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Medical systems are at the forefront of providing interpreter services to limited English proficient (LEP) populations in the United States. In geographic areas hosting large immigrant communities, decades of historical immigration has spawned the next generation of bilingual speakers. These bilinguals have the potential to replace interpreters by serving under a new model of language concordant providers, especially in Spanish.
Professional interpreters have been increasingly necessary to facilitate LEP access to services, but the need decreases as immigrant trends stabilize and populations assimilate. Spanish interpreters could become superfluous as language concordant providers serve the monolinguals and medical system training programs leverage the skills of bilingual employees to develop a new corps of dual-role health care providers.
I. Interpretation Services in American Medical Systems
The need for interpreters in American medical systems has been driven by a historic divergence between patients and health care providers in cultural, ethnic, and linguistic arenas. In 2010, there were approximately 25 million LEPs in the United States, representing 9% of the total population over age 5 (Pandya, McHugh, and Batalova 1). Of this LEP population, 66% are speakers of Spanish (6).
Medical and other systems that are beneficiaries of American government funds are essentially required to provide interpretation services to LEPs under Title VI of the Civil Rights Act. The Civil Rights Act prohibits discrimination based on national origin. Executive Order 13166 "Improving Access to Services for Persons with Limited English Proficiency" mandates that LEPs have meaningful access to federally conducted and/or funded programs and activities (“Frequently Asked” pt. 3). It became effective in 2002. In practice, this usually requires a language interpreter.
Qualified interpreters are a beneficial component of LEP access to medical systems in procedural, ethical, and business terms: when LEPs communicate through a professional interpreter or bilingual health care provider, the best medical outcomes, highest levels of patient satisfaction, and lowest rates of errors are achieved (Flores et al. 392). In research on hospital interpreter services in the state of New Jersey, where LEPs represented up to 35% of the hospital patient population at the time of study, 1 in 17 patients surveyed reported that they did not seek medical care for their children “because of language issues” (Flores et al. 392). Finally, there may be cost savings for the hospital in using a professional interpreter over an ad hoc interpreter. The study “Professional Interpreters and Bilingual Physicians in a Pediatric Emergency Department” found that physicians’ testing and care decisions were “most cautious and expensive when non-English speaking cases were treated in the absence of a bilingual physician or professional interpreter” (Hampers and Mcnulty 1). In short, interpreters are not only mandated, but are an ethical choice, and a smart investment in patient care.
II. Demographic Context and Trends in the US Hispanic Population Segment
The United States is the leading destination for immigrants (Brown 2). The recent immigration boom has been led by Spanish-speaking, Latin American immigrants, frequently referred to collectively as “Hispanic” (Pew 1). The immigrant population increased by 30% in the US between 2000 and 2011when the foreign-born population (including LEPs and English proficient speakers) reached 40 million people (Pew 1). Mexico was by far the largest source of this population at 29%, dwarfing number two India at 5% (Puerto Rico was not tracked as “foreign”) (Pew 3).
The majority of Mexican immigrants fall within the “unauthorized” status (Passel, Cohn, and Gonzalez-Barrera 1), having entered the country without the required documentation and approvals. Unauthorized immigration has reversed its growing trend, beginning to fall in 2008. As a result, while by 2014, 35% of Hispanics were foreign-born, the US Census Bureau predicts that this will fall to 27% in 2060 (Brown 2). The stagnation of Hispanic immigration is attributed to less favorable American economic conditions, tighter border controls, and emigration to Mexico (3). Overall Hispanic population growth in the US is also reversing its growth trends on decreasing birth rates (Livingston and Cohn 1). US births represent 78% of Hispanic population growth, and the birth rate for Mexican immigrant women fell by 23% from 2007-2010 (1).
The future need for Spanish language interpreters is heavily based on new immigration, as Hispanic immigrants fully assimilate linguistically within an about two generations (Rumbaut, Massey, and Bean 458). Applying Rumbaut’s theory, if there were no new immigration, Spanish monolinguals will literally die out (Hurtado and Vega 139). LEP status perseveres little more than one generation: in the case of Spanish, LEPs transition from monolingual to bilingual in an average 15 years to one generation, and switch to monolingual English by the third generation (Rumbaut, Massey, and Bean 458). Immigrants are concentrated among urban areas, sometimes in “sociolinguistic domains” (Hurtado and Vega 140), although not to the extent that this linguistic assimilation is hindered, according to the Pew Hispanic Center (Suro and Tafoya 1). Within the urban areas themselves, Hispanic communities are not as concentrated as widely believed (Suro and Tafoya 1). Researchers also make the case that loss of stigma associated with LEPs and urban concentrations of LEPs has not yet increased heritage language longevity across generations and over time (Rumbaut, Massey, and Bean 459). Therefore rapid language assimilation can be expected to continue (Hurtado and Vega 139).
Moreover, as previously stated, 78% of Hispanic population growth is fueled by US births, shortening the before-referenced average generational timeframes of language assimilation. The Pew Research Center reports that “nearly all Hispanic adults born in the United States of immigrant parents report they are fluent in English” (Hakimzadeh and Cohn 1). In summary, whereas historical generations of immigrants were of LEP status for generations, the main component of Hispanic population growth is now stateside and may never be classified as LEP. If future immigration rates decline, it can be expected that the need for professional interpreters could decline as existing LEPs assimilate and new population growth is English-proficient. Under this assumption, the next generation of bilinguals will drive attrition in the Spanish-speaking LEP population. Conversely, if immigration rates increase, the need for interpreters could be expected to increase.
Clearly, while Hispanic immigration trends have slowed, immigration prevails, and so do Spanish-speaking monolinguals and LEPs. However, the context for this population has changed. The historic immigration boom has created a new corps of bilingual Spanish-English speakers. Half of second-generation Hispanics in the US are now bilingual, and “widespread bilingualism has the potential to affect future generations of Latinos” (Krogstad and Gonzalez-Barrera 1). In other words, Spanish is effectively an established language in the US. New immigrants arrive to a different landscape. Years of immigration from Spanish-speaking countries has resulted in more educated Hispanics in a wider range of areas in the workforce (Alarcon and Heyman 114), who serve as a linguistic resource for the recent immigrant and LEP populations.
For example, one in three New York City police officers is Hispanic (NYPD). In the Harlingen, Texas, police department, 79% of the police officers and 93% of the civilian employees speak both Spanish and English (Texas 4). At one hospital in New Jersey, 98% of the physicians are bilingual (Flores et al. 397). As a result, new models of interpreter services are emerging to leverage the skills of this post-immigrant bilingual population.
Health Care Interpreter Service Models
Interpreting services in medical systems are provided through four basic models as follow:
A. Professional medical interpreters
Interpreters exclusively dedicated to the role of interpretation, with training, and/or experience, and/or certification in medical interpreting. Researchers found that professional interpreters can eliminate the negative impact of the language barrier on quality of care (Davis et al. 2). These interpreters may be on-site interpreters: e.g. hospital staff, independent contractors, volunteers, or staff sourced by a language service provider; or off-site interpreters, usually via third party telephonic services (Flores et al. 406). The latter is becoming more common; in New Jersey, 97% of hospitals surveyed do not have on-site interpreters and instead use telephonic services (406). While telephonic providers rate low on patient satisfaction, provider opinions are mixed; they can be more cost effective from a resource management perspective, and efficiently meet rare language needs (406).
B. Ad hoc interpreters
Bilingual family members, other “at hand” bilinguals, and health care providers within some second language knowledge who are not professionally trained and assessed as interpreters. Hospital systems vary widely on their use in theory and in practice of ad hoc interpreters. While they may be immediately available, they are less reliable from a procedural and consistent availability perspective (Martinez). Patient familiarity may be a favorable or negative variable, depending on the situation. In summary, there are numerous ethical and procedural complications that can arise that are noted, but not discussed, herein.
C. Dual-role interpreters
Bilingual human resources within the health care institution who lend their skills as needed, either formally or informally, to serve as interpreters. Hospitals employ various methods for their deployment, ranging from informal identification and assignment, to internally published registers of bilingual employees, and fully established training and compensation programs for their identification, development, and assignment.
As in the case of ad hoc interpreters, availability can be a positive or negative feature of their deployment. Dual-role interpreters can be a cost effective resource to a medical system, given low incremental training costs, cultural awareness strengths, and knowledge of contextual ethics and procedures (“Talking” 1). However, there can also be conflict of interest and competence issues, resource allocation challenges, and role confusion (Moreno, Otero-Sabogal, and Newman 334). Moreover, training and assessment are key variables. Researchers found that one in five dual-role interpreters at a large health care organization had insufficient bilingual skills when tested as interpreters (334). In the survey, some dual-role staff interpreters in these context were LEP themselves and did not have the English skills to understand medical providers (334).
A Nebraska Department of Health and Human Services survey of its dual role interpreters determined that they should be used “with caution” (Kenney 27). The survey found that the use of dual role interpreters was challenging for the hospital, the interpreter, and the patient, finding that “[t]he responsibilities of the primary role are often in direct conflict with the role of interpreter” (Kenney 27).
D. Language concordant providers (LCPs)
Service providers who are matched to serve patients that speak the same language, usually as native speakers. There are both cost and quality of care benefits. Kaiser Foundation Health Plan in California gives their LCPs “financial incentives,” which are more than offset by ads on interpreter cost, with additional unquantified cost savings in “reduction of lab utilization in the emergency room, hospital admissions, and return clinic visits” (Language Concordance Program 1). There can also be a cultural advantage beyond that of simply language. A hospital emergency department study showed that monolingual Spanish-speaking patients with LCPs were more likely to comply with medication instructions and less likely to be readmitted (Manson 1125).
There is precedent for LCPs outside of medical systems in law enforcement, customer service call centers, and banking, among other industries and systems. In many urban police departments, LCPs are a critical factor for success:
People who do not speak or understand English, and who therefore cannot communicate easily with police, may not report crime, assist officers in criminal investigations, or partner with an agency to advance community policing. (Shah, Estrada, and Pope 2)
Finally, in high pressure law enforcement situations requiring quick response times and decision making, LCPs have been found to improve employee safety (Texas 1).
However, there is a limited availability of such providers, and the same issues in competency and availability discussed for dual-role interpreters prevail (Ngo-Metzger et al. 324). In the case of health care providers with specific areas of specialty, there is pressure to stretch their role into non-core areas (e.g. appointment scheduling and giving directions) to the extent that the National Council on Interpreting in Health Care recommends that they “must often be complemented by the use of interpreters” (Downing and Roat 6).
Finally, ethical challenges present in dual-role situations. “Dual relationships are filled with complexities and ambiguities” (Guthmann 2006).” In a medical system, this challenge is especially significant due to the high personal stakes involved.
III. Emerging Interpreter Service Model Focus
While professional and ad hoc interpreters have long been providing language interpretation in medical systems, the formalization of programs for dual-role interpreters and LCPs can be considered emerging models (“Talking” 2). The medical systems pioneering these programs, characterized by their maintenance of participating employee registries, training programs, and financial incentives, appear to have done so largely within the last decade. New programs are under development nationwide based on their success stories (NYPD).
Most hospitals in the US are subject to the federal laws essentially requiring interpretation services for LEP, as discussed earlier in this paper. The US government has recognized that bilingual service providers, such as dual-role employees and LCPs, preclude the Title VI requirement for interpreters:
People who are completely bilingual are fluent in two languages. They are able to conduct the business of the workplace in either of those languages. Bilingual staff can assist in meeting the Title VI and Executive Order 13166 requirement for federally conducted and federally assisted programs and activities to ensure meaningful access to LEP persons… This is sometimes called ‘monolingual communication in a language other than English.’ It does not involve interpretation or the translation between languages. (“Frequently Asked” pt. 11)
In the case of Spanish-language interpreters, the demographic implications of high historical levels of immigration, and the continuous linguistic assimilation of these LEP populations, has spawned a generation of bilingual speakers. There are various examples across the United States of this generation replacing dedicated, professional interpreters in the form of LCPs and dual-role interpreters, as follows.
A. Language concordant providers: cases in practice
The use of LCPs is emerging in all areas, not only in medical systems, potentially serving as a harbinger of future trends. The state of Texas was one of the first to receive high levels of immigration from Mexico. According to the US Census in 2000, with the exception of one county in California, the counties with the highest proportion of LEPs are all in Texas (Texas 1). Programs developed in Texas could be expected to extend to other states and systems, for example:
1. The US Department of Justice required voting precincts in Texas that had 100 or more registered voters with Hispanic surnames to hire bilingual election workers (Hensley 1). Interpreters were not reported to be under consideration. The Texas county of Brazos hired a full-time bilingual election coordinator whose additional responsibilities include translating during department meetings and reviewing Spanish polling signs (Hensley 1).
2. The Texas Law Enforcement Management and Administrative Statistics program reported in 2006 that it has long been using LCPs in the regular course of its activities:
While the rest of the country is beginning to deal with the problems of having significant population portions who are LEP, Texas has faced the challenge for decades, particularly by hiring bilingual police officers or training those already hired to effectively communicate in a second language. (Texas 1)
States which are newer recipients of immigration, and do not have the depth of second generation bilinguals as earlier recipients like Texas, are adopting creative strategies to develop their own LCPs:
3. To meet the needs of its Spanish-speaking LEP clients in South Carolina, the Founder Federal Credit Union runs a mandatory training program for its employees in Hispanic culture and banking terminology in Spanish, expecting the employees to serve the LEPs in their language without an interpreter (Collins 12).
4. In Lexington, Kentucky, police officers study Spanish for one year, and then are sent to Mexico for five weeks language and cultural immersion programs in order to better serve the Spanish-speaking community. (Shah, Estrada, and Pope 8-13)
Similar trends are emerging in medical systems, especially those in urban areas and states bordering Mexico that have an existing base of bilingual professionals created through decades of immigration and subsequent American education. In a review of such programs for a George Washington University study, the researchers remark that it has come time for medical systems “to both assess the languages spoken by their physicians and nurses and reinforce those skills with incentives” to serve as LCPs (“Talking” 2). Cases of such programs in medical systems follow.
5. In California, Kaiser Hospital system reports that 12% of its member patients prefer to communicate in Spanish. Its established LCP program purports to improve medical outcomes, be sound business strategy, and increase patient satisfaction. The program is being rolled out at Kaiser’s clinics across California. As a result, there has been an 8% increase in Spanish LEP appointments and a reduction in staff interpreters. “The key is to consider language concordance as an integral part of the process when booking appointments and assigning primary care physicians” Kaiser’s glossy program brochures emphasize (Language Concordance Program 1).
6. At Cambridge Health Alliance in Massachusetts, a patient can request an LCP when making an appointment. Provider fluency is tracked in a provider registry that has 80 LCPs speaking a total of approximately 20 languages (Hacker 1).
7. At California’s Sutter Health system, 33% of patients are LEP. Bilingual staff is tested in 16 languages for medical terminology, cultural awareness, and procedural details. The majority of its employees pass the assessments and undergo online training as interpreters to enter an interpreter pool (Moreno, Otero-Sabogal, and Newman 16).
B. Dual-role interpreters: cases in practice
With similar characteristics of the LCP programs, across industries a new generation of bilingual English-Spanish speakers is being called upon to serve in a dual role as service provider and interpreter. Examples across program pioneering systems follow.
1. The New York Police Department (NYPD) tests and trains bilingual officers, representing a total of 75 different languages, to serve as dual-role interpreters for the public and in investigations. There are currently 1,400 certified volunteers (NYPD). In the case of Spanish, officers have access to telephonic interpreting but usually can deploy an LCP, precluding the use of a dedicated interpreter (Cavali).
2. To involve their existing base of bilingual employees in interpretation, the Los Angeles Police Department gives a 2.75% bonus on top of salary to bilingual officers and employees, and a 5.5% bonus for bilingual employees who also can write in the second language (Texas 2).
3. Bilingual staff at customer service “call centers” are a well established case of dual-role interpreters. In the specific case of Spanish-speakers, the employees are trained and utilized based on the work involved while “treating the language more as an innate talent than as a technical competence” (Alarcón and Heyman 112), displacing the dedicated interpreter function.
Medical systems are already quite advanced in this area. Flores’ study shows that 75% of hospitals with interpreters on-site used some form of dual-role interpreters (Flores et al. 406). Examples include:
4. New Jersey Health Research and Educational Trust developed a program to train bilingual hospital staff members as interpreters and create an available pool of dual-role medical interpreters. They were pilot-tested in six hospitals under a grant from the state’s Office of Minority and Multicultural Health (Interpreter Training 1).
5. The University of New Mexico Hospitals system developed a training program for bilingual employees called “Bridging the Gap” for its bilingual employees to learn roles, modes, and ethics in interpreting and be assessed to become a “Dual Role Interpreter” or “Senior Dual Role Interpreter” (Training).
6. The University of Massachusetts Medical School runs an interpreter training program as a service to their Medicaid provider hospitals and community health programs (“What is Medical”). The training is specifically designed for existing bilingual health care staff.
7. Lee Memorial Hospital in Florida defines dual-role interpreters as “bilingual employees who have a primary job in the system with a secondary job of ‘interpreter’” (Quality Board 20). The employees are trained and assessed, and made available during their normal shift.
8. Adventist Health in the state of Maryland developed a Qualified Bilingual Staff program to “increase our capability to provide culturally and linguistically appropriate services” to LEPs and their families” (“Qualified Bilingual” 1). Dual role interpreters are tested in fifteen different languages and certified at QBS Level 1 (customer service encounters) or Level 2 (medical encounters).
IV. Drivers and Variables in Interpreter Redundancy
The existing population of Spanish-speaking LEPs is increasingly served by emerging model of dual role interpreters and language concordant service providers, especially in urban areas of high immigration where Spanish is well established. The Pew Research Center reports that “widespread bilingualism has the potential to affect future generations of Latinos” (Krogstad and Barrera 1). Furthermore, LEP population attrition in the context of stagnating immigration levels and language assimilation is expected to continue. The US Census Bureau projects that Hispanics who speak only English at home will rise from 26% in 2013 to 34% in 2020 (Krogstad and Gonzalez-Barrera 2).
These demographic trends and emerging interpretation models are already reducing the ranks of dedicated professional interpreters, as major US health care systems with established programs report that a reduction in interpreter staff results from leveraging existing employees through the new models (Language Concordance 1). The Robert Wood Johnson Foundation, the largest health philanthropy group in the US, advises medical systems: “Before hiring outside help to function solely as medical interpreters, you may want to look within your organization for bilingual staff” (“Medical Interpreting Standards”). The NYPD touts that their language services, led by LCPs, have “set the standard worldwide for foreign language access” (NYPD). It is clear from these experiences in the field that the use of these emerging models is not to augment the ranks of professional interpreters, but to be cost effective in controlling or reducing them.
Meanwhile, the need for interpreters is still widely expected to grow significantly. The US Bureau of Labor Statistics reports that projected employment growth for interpreters is 46% from 2012-2022, outpacing the total for all occupations of 11% in the same period (USDL). There is no official data, and limited data from other sources, of the detail on interpreter job growth projections by language or specialty. However, the Bureau does report that “interpreters and translators of Spanish should have good job prospects because of expected increases in the population of Spanish-speakers in the United States” (USDL).
But if Hispanic population growth in the US is the key driver, and the LEP segment of it has now stagnated as presented earlier in this paper, the job prospects for interpreters would also stagnate, all else being equal. However, there are other variables, the relevance of which the Bureau report does not address, such as higher usage rates of interpreters for the LEP population. This could be driven by greater familiarity with or availability of interpreters, legal requirements, or policy changes regarding interpreter use. For example, the Affordable Care Act has instituted penalties for hospitals with high readmission rates, an area in which interpreters have proven to ameliorate (USDHHS). This is a potential driver for the increased rate of use of interpreters.
Independent of demographic trends, job prospects for professional interpreters are likely to continue to be cannibalized by the emerging trends presented in this paper of employing dual-role interpreters and LCPs. This is another area with limited data as it is in its nascent stages. For example, George Washington University reported in 2008 that only 28% of hospitals even have policies related to the use of bilingual doctors and nurses serving as interpreters. Training programs in interpreting for dual-role interpreters and LCPs are rapidly developing and generating success stories (“Talking” 1-3). The NYPD implies that its LCP program is successful even without interpreting training or assessment programs to support it, defending the practice as successful regardless:
Routinely, non-certified speakers who have grown up speaking a foreign language are relied upon to use their language skills. There is no Federal law or regulation that bars us from using foreign language speakers who are not certified. Beyond that, there is not a single documented case in which the use of a non-certified employee failed to translate properly[LL1] . (NYPD)
With these emerging models in growing deployment, supported by strategy recommendations from health policy advisors and successful results in the field, both as previously discussed, emerging models of interpretation are expected to proliferate.
Professional interpreters are at risk of displacement as these emerging models are sought in the context of health care system business productivity initiatives. Hospital systems are managed according to various objectives. Cost is among them: even academic, not-for-profit medical centers must be cost-efficient. The Froedtert Hospital System of Wisconsin articulates in its mission that it “delivers highly coordinated, cost-effective health care” (“Vision”). Kaiser Hospital system maintains that the financial incentives given to LCPs are offset by not only savings on the cost of the interpreter service, but also by time savings on the part of the provider (Language Concordance 1).
Training programs targeted to bilinguals will allow employees working in non-interpreter functions to bridge the gap for LEPs while observing institutional protocol and meeting competency standards. Such LCP trends are emerging as productivity initiatives in medical and other systems that provide services to LEP populations. A research study published in the Journal of Internal Medicine by a team of medical doctors, public health specialists, and researchers concludes that while health care interpreters are necessary, they are an imperfect solution, and health care systems should recruit and train LCPs instead of interpreters (Ngo-Metzger et al. 324). Currently, in the case of Spanish interpretation, with immigration slowing, LEPs assimilating to bilingual and English status, and new resources from emerging interpreting models, I expect that in some cases professional interpreters will be redundant.
As a new generation of LEPs becomes bilingual and educated, the Spanish language is “undergoing realignment of its linguistic system in a context of globalization and renationalization,” and Spanish in the US is becoming a functional working language instead of being limited to manual labor contexts (Alarcón and Heyman 114). Emerging interpreting models in states like Texas, California, and New York are a leading indicator of how bilingual employees are replacing professional interpreters.
I expect that there will always be a need for Spanish medical interpreters. Varying needs by geographic region, individual hospital, and even time of day would be difficult to be predictably matched by an in-house team of bilingual employees. This is similar to the economic concept of “structural unemployment,” which is considered to be a permanent component of the unemployment rate and the reason why it theoretically cannot be at 0%. The assumption is that there will always be some component of mismatched labor supply and demand, be it on an industrial, competency, or geographic level. Furthermore, immigration trends and linguistic assimilation are dynamic and fluid phenomena, and their impact on interpreter needs is significant yet unpredictable. Even the distinguished Pew Research Group deems predicting future immigration rates a “tricky process” (Brown 2).
While professional interpreters are increasingly necessary to bridge language diversity in the context of globalization, the need for interpreters is in large part transitional and redundancy presents as languages establish. In the case of Spanish, it can be expected that as a new generation of US-educated, bilingual Hispanics incorporate the job function of interpreter into their functional roles, and the overall need for Spanish language interpreters is reduced on demographic trends, professional interpreters become redundant in many areas. Case examples shown in this paper are leading indicators of interpreter displacement, which is not unprecedented. The immigrant population share of the US population peaked at the turn of the 20th century on a boom in European immigration (Pew 1), presumably making German and Italian interpreters in high demand. But today neither language is offered for medical interpreter certification, and the top client-requested languages for interpretation in general are now Spanish, Arabic, Mandarin, and Vietnamese (Language Line 1). In my opinion, this too shall pass.
Alarcón, Amado, and Josiah Heyman. "From “Spanish-only” Cheap Labor to Stratified Bilingualism: Language, Markets and Institutions on the US-Mexico Border." International Journal of the Sociology of Language 2014.227 (2014): 101-17. Web. 6 Apr. 2015.
Brown, Anna. U.S. Immigrant Population Projected to Rise, Even as Share Falls among Hispanics, Asians. Rep. Pew Research Center, 9 Mar. 2015. Web. 4 Apr. 2015.
Cavali, R. "New York Police Officer Interview." Personal interview. 3 Jan. 2015.
Collins, Jan. "Reaching Out to Latinos."Business and Economic ReviewJan 2008: 12-4.ProQuest.Web. 23 Feb. 2015.
Davis, Roger B.,Pracha P Eamranond, Russell S Phillips, and Christina C Wee. “Patient-Physician Language Concordance and Primary Care Screening among Spanish-Speaking Patients.” Med Care (2011): 668-672. Web. 31 Mar. 2015.
Downing, Bruce, and Cynthia E. Roat. Models for the Provision of Language Access in Health Care Settings. Working paper. N.p.: National Council on Interpreting in Health Care, 2002. Web. 2 Apr. 2015.
Flores, Glenn, Sylvia Torres, Linda J. Holmes, Debbie Salas-Lopez, Mara K. Youdelman, and Sandra C. Tomany-Korman. "Access to Hospital Interpreter Services for Limited English Proficient Patients in New Jersey: A Statewide Evaluation." Journal of Health Care for the Poor and Underserved 19.2 (2008): 391-415. Web. 2 Apr. 2015.
"Frequently Asked Questions (FAQs)." LEP.gov. United States Department of Justice, n.d. Web. 07 Apr. 2015.
Guthmann, Debra, Ed.D. One Client: Many Provider Roles - Dual Relationships in Counseling Settings. Western Oregon University, n.d. Web. 6 Apr. 2015.
Hacker, Karen, Yoon Susan Choi, Lisa Trebino, Leroi Hicks, Elisa Friedman, Bonnie Blanchfield, and G. Scott Gazelle. "Exploring the Impact of Language Services on Utilization and Clinical Outcomes for Diabetics." Ed. Joseph S. Ross. PLoS ONE 7.6 (2012): E38507. Web. 6 May 2015.
Hakimzadeh, Shirin and D’Vera Cohn. English Usage Among Hispanics in the United States. Rep. Pew Research Center, 29 November 2007. Web. 23 Apr. 2015.
Hampers, Louis C., and Jennifer E. Mcnulty. "Professional Interpreters and Bilingual Physicians in a Pediatric Emergency Department." Archives of Pediatrics & Adolescent Medicine 156.11 (2002): 1108. Web. 2 Apr. 2015.
Hensley, Laura. "Brazos Monitored for Bilingual Staffers."McClatchy - Tribune Business News: 1. Nov 08 2006.ProQuest.Web. 23 Feb. 2015.
Hurtado, Aida, and Luis A. Vega. "Shift Happens: Spanish and English Transmission Between Parents and Their Children." Journal of Social Issues 60.1 (2004): 137-55. Web. 4 May 2015.
Interpreter Training Program for Bilingual Staff in Health Care. Health Research and Educational Trust of New Jersey, 2009. Web. 31 Mar. 2015.
Kenney, Anne M. Interpreters Speak Out: Nebraska Language Access Survey. Rep. Lincoln: Nebraska Department of Health and Human Services, Division of Public Health, Office of Minority Health and Health Equity, 2008. Web. 7 May 2015.
Krogstad, Jens and Ana Gonzalez-Barrera. A majority of English-speaking Hispanics in the U.S. are bilingual. Rep. Pew Research Center, 15 Mar. 2015. Web. 7 Apr. 2015.
Language Concordance Program. N.p.: Kaiser Foundation Health Plan, n.d. Print.
Language Line Services. Language Line Services Report Shows Arabic, Vietnamese, Mandarin Are Top Spoken Foreign Languages in U.S. After Spanish. Language Line Services Report Shows Arabic, Vietnamese, Mandarin Are Top Spoken Foreign Languages in U.S. After Spanish. PR Newswire Association LLC, 24 Apr. 2012. Web. 11 May 2015.
Livingston, Gretchen, and D. Cohn. "US birth rate falls to a record low; decline is greatest among immigrants." Pew Research Center Social and Demographic Trends (2012). Wb. 11 May 2015.
Manson, Aaron. "Language Concordance as a Determinant of Patient Compliance and Emergency Room Use in Patients with Asthma." Medical Care 26.12 (1988): 1119-128. Web. 7 Apr. 2015.
Martinez, Sonia. "Jackson Hospital Interpreting Services Manager Interview." Telephone interview. 30 Mar. 2015.
"Medical Interpreting Standards of Practice." RWJF. Robert Wood Johnson Foundation, 2015. Web. 11 May 2015.
Moreno, Maria R., Regina Otero-Sabogal, and Jeffrey Newman. "Assessing Dual-Role Staff-Interpreter Linguistic Competency in an Integrated Health care System." Journal of General Internal Medicine 22.S2 (2007): 331-35. Web. 2 Apr. 2015.
Ngo-Metzger, Quyen, Dara H. Sorkin, Russell S. Phillips, Sheldon Greenfield, Michael P. Massagli, Brian Clarridge, and Sherrie H. Kaplan. "Providing High-Quality Care for Limited English Proficient Patients: The Importance of Language Concordance and Interpreter Use." Journal of General Internal Medicine 22.S2 (2007): 324-30. Web. 6 Apr. 2015.
"NYPD's Foreign Language Outreach." NYC.gov. The City of New York, 2015. Web. 06 Apr. 2015.
Pandya, Chhandasi, Margie McHugh, and Jeanne Batalova. "Limited English Proficient Individuals in the United States: Number, Share, Growth, and Linguistic Diversity. LEP Data Brief." Migration Policy Institute (2011). Web. 11 May 2015.
Passel, Jeffrey S., D’Vera Cohn, and Ana Gonzalez-Barrera. Net Migration from Mexico Falls to Zero—and Perhaps Less. Rep. Pew Research Center, 23 April 2015. Web. 23 Apr. 2015.
Pew Hispanic Center. "A nation of immigrants: a portrait of the 40 million, including 11 million unauthorized."Washington, DC: Pew Hispanic Center (2013). 6 Apr. 2015.
“Qualified Bilingual Staff Program.” Adventist Health care. Adventist Health care, n.d. Web. 07 May 2015.
Quality Board and Full Board of Directors Meeting. Meeting Minutes. Fort Myers: Lee Memorial Health System, 2012. Web. 11 May 2015.
Rumbaut, Rubén G., Douglas S. Massey, and Frank D. Bean. "Linguistic Life Expectancies: Immigrant Language Retention in Southern California." Population and Development Review 32.3 (2006): 447-60. Web. 6 Apr. 2015.
Shah, Susan, Rodolfo Estrada, and Jill Pope.Bridging the Language Divide: Promising Practices for Law Enforcement. Vera Institute of Justice, Center on Immigration and Justice, 2009. 6 Apr. 2015.
Suro, Roberto, and Sonya Tafoya. Dispersal and Concentration: Patterns of Latino Residential Settlement. Rep. Washington DC: Pew Hispanic Center, 2004. Web. 6 Apr. 2015.
Talking with Patients: How Hospitals Use Bilingual Clinicians and Staff to Care for Patients with Language Needs. Issue brief. Washington DC: George Washington U School of Public Health and Health Services, 2009. Web. 31 Mar. 2015
Texas Law Enforcement Management and Administrative Statistics Program. (2006). Bilingual Police Officers: Policing in a Diverse America. (Vol. 13.) Huntsville: Hector Garcia. Web. 23 Feb. 2015.
“Training – Bridging the Gap.” UNM Hospitals. The University of New Mexico Hospitals, n.d. Web. 1 May 2015.
United States Department of Health and Human Services (USDHHS). Centers for Medicare & Medicaid Services. Readmissions Reduction Program. Baltimore, MD: Centers for Medicare and Medicaid Services, 2014. 4 Aug. 2014. Web. 1 May 2015.
United States Department of Labor (USDL). Bureau of Labor Statistics. Occupational Outlook Handbook. 2014-15 ed. Washington, D.C.: Bureau of Labor Statistics, 2014. Interpreters and Translators. 8 Jan. 2014. Web. 1 May 2015.
"Vision, Mission and Values." Froedtert & the Medical College of Wisconsin. Froedtert & the Medical College of Wisconsin, 2015. Web. 11 May 2015.
"What Is Medical Interpreter Training?" Massachusetts Medical Interpreter Training. University of Massachusetts Medical School, 2010. Web. 1 May 2015.