BACKGROUND: Language access is a system-level component of behavioral health service delivery for individuals with limited English proficiency. In behavioral health settings, where care depends on accurate communication, trust, confidentiality, and continuity, gaps in interpreter access, language-concordant communication, translated materials, and referral support may affect how Spanish-speaking adults enter, navigate, and remain connected to care. Limited evidence describes how these barriers recur across multiple behavioral health service settings. METHODS: This systems-level, multi-setting qualitative health services study examined language access barriers related to behavioral health service access and continuity among Spanish-speaking adults in San Bernardino County, California. Eighteen behavioral health stakeholders from six organizations completed semi-structured interviews across hospital-based behavioral health, crisis stabilization, outpatient behavioral health, and long-term care/community-based settings. Interviews focused on interpreter availability, documentation of preferred language, referral and follow-up processes, scheduling, discharge communication, telehealth, and cross-setting coordination. Data were documented through structured contemporaneous notes and analyzed using qualitative descriptive content analysis. RESULTS: Seven recurrent categories of language access barriers were identified: interpreter availability and modality; navigation and follow-through; staffing and training capacity; capacity, scheduling, and wait times; technology and telehealth; community partnerships and coordination; and stigma, trust, and privacy. Participants described delayed or inconsistent interpreter access, reliance on ad hoc communication strategies, limited Spanish-language materials, fragmented referral and follow-up processes, lack of bilingual navigation support, and telehealth workflows that did not consistently account for language needs. Barriers differed more by service setting and workflow point than by professional role. Hospital-based and crisis settings emphasized time-sensitive interpreter access and discharge communication, while outpatient and community-based settings emphasized scheduling, follow-up, telehealth support, and sustained navigation. CONCLUSIONS: Language access barriers in behavioral health care extend beyond individual clinical encounters and appear across referral, scheduling, discharge, follow-up, telehealth, and cross-setting coordination processes. Findings suggest that language access should be treated as a system-level component of behavioral health service design. Improving access and continuity for Spanish-speaking adults requires coordinated approaches integrating qualified interpreter access, bilingual navigation, workforce training, Spanish-language materials, telehealth support, and standardized referral workflows. TRIAL REGISTRATION: Not applicable.
Alexandra Lopez Vera (Wed,) studied this question.