EO 13166, Improving Access to Services for Persons with Limited English Proficiency, requires that all federal agencies take reasonable steps to ensure meaningful access to their programs and services for people with LEP. DOJ has issued guidance that spells out four factors agencies need to consider in determining whether they are taking reasonable steps in this regard: (1) the number or proportion of LEP persons in the eligible service population; (2) the frequency with which LEP individuals come in contact with the program; (3) the importance of the services provided by the program; and (4) the resources available. Reasonable steps to ensure meaningful access could include developing language access services and guidance for implementing these services. The EO required that each federal agency create a plan outlining steps it will take consistent with DOJ guidance to ensure meaningful access to its services by LEP individuals. The EO did not require DOJ to evaluate the plans or to monitor the implementation of these plans. In 2002, in response to EO 13166, VA created and implemented VHA Directive 2002-006. It provided a framework for VA medical centers to assess and determine if there was a need to develop language assistance policies and language access services. The medical centers retain flexibility to determine exactly how they will comply with the EO, but they must do so in accordance with the four factors as outlined by DOJ and reiterated in the LEP Directive. In February 2007, VA issued VHA Directive 2007-009, which renewed VA’s guidance on language assistance policies. In its LEP Directive, VA outlined the steps that constitute an effective language assistance program at its medical centers, including an assessment of the language needs of the veteran population served and identification of the non-English languages encountered by medical center staff. If a VA medical center identifies a specific language need among its veteran service population, VA’s LEP Directive also indicated that the medical center should develop and implement a language assistance policy to ensure meaningful communication. According to the directive, the policy should describe how the medical center plans to provide language access services and ensure that all veterans receive meaningful access to VA health care services, regardless of the veterans’ level of English proficiency. VA’s LEP Directive also provided medical centers with examples of ways to provide language access services—including, translating written materials, hiring bilingual staff, and contracting with interpreter services. VA’s Equal Employment Opportunity (EEO) office is responsible for overseeing the implementation of VA’s LEP Directive. As such, this office conducted surveys of VA medical centers to assess whether medical center officials were following the steps outlined in the LEP Directive, such as conducting an assessment of language needs, or otherwise taking reasonable steps to provide language access services for veterans being served. VA’s Center for Minority Veterans (CMV) is also involved in helping medical centers meet the language and cultural needs of the veteran population. CMV is responsible for ensuring that eligible minority veterans receive VA benefits and services. Culturally appropriate health care is care that is respectful of and responsive to the cultural needs of patients. According to HHS, providing culturally appropriate services to culturally diverse patients has the potential to improve access to care, quality of care, and ultimately, health outcomes. HHS has published a set of standards for all medical facilities regarding the delivery of culturally appropriate care. Other national organizations also recognize the importance of culturally appropriate care and have established standards or recommendations for its provision. For example, the Joint Commission has standards related to culturally appropriate health care that must be met by hospitals, including VA medical centers, to receive accreditation. VA medical centers are implementing VA’s LEP Directive in terms of assessing the language needs of its veteran service population, and, if necessary, developing language assistance policies. VA medical centers and facilities have offered language access services that include providing translated materials and interpretation services to meet the needs of veterans with LEP. VA medical center officials reported a low utilization of these language access services. However, VA and medical center officials told us that they expect the demand for language access services to grow as the increasingly diverse servicemember population transitions to veteran status. VA stated that by June 2007 all of its medical centers had taken actions to implement the guidance in VA’s LEP Directive. According to VA, all of its medical centers have assessed the language needs of its veteran service population, and, as necessary, developed language assistance policies. Our visits to three VA medical centers and in-depth telephone interviews with staff at three VA medical centers provided a more detailed account of the variety of language access services being offered at VA medical centers. VA first surveyed each of VA’s medical center directors in December 2005 to assess if medical centers were following the guidance in VA’s LEP Directive. The survey contained 10 “yes” or “no” questions to gauge the extent of medical centers’ efforts to implement the LEP Directive. The questions ranged from issues such as overall language assistance policies to efforts to provide language access services. If a “no” response was provided for any question, the medical center directors completing the survey were instructed to indicate a tentative date by which they would take action to address the item. VA required medical center directors and VISN directors to ensure that the responses for individual medical centers were completed. However, VA did not require that VISN or medical center directors provide documentation to support their “yes” responses to the survey. The results of the 2005 survey showed that 65 percent of VA medical centers had assessed the language needs of their veteran service population and that 60 percent of the centers had developed a language assistance policy. While completing the survey, VA medical center directors reported information about other medical center efforts to meet the needs of LEP veterans, including efforts to translate documents and hire bilingual interpreters. For example, 87 percent of VA medical center directors reported establishing a list of staff available for interpretation services and that 24 percent of VA medical centers had translated written documents into languages other than English. After conducting its initial survey, VA took several steps to help medical centers improve their efforts to implement the LEP Directive, according to a VA official. VA staff made follow-up calls to VA officials from the medical centers that did not respond to the survey or that were identified by the survey as not conducting efforts consistent with the LEP Directive. During these follow-up efforts, VA staff offered guidance to medical center officials on conducting language needs assessments and developing language assistance policies in ways that were consistent with the LEP Directive. According to officials we interviewed at two VA medical centers, the guidance was helpful in their facilities’ assessment of language needs among their service population and development of language assistance policies. According to VA, the follow-up efforts proved successful, as all medical centers reported that they had assessed the language needs of their veteran service population, and, as necessary, developed language assistance policies. In July 2007, VA reported that as a result of its follow- up efforts, all of VA’s medical centers, in accordance with the LEP Directive, had assessed the language needs of their veteran service population and developed language assistance policies as needed. VA concluded that because of the progress and efforts made by its medical centers to implement the LEP Directive, VA would not conduct any additional evaluations of medical center implementation of the LEP Directive. Instead, VA said it would rely on the medical centers to monitor their own LEP language access needs and programs. VA medical centers and other VA facilities have access to a variety of translation services. At the national level, VA has translated its widely distributed benefits publication into Spanish and makes information from this publication available in Spanish on its Web site. All VA medical centers have computer software that offers medical treatment consent forms in Spanish and additional software that allows VA staff to access patient education materials in several languages other than English, such as Spanish and Korean. The VA medical centers and facilities included in our in-depth review also provide translated materials to meet the various language needs of their veteran service populations. We found that all six medical centers in our in-depth review translate written materials on their own. For example, staff at one medical center we interviewed told us that they translated educational materials on traumatic brain injuries into Spanish. However, staff at the medical centers reported that they primarily rely on publicly available translated documents rather than translating written materials on their own because of the cost of independently translating documents. The sources of these publicly available materials range from other federal agencies to results of an Internet search. For example, according to VA officials, patient educators at some medical centers use patient education materials on a range of topics including heart disease and diabetes that have been translated into Spanish by HHS’s Food and Drug Administration. VA medical center staff can also use materials translated by staff at other medical centers. For example, staff at one medical facility we reviewed reported that the VA medical center located in San Juan, Puerto Rico, has shared patient education materials they have translated into Spanish with other VA medical centers. Medical center staff we interviewed also reported using professional groups within VA, such as EEO managers or patient educators, to identify and share existing translated materials. However, these groups are limited in their membership and, as such, might not be aware of all translated materials available at VA medical centers. Additionally, VA medical facilities included in our review generally offer translated materials specific to the services they provide, when needed. For example, one Vet Center we reviewed translated a pamphlet on post-traumatic stress disorder into Spanish for its largely Hispanic veteran service population. As part of language access services, VA medical centers we reviewed in depth provide language interpretation services to help address the language needs of veterans with LEP. Staff we interviewed at all six medical centers we reviewed had the ability to provide interpretation services to veterans with LEP and were doing so in several different ways. For example, staff members at all six of these medical centers maintained a list of bilingual medical center staff who volunteered to provide interpretation services during a clinical encounter between a provider and a veteran with LEP. Medical center staff primarily used people from this list to provide needed interpretation services. In addition, staff at five of the six VA medical centers had contract telephone interpretation services available as a means to help effectively communicate with veterans and their families with LEP. Moreover, two of the three medical centers we visited advertised within the medical center, in languages other than English, the availability of language interpretation services to veterans and their families with LEP. In these medical centers, we observed signs posted near entrances and elevators that advertised, in multiple languages, free language interpretation services for veterans and their family members. In addition to efforts made by VA’s medical centers to provide language access services, some of VA’s Vet Centers have also made efforts to provide language access services to ensure that veterans with LEP have meaningful access to counseling and other services. Vet Centers provide language access services to veterans’ family members with LEP to ensure that they are able to participate in counseling sessions, such as marital and family counseling. For example, at one Vet Center we visited, the entire staff was bilingual to help accommodate the needs of its mostly Hispanic veteran service population. In cases where bilingual staff were not available, four of the five Vet Centers where we conducted interviews had agreements with the local VA medical center to access its list of bilingual staff available for interpretation services. Officials at the VA medical centers and facilities included in our in-depth review reported that veterans seldom use VA’s language access services. For example, officials and staff we interviewed from five of the six medical centers in our review stated that their facility had a contract in place for telephone interpretation services but only one medical center reported ever utilizing these services. Staff at the medical center that reported utilizing the interpretation service stated that the use was infrequent. Moreover, staff we interviewed at the six VA medical centers we reviewed reported that most veterans speak English and staff at one medical center reported that veterans prefer to receive written materials in English. Staff at one medical center told us that they stopped routinely offering translated materials after veterans—for whom English was not their primary language—stated their preference for materials in English. However, translated documents were made available upon request. Despite the low utilization of interpretation services, such as the use of a contracted telephone interpretation service, officials at all six medical centers in our in-depth review reported using bilingual staff to serve as volunteer interpreters when needed. In addition, in our review of 17 other medical centers’ language needs assessments, officials from one medical center volunteered utilizing telephone interpretation services four times in the 2 years prior to our request in July 2007, while another medical center volunteered in its assessment that veterans at the facility never used the facility’s contracted telephone interpretation service. VA medical center officials told us that they expect the demand for language access services to grow as the increasingly diverse servicemember population transitions to veteran status. The servicemember population is more diverse—in terms of race, and ethnicity—than the current veteran population. VA officials we interviewed projected that the increased diversity of the military servicemember population will directly translate to an increased level of diversity in the veteran population as these servicemembers end their military careers and become veterans who may be eligible for VA health care services. Staff from several VA facilities told us that they have recently witnessed demographic changes in their service population. For example, two Vet Centers we visited told us that they have experienced an increase in the number of veterans and family members needing language access services in Spanish to facilitate marital and family counseling sessions. In an effort to address the cultural differences represented in its veteran service population, VA medical centers have conducted training programs to increase staff awareness about cultural diversity and the need for culturally appropriate health care services. Additionally, VA medical centers and facilities tailored a variety of health care services to different segments of the veteran population and promoted the availability of culturally appropriate health care services by targeting outreach efforts to different segments of the veteran population. VA medical centers have provided a variety of training programs for staff to both raise cultural awareness and to assist medical center staff in providing culturally appropriate health care services. According to VA medical center officials we interviewed, medical center staff are required to annually complete one mandatory VA-developed training course on the health care needs of veterans of various age groups. The six VA medical centers we reviewed have offered training to help staff understand cultural diversity as well as appreciate the need for culturally appropriate health care. These training efforts included locally-developed training on diversity given to new staff during orientation and on-line diversity training that is available to all staff. One of the six medical centers we reviewed in depth also developed training to help staff better understand what it was like for a veteran in general to serve in the military, as well as what it was like for a veteran who served during a particular military service era, such as the Vietnam War. The training materials also provided information on the types of medical diagnoses that may be related to a veteran’s service, such as exposure to environmental hazards. Additionally, individual medical centers developed programs designed to increase awareness of veteran diversity and different cultural practices. For example, four VA medical centers we reviewed reported using celebrations and events in conjunction with heritage months (e.g., African American Heritage Month and Women’s History Month) as educational opportunities to increase medical center staff awareness of veteran cultures and diversity. Programs included speakers, cultural fairs, and presentations open to staff and veterans at the individual VA medical centers. VA medical centers and facilities have provided numerous health care services designed to meet the needs of the culturally diverse veteran population that differs in terms of race, ethnicity, sex, as well as age. According to VA officials, these services have varied across VA medical centers, CBOCs, and Vet Centers, depending on the needs of the veteran populations served. During our in-depth review of 16 VA medical centers and facilities, officials identified a number of health care services that are provided in a culturally appropriate manner: Two medical centers and one Vet Center offer spiritual services, which include the use of medicine men and traditional healing rituals, in order to meet the needs of Native American veterans. Three medical centers and one CBOC have increased the use of modern technology, such as text-messaging appointment reminders, to communicate more effectively with younger veterans, who are typically accustomed to such means of communication. One Vet Center offered a counseling group exclusively for African American veterans and one Vet Center offered counseling groups for women veterans. According to staff we interviewed, services tailored to different segments of the population are often designed using information gained from specific veteran requests, veteran focus groups, or through recommendations of special-emphasis population groups. To facilitate the delivery of culturally appropriate health care services, all VA medical centers have a minority veterans program coordinator. The role of the minority veterans program coordinator is to identify barriers to health care and advise medical center officials in developing services to make health care more accessible and culturally appropriate for minority veteran populations. Minority veterans program coordinators also work directly with minority veterans in an effort to facilitate access to and use of VA health care services. To promote the availability of culturally appropriate care, the six VA medical centers included in our in-depth review have implemented a variety of targeted outreach efforts to different veteran populations. For example, officials at two of the six medical centers we reviewed reported working closely with military and National Guard bases located near the medical center to increase awareness of VA health benefits among younger veterans and their families. According to VA staff, these outreach efforts helped younger veterans understand that VA was not just “their grandfather’s VA” and that VA medical centers serve veterans from all military conflicts. At one medical center, officials we interviewed reported outreach efforts to help Hispanic, younger, and female veterans recognize when they might need medical services, for example treatment for post- traumatic stress disorder or depression. These outreach efforts included participating in community health fairs and ceremonies held to welcome home servicemembers from the combat theaters. VA staff said they tailored these efforts to different communities, and staff at one medical center reported including materials in Spanish. VA reviewed a draft of this report and sent us comments by email. VA agreed with the information presented as it pertained to VA. In commenting on the development of resources and education to help facilitate the delivery of culturally competent care, VA noted that there are different solutions based on local needs and supports a multimodality strategy as opposed to a “one module fits all” approach. We agree and as we discussed in our report, VA medical facilities do conduct training for staff and tailor health care services in an effort to address the differing needs for culturally appropriate health care services in particular locations. These efforts and services are often locally developed in response to the characteristics and needs of the veteran population served. As arranged with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days after its issuance date. At that time, we will send copies of this report to the Secretary of Veterans Affairs. We will also provide copies to others upon request. In addition, the report is available at no charge on the GAO Web site at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff that made major contributions to this report are listed in appendix I. In addition to the contact above, Marcia Mann, Assistant Director; Melanie Anne Egorin; Krister Friday; Adrienne Griffin; Samantha Poppe; and James Walker made contributions to this report.

Summary: The Department of Veterans Affairs (VA) faces challenges in bridging language and cultural barriers as it seeks to provide quality health care services to an increasingly diverse veteran population in terms of race, ethnicity, sex, and age. To meet the needs of veterans with limited English proficiency (LEP), VA issued an LEP Directive that provides guidance for medical centers in assessing language needs and, if needed, developing language access services designed to ensure effective communication between English-speaking providers and those with LEP. In addition, VA is also challenged to deliver health care services in ways that are culturally appropriate--that is, respectful of and responsive to the cultural values of a diverse veteran population. In light of these challenges, GAO was asked to discuss the (1) actions VA has taken to implement its LEP Directive and the status of veterans' utilization of language access services, and (2) efforts VA has made to provide culturally appropriate health care services. GAO reviewed VA's policies and the LEP Directive, interviewed VA officials and reviewed efforts by 6 VA medical centers and 10 other VA facilities to implement VA's LEP Directive and to provide culturally appropriate health care services. GAO also reviewed documents from 17 other VA medical centers related to implementation of the LEP Directive. VA reported that as of June 2007, all of its medical centers had taken action to implement the guidance in VA's LEP Directive. Specifically, medical center officials told VA that they had assessed the language needs of their veteran service populations, and, if necessary, developed language assistance policies and offered language access services, including providing translated materials and interpretation services. The VA medical centers GAO reviewed provided translated materials to meet the various language needs of their veteran service populations and offered interpretation services as well. For example, VA medical centers maintained a list of bilingual medical center staff who can provide interpretation services during a clinical encounter between a provider and a veteran with LEP. In addition, five of the six VA medical centers GAO reviewed can access telephone interpretation services that are provided through a contract to help ensure that medical staff can communicate with veterans and their families with LEP. According to officials at medical centers GAO reviewed, utilization of language access services is low. However, VA officials told GAO that they expect the demand for language access services to grow as the increasingly diverse military servicemember population transitions to veteran status. VA medical centers are addressing the need for culturally appropriate health care services through staff training and tailoring health care services. Medical centers provide training for medical center staff to facilitate the delivery of culturally appropriate health care services including an annual mandatory training on the health care needs of veterans in various age groups. VA medical centers and other VA facilities GAO reviewed have implemented a variety of measures to meet the needs of their culturally diverse veteran populations. For example, three VA facilities GAO reviewed offer spiritual services, such as the use of medicine men and traditional healing rituals, in order to meet the needs of Native American veterans. Also, VA has minority veterans program coordinators at each medical center to identify barriers to health care for minorities and advise medical center officials in developing services to make health care more accessible and culturally appropriate for minority veteran populations. VA medical centers GAO reviewed have also initiated outreach efforts to promote the availability of culturally appropriate care. In commenting on a draft of this report, VA stated that it agreed with the information presented as it pertained to VA.