building Bridges

Adding language into an already overstuffed medical curriculum can be a hard sell for educators and students alike, Moore noted.

Communication is a hundred percent one of the top priorities in medicine.

"Communication is a hundred percent one of the top priorities in medicine," Moore said. "Practitioners who have been in those spaces know that when you're working with a Spanish-speaking population, you better start learning Spanish. But when you're in medical training, there's such a jammed and strict curriculum, it's hard to advocate that Spanish language learning is a priority in learning and caring for patients."

Within UNC's Family Medicine program, she continued, "We want to provide support and mentorship for our medical residents who are actually taking on a dual language program: learning the language of medicine and the language of their patients at the same time."

In 2023, UNC Family Medicine partnered with Piedmont Health Services, a Federally Qualified Health Center (FQHC) with rural locations across North Carolina, to enhance training for medical students and residents in the program's rural health track. The five-year HRSA-funded project aims to improve care for LEP patients and patients with disabilities by providing additional training opportunities for the six UNC residents working at Piedmont Health Services clinics. More than half of the population served by those clinics speaks Spanish, with a high volume of LEP patients.

The language access component of the project provides enhanced support for bilingual medical scribes — often pre-medical graduates taking a gap year before medical school — and pairs them intentionally with residents who need language support: "The scribe is learning from the resident, while the resident is learning Spanish," Moore explained. The grant has also expanded immersion opportunities for medical students and residents, allowing UNC to send learners for two-week medical Spanish training with integrated clinical experiences in Spanish-speaking countries.

"We are fortunate in North Carolina: If you're a rural provider, Spanish language is the predominant need," Moore said. "And so as a rural provider, it's a little bit easier to say, 'I'm going to commit to this language.'"

That isn't to say that other languages aren't spoken in rural North Carolina, Moore noted: Like other parts of the country, North Carolina has seen an influx of indigenous language speakers. The state also sees stream workers — agricultural workers who move up and down the East Coast depending on the season — who speak Haitian Creole, she said; in response, UNC residents and community providers have helped to recruit Haitian Creole speakers in North Carolina in an effort to bridge essential language needs for workers navigating the health care system.

"A lot of us [in rural and farmworker health] across the country are experiencing changes in who's arriving to work," Moore said, noting that rural providers should take advantage of community resources and national networks to serve LEP patients, including those patients who don't speak Spanish.

"I think sometimes rural health can feel isolating when you're the only doctor and there are so many patients," she said. "But we don't need to speak all the languages or develop everything ourselves. Building bridges and connections is really helpful in supporting these populations."

Two years into rethinking Gunnison Valley Health's language processes, the hospital has seen a significant increase in visits from Hispanic patients — due in large part, administrators believe, to the bridges and connections the hospital has built with community partners. But the work doesn't end at changing internal policy or processes, hospital administrators know.

It doesn't matter what kind of processes we put into place to improve things — unless we show the community and talk about it, it isn't really going to change anything.

"It doesn't matter what kind of processes we put into place to improve things — unless we show the community and talk about it, it isn't really going to change anything," Huff said. "It was imperative that we get out there and educate. And we've seen that turn around now, and that trust level build."