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Part 2: Promising Practices - Accessibility and Language Access

The following is a text alternative description for Telehealth Webinar for Community Based Organizations Series - Part 2: Promising Practices - Accessibility and Language Access 

[This is a webinar recording of  the Telehealth Webinar for Community Based Organizations Series - Part 2: Promising Practices - Accessibility and Language Access. It features the slides and audio from the operator and presenters from the webinar.] 

[Presenter - Operator]: 

Welcome and thank you for joining today's conference. Before we begin, please ensure you've opened up the WebEx participant head chat panels by using the associated icons located at the bottom of your screen. Note that all audio connections are muted at this time. If you require technical assistance, please send a chat to the event producer. With that I'll go ahead and turn the conference over to Cheryl Levine. 

[Presenter - Cheryl Levine]: 

Hello, good afternoon. This is Cheryl Levine. Thank you for joining our webinar. We're focusing on telehealth for community-based organizations and our webinar today is on best practices for accessibility and language access. Welcome back this is our second webinar series and I’m Cheryl Levine with H-H-S. I am the lead for our At-Risk Individuals program with the Office of the Assistant Secretary for Preparedness and Response. Thank you to HUD for being our co-sponsor in this webinar series. Benjamin DeMarzo is the Assistant Deputy Secretary for Field Policy and Management with the U-S Department of Housing and Urban Development. My other partner for this web series is Liz Palena Hall. She is a long-term and post-acute care coordinator with the Office of the National Coordinator for Health Information Technology, or O-N-C as we call it, with H-H-S. With that, I'll hand it over to Ben for some opening remarks.

[Presenter - Ben DeMarzo]:

Thank you so much, Cheryl. I appreciate it. Thank you everyone for joining today's call. My name is Ben DeMarzo. I'm the assistant deputy secretary here at HUD for our Office of Field Policy and Management, which oversees our place-based programs which includes the envision center demonstration and promise zones, and also our efforts on opportunities zones. So as I said on the last call with all of you health and wellness services or the number one request that we saw from envision center sites and local community partners. We really appreciate H-H-S assisting us in putting together the seminar for everybody. I know a lot of you are now dealing with the dual reality of a pandemic and a hurricane hitting the Gulf Coast. Now more than ever people need remote mobile access to health services. We really appreciate everything everyone on this call is doing as the first line of support for people who are the most in need in our country. So I'm going to keep it short today because we have a lot to get through in this presentation, a lot of important services and information. I just want to say on behalf of Secretary Carson, I want to thank everyone for everything you're doing during these difficult times. And we know that the people you serve or are very appreciative of your efforts. So Cheryl, I want to turn it back over to you to start today's presentation.

[Presenter - Cheryl Levine]: 

Thank you, Ben. Thanks for, for joining us today. So again, this is a webinar series. This is part two of a three-part webinar series, and we, again, are so appreciative to HUD for helping us to host this. For our webinar today, we will use the chat box for questions. If you have questions for the speakers, go ahead and enter them in the chat box and we'll address those at the end of the webinar. We are recording the webinar and we'll be able to post it for you to be able to receive those resources at a later date. We did have an earlier webinar a month ago, we had a focus on services, payment and partners. Telehealth 101 and those resources are now available on our webpage at H-H-S ASPR, including the recorded webinar, the transcripts and the Q and A from the audience.

To kick us off a little background on addressing accessibility on language access in emergencies, there is a series of federal laws, executive orders, and various national guidance that provides sort of the backbone of describing equitable access requirements for equitable access to programs and services. And some of these federal requirements are specific to disasters and public health emergencies, but others apply more broadly to preventing discrimination against at-risk individuals with access and functional needs. I wanted to highlight a couple of those executive orders that I think helped frame our discussion for today. First, Executive Order 13347 - Individuals with Disabilities in Emergency Preparedness from 2004: this executive order requires that federal government appropriately support the safety and security of people with disabilities in all types of emergency situations through a coordinated effort. This includes considerations for the unique needs of people, employees of the agency and their disabilities, as well as others they serve. Encouraging consideration of the unique needs of employees and people with disabilities served by state, local, and tribal government organizations and private organizations and emergency preparedness planning and facilitating cooperation among federal state local tribal and territorial governments, as well as private organizations.

The other Executive Order I wanted to mention is 13166 from 2000; in fact, we're this month celebrating the 20th anniversary of that Executive Order on Improving Access to Services for People with Limited English Proficiency. Under this executive order, the federal government committed itself to two goals: first is to identify, develop, and implement policies that will ensure that individuals with limited English, proficiency or L-E-P have meaningful access to federal programs and activities. And the second goal is to provide guidance to help recipients of federal financial assistance understand and comply with their obligations to overcome language barriers and compliance with the national origin non-discrimination provision of Title Six of the Civil Rights Act of 1964. As a helpful tool that I think can emphasize some of those requirements, we do have an H-H-S ASPR Fact Sheet on communication access that provides some promising practices and resources for address, addressing effective communication in emergency. With that I'm going to turn it over to Liz and have her introduce our speakers. 

[Presenter - Liz Palena-Hall]: 

Thank you, Cheryl. We have, as mentioned, an exciting agenda for you today. First we are going to hear about assistive technology and accessible telehealth. Specifically we'll learn about the State Assistive Technology Program: what is the technology, how it can be leveraged with telehealth, and some success stories. Next we'll hear about telehealth and culturally and linguistically appropriate services that can help improve quality care for patients and advance health equity. Finally, we'll be hearing about promising practices for addressing social isolation and loneliness among adults in senior housing through the work of the A-A-R-P foundation Connective Communities that are providing really innovative solutions to address some of these challenges during the pandemic.

With that, I will introduce our speakers today. First we will hear from Brian Norton, Brian is the Director of Assistive Technology at Easterseals Crossroads. He is responsible for the agency's assistive technology services that include clinical assistive technology and the end data project, a federally funded statewide assistive technology program for the agency. Next we'll hear from Kathy Wibberly. Kathy is Director of Mid-Atlantic Telehealth Resource Center, one of the twelve Regional Telehealth Resource Centers serving the country. The Telehealth Resource Centers are federally funded to assist with telehealth program development and sustainability in order to increase access to quality care for rural and other underserved populations. Lastly, we'll hear from Ryan Elza. Ryan is a Social Entrepreneur in Residence for Social Connectedness at A-A-R-P foundation and leads the A-A-R-P foundation’s social isolation and digital inclusion work. He has an extensive background in social determinants of health, design thinking, and civic engagement. With that, I'm going to turn it over to Brian.

[Presenter - Brian Norton]: 

Excellent. Thank you, Liz. Again, yeah my name is Brian Norton, super excited to be here today with you. Let's move over to my slides, there we go. I'm super excited to be here with you today. I'm going to be going over, as Liz mentioned, several different things, just providing some information about state A-T programs and the services we provide, kind of level setting everybody on what assistive technology is and why it's important to talk about, what to consider when choosing online meeting tools or telehealth tools, discussing the common accessibility features found on those tools, and then talk about some resources and some success stories. Let's go ahead and just jump in. State A-T programs funded through H-H-S and A-C-L, there are 56 state assistive technology programs. There's one in every state and every territory, and these are great resources for accessibility and assistive technology for you and your consumers or clients.

Really state A-T programs have two main goals. One is awareness, making sure that people know about assistive technology, how it works, and where they can get their hands on it. The second is really about acquisition: getting people's hands, actually on the assistant technology. We do that in a variety of different ways. Those are listed there. Device demonstration: help people become familiar with assistive technology by comparing and contrasting different devices and tools. Device loans: allow people to borrow assistive technology for short periods of time to really try something before they purchase it. Device reuse: we receive assistive technology that's no longer used or needed by its original owner. Then we help connect those devices to other persons in need. And then we also offer state financing, which helps people acquire their own assistive technology, if they're not connected with a funding source.

To level set everyone on what assistive technology is and why it's important: there are a lot of technical definitions, more technical than the one I have on your screen, but this is how I kind of explain it to folks. It's really any device or system that helps someone do something they wouldn't otherwise be able to do. While we're here, I'll just mention assistive technology is one thing, accessibility is another. Accessibility really is kind of more about the usability of the tool, whereas assistive technology is a device that provides access to something. And so although they might have the right tools to be able to access telehealth, like a keyboard or a mouse or a large monitor or other kinds of things like that, it really comes down to the usability or the accessibility of that tool to whether they can access that well or not. So there is some nuances there between accessibility and assistive technology.

Really the purpose behind assistive technology, or how I view assistive technology, is obviously increase the efficiency or effectiveness of a person and the task that they're doing. It decreases degenerative nature of a disability and helps people avoid injury. But ultimately I think it all rests on – we want people to be independent. We want to people to be as independent as they can in all areas and all walks of their life. Assistive technology can become a really important tool for folks.

It comes in all different shapes and sizes. You'll hear it referred to as low-, mid-, or high-tech, lots of different cost ranges. Sometimes it doesn't cost anything, sometimes it can cost a lot. Got a range of different devices there on your screen. One is a Braille panel, at the very top there, those can be really expensive, but allows a person who is blind or visually impaired a way to be able to get tactile feedback from the computer, all the way down to either maybe using a large print monitor or some other device an adaptive keyboard or pointing device so they can access to a computer. Again, all different shapes and sizes, lots of different things to be able to look at and try. And that's where the state A-T programs come in. They have libraries, as we mentioned before, where people can borrow equipment to really better understand what's out there and what they could use. I do think it's important with assistive technology to recognize that one size doesn't fit all, that disability affects everyone a little bit differently, and that really our choices with what we want to use to be able to access different things will be based upon, a lot of times, our experiences, what our preferences are, and what our tolerances are for the types of technologies that are before us. What people use can vary greatly from one person to the next.

Online meeting platforms or telehealth tools, there's lots of choices, especially nowadays. It seems like there have been hundreds that have popped up that maybe no one's ever heard of six months ago. There's lots to choose. So what do you need to consider when you choose an online meeting tool? I think for most of us choosing an online meeting tool really matches the process for choosing any other technology. We often look at the tools and features of a product and decide if that's the right fit for what our need is. One thing that I think is really important for community-based organizations and people to think through is to be able to think through the importance of accessibility from the onset of that decision-making. Although it might have the right tools and the right features, I really think we need to think about accessibility as a part of that initial look at what we're looking for. So build that accessibility and the importance of that into your process for selecting tools.

A lot of times technology or these online meeting platforms can be simple or complex and really, depending on what you're doing, if it's just a face-to-face meeting or a conversation you may choose a completely different tool than if you have to share a document or conduct a webinar like we're doing today. Often what we are going to be doing within these meetings will often drive the tools that we choose. There are always a lot of different features available, and it's becoming familiar with those different features. Again, this would bleed into how you're interacting with your consumers, with your clients. Common features found in online meeting tools include video, face-to-face conversations, recording, screen-sharing, remote control, security. Again, goes back to what type of meeting are you facilitating and what types of tools will you need to be able to make that go well? 

As I said, always think about assistive technology or accessibility at the beginning as you start looking at tools. There's a couple of things to be able to look for when you talk to companies about their tools and what they provide. There is something called a V-PAT or a Voluntary Product Accessibility Template. This is a document that explains how information and communication technology products such as software, hardware, content, support documentation, and much more conform to the revised 508 standards for I-T accessibility. You'll also find that a lot of companies, Zoom, Teams, other products, they also have an accessibility help desk which specifically allow folks that use assistive technology to call in and get their accessibility questions answered. So a couple of tools to be able to think through there.

Let's talk a little bit about the various accessibility options and features available in many of today's tools, many tools like Zoom, Google Duo, Meetings – I'm sorry, Microsoft Teams – provide automatic subtitles and captions. A lot of tools are starting to use artificial intelligence to provide automatic captioning to those, to whatever meeting that you conduct. You can also have live captioning. You often find in the tool bar and many tools a C-C button to be able to turn captions on. It's important to note that live captions have proven to have higher accuracy rates than some of the artificial intelligence ones. That is because you actually have a person listening in and typing the captions and provide oftentimes a little bit better content and information and just a higher accuracy rate when listening to those. Other things to consider just the ways and the modalities that people get access to the meetings.

A lot of one – a lot of tools will provide computer audio and/or phone-based audio, so that if you're working with folks who don't have a tablet, don't have a Smartphone, don't have the technology – a piece of technology that can allow them to get access to tools or to your meeting, making sure that there's a phone base where they can just pick up their landline and call in to be able to listen in. If you're using audio, think about a headset or noise canceling headsets, to be able to help limit the background noise in meetings. Always considered keyboard accessibility. That's super important for folks who are visually impaired so that if they're trying to click on something or find a button or a function or words on the screen, a lot of tools will allow keyboard functionality. You can just press the keystroke to jump to different areas like the chat room or the participant list or other types of things.

High contrast is also a feature in a lot of different programs. Specifically, for folks who have difficulty with vision, again, being able to see the words on the screen a little bit easier. You can change it from black text on a white background to a little bit more high contrast or white text on a black background. High contrast settings are also a part of those tools. Other things, adjustable fonts – you'll find that a lot of programs offer adjustable fonts. I would always consider lighting whether you're a presenter or the participant, making sure that you have proper lighting so that they can see your face. If a person reads lips and can't see you that can be very difficult for folks. A rule of thumb for that is always have the lighting in front of you not from behind because that's going to cast shadows and make it more difficult to see you. 

Always provide accessible content beforehand, so if you're going to be passing around a PowerPoint or handouts or slides or those types of things make sure that's available for folks before the meeting so they can review them and take notes on those. Another thing that we have found really useful for the folks that we serve when we're doing telehealth or online meetings with them is a way for them to think about positioning a tablet or a Smartphone. Oftentimes holding it for a person with a disability can get challenging – you're not being able to see them very well, they have to adjust and do those types of things. So thinking about some way to mount or position whatever device they're using in a way that they can be able to better participate in the meeting and be there with you.

A couple of end user things and I'll kind of briefly just run through these. Prep your technology as an end user – things to coach your clients and consumers on. Hopefully, they can prep their technology to know what's being used by the provider. If you need an accommodation as a participant ask for it, request it. consider getting on early doing test runs. Make sure that again, with that positioning, looking at how are you going to position your technology, your phone or tablet. Make sure that your technology is charged, your phone is charged, your computer is charged. You don't want that to go off in the middle of your meeting. Prep your environment, go to a quiet room. Sometimes that's harder than we might want to realize. Test your audio connection, prepare your assistive technology, make sure it's ready to go. Again, accommodation requests: sometimes even having someone there to be helpful in your telehealth visit can be helpful to be able to take down information and write notes. Lots of things from an end user perspective as well.

And then really, you know, just to note a couple of success stories. The first one I'll just mention is Eli. Eli's a three-year-old. He has cerebral palsy with developmental delays and currently because of the pandemic, he's at home receiving O-T, P-T, and speech therapy through Zoom with his O-T, P-T, and speech therapists. What they have done, as the parents have described to me, is taken the partnership and that therapy to a whole new level for them. It's allowed them to be able to be hands on and participatory in that therapy, which has just helped them – once they're done and out of the therapy session with their therapist, they are able to then take that and kind of work what they've learned from the therapist into their daily routine and rhythm of life. One unique thing that their therapist has done is use visual age – aids as a part of their therapy. And so one thing they end up doing is taking a doll and when they need to move the arm in a certain direction, they take that doll and they help show them how to move it so that they can kind of better understand what they're doing with that. And so, just a great way and a great story about how telehealth has really improved access and created a real partnership between people.

Another person is Cindy. Cindy has got a dual sensory loss was being seen for a communication assessment. She has low vision and she's hard of hearing. They will use the way Velo app, which is a free iOS an Android app. It provided three-way conversation between her, our person – our technologists and their interpreter to be able to have conversations. What was really great is it was familiar technology to this person and to the other folks that were in the meeting and it really expedited the service. We didn't have to wait until it was the proper time to go visit her and we were able to expedite things on with her.

Just a couple of ways that telehealth has kind of helped folks in the current situation that we find ourselves in, either with a different way to receive services or with expediting services as well. I’ll kind of leave you with a couple of links and these will be, I'm sure, in the PowerPoint that you can get, but just ways to connect with your local state A-T program or with Rob Groenendaal, who is with ACL, to learn more about state A-T programs and the things that they offer. Then again, additional resources and information about other telehealth resources with regard to accessibility.

And I'm going to pass this off to Kathy and so – let’s see if I can do that. Here we go.

[Presenter - Kathy Wibberly]:

Okay. Thank you. I’m going to basically give the level setting for the Culturally and Linguistically Appropriate Services standards related to language and communication services. Big picture wise the CLAS standards are intended to advance health equity, improve quality, and help eliminate a lot of the healthcare disparities that many of you who are working in the field see every day on an ongoing basis. The principal standard really is to provide effective, equitable, understandable, and respectful quality care and services that are responsive to the whole diversity of health, beliefs, practices, languages, literacy, communication needs. What we're going to focus on right now are standards five through eight, which are the Communication and Language Assistance standards. I would basically say that this is the gold standard for communication and language assistance. We know, and the government knows, that not everyone can meet these standards, but we're holding the bar high and hoping that we can rise to this.

Standard five is to offer language assistance to individuals who have limited English proficiency and/or other communication needs at no cost to them to facilitate timely access to all health care services. Standard six is to inform all individuals of the availability of language assistance services clearly and in their preferred language verbally and in writing. Seven is to ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided. Then eight would be provide easy to understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. We all know that that does not always happen and sometimes in some places it rarely happens. Basically, what the office of civil rights looks at is for any recipient of federal financial assistance from Health and Human Services, they're expected to take reasonable steps to provide meaningful access to L-E-P persons.

And so what does reasonable and what does meaningful mean? Well, they did provide a little bit of a guidance around that. To assess whether something is reasonable and meaningful is based on the number or proportion of L-E-P persons eligible to be served. For example, if you live and your clinic or health care clinic is in a neighborhood that is just you know 50% Latino or 80% refugees from whatever country, you know that your population, your patient base, is going to be significant in the number or proportion. In those situations, the expectation is higher that you will be able to serve that population with language access services. Again, the frequency with which L-E-P individuals come into contact with the program, the nature and importance of the program activity or service being provided and then the resources available.

Again, we always look at, you know, is this someone who can actually have the resources? If you are a large hospital health system and you are – you have a huge endowment and you're working with a population that has needs language access, you’re going to be expected to provide language access services, free of charge. But if you are, let's say a small free clinic and you are basically working on a shoestring and are scraping bottom just to keep the doors open, you know, that meaningful and reasonable criteria is obviously held a little bit differently for you.

Let's talk a little bit then about your role in terms of helping a patient or client navigate, because we all know what this pandemic people are flipping to telehealth both for access to care, but also for avoiding exposure. And so clinicians are doing the same thing. They don't want to be exposed to COVID-19 and people and family members, patients don't want to be exposed. Then how do we then deal with patients who have language and communication needs?

Some things to really consider as you're helping these individuals are: does my client require language assistance? That's really the first question that you need to ask. It seems basic but it's not always that basic. Sometimes bilingual individuals or people who are just learning English, they may actually speak pretty well in terms of everyday conversation. They can go to a restaurant and order a meal, or they can have a conversation in the street and ask for directions. But, does this client know and understand healthcare terminology? Think about your average, let's say eight-year-old or ten-year-old, how much terminology in terms of healthcare and medical anatomy and physiology do they understand? Because if you're thinking about someone who's learning English as a second language, that is usually not the terminology they are receiving in their E-S-L classes. As you think about does my client require language assistance, also take it the next step further: does my client understand basic medical and healthcare terminology in their repertoire of English?

If they do require language assistance, is it just language assistance or is there a need for a cultural broker? What does that mean? It means that oftentimes people coming into this country do not know or understand the cultural context in healthcare. They also don't understand the infrastructure of healthcare. And so if you're coming from a country where healthcare is free, where it’s universal healthcare, and you basically feel like if you get healthcare, you just get healthcare – you just go to wherever you go, you can show up in the emergency room, or you can go to a private office, there's going to be some cultural navigation in terms of helping them to understand, everything from third party payment, Medicare and Medicaid, navigating of that all the way to the cultural context of somatic symptoms and how you describe symptoms. I’m actually from an Asian culture, even though I grew up in the United States, and in Asian cultures it's often it's much more acceptable to describe things from a somatic point of view as opposed to let's say a mental health or emotional point of view. If I'm having emotional problems, I may say I have frequency of stomach aches and headaches. For someone, for a provider who may not be aware of that social context, it often is very helpful to have a cultural broker, basically be able to navigate that. Think about that in that context as well.

You also need to think about what resources are available to you or them, and are these resources available onsite or remote? The obvious gold standard is you have a trained healthcare interpreter and you have access to that person. Many times, that is not possible or feasible. So then you think down the list. Are there some bilingual healthcare workers that I might be able to bring into the situation? If the answer is no, is there a bilingual staff that might be non-healthcare staff, but let's say, you know, it could be the person who is the receptionist answering the phone, or it could be you know, someone who's in the daycare center who's bilingual. Then you can really think about, you know, if none of those are options, are there some bilingual friends or family members, and often this is not advisable because of privacy and just contextual pieces of healthcare. Oftentimes you don't want to ask a patient sensitive information if they have a friend or family, like if you're asking them about sexual health, oftentimes people are uncomfortable answering those questions in front of a friend or family member and certainly not with a minor child trying to be in the interpreter. I think these can put you in very awkward situations where you may or may not then get useful healthcare information.

Some other things to really consider are does my client's cultural beliefs impact their acceptance of technology. This is going to be an interesting one because there are definitely cultural beliefs around technology. Some cultures are very embracing and accepting of technology, but there are also some cultures, and I’m even thinking about US cultures like some of the Appalachians cultures, where technology is suspect: it's part of big government they're listening in on me. And so you really need to, see if you can understand and get a hold of, what are those beliefs around technology.

Will my client be able to provide consent for telehealth services without an interpreter or translated consent materials? This is a really important piece because many times States’ or even funder requirements require a consent for telehealth services. Some of these things have been more relaxed as a result of COVID, but at some point COVID will be over, and we may still have to go back to requiring that written or at least verbal consent. Is that consent form going to be available in that person's native language? And if not, are they going to need an interpreter to be able to explain what they're consenting to? Because it's no longer informed consent if they can't understand that.

Then you need to really ask: what device will my client be using to connect with his or her healthcare provider. And that should say how many video or audio connections are possible or feasible. What you'll need if you're bringing an interpreter is a multi-point connection, unless the interpreter is there with the client or patient. If you're bringing in someone, let's say a bilingual staff person or a bilingual family member, and they are not there with the patient or client, they're going to need to be able to connect it to whatever is being – whatever's happening with the provider and the patient.

What can you do to assist? One is to make sure that the provider knows that your client or patient will need language and/or cultural broker assistance and that you and the provider know exactly what language or dialect is needed. This is very important, particularly in languages where there are multiple dialects and regional variations, Spanish being one of them. Oftentimes you just say, I have a Spanish speaker. Well, great, but are they from Spain or are they from Columbia? Where are they from? Because even something as simple as the word for, let's say baby bottle – that can vary significantly from region to region. So when you're using healthcare interpretation and you may be talking about a baby, there are going to be some issues with the word for word translation, even if you're saying that my client knows Spanish. We really need to kind of think through the language and then the dialect.

Find out what language access options the provider might have available. Also do all these things in advance of the visit as much as possible. Find out what platform the provider is using. Will the technology allow multi-point video connections or have integration of healthcare interpreter services? If not, find out if the provider would be willing to use one that does and some of you are acquiring technologies just to assist with other things. Brian did a great job of talking to you through some of the technology things to consider, so I'm not going to go through all of that. But it's really the very much the same thought process in terms of the, what platform do you use and what can we do? 

Assess the best workable options and alternatives. Video interpretation is by far better than just audio only, as we all know; I think that the vast majority of communication comes from body language, from nonverbal. The more that the interpreter can see what's going on with both the patient and the provider, the better the context will – of the interpretation will be. Some telehealth platforms integrate healthcare and transportation services as part of their license agreement. We are seeing more and more of this happen. We've seen several major companies add interpretation just during the pandemic because they are realizing that this is really important. Don't be afraid to ask the health care provider, do you already have this service? Can you enable it, because this is what's needed? We know many of you are using Zoom. Zoom for healthcare has a feature for designating interpreter. If you have an interpreter this is the web link for how you designate someone as an interpreter in a three-way or multi-way video conference, and that is a nice feature to be able to use.

A trained healthcare – and I already said this once – but a trained healthcare interpreter will almost always be better than using staff, family, or friends because, one, they're trained in medical terminology, they're trained in best practices in terms of interpretation. But there are some remote interpretation companies that will come in using a video: Stratus Video/InDemand Interpreting and LanguageLine Solutions, they all have video-based language interpretation. Make sure you ask for a healthcare interpreter if you are going to be using those services, because oftentimes some of these people are trained in, let's say, legal interpretation or other contexts of interpretation and healthcare definitely has a different set of terminology. Do not use Google Translate for healthcare interpretation. This is just a big red flag warning, because Google Translate is used a lot for kind of everyday conversation. But Google Translate – they've done some studies on it, and it's only about 57% accuracy when used for medical phrase translation. That is not what it's built for. It's not what it's designed for. Just urge caution in using things like that.

If you have no other options, can't reschedule the visit, it has to be that time, that day, you don't have an interpreter, you don't have anyone on hand, a somewhat better option is Instant Language Assistant software or app that's being made available a free during the pandemic. You can download that. But again, using an app for interpretation is really not your best choice. That really is kind of your last resort.

These are a number of useful resources and links in terms of where you can go. The National Board of Certification for Medical Interpreters, if you have bilingual folks on your staff that you think might make good medical interpreters for your patients or clients or people that you serve, you know, it might not hurt to get them certified as a medical interpreter. National Council on Interpreting in Health Care, State Law Requirements Addressing Language Needs in Health Care, a Guide to Understanding Interpreting and Translation in Health Care, and a Practice Guide to Implementing the National CLAS Standards. Those are all very useful resources that you can draw on.

Last but not least, I’m a part of a regional telehealth resource centers. The telehealth resource centers are federally funded, our services are free of charge, and we're really here to help you and provide – health care providers, know how to use technology better in order to deliver health care and deliver better access to health care. You can reach out to us – our website is, so it’s very easy. From there, you can reach out to any of the regional resource centers that [00:39:25 inaudible] my States are the dark purple state on that map. This is my contact information, and I'm happy to take emails or requests if you are in my region, or if you're not in my region and you email me, I will direct you to the telehealth resource center that says where you are. That is what I have, and I will pass the ball to Ryan.

[Presenter - Ryan Elza]: 

Thanks so much, Kathy. Hi, everyone as mentioned, I'm Ryan Elza, Social Entrepreneur in Residence at A-A-R-P Foundation. Those of you who may not be as familiar with A-A-R-P Foundation as our famous sister organization, we are the charitable affiliate of A-A-R-P and we serve members and non-members alike around two main pillars to end senior poverty, and that’s building economic opportunity and social connectedness. Today I'm going to talk about our work to promote digital equity within affordable housing, by working with providers of multifamily in order to make sure that residents have access to broadband, hardware, and devices and the wraparound training a part in order to use those devices to promote social connection, and also how they can use it to maintain their independence and remain in place.

At A-A-R-P foundation, when we talk about social connection, we really think of two constructs. We think of social isolation, which is the quantifiable measurement of an individual’s social network size and the frequency of engagement with individuals within their network, the availability of transportation, and their ability to access resources and information. We also think about loneliness. So loneliness is actually how individuals perceive their experience and whether or not they feel isolated. Social isolation is a health issue, and it's equivalent to smoking 15 cigarettes a day, which is pretty significant When you think about the frequency and prevalence of social isolation in older adults and people with disabilities, especially now during the global pandemic in which most of us are forced to socially distance and don't have the ability to connect in person in a way that we did previously. Social isolation is associated with increased higher blood pressure, increased susceptibility to flu, greater risk of heart disease, and early onset of dementia. All of these health impacts add up so older adults who described themselves as lonely face a 59% greater risk of functional decline, a 45% greater risk of death, and, also, an increased cost associated with Medicare of about $1,600 per individual, which equates to $6.7 billion annually.

It’s really important to understand social isolation and connection as you think of addressing it and specifically within the populations that you're serving. Social isolation is often the confluence of many different risk factors at the societal, community, and individual levels. So when we think about residents within affordable senior housing, we see that these risk factors often happen at higher rates. And so residents often have frequently have lower incomes, less social support and worse health compared to those who continue to live in – live on their own and their community. We know that social isolation prior to the pandemic affect is about one in four older adults in senior housing and that nearly 70% of adults in senior housing reported some feelings of loneliness which is pretty startling.

At A-A-R-P foundation, when we're trying to develop new programs and services to address root cause issues, we really look at a human centered design approach about how we can develop solutions for individuals. We follow a three-step process that we have built out within our A-A-R-P foundation Connect2Affect Connected Community Program. First we really start with assessment and awareness. So we take a person-centered, holistic assessment of individuals related to their condition of social connection and isolation, and technology needs, and their interests. And then kind of identify what are the barriers impacting individuals and their ability to access technology, such as access to broadband and affordability. Then, you know, from a public health perspective, how can we increase awareness about social isolation and loneliness and the importance and opportunity for social connection? Then we work with organizations in order to facilitate the connection to broadband technology and training. And we have worked successfully with multifamily providers, most recently to leverage reserve funds in order to explain infrastructure upgrades within their communities, to make broadband marketable within their communities, and provide opportunities for synchronous and asynchronous classes and education. And then also provide tool kits for organizations to think about how they adapt their current programming from in-person engagements to virtual engagements during COVID-19 to make sure that there are safe interactions between residents and staff and the community.

A-A-R-P Foundation’s Connected Community – Connected Communities was the result of a rigorous research and extensive, you know, look at how we could leverage the power of voice-first technology to promote social connection within affordable housing. We work with providers to, first, understand how they can make sure that broadband access is available to every resident. We then help them identify what type of technology might have the most meaningful impact within their communities and how they can basically distribute that technology to every resident, and provide wraparound training and support for both staff and residents and education and curriculum about how they can use the technology for social connection. Then we've also built our own A-A-R-P foundation, voice-first applications available on Amazon Alexa and Google Home. One of the applications is called Community Hub, and it's a system that allows resident services staff within the affordable housing communities be able to interact and engage with the residents and makes information available to residents on demand through their Amazon Alexa or Google Home Smart Speaker. So it essentially turns Amazon Alexa to a concierge for senior living and provides providers with the tools to be able to interact and engage with the residents directly in their home in a safe and meaningful way.

There's a couple of different steps to how we have created an out-of-box experience. The original program design relied heavily on creating in-person engagements and training for both staff and residents. We have since pivoted all of our training into a train-the-trainer model that is available through remote training that allows organizations to really think about how to do it in a sustainable and cost-effective way. So we provide training to staff and volunteers. We have facilitator guide to accompany those trainings. We've created remote workshops and presentations that also have guided recorded trainings that organizations can deliver to their residents in small group settings. Then we have explainer videos that also accompany that curriculum.

Most recently we've been working to develop a telehealth 101 curriculum for residents that really focuses on that consumer education to – for residents to understand what is telehealth, how can they access it? How can they prepare for their visits and what questions do they need to be asking their providers? The reason why we have now ventured into this telehealth consumer education space is immediately when the country started closing down, we heard from numerous providers stories of residents within affordable housing who were forgoing their regular doctor's appointments and healthcare due to concerns and fears of COVID-19 treatment transmission. It really was brought to our attention as an acute pain point and need that exists out in the community and we have since developed a curriculum to help try to support organizations as they try to support their residents during this time. Also we have course handouts.

Technology offers a – equitable access to not just the internet and information, but also calling and messaging, accessing essentials, such as online grocery ordering or, especially now, making sure that people are able to order and get their medications delivered to their home, exercise and wellness, information and resources, online communities and opportunities for education, news, virtual volunteering – really trying to maintain purpose during this time when many of the in person interactions and engagements that we used to participate in are no longer safe to do so – entertainments and games, books, and, as mentioned, telehealth.

As a part of our response to COVID-19, we've actually been expanding our programmatic model to be inclusive on different types of technology. The original model really focused on Smart Speakers because the original research that we did within affordable housing was that voice assistance and natural language processing really provided a much easier to use interface for older adults. It was less intimidating and it was actually providing companionship, anecdotally from individuals. We've since expanded into working with 4-G L-T-E enabled tablets. In trying to respond quickly, it's not always possible to upgrade an individual property’s infrastructure in order to have broadband accessible. We have been working with companies to make sure that if that is not an option that any device that is sent out has those data capabilities in order to access other types of softwares and services. We've also been working to deploy smartphones and at the core of all of these devices, making sure that the voice assistant capabilities of these devices is really, first and foremost you know, presented to residents since it, from our experience, provides one of the easiest to use interfaces.

I'm going to tell you just a couple stories of one of our most recent bulk deployment that we did in collaboration with Mercy Housing. There are some amazing stories about how residents have been using the 4-G L-T-E tablet that has been recently deployed. We approximately deployed about 800 devices with the goal of a thousand devices across 90 of their properties. Residents are using it to connect to face. Now that residents are unable to gather at churches or their place of worship, we have residents who are participating in Bible study and services through virtual experiences. We have residents who are connecting to their neighbors. So service coordinators who have adapted their programming to create remote engaging experiences available through Zoom. We have residents who are connecting globally, so residents who haven't been able to see their family members who live across the globe being able to do video conferencing to talk with them.

And then residents who are connecting to services. So one resident who had major abdominal surgery earlier this year, used the tablet to video chat their family back East to finalize her travel plans to visit them. She used the tablet to complete all the paperwork for her new driver's license and Real ID so that she didn't have to go into the DMV and wait in all those long lines that we all appreciate so much. Then residents are also using the devices to connect to resources. The ability to access services through their local libraries, to read books, interact and engage with friends and family, and play games with them as well, and then also connecting to wellness. So those residents who participated in different types of physical activity classes are now being – are now able to practice within the safety of their own home, those same routines that they were accustomed to doing. And so in this picture here, we had one resident who now attends her regular Monday yoga class using the tablet and the video conferencing. With that, I'm actually going to hand it back over to Cheryl, and we're going to go into question and answer period.

[Presenter - Cheryl Levine]: 

Thank you, Ryan. Thank you to all our presenters. I think that was a lot of really outstanding information. And s we're going to open it up to a few questions. If you do have a question and you would like to include that in the chat, please go ahead and do that now. I'm going to go back up – we had a few questions early on. So I'm going to go back to Brian and ask if Brian Norton you can ask could answer a couple of questions. First of all, do you know – we had questions – does the US Virgin Islands have their own Assistive Technology program? You mentioned the States have their A-T programs. Do the territories also have their own A-T providers?

[Presenter - Brian Norton]: 

Yes, but the answer is yes to that. So all States and all territories do, so Virgin Islands does have a state A-T program.

[Presenter - Cheryl Levine]: 

Great. We'll make sure we share that with everyone, how to find those A-T programs. And then finally for you, Brian, one more question. How does someone that does not have internet access use assistive technology? Are those complementary or is there a challenge there?

[Presenter - Brian Norton]: 

Yeah, well, I mean, assistive technology again comes in all shapes and sizes, but it doesn't necessarily rely on – some things don't necessarily rely on internet access, but if you are using something that requires internet access, there are options or there are some considerations and things to look into. I know here in Indiana, where I'm located, we have a broadband map of where broadband access is and we work very closely with providers like Comcast and A-T-and-T. They have low cost internet options for folks who have difficulty with funding. Comcast essentials is as an example of that, where it's $9.99 a month. During this pandemic I believe they've suspended payments on those through the end of the year and have given some grace to folks just to be able to give them access that they need. It is a challenge. We have a lot of rural areas in America, and broadband and internet access isn't readily available for a lot of folks. That's a challenge. It really kind of depends on individual situations and what they're trying to use and access.

[Presenter - Cheryl Levine]:

Thanks, Brian. Liz, did you want to handle a question for Kathy? 

[Presenter - Liz Palena-Hall]: 

Absolutely. Yeah, so Kathy, we had a comment in the chat about certification for the medical interpreters. And the comment was there are two national certification bodies in the U-S: the Certification Commission for Healthcare Interpreters, C-C-H-I is noted as being preferred. They are accredited by the N-C-C-A and National Board lost its accreditation several years ago. So I wondered if you were able to just make a few more comments on certification. 

[Presenter - Kathy Wibberly]: 

Yeah, so I think there are some national certifications, but there are also some local certification bodies that are under these national bodies. Quite frankly, I would say the certification bodies provide kind of the standards for what should be trained and they provide kind of the training the core curriculum in terms of training. But Most of that training takes place at a local or regional level. From my perspective, and this what I'm hearing from other people, it really doesn't make a whole lot of difference which certification body is used, but really thinking about the training standards and that that person gets trained. Does that answer the question?

[Presenter - Liz Palena-Hall]: 

Yep. Thank you. 

[Presenter - Cheryl Levine]: 

Thanks, Kathy and then I have a couple of questions for Ryan. What do you recommend for making virtual presentations about Medicare benefits more engaging for seniors? We have a listener who says their organization does presentations to educate seniors, but they’re – they've now shifted to more visual presentations because of COVID. Do you have ideas for making things more engaging?

[Presenter - Ryan Elza]: 

Yeah, absolutely. Thank you for the question. I think in terms of best practices for delivering education to older adults is making sure the information is in manageable, bite-sized chunks. The more visual - the more visuals you can provide is really effective. Then also providing any opportunity for engagement and interaction is always helpful and kind of reinforcing the content and addressing the needs of the community.

[Presenter - Cheryl Levine]: 

Thanks, Ryan. Then another question folks are interested how they might get a tablet from A-A-R-P and what does it take to get those tablets to older adults – sort of what is the lead time for, for training and getting those into use?

[Presenter - Ryan Elza]: 

Yeah, great question. Folks are welcome to visit our website for Connected Communities, which is there is a Contact Us form there. Individuals can submit the request to kind of learn more about our current programmatic offerings. To date, we've been primarily working with providers of affordable housing and multifamily to make technology accessible to older adults. And the lead time for being able to deploy those tablets, it's actually a pretty quick turnaround now that we've kind of built out the content, so it could be done within a couple of weeks after all the paperwork and signing and information completed.

[Presenter - Cheryl Levine]: 

Okay, well, we have a few more questions and I think we'll be able to respond to those later probably on paper, but I did want to make sure folks know that apologies we did not have this captioned in real time for you. We will have a transcript and the recorded webinar for you at a later date we will be able to share the PowerPoint slides and all the information, including the links to the resources that were shared to you, at a later date. For folks who are looking to find the resources for the first webinar that is all up and available. I have listed here our Telehealth 101: Services, Payment, and Partners webpage where you can access the resources for that first webinar. Likewise, we'll get everything up in one place for you for this webinar on Accessibility and Language Access. And then mark your calendars, we have one more webinar in our series coming up on addressing barriers – thinking about things of individuals experiencing homelessness and connectivity. That will be a month on September 30th. And so with that, thank you everyone for joining us today.

[Presenter - Operator]: 

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