The Impact of Using Professional Bilingual Interpreters
Elderly Hispanic patients experience numerous challenges when seeking for healthcare services since they are only eloquent in their native language and are classified as Limited English Proficient (LEP) patients. This paper examines patient-provider communication between these patients and healthcare providers. The evaluation is carried out to determine the role and significance of bilingual interpreters in promoting medication adherence among elderly Hispanic patients aged 50-75 years. The project will be implemented in an outpatient clinic and community center that provides care to different kinds of patients including elderly Hispanics. This project demonstrates that bilingual interpreters would help promote medication adherence and compliance with treatment among these patients.
Keywords: elderly Hispanics, patients, medication adherence, bilingual interpreters, treatment, patient-provider communication, healthcare providers.
Statement of the Problem
Hispanic population is one of the fastest growing groups of people in the United States, particularly among Americaâ€™s elderly population. According to Markides et al. (1997), Hispanics have increased significantly in the United States over the past few decades. As the number of Hispanics continues to grow, this population is faced by numerous challenges including health problems. Health problems or conditions have become common and prevalent among this population to an extent that culturally-appropriate care is considered necessary toward enhancing their health and wellbeing. The healthcare sector in the United States is increasingly developing new measures for providing culturally-appropriate care to Hispanics and other patient populations across the country. Elderly Hispanics account for a significant portion of the groupâ€™s patient population.
A significant portion of elderly Hispanics aged between 50 and 75 years are only eloquent in their native language. Consequently, these patients are referred to Limited English Proficient (LEP) patients since they are only eloquent in their native language. Given their eloquence in their native language, elderly Hispanics are always disadvantaged due to language barriers that often necessitate the use of an interpreter in the healthcare delivery process. In urgent medical cases like diabetes, ad hoc interpreters who are usually family members act as interpreters between the patient and the healthcare provider. While these family members continue to play a critical role in patient-provider communication, many elderly Hispanics fail to adhere to medications and other treatment regimes effectively. This compromises the quality of healthcare and patient outcomes among this population, especially those suffering from diabetes.
Therefore, the healthcare sector is faced with the need for improving patient-provider communication among elderly Hispanic patients suffering from diabetes. The poor patient outcomes associated with the use of family members as interpreters contributes to the need for involvement of professional interpreters in the care delivery process. Existing literature demonstrates that professional interpreters help improve patient-provider communication, which in turn results in better patient outcomes. It is important to determine whether bilingual interpreter call during provider visit improves communication between the patient and care provider and contribute to better health outcomes. While the government of New South Wales (NSW) policy establishes a standard procedure where professionals like bilingual interpreters are invited to provide interpretive services, these professionals are not adequately integrated in the healthcare delivery process. Additionally, the impact of bilingual interpreters in enhancing medication adherence among patients, particularly elderly Hispanic patients, remains unknown.
Background and Significance
Hispanic population accounts for a significant portion of the U.S. population as they account for over 50 million people. Diabetes is one of the major health issues among this population with prevalence rates estimated at 18.3% for diagnosed and undiagnosed patients (Sentell & Braun, 2012). The prevalence rates of diabetes among elderly Hispanics remain relatively high. Elderly Hispanics are predisposed to diabetes because of various factors such as limited knowledge, cardiometabolic abnormalities, and lack of access to resources. The prevalence rates of diabetes among Hispanics are significantly higher in comparison to non-Hispanic populations. Diabetes disorders among this population are associated with other health conditions like end-stage renal disease (Office of Minority Health, 2016).
The management of diabetes and other health conditions affecting elderly Hispanics requires close collaboration between patients and their healthcare providers. Patients need to interact with their physicians on a one-on-one basis as part of effective patient-provider communication. Improved interactions help patients to articulate their health issues effectively while enabling physicians to better understand the health needs and challenges of patients. Effective patient-provider communication is critical in the healthcare delivery process since it has a direct impact on patient outcomes. When combating diabetes, better patient-provider communication helps in active management of the disorder with regarding to maintenance of optimum glycemic index and monitoring lifestyle factors (Jacobs et al., 2006).
While effective communication between patients and healthcare providers is recognized as an important element for improving diabetes management among elderly Hispanic patients, most of these patients face language barriers when interacting with care providers. Language barriers emanate from the fact that many elderly Hispanics are only proficient in their native language. Elderly Hispanic patients are not eloquent in English language, which is commonly used in healthcare settings making them Limited English Proficient (LEP) patients. Healthcare providers face significant challenges when trying to teach LEP patients like elderly Hispanics on self-management practices and engaging them outside the healthcare setting or environment. According to Lee et al. (2002), Hispanics account for a significant percentage of the patient population though its only 20% of them who can communicate adequately in Spanish.
De Moissac & Bowen (2017) state that language barriers create the need for using third parties to facilitate communication between LEP patients and healthcare providers. Healthcare providers recognize the role and significance of effective communication between them and patients in improving medication adherence and patient outcomes (Hadziabdic, 2011). However, the current healthcare setting lacks comprehensive systems that are designed to deal with the challenges brought by language barriers when administering health services to LEP patients. Additionally, these patients are unaware of the significance of professional interpreters as they receive health service. These factors have contributed to lack of comprehensive data on the impact professional/bilingual interpreters on medication adherence and treatment outcomes among LEP patients like elderly Hispanic diabetics. This has in turn continued to affect the health outcomes and wellbeing of LEP patients.
Significance of this Project
This project seeks to examine whether the use of bilingual interpreter call during provider visit improve medication adherence among elderly Hispanic patients aged between 50 and 75 years within a 3-month period. The project will help address the gap in existing literature on the significance of linguistic assistance services in the clinical setting. This research will provide significant insights on the effectiveness of linguistic intervention in the administration of healthcare services, which is currently not comprehensively addressed in literature (Jacobs et al., 2006). Better research is currently needed on the extent with which language barriers affect the quality of healthcare and the impact of interventions like linguistic interpreters on healthcare delivery processes. Through addressing these issues, this study will inform policymakers on the importance of designing comprehensive linguistic intervention systems toward dealing with language barriers in the clinical setting and improving health outcomes among patients.
This project on diabetes management among elderly Hispanic patients will be conducted in an outpatient clinic and community senior center that targets this population among other patients. An outpatient clinic and community senior center provides a suitable setting for examining the impact professional interpreters have on medication adherence among elderly Hispanic patients suffering from diabetes. When conducting this project in such a setting, individual elderly Hispanic diabetics will be recruited using informational flyers and brochures in the clinic and/or community center. Participation in this study will be voluntary while the research is designed in a manner that will not compromise the healthcare delivery processes in the healthcare setting.
The outpatient clinic and community center will comprise different stakeholders involved in delivery of healthcare services to these patients. The clinic and community center will be headed by the management who will help in decision making and approval for this project. Healthcare staffs i.e. physicians, doctors, and other non-clinical staffs will work together with professional interpreters under the guidance of the management team and the project team. The other members involved in delivery of care services in this center are patients and their families. As shown in Figure 1, the organizational system has a top-down or hierarchical structure comprising the management team, clinical and non-clinical staffs, and patients and their families. For this project, the organizational system will also include professional interpreters and the project team.
Each of these stakeholders will be assigned specific roles that will help in the implementation of this project. The management team will help create a suitable healthcare environment through which bilingual interpreters will be allowed to provide interpretive services during the healthcare delivery process. They will also provide financial and non-financial support and resources for effective implementation of the project. The financial support from the management team is attributable to the fact that the project is designed based on the assumption that the provider will underwrite all direct costs relating to project execution. Bilingual interpreters will act as intermediaries between patients and providers with regards to provide linguistic interventions for language barriers. These stakeholders will communicate with patients and providers to help patients articulate their issues better and promote improved understanding of patientsâ€™ issues by the care provider. Clinical and non-clinical staff will collaborate with the patient and bilingual interpreter to provide a suitable healthcare environment and ensure appropriate treatment approaches are adopted to address the patientsâ€™ conditions. The project team will provide supervise the project implementation based on the desired objectives and will collaborate with the healthcare staffs during this process. The collaborative approach adopted in this project ensures that all stakeholders provide feedback to one another during the implementation process as they work together. The roles of the stakeholders are intertwined to ensure process flow when executing the project.
Definition of Clinical, Satisfaction, and Cost Outcomes
The implementation of this project is expected to generate numerous benefits to patients and the healthcare setting/environment. To achieve the purposes of this project, the researcher has developed a comprehensive data collection plan that will help collect rich data. Some of the data collection instruments include interviews and video and audio recordings, which will be translated and transcribed. As shown in Table 1, the data collection outcomes included in the data collection plan are clinical, satisfaction, and cost outcomes.
Clinical outcome refers to measurable changes in the quality of care or health as a result of a healthcare intervention. Clinical outcomes play a critical role in determining the success of this project since medical interventions or treatments are designed to help improve the health or quality of life of patient populations while lessening the occurrence of undesirable outcomes (Velentgas, Dreyer & Wu, 2013). For this project, the clinical outcome is changes in treatment approaches and patient outcomes following the implementation of the intervention. Therefore, the clinical outcome that will help determine the success of the project is medication adherence i.e. enhanced compliance with medication and treatment over the 3-month period. Improved medication adherence is a critical success factor for this project since its major issue being analyzed in the study.
Satisfaction outcomes refers to changes in patient satisfaction following a treatment or clinical intervention. Satisfaction outcome is an important success factor in a clinical project since its usually an outcome of care or treatment intervention and a top priority for healthcare providers (Kennedy, Tevis & Kent, 2014). Satisfaction outcome is usually influenced by the impact of the treatment intervention on the quality of health or care of a patient. For instance, if a clinical condition improves, satisfaction with the treatment increases, which indicates that the intervention is effective. For this project, there are two satisfaction outcomes that would help determine its success i.e. improved patient-provider communication and better patient satisfaction. Changes in patient-provider communication will be identified on the premise of changes in interactions between these parties while improved patient satisfaction will be evident through the number of recommendations by patients for others to use bilingual interpreters.
The effectiveness of a treatment intervention is also determined through a cost-benefit analysis. The extent with which the proposed intervention contributes to decreased costs in healthcare services will be a critical success factor. As a result, the cost outcome that will be examined in this project is patient outcome, which refers to reduced provider visits or re-hospitalization of elderly Hispanic diabetics. The project will be considered successful if it results in better medication adherence among these patients, which in turn lessen provider visits and re-hospitalization. The reduced provider visits and re-hospitalizations in turn lessen the costs of healthcare processes. Therefore, the cost outcome for this project is directly linked to the clinical outcome since improved medication adherence results in better patient outcomes, which in turn reduces healthcare costs.
Methods of Measuring Clinical, Satisfaction, and Cost Outcomes
After determining the data collection elements, its important to identify appropriate methods for measuring them. Clinical outcome will be measured using a physician post-visit interview that will focus on determined improved compliance with medication adherence among elderly Hispanic diabetes over a period of 3 months. The criterion for success when examining this clinical data will be improved medication adherence by more than 50% among the research participants. The physician post-visit interview will be conducted after the intervention i.e. bilingual interpreter call during provider visits is administered or utilized. Physician post-visit interview will be used as part of recording and analyzing physician-interpreter-patient interactions. This metric has proven reliable and valid in previous studies in the clinical setting including studies that examined use of professional interpreters in the healthcare environment. It has proven a valid and reliable metric for documenting and analyzing interactions between physicians, interpreters and patients (Aranguri, Davidson & Ramirez, 2006).
On the other hand, cost outcome will be measured through logs that help track patient provider visits and re-hospitalization. Logs at the healthcare facility document data in a patientâ€™s electronic health record. This data will be retrieved and analyzed to determine the extent with which the patient has revisited the provider or been re-hospitalized within 3 months of the implementation of this intervention. The criterion for success when using this metric to determine cost outcome is reduction of provider visits and/or re-hospitalization among 90% of the studyâ€™s participants. According to Karliner et al (2007), the reliability and validity of logs as a measurement metric is face validity, which refers to the extent with which an intervention or procedure seems effective based on its stated objectives. Since logs are simple, face or logical validity will be a suitable measure for measuring cost outcome. In this regard, the intervention will be considered effective if the number of provider visits or re-hospitalization decreases due to enhanced medication adherence brought by the use of bilingual interpreter call during provider visits in the healthcare setting.
For satisfaction outcome, two metrics will be utilized since there are two aspects of this data collection element i.e. patient-provider communication and patient satisfaction. Patient-provider communication will be measured through analyzing changes in the total score from participants over 3 months of the projectâ€™s implementation. In this case, post hoc analysis will be carried out to determine whether the total score in patient-provider interactions improved from <5 to <15. Lee et al. (2002) states that post hoc analysis is used to evaluate satisfaction as continuous variable through examining comparing satisfaction scores based on face validity. The other metric that will be used to measure satisfaction outcome is patient post-visit interview whose validity is also established based on face validity. In this regard, improved patient satisfaction will be achieved if 80% of the participants say yes on the question of enhanced satisfaction following the implementation of the intervention.
Implications of Outcomes for Quality Management
As previously mentioned, this project is significant because it helps to establish the premise for incorporating comprehensive linguistic interpretive systems in healthcare delivery processes targeting Limited English Proficient (LEP) patients. The significance and implications of this project is centered on the role it plays in shaping policies relating to offering linguistic services to LEP patients. This implies that the clinical, satisfaction, and cost outcomes of this project have vital implications for the healthcare setting and stakeholders. The implications of these outcomes would impact quality management initiatives adopted at the local, regional or national level.
From a national level, the clinical, satisfaction and cost outcomes would help in the achievement of quality improvement initiatives relating to patient-centeredness in delivery of healthcare services. According to the Institute of Medicine (IOM), patient-centeredness is one of the most important elements to delivery of quality care services (Tzelepis, Sanson-Fisher, Zucca & Fradgley, 2015). Patient-centeredness has six major dimensions including providing information, communication, and education. In this regard, healthcare providers need to offer information, communication, and education in order to integrate patient-centeredness in the delivery of healthcare services. Without improved measures for providing information, communication and education, healthcare providers are unable to provide patient-centered care, which is crucial toward enhancing the health and well-being of populations.
The Institute of Medicine (IOM) recommends that patients should be provided with clear, precise and understandable information regarding the different aspects of care based on their individual preferences. These recommendation was established as a critical measure toward enhancing the quality of care given that existing literature demonstrates that different patient populations have unmet information needs during diagnosis and treatment of their condition. Diabetes patients are among the most affected patient populations since most of them have reported dissatisfaction with information they obtained during diagnosis of their condition. Most diabetics have expressed their need for more information regarding the condition and medications (Tzelepis, Sanson-Fisher, Zucca & Fradgley, 2015).
The clinical, satisfaction and cost outcomes emerging from this project would help in quality management at the national level through improving the delivery of information, communication, and education of patients are recommended by the Institute of Medicine. The project seeks to address this critical aspect of patient-centered care through addressing language barriers that affect communication between patients and healthcare providers.
Patak et al. (2009) states that a patientâ€™s right to effective patient-provider communication is supported by regulatory guidelines and accreditation standards at the local, regional and national level. Based on these guidelines and standards, patients have the right to receive adequate information regarding diagnosis of their conditions and treatment they receive. Additionally, they have the right to be listened to by healthcare providers in order to make informed decisions about their care. However, many patients, particularly non-English speaking patients, experience language barriers due to lack of interpreter services and unavailability of language access services in the healthcare environment. This project will promote the achievement of this quality improvement initiative through providing language access or linguistic interpretive services established in regulatory and accreditation standards/guidelines.
One of the most important components toward the success of this project is ensuring ethical balance since the research will entail working with human subjects. Ethics is identified as an important component when working with human subjects in a study because of the moral or ethical issues that are likely to arise during the research process. Center for Innovation in Research and Teaching (n.d.) define ethics are standards or norms for distinguishing right and wrong. These standards or norms in turn become the premise for governing peopleâ€™s decisions, behaviors, and actions.
Over the part few years, ethics has become an important component in research because researchers have a moral responsibility to protect their participants. This mandate has contributed to the development of the concept of experiment ethics, which is applied in situations involving the use of human subjects in a study. Researchers need to ensure that they carry out their study in an ethical manner that safeguards the interests of all parties i.e. the researcher and study participants. In light of the role and significance of experiment ethics, institutions of learning have established guidelines for students to follow when conducting research. These guidelines include ethical standards for conducting a research study and providing credible, reliable, and valid research findings.
This project will involve working with human participants who are the key stakeholders in the research process. The human participants are different stakeholders in the healthcare organization including the management, professional interpreters, and patients. Therefore, protecting the interests and rights of each of these groups is critical toward enhancing the effectiveness of the project in achieving desired objectives and outcomes. Similar to most studies involving the use of human subjects, research participants in this project are faced with potential risks that could raise ethical issues. These potential risks or ethical issues include privacy and confidentiality problems, probable complications arising from the integration of bilingual interpreters in the care delivery process, and complicating the healthcare delivery process.
These potential risks or ethical issues will be addressed through a comprehensive framework for ethical balance. Privacy and confidentiality issues will be addressed through ensuring that participation in the project is voluntary and requiring participants to complete an informed consent form. None of the research participants will be coerced to engage in the study or enlisted in the project without their consent. Participants will also be granted the liberty to withdraw from the project at any time and for whatever reasons. During this process, researcher participants will not be required to provide any personal identification information as a means of safeguarding their privacy. Additionally, the researcher will also ensure that information obtained for this project will be utilized for the purposes of this research and not disclosed to third parties.
With regards to complications and risk of prolonged illness due to the proposed intervention, the project is designed in a manner that ensures collaboration between the different stakeholders. Through collaboration, the proposed intervention will be implemented in a way that enhances the care delivery process. Moreover, the researcher has ensured that the projectâ€™s implementation is characterized by little to no interruptions in the care delivery process.
Sustainability Plan for Translating Evidence into Practice
The success of this project would be its contribution to change in clinical practice, which would in turn help improve the quality of care and health of elderly Hispanic diabetics. As previously indicated, this patient population experiences challenges when seeking for healthcare services for their condition due to language barriers. Language barriers emanate from the fact that most of these patients are only eloquent in their native language and not proficient in English. Consequently, elderly Hispanics are classified as Limited English Proficient (LEP) patients because they are only eloquent in their native language. The language barrier problems in turn compromise patient-provider communication between elderly Hispanic patients and their healthcare provider.
As shown in the review of existing literature, improving patient-provider communication between these patients and their clinicians is essential toward improving their health and wellbeing. Patient-provider communication is identified as an important factor toward delivery of patient-centered care. While improved patient-provider communication is recognized as an important factor toward better patient outcomes, family members are commonly used as interpreters between Hispanic patients and providers. The use of family members as interpreters has been characterized by poor medication adherence and treatment outcomes among elderly Hispanic patients suffering from diabetes (Juckett & Unger, 2014).
In light of these factors, a change in clinical practice is required to help enhance the health outcomes of elderly Hispanic diabetics. The healthcare system requires a comprehensive framework for providing linguistic interpretive services to these patients or language access services. Elderly Hispanic patients are unable to comply with medications and treatment approaches in an effective manner due to poor communication between them and providers. Dealing with the language barriers would help address the problem while achieving the recommended quality improvement goals relating to providing clear and accurate information, communication, and education.
A comprehensive framework for linguistic interpretive services or language access services is the most suitable approach for translating evidence from this project into clinical practice. This implies that findings from this project should be utilized to develop a system through which LEP patients are provided with linguistic interpretive services that addresses their language barriers or communication problems in the clinical setting. A sustainable change in practice to address language barrier problems facing LEP patients as they seek for healthcare services would require the establishment of a comprehensive linguistic interpretive systems within the clinical environment. The system should provide avenues through which healthcare providers collaborate with bilingual interpreters when communicating with patients. In essence, the bilingual interpreters would act as intermediaries between patients and providers.
The first step toward creating a sustainable change in practice relating to this issue is enactment of relevant policies for providing linguistic interpretive services to patients. Policy changes are required to provide a foundational framework for integrating language assistance services or linguistic interpretive services in care delivery processes. Current policies and healthcare delivery systems do not provide a framework for patients to be provided with such services even when facing language barriers (Lee et al., 2002). Therefore, a sustainable change in practice on this issue will require enacting policies at the local and organizational level for provision of language assistance services to patients.
Once the policies have been established, the organization should create a system in which patient-provider communication is mediated by bilingual interpreters, particularly LEP patients. Linguistic interpretive services system should be established as part of patient-centered care within the organization. This would entail restructuring the healthcare delivery processes, especially those targeting Limited English Proficient (LEP) patients. Healthcare delivery processes would involve incorporating bilingual interpreters as part of the clinical staff at the healthcare facility. Integrating these professionals as part of the clinical staff help to ensure that long-term, sustainable linguistic interpretive services are available to all LEP patients at the healthcare facility at all times. Through this process, research evidence is translated into sustainable change in clinical practice.
In conclusion, language barriers are among the major issues facing LEP patients in their interactions or communication with healthcare providers. Elderly Hispanic patients suffering from diabetes are among LEP patients who suffer from language barriers since they are only eloquent in their native language. These patients need a better framework for communication with healthcare providers because the use of family members as interpreters has proven ineffective in promoting medication adherence and compliance with treatment. This project seeks to examine whether the use of bilingual interpreter call during provider visit would improve medication adherence among elderly Hispanic patients. The findings of this project would help promote sustainable change in clinical practice on LEP patients.
Aranguri, C., Davidson, B. & Ramirez, R. (2006, June). Patterns of Communication through Interpreters: A Detailed Sociolinguistic Analysis. Journal of General Internal Medicine, 21(6), 623-629.
Center for Innovation in Research and Teaching. (n.d.). Ethics in Experimental Research. Retrieved from Grand Canyon University website: https://cirt.gcu.edu/research/developmentresources/research_ready/experimental/ethics
de Moissac, D., & Bowen, S. (2017). Impact of Language Barriers on Access to Healthcare for Official Language Minority Francophones in Canada. Healthcare Management Forum, 30(4), 207-212. http://dx.doi.org/10.1177/0840470417706378
Hadziabdic, E. (2011). The Use of Interpreter in Healthcare â€“ Perspectives of Individuals, Healthcare Staff and Families. Retrieved July 21, 2018, from https://www.diva-portal.org/smash/get/diva2:444194/FULLTEXT01.pdf
Jacobs, E., Chen, A., Karliner, L., Agger-Gupta, N. & Mutha, S. (2006). The Need for More Research on Language Barriers in Health Care: A Proposed Research Agenda. The Milbank Quarterly, 84(1), 111-133. http://dx.doi.org/10.1111/j.1468-0009.2006.00440.x
Juckett, G., & Unger, K. (2014). Appropriate Use of Medical Interpreters. Aafp.org. Retrieved 26 January 2018, from https://www.aafp.org/afp/2014/1001/p476.html
Karliner, L.S., Jacobs, E.A., Chen, A.H. & Mutha, S. (2007, April). Do Professional Interpreters Improve Clinical Care for Patients with Limited English Proficiency? A Systematic Review of the Literature. Health Services Research, 42(2), 727-754.
Kennedy, G.D., Tevis, S.E. & Kent, K.C. (2014, October). Is there a Relationship between Patient Satisfaction and Favorable Outcomes? Annals of Surgery, 260(4), 592-600.
Lee, L.J., Batal, H.A., Maselli, J.H. & Kutner, J.S. (2002, August). Effect of Spanish Interpretation Method on Patient Satisfaction in an Urban Walk-in Clinic. Journal of General Internal Medicine, 17(8), 641-646.
Markides, K.S., Rudkin, L., Angel, R.J. & Espino, D.V. (1997). Health Status of Hispanic Elderly. Retrieved August 12, 2018, from https://www.ncbi.nlm.nih.gov/books/NBK109838/
Office of Minority Health (2016). Diabetes and Hispanic Americans. Retrieved from https://minorityhealth.hhs.gov/omh/browse.aspx?lvl-4&lvlid-63.
Sentell, T., & Braun, K. (2012). Low Health Literacy, Limited English Proficiency, and Health Status in Asians, Latinos, and Other Racial/Ethnic Groups in California. Journal of Health Communication, 17(sup3), 82-99. http://dx.doi.org/10.1080/10810730.2012.
Patak et al. (2009, September). Improving Patient-Provider Communication: A Call to Action. Journal of Nursing Administration, 39(9), 372-376.
Tzelepis, F., Sanson-Fisher, R.W., Zucca, A.C. & Fradgley, E.A. (2015, June 24). Measuring the Quality of Patient-centered Care: Why Patient-reported Measures Are Critical to Reliable Assessment. Patient Preference and Adherence, 9, 831-835.
Velentgas, P., Dreyer, N.A. & Wu, A.W. (2013). Chapter 6 â€“ Outcome Definition and Measurement. Retrieved August 12, 2018, from https://www.ncbi.nlm.nih.gov/books/NBK126186/
Figure 1 â€“ Organizational System
Table 1 â€“ Data Collection Plan
Variable type Variable name How defined How measured Criterion for success Evidence for reliability/
validity Satisfaction Outcome Communication Post hoc analysis Change in total score over 3 months Total score improved from <5 to <15 Lee et al. (2002) Clinical Outcome Medication Adherence Physician post-visit interview Improved compliance with treatment over 3 months Medication compliance improved by over 50% within 3 months Aranguri, Davidson & Ramirez (2006) Satisfaction Outcome Satisfaction Patient post-visit interview Recommend intervention to another patient 80% of patients say yes Aranguri, Davidson & Ramirez (2006) Face validity Cost Outcome Patient Outcome Log Reduced provider visits or re-hospitalization 90% of patients experience reduced provider visits Karliner et al. (2007) Face validity
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You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.
4. Download the paper
The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.
PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET A PERFECT SCORE!!!