Is Mandated Threshold Language Assistance Programming Associated with the Quality of Care Provided by Mental Health Agencies?

Background: Limited English proficiency (LEP) represents one particularly important barrier to receiving high quality general medical care and is an especially great barrier to receiving high quality psychiatric care. Because many mental healthcare evaluations and treatments, such as psychological “talk therapies,” rely on strong communication, persons with LEP may be especially inhibited from seeking mental health treatments and from receiving treatments at a minimally adequate level of quality. When interpreter services are absent or poor, LEP can lead to misunderstanding of client reports and practitioner interventions, sometimes distorting the presentation and comprehension of clinical problems. Thus, offering interpreter services or other language assistance programing to persons with limited English proficiency in need of specialty mental health services should, according to prior research, improve the quality of behavioral healthcare provided to those persons. However, few studies that have examined this topic to date were large-scale, generalizable, quasi-experimental studies. We exploited a quasi-experimental longitudinal study design to examine the effects of implementing language assistance programming on quality of care, using medication follow-up visits during the early stages of treatment as an indicator of quality.

Intervention:  Title VI of the 1964 Civil Rights Act prohibits federal fund recipients from providing care to persons with LEP more limited in scope or lower in quality than care provided to others. In 1999, the California Department of Mental Health implemented a “threshold language access policy” to meet its Title VI obligations. This policy required Medi-Cal agencies to provide language assistance programming when county Medi-Cal populations contained 3,000 residents or 5% speakers of a language.

Methods: We examined the impact of threshold-required language programming on the quality of care provided to Spanish speakers with LEP that had been diagnosed with schizophrenia, major depression and bi-polar disorder, before and after county agencies implemented language programming, in comparison to control counties.  We measured quality by the rate of focal clients in each county receiving at least two follow-up medication visits within 90 days of an initial medication visit, across 38 quarters. Linear regression with county fixed-effects was used to assess the effect of threshold-required language programming on whether new clients received adequate follow-up medication visits. The analysis was conducted at the county-quarter level. Standard errors were adjusted for clustering within counties over time.

Results:  The average rate of focal clients receiving at least two medication follow-up visits within 90 days was only 35 percent. In multivariate analyses, language programming was not associated with clients receiving at least two medication follow-up visits (-1.34 percentage points, 95% Confidence interval: -7.57 to 4.88).

Conclusions: This study found no evidence that language programming led to increased rates of follow-up medication visits for clients with LEP. Under threshold policy, translators, bi-lingual staff, telephonic assistance, and other forms of capacity must increase with the supply of LEP clients, but the policy appears not, in itself, to provide resources to meet these needs or suggest how needed resources might be acquired. Additional measures of quality should be considered in future work.