Home Health Care Managers and Patients With Language Barriers: Exploring Decision-Making Processes

BACKGROUND: Patients with limited English proficiency (LEP) experience poorer health outcomes and face persistent barriers to interpreter use. Although language access is essential to high-quality care, little is known about how home health care (HHC) managers operationalize language services in this setting. OBJECTIVES: To explore HHC managers' perspectives on delivering care to patients with LEP and identify organizational challenges and strategies related to language access. METHODS: We conducted a qualitative secondary analysis of semistructured interviews collected between 2016 and 2017 as part of a parent study examining language barriers in HHC. Participants included 14 managers from a large U.S. home health agency serving a high volume of patients with LEP. Interviews explored experiences managing care delivery, including communication strategies, staffing decisions, and system-level constraints. RESULTS: Five themes and several subthemes emerged from the data. Major themes included strategies for ensuring language-concordant care; structural factors impeding language-concordant care; staff using ad hoc strategies to "get by"; perceived impacts on outcomes; and interventions to address structural factors impeding language-concordant care. Managers described multiple strategies to address language barriers with patients. However, these approaches were constrained by shortages of bilingual clinicians, competing demands that prioritized clinical expertise over language concordance, and variability in language needs across patient populations. Interpreter services, particularly telephone-based language lines, were often perceived as inefficient or unreliable, leading some clinicians to rely on ad hoc communication strategies or "getting by." These and other barriers were perceived to contribute to communication breakdowns, reduced care quality, patient confusion, and potentially avoidable health care utilization, including emergency department visits and readmissions. DISCUSSION: Improving language access in HHC requires system-level interventions, including investment in a linguistically diverse workforce, clearer protocols for interpreter use, improved communication across care transitions, and organizational support for culturally and linguistically appropriate care. Addressing these challenges is essential to advancing equity, patient safety, and quality of care for patients with LEP.