A Focus on California: Facilitated Discussion



Topical Conference Call 1

Language Access: Implications for State MCH/CSHN Programs

A Focus on California

This call was conducted on October 4, 2001, 3:00 – 4:30 PM, E.T.

The featured speakers was:

Gregory A. Franklin, M.H.A., Presently: Deputy Director of Health Information and Strategic Planning Division, California Department of Health Services

At the time of the call: Chief, Office of Multicultural Health, California Department of Health Services

Tawara Goode: Mr. Franklin is currently a member, of the California Department of Health Services Executive Staff and Chief of the department’s Office of Multicultural Health. In this capacity, he’s responsible for the development an analysis of policy regarding multicultural health.

Before coming to this position, Mr. Franklin was the chief of the department’s managed care, education, and outreach and health plan contracting activities. In this role he created guidelines and standards that are currently in use to inform persons eligible for Medicare of their health plan choices. He was also instrumental in the implementation of the state’s two-plan model of MediCal Managed Care and the development of enrollment policies.

He has held positions in the state’s medically indigent services program, tuberculosis control, and also refugee health program. So without further ado, Mr. Greg Franklin.

Greg Franklin: Okay, great. First of all I want to thank the NCCC or the National center for highlighting California first, it’s certainly a great pleasure, and being first always means that you’re somewhere near the top in folks’ minds.

Wendy Jones: I’ve got the first question for you, Greg.

Greg Franklin: Okay, Wendy.

Wendy Jones: Can you briefly describe the responsibilities of your office and your role there?

Gregory Franklin: Okay, our office is essentially a policy office here in the state of California in the Department of Health Services. We report directly to our director, Dr. Diana Bonton by being positioned in the director’s office, that gives the Office of Multicultural Health some authority over the programs in our entire department, but not authority to the point to where we actually get out and punish people, but certainly we do have influence over some of their programs and some of their program policies, but we try to collaborate as much as possible.

The other thing in regards to my role, I function primarily internally as a consultant and externally, as a liaison, to a lot of the community groups, advocacy groups, physician’s organizations, nurse’s organizations, it’s more or less a catch-all position for dealing with issues related to multicultural health. We do a lot of policy and legislative work, a lot of marketing of our programs and a lot of ensuring that our programs are culturally competent.

Wendy Jones: Can you give us some idea of what the demographics of the area are and/or the population served?

Gregory Franklin: Well, California is very diverse, in fact in 1990, 57 percent of our population was Caucasian, around 26 percent Hispanic. But the 2000 Census indicates that we have experienced a decrease in the white population of 46 percent and our Hispanic population has risen to 32 percent. There’ve also been increases in our Asian population.

So that’s pretty much the diversity of our state, but within that, because again, I’m talking about the major ethnic groups, within that there are a significant numbers of language we serve including Arabic, Armenian, Cambodian, Cantonese, Samoan, Spanish, Tagalog, Thai, Turkish, Korean, Italian, and a host of others, so actually there’s like 29 different languages we serve in our public health programs.

Wendy Jones: Excellent. Can I ask you one more question and then I’ll turn it over to Diana. Why do you use the term multicultural health rather than minority health?

Gregory Franklin: Well it’s important that we understand that we’re not a minority, but more importantly, multicultural is more inclusive. Minority kind of revisits some of the past things that occurred in the sixties and some of the past terminology of the sixties. Multicultural has also been more palatable for our legislative folks, they tend to stay away or shy away from the word “minority” in many of the things that we may send up to them.

So I believe we made that decision in 1992, there was a report put out by Congress on black and minority health, I want to say in the early ‘90s, and there was a decision, or a discussion, regarding how we should term our office, and by and large, almost to a person, everyone said, well, multicultural health is more appropriate, it’s more futuristic, and certainly more palatable to those folks who are ultimately going to make decisions.

Diana Denoba: Thank you Greg, and by your telling us of the different languages of the people that you serve, I guess it may be obvious, but could you just tell us how language access became a priority in your program, was it your population only, was it the Title VI of the Civil Rights Act?

Gregory Franklin: Well you know I think the law had something to do with it, but I also believe that it’s beyond priority, it’s actually essential. The people we serve are very diverse. The people we serve who are eligible for our programs happen to be this very same diverse population and by making this essential, I mean essential to the business that you do, essential to your survival, thinking of it in those terms will ensure that you actually visit that each and every time you plan a program, each and every time you look at making adjustments to a program.

Up until ten years ago, our department was pretty much monolingual. All of our media spots, our radio, our television, were pretty much English only. Bilingual recruitment, it occurred, but I think it really occurred very rarely and on a limited basis. Today we have radio spots in Cantonese, in Spanish, in Hmong, and they’re also on ethnic networks like Univision, they’re also on public access television, so it’s absolutely essential to our survival that we think about language and, with that, that we think about translations. And by that I mean translating those vital documents into the languages that are going to reach the population that we want to serve. And thinking about translations, you also have to think about literacy as well.

Diana Denoba: Excellent. In your agency, are there some current policies or structures in place that specifically address the provision of language access services? And if so, can you please give us an example or two?

Gregory Franklin: We have two that I can talk to you about. One is within our MediCal program, which is our Medicaid program, and the other is a law that was passed, maybe, I want to say about six years ago, it’s the Dimely-Allatori Bilingual Services Act. And that requires all state agencies to survey the population they serve and if more than five percent of that population speaks a language other than English, you’re required to have a significant number of bilingual persons on staff.

Now that gets at the issue of state agencies and our ability to work with individuals who call us directly, or individuals with whom we may work in the community and who prefer to be communicated with in a certain language.

With that Act comes some requirements, of course, that we do our survey every other year, but there are also requirements that we do actively recruit for people.

With regards to the MediCal managed care policy letters, those have been fairly, I guess, taught throughout the United States so far, but when we embarked on moving MediCal beneficiaries into managed care arrangements, there was a sense, or a thinking that a lot of the commercial health plans we were going to be using really had no notion of what cultural competence was.

We convened a group of individuals, advocates, community folks, health plans, provider groups, other state agencies, and many more to help us craft these cultural and linguistic competency standard policy letters. And we wanted to address things like linguistic services, translation of written materials; we wanted our health plans to convene community advisory committees, so they could have their pulse on the community and understand some of the changes that needed to be made as time went on.

We wanted them to look at and also do group needs assessments, and that is, you start with their providers, take a sample of the community as well to memorialize some of their findings and hopefully look at it as each year passes. And then of course we did lay out a guideline on how to operationalize all of that. So those are, I think, two really good examples of policies that we have.

Diana Denoba: That’s great, and since you’ve had these policies or structures in place, Greg, have you seen an increase in access to services or utilization of services by people with limited English proficiency?

Gregory Franklin: I believe we have, I think any time you mandate, for lack of a better word, some activities, and where our health plans are concerned, tie it to some compliance issues and, maybe if things go correctly, some sanctions in regard to funding, I think we have.

I think also just by doing that we’ve seen an increase in education and awareness of the people we do business with contractually, because now they too are also more sensitive to the issue, they too, because of the increase of enrollment, the increase of beneficiary assignment, and I’m talking about our MediCal managed care program, they too are actively recruiting physicians who are bilingual, they too are actively recruiting nurses who are bilingual, they too are not asking for, quote, “compensation reimbursement,” but they understand that a significant number of the folks they do business with require these services, and if they want to stay in business they have to provide these services.

With regard to Dimely-Allatori, state agencies have to perform because every now and then we’re called before the legislature to be accountable for the things that they say we should do. So I have seen, even with our department, an increase in activities to hire and also retain bilingual staff.

Diana Denoba: Okay, thank you.

Wendy Jones: Greg, I think I heard you say something related to involvement of communities, I’d like you to expand upon that a little bit more? So is there a mechanism that ensures the involvement of family or community members in development and/or ongoing assessment of program policies and practices?

Gregory Franklin: Definitely. We have, I’d venture to say, well over 100 committees, advisory committees, that include community people, we have a Women’s Health Advisory Council, we have a Black Infant HHHHealth Advisory Council, we have my task force on multicultural health, we have a Refugee Health Advisory Council, Indian Health Advisory Council, Laotian Women’s Community Advisory Council, Cultural Linguistic Standards Advisory Council, I mean they all include folks in the community, it’s rotational, they’re appointed by the director, it is a very interactive process, the director attends these council meetings periodically, she’s interested in hearing from individuals personally.

With regards to what occurs at the health plan level with their community advisory committees, they bring in members from the community, actual people who are receiving services through the MediCal managed care program, and they get that input, and they bubble that input up to their executive staff. So there is an extensive network of community advisory type entities that pull in community input.

Wendy Jones: Thank you.

Diana Denboba: You were talking about a number of activities that you’ve been involved in and you talked about the mandate of your program, but how do your budgets support the cost that might be associated with the implementation of some of your language access services? First of all, can you just tell us what a few of them…you mentioned the media and working, training of your providers, what are some other language access services that you have and what about your budget for them?

Gregory Franklin: Pretty much each of our programs do something in regards to language, be that bilingual forms or translating forms into other languages, or developing other types of outreach campaigns, or having health fairs in given communities and enlisting the help of CBOs to pull in, to bring them in and work with some of our language issues.

For example, our WIC program, does a lot in the community and they also do a lot with regard to providing language access. Our Health Families Program, which is our SCHIP program, does quite a bit in terms of being on public access radio and conducting little talk shows or, again, putting on health fairs in communities that speak a language other than English.

As far as budgetary issues, it really depends on the program, and I’ll give you an example. When SCHIP was first rolled out, there was a lot of money and there was a sense, from the data, that over 70 percent of the individuals eligible in California were Latino or, in this case, Hispanic. So in order to be effective in reaching that population and getting them enrolled, we had to address their issues, therefore having our campaigns in that language, a lot of our outreach material in that language, a lot of the bus board materials in that language, that became appropriate.

Now another example where it may not be a budgeted situation but yet, still, there’s a community out there that needs to access our service, is our WIC program. The numbers in WIC are not as dramatic as those in SCHIP, so therefore WIC, who does not receive specific funding to do language activities, made a conscious decision on their own in terms of program management and program targeting, to target the impacted communities and that involved, again, translating materials into different languages, it involved recruiting bilingual staff, it involved working with community-based organizations, and a lot of our community-based organizations in California really do a lot of work for us without compensation, and that’s because of their own personal interest in seeing that folks have access to services.

Diana Denboba: I have another question, Greg. Have you see that this whole effort has helped to identify more children with special health care needs, or have you seen an increase in ongoing assessments of these kids?

Gregory Franklin: I think certainly this has helped to identify children with special health care needs, because each of the entities I talk about, and this is one of the positive things about, certainly, collaboration, each of the entities I talk about have made referrals into our CHDP program before, in fact they make many referrals into our CHDP program.

There has been a significant increase, I think in ’98, we had over two million kids referred to CHDP, children and adolescents, I’m sorry, and again, we wouldn’t have known or been able to communicate effectively without an effective approach to this language issue.

Diana Denboba: And I have one other question associated with cost. I know for some states there is an issue in terms of a reimbursement level, number one, of just spending additional time with children with special health care needs, above and beyond like the ten minutes that providers and managed care systems say that they can give. But if you’re asking for some of the language access services, do you feel that in the future you can legislate or implement something in terms of increased reimbursement for these providers?

Gregory Franklin: I would love to be able to say yes, but I don’t know if it would necessarily happen like that. And I sort of have a feeling that the issue might not be—and this is my own personal thought—so much as do we need to approach it from reimbursing for the language part of the visit, more so than looking at the base rate, are the rates that providers are being paid now, are they currently appropriate? And if they’re not, then maybe a partnership with those folks who have issue with the extended amount of time it takes to service a patient.

For example, in California, we know what the population is and we know that our population has a language need, and the child may have a special health care need. Well as part of you, the provider, taking on that responsibility, one is you have an obligation to provide quality service. The other is if the rate for that quality service is not inclusive of what you’re putting out, then you need to address it from a rate standpoint.

In California, this is going to be part and parcel of doing business, being able to provide effective communication and quality health care, and being able to do that and still adjust to language needs.

Diana Denboba: Great, thank you.

Wendy Jones: Greg, what do you see as the relationship between language access and the reduction of health disparity, do you see a connection there?

Gregory Franklin: Well there is a connection, again, like I was saying earlier, you need to be able to communicate effectively with the individuals who are coming to you for service or potentially eligible for services. I know Diana talked earlier about the goals and a ten-year action plan and all those things, and my understanding is that one of those goals happens to be that all children will be screened early and continuously for special health care needs. Well part of that is getting children in to be screened, and once they are screened, keeping them engaged in the system, and the best way to do that is to be able to make them comfortable, to put them in a situation to show, their parents and the children as well, they’re actually being heard and their needs are actually being addressed. Certainly the collaboration piece is important, because everyone up and down and throughout the network needs to be able to communicate effectively as well.

With regard to health disparities, even though it’s anecdotal at this point, most believe that compliance issues will increase or certainly will be improved if individuals can provide services in the preferred language.

Diana Denboba: Right. You know, you mentioned our Healthy People 2010 Goals for children with special health care needs and their families. There is a goal about families being able to partner with providers and being satisfied with services, so I’m sure that language access would help towards achieving this goal.

When we talk about some of the outcomes from your efforts, are there plans underway to evaluate these efforts in partnership with Title V?

Gregory Franklin: I can’t say there are specific plans but I can tell you our Title V program evaluates this program’s activities probably more than our contractors would like. There’s always a look at everything we do and everything we contract for, continuously. It occurs extremely frequently, I would also say that at each time we submit an application, there’s an extensive review of what occurred in that period in a positive way, or what occurred in a negative way, and adjustments are made to the program.

Diana Denboba: Okay, and based on your experiences, are there any lessons learned that you could share with those who are interested in improving language access? Maybe some strategies that worked pretty well and then maybe those that didn’t.

Gregory Franklin: Yeah, I think that probably the message is, and I don’t know where states are in terms of this effort, you definitely want to try and partner with the community as much as possible. The community has an understanding of reality and often we at the state level tend to be several steps removed and really don’t understand the issues as well as folks at the community level. I really think that’s the key.

And I think the issue of leadership may, sort of resolve itself, but what has to be remembered is that the community can educate us and at the same time, we can provide the community, if at all possible, with education about our programs and how they work to better equip them.

In regards to things that I probably wouldn’t do or things that were detrimental, I tend to believe that anything you can do, even if it’s a failed experience, will help you in some kind of way. Now, of course I’m not advocating going out there and failing, but I just think you need to look at everything as a positive event, if you have a situation that maybe didn’t occur the way you wanted it to, learn from that, make adjustments, and move on.

Diana Denboba: And in terms of our Title V programs at the state level, our programs are to provide technical assistance to their communities in terms of developing service systems, which would include outreach to populations that have limited English, what support do you think communities could use most from states in terms of improving language access?

Gregory Franklin: I would say access to expertise. When our Title 5 programs go out and they provide technical assistance, no one knows everything about everything. We have expertise within the state, we have expertise that we’re aware of in regards to other folks out in the community who may be practicing, and sort of linking them to other communities that have done well, linking them to organizations that have done well, providing that type of technical assistance is extremely important and invaluable.

Another critical area has to do with assisting with the development of policy. One of the things that I advocate for is that the whole notion of cultural and linguistic competency needs to be within an organization’s strategic plan, it needs to be filtered throughout the organization so that it’s not a special occurrence but a common occurrence. And this can be done without impacting that organizations bottom line, because in actuality what you’re doing, you’re changing a paradigm, you’re changing organizational behavior. That’s the kind of technical assistance that I think would be valuable.

Diana Denboba: Great, what about funding for communities?

Gregory Franklin: In regards to Title V programs providing funding for communities?

Diana Denoba: Yeah.

Gregory Franklin: We’ve done that in the past in other programs such as our MediCal program, where we’ve funded community-based organizations to actually do outreach for us. We’ve, and this is our third year doing it, we’ve funded community-based organizations to do focus groups for us. We’ve funded community-based organizations to be enrollment entities for us. So I think it’s a very good strategy, because these are the individuals that the communities trust. We’ve also, again, gone down into the community and hosted forums to gather and get their opinion, so I think anything you can do at the community level will definitely be positive.

Wendy Jones: Great, what final words would you give for states to get started?

Gregory Franklin: I really think you have to start with an assessment of where you are, you may actually be more culturally competent thank you think. Start with an assessment of where you are, talk to your community, talk to your stakeholders, once you’ve done that, look to put specific language within your organization’s strategic plan, make it something that everyone can see and go forward.

Wendy Jones: Okay, two more questions, I think, from me. What was the greatest barrier that you might have encountered in terms of putting initiatives or policies and practices in place regarding language access services?

Gregory Franklin: Educating people was probably the greatest barrier. I think that this change in demographics, it happened so quickly that there was a need to educate people on the importance of it, and also on the sheer reality that this is the world around you. That was probably the biggest barrier.

And then after that came the challenge of putting together the different coalitions, putting together the actual community type groups that would help you and convincing them that we were sincere about our efforts.

Wendy Jones: Thank you, now on the flip side, what have been the greatest successes?

Gregory Franklin: I think the greatest success that I can see in this department is that—and our department’s strategic plan reflects our will to address health disparities, it reflects our will to be culturally competent, but also in our individual programs, divisions, that same expression is in their own strategic plans. And as a result, I don’t have to be 150 places within this department, everyone is thinking in regards to the population they serve, they’re thinking about linguistic issues, they’re thinking about translation of documents, they’re thinking about culture, and to me that is the greatest success.

Diana Denboba: Greg, I just had one question, when you talked about having to educate the people, what about attitudinal barriers?

Gregory Franklin: Well, you know, you always have that from some people, but the way to overcome that, because technically you’re not going to change a person’s personal perception, it’s been ingrained and learned over years, but you have to get them to a point to where they can live with certain things. And it’s not that you’re asking someone to throw out their own personal beliefs, but you’re convincing them, in a factual way, that in order to be effective, in order to deliver quality services, in order to retain what I like to call, now this is very commercial, in order to retain a significant market share of the population that we want to serve so that you don’t have people running around without health insurance, you don’t have people running around with special health care needs that are unmet, you must convince them, in a factual way, that this is the way to go.

Now of course for those folks that you can’t convince, I think that’s why you have the Office of Multicultural Health reporting directly to the director, because then you have to talk to them in another kind of way.

Diana Denboba: Greg, do you have any final words before we open the question and answer session?

Gregory Franklin: No, I don’t, I just really appreciate the opportunity.

Diana Denboba: Thank you, call operator, we’re ready to accept questions.

Call Operator: All right, would you please just press zero, one if you have questions and we’ll prompt you for your name. David Hepple has the first question.

Carol Golotti: This is actually Carol Golotti on behalf of David Hepple. But we at the Maternal Child and Health Bureau have been working with community health workers and I have two questions related to that. There has been some feeling that community health workers are one of the keys to overcoming the communication barrier, the linguistic and the cultural barriers, and I a), wondered if you could comment on that and b), related, we are undertaking an evaluation to look at this and wondered what, we are looking at a number of factors that we can evaluate, because one of our main goals is to show to Medicaid payers, to private sector payers that hiring community health workers who understand the language and customs of the people who are being served will be cost-effective.

Is there any way that you can see that we could show that this linguistic characteristics and the linguistic access, that we could show Medicare and Medicaid that this is valuable.

Gregory Franklin: Let me start with the first part of your question, about community health workers. We also have done a similar thing with community health workers, and we’ve shown that community health workers are valuable to our effort, but at the same time, we’ve also shown that their work tends to need…that we need to support them, let’s say that. They cannot do it all on their own, so to answer the first part of your question, I think they are very valuable.

In regards to the second part of your question and showing your Medicaid agency the value of linguistic services, we’ve done similar assessments with our own organization here at the state level, and really we’ve asked questions, and sort of looked at the issue of health status in the beginning and then looked at things such as increased enrollment, at things like outreach activities and how our outreach activities have resulted in increased enrollment. We’ve also looked at this whole notion of access to services and looked at it in partnership with our own utilization numbers as well.

Then we asked the question regarding training, and the training question that we’ve asked has been, had we not had whatever mechanism in place, how that has impacted some of our training efforts to again, trying to enlist and train a whole group of people to get out and do the work that the community health worker does.

What the Medicaid agency responds to, at least what we found here in California, is that they respond to actually increased enrollment and people accessing services. If those two things are present, they’ve been fairly receptive to some of the things that we’ve put forward, at the same time they’ve also, and again, I think on the website, there’s a letter where they talked about providing reimbursement for linguistic services.

So I really think in terms of proving your case, you have to be strategic and you definitely have to address the issue of increased enrollment, and actually, I think utilization is also important.

Carol Golotti: Thank you, can we follow up with you later on off the phone?

Gregory Franklin: Sure.

Carol Golotti: Thank you very much.

Operator: Kathy Willis has the next question.

Kathy Willis: Good afternoon, I’m calling from Connecticut, and we’ve had a lot of difficulty with compliance in our state.

Gregory Franklin: Did we lose Kathy? We’ve lost Kathy.

Diana Denboba: Operator, can you help us, please?

Operator: Yes, I’m here, Kathy, can you speak up just a little bit, we’re losing you.

Kathy Willis: Sure. Just briefly, as far as compliance, what have you done with the MediCal health plans in California to ensure that they do provide linguistic competent services?

Gregory Franklin: We just recently released, or I should say, we’re testing a monitoring tool that was based on those five policy letters I talked about. And really, for our health plans and probably for everyone else, this is something that has been happening in an incremental kind of way, our own assessment of what it is they’re doing.

But we’re going out and we’ve tested this with the five health plans so far, is my understanding, we’re going out and we’re assessing them based on what we’re trying to do in the policy letters. And by the way, those same policy letters are also in our S-Chip program, which by that, I mean our S-Chip has also put this in the contract language and those folks who are contracting with them for S-Chip also have to comply. And in most cases it’s the same health plans that are in MediCal managed care.

But right now we are in the process of evaluating health plans for their functions as described by the policy letters and looking at it that way. We have not to date, that I know of, sanctioned anyone or anything like that. The health plans themselves, though, I do know of one health plan who found providers in their network out of compliance and they have written those providers letters reminding them of what needs to occur and also inviting them for technical assistance, if they need it, to be given by the health plan.

Kathy Willis: Thank you.

Operator: Julie Ray has the next question.

Julie Ray: Hi, I’m calling from John Stone Corporation in Boston, and we work with the Maternal and Child Health Care doing technical assistance. My question actually was more related to the climate in California. I remember a few years back, and I think this was a legal issue, of this English only or English as first language, and I have to admit, I don’t know the status of that law now, but when I hear about California and language, I always think of that and I wondered how you overcame that barrier and if it was a legal issue as well.

Gregory Franklin: No, it’s not a legal issue, I’m not even sure if that law is still on the books, it was quite a while ago, under another governor.

That really wasn’t a barrier for us because, even as I say, I’m trying to recall, if it’s an issue of we don’t require people to quote, speak a language other than English, and we don’t require people to learn English in order to go to school, in order to access government services. So if it was a barrier, it was quite a while ago and I’m sorry, I can’t remember even if it’s still on the books.

I do know, there have been things, other laws, that have been put out there in the past that may signal that we’re not language-friendly, but those haven’t been barriers at all.

Julie Ray: Okay, I won’t drill this in, but what about this accelerated movement from bilingual classes in public schools to the English only? I know that they were trying to get rid of the bilingual education, now I’m not being accusatory, because this sounds like a really terrific program, and I was surprised, because I thought there might be more public resistance to it than it sounds like you’ve gotten.

Gregory Franklin: Well, frankly, I don’t have enough information to even address it, I’m not up not that right now. Let me say this. It hasn’t been something that’s been bubbled up and really talked about publicly a lot if that’s the case.

Operator: Cindy Ingram has the next question.

Cindy Ingram: Hi, I’m calling from Vermont, and unlike sign language interpreters, spoken language interpreters don’t have any nationwide certification process, so I’m wondering what you’re doing in California to ensure the quality of the interpreters that are used both by the state, or are recommended to be used by providers.

Gregory Franklin: That is true, what you said about the nationwide qualification and the standards and all that. There is an organization within California, the California Health Care Interpretive Association. They’re working on a standard or at least something that could be used as a standard for medical interpreters.

That’s one of the problems that I think will be presented when states go to HCFA, or CNS now, to seek reimbursement for interpretive services, and that being that there is no set standard on what’s a quality interpretive experience. There is no certifying body.

What we do currently is, the health plans are more or less at risk in terms of ensuring that quality interpretive services are provided. And that has seemed to work fairly well, we haven’t had any major, major problems with it, but you’re absolutely correct, there is no national standard.

Wendy: Cindy? This is Wendy. While there appears not to be a national standard regarding certification, national certification for interpreters, it sort of varies from state to state, some states do have guidelines, some do have written policies and procedures regarding the level of education, the level of knowledge required for an interpreter.

I’ll give you an example, this is not really health-related, but court interpreters have to be certified through very rigorous exams, so at this point, efforts are underway in certain states, and Washington state is an example of a state that actually does have some guidelines around certification for interpreters in terms of the medical and health fields.

Gregory Franklin: And California does have certification for legal interpreters, but health care interpreters have really been our issue.

Tawara Goode: This is Tawara, and Washington state also, in addition to the certification process, offers a pay differential for those employees who pass the test and are able to provide interpretation or translation services.

Cindy Ingram: Thank you, that’s good input.

Operator: There are no more questions at this time.

Diana Denboba: We’ll wait a few more minutes and see if there are additional questions.

Operator: Diane McCann has a question.

Diane McCann: Hi, I am from New Hampshire and I just had a question about your policy letters, are those available on line for examples?

Gregory Franklin: Diane, you can give me a call, we’re trying to put them on line, they’re over in another department right now and we’re trying to put them on line, but if you can call me and give me your particulars, I’ll gladly mail you a copy.

Diane McCann: Is your phone number somewhere in your literature?

Gregory Franklin: I don’t know, I don’t think it is. [end of side A, side B is evaluation and closing remarks, which we were not instructed to transcribe, save for one last question as follows]:

Operator: David Hepple has a question.

Carol Galotti: The only question I have at this point is could Gregory Franklin give us his telephone number, I think there are a number of us who probably want it.

Gregory Franklin: Yes, I could do that.

Carol Galotti: Thank you very much.

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