Applicant File Review Center Level Direct Threat Health Care Needs

Valerie R. Cherry, PhD Lead Mental Health Specialist Sara Mackenzie, MD, MPH Region 6 Medical Health Specialist Health Support Contract Humanitas, Inc. 2

ObjectivesObjectives Articulate the center’s role in direct threat and health care needs assessments. – Identify the steps involved in the file review procedure – Clarify the process and documentation requirements for conducting direct threat and health care needs assessments, – Mental health, medical, and TEAP scenarios Q and A

PRH 1 Part 1—Center File Review Process Highlights 4

Applicant File Review Procedures Step 1: File is received on center by the records staff who records the file in the records log and tracks its movement Step 2: Records forwards the sealed medical, health, or disability-related information unopened to the Health and Wellness Manager (HWM). Step 3: The HWM opens the sealed information and conducts a health documentation review and initial direct threat review of the applicant’s file. 5

Initial Review Step 4: The HWM determines who else may need to review the protected information based upon his or her determination of “need to know.” This is essentially your File Review Team. – Academic Manger would review IEPs, 504 plans, educational reports including special education assessment – Center Mental Health Consultant (CMHC) reviews mental health-related information – Center Physician review medical information – Center Dentist reviews dental information – TEAP Specialist reviews substance-related information 6

Assessments & Requalification Step 5: The appropriate members of the file review team determine if a health care needs or a direct threat assessment is necessary or if there is a need to revisit the eligibility factors. 7

Reasonable Accommodation Step 6: For Direct Threat Assessment: – When completing the direct threat assessment, the reasonable accommodation committee (RAC) must convene to consider reasonable accommodation (RA). In this scenario, the RAC would only be comprised of those staff members with a need to know and would likely consist of the center clinician, the HWM/DC, and must include the applicant. 8

Reasonable Accommodation Step 6 (Cont.): For Health Care Needs Assessment: – When completing the health care needs assessment, the reasonable accommodation committee (RAC) must convene to consider reasonable accommodation (RA) if condition rises to a level of a disability. Appendix 605 for definition of a disability. In this scenario, the RAC would only be comprised of those staff members with a need to know and would likely consist of the center clinician, the HWM/DC, and must include the applicant. 9

RAC Recommendations Step 7: In case of direct threat and health care needs assessments, the RAC will submit its accommodations recommendations to the file review team. -See Appendix

File Review Team Consideration of Reasonable Accommodation Step 8: Review RAC Recommendations Direct Threat – Consider if accommodations and/or modifications would remove the barriers to enrollment by sufficiently reducing the threat to below a level of direct threat or eliminating the direct threat. Health Care Needs – Consider if accommodations and/or modifications would remove the barriers to enrollment and make condition manageable at Job Corps as defined by basic health services in PRH Exhibit

Accommodation Reasonableness Step 9: Complete reasonableness review if the center director believes that the provision of the requested/agreed upon accommodations are unreasonable. – Unduly costly – Result in a fundamental alteration to the program Complete the Accommodation Recommendation for Denial and Justification Analysis Documentation Form (See Program Instruction 11-16). 12

Application Recommendation Step 10: Determine recommendation of application Any applicant file recommended for denial for direct threat, health care needs, or new information will be forwarded to the regional office for a final disposition. 13

Application Outcomes Enrollment Ineligible (OA) Applicant withdrawal Recommendation for denial (Center) –Direct threat –Cannot meet basic health care needs Refer to another more appropriate program Consider admission to another center –New information (Requalification of eligibility) 14

Center Role in Withdrawals 15

Applicant Withdrawal Processing an applicant request for withdrawal of application: –IF prior to file coming to region Center documents request and returns file to the outreach and admission –IF after file has been sent to region Regional must still complete process and will take over administratively in withdrawal 16

Applicant Withdrawal One other potential situation for withdrawal: Center is unable to reach applicant. – If center cannot reach applicant to conduct clinically related interviews, then the center must document attempts to contact applicant and the file would be returned to Outreach and Admission. – If the center has contacted applicant and requested additional documentation about an applicant but does not receive that information, the center must make a decision on the information that is available to it. File must move forward to enrollment or regional request for denial NOT be returned to OA. 17

Center Role in Recommendations for Denial Direct Threat and Health Care Needs Assessment 18

Appendix 609 Direct Threat Assessments 19

Direct Threat Applicant has significant risk of substantial harm Threat is imminent: current specific behaviors, symptoms indicating instability With disability, must consider whether accommodations decrease threat to acceptable level

Direct Threat Assessment Appendix 609 Specific Questions 1.What factors triggered a review of individual’s file for direct threat? 2.What is the nature/severity of potential harm? A.What kind of harm is posed by the individual’s medical condition or disability? B.What is the seriousness of the potential harm? (e.g., death, serious injury, minor emotional distress) 3.What is the duration of the risk (e.g., how long will risk last)? 4.What is the likelihood that the potential harm will occur (e.g., high, moderate, low)? 5.What is the imminence of the potential harm (e.g., how soon likely to occur)? 6.Based on factors above, does the named individual have a medical condition or disability that poses a significant risk of substantial harm to the safety of him/herself or of others if s/he participated, or continues to participate, in JC?  In my professional judgment, the individual’s participation poses a direct threat.  In my professional judgment, the individual’s participation does not pose a direct threat.

Direct Threat Assessment Appendix 609 (New Section) 7.List below any accommodations or modifications that could either eliminate the risk or reduce it to an acceptable level (examples to follow) After review of the factors considering the accommodations/modifications listed above, the threat can be eliminated or reduced to a level below DT. After a review of the factors considering the accommodations/modification listed above, the threat cannot be eliminated or reduced to a level below DT.

Direct Threat Assessment Appendix 609 (New Section) Center Director Only 8.If accommodations or modifications are listed in #7 above, you are responsible for making a determination as to whether such accommodations or modifications would be “reasonable” or pose an undue hardship. Document your determination on the space provided. Attach additional sheet or information if necessary. – Complete the Accommodation Recommendation for Denial and Justification Analysis Documentation Form (See Program Instruction 11-16).

Accommodations vs. Care Management Accommodations: – Distraction-free space – Modified schedule – Frequent breaks – Peer buddy/tutor – Positive behavior support – Visual supports – Single room/smaller dorm – Schedule adjustments (leave class early; time out to attend off-center appt) Care Management (not accommodations) – Meet weekly with CMHC – Brief, periodic check-ins with CMHC – Meet with MD for medication management – Diabetic is monitored for medication compliance, glucose levels, etc. – Educate student about stress reduction – Encourage participation in social skills group – Attend off-center therapy Note: Accommodations and modifications will help applicant/student participate in program (not treat impairment)

Remember!Remember! Job Corps does not deny applicants solely based upon the need to provide accommodation. The RAC would need to: – explore funding options, – identify equally effective alternatives, if possible – likely offer the opportunity to enroll without the benefit of accommodation. 25

26 Let’s Practice YES NO MAYBE

Mental Health Examples Qualify for Direct Threat Assessment? History of superficial mutilation that requires no medical attention (cuts, burns, pinches, scratches) on body. Not in treatment History of chronic impulsive suicidal/homicidal behavior with injury to self or others or threats when off meds. Reports being currently stable (in the past 3 months). Stopped treatment and meds two weeks ago. Has never had more than 3 months of symptom free behaviors without meds Repeated and recent incidents of violence towards self and others while under the influence of intoxicating substances and reports presently using substances and no treatment Mild mental retardation, mild autism, or other mild cognitive deficit with no history of living in a group setting. Evidence of mild impairments in social judgment, social cues History of sexual assault or sexual predatory behavior toward adult and/or minor with no evidence of treatment completion or incomplete treatment 27 NOYES NO YES Maybe Appendix 103

Medical Examples Direct Threat Assessment? Type 1 diabetic with hospitalization 1 month ago for DKA and initial diagnosis; being seen by endocrinologist but difficult to control diabetes Applicant with asthma who has had 3 visits to emergency room in past 4 weeks; does not take medications regularly; has history of hospitalization and intubation a year ago due to not adhering to medications 28 YES

Direct Threat Assessment Summary Imminence is key term – Suicidal behavior – Homicidal behavior – Impaired judgment – Paranoid thinking – Threat of violence/assaultive behavior – Self-harm behavior due to drug and alcohol use – Medical condition with imminent high risk 29

Appendix 610 Health Care Needs Assessment 30

Health Care Needs Health care needs beyond JC basic health care responsibilities red flags: – Frequent recent ER visits – Newly diagnosed or uncontrolled health issue – Symptoms/condition not well managed in similar environment as JC – Require extensive resources/intervention.

Exhibit 6-4 Job Corps Basic Health Care Responsibilities Mental Health: – Assessments (not psych testing) – Short-term counseling, defined as no more than 6 sessions with mental health checks as needed, with a focus on retention and behaviors that represent employability barriers – Collaboration with center physician and health and wellness staff on psychotropic medication monitoring – Psycho-educational groups as needed in collaboration with counseling – Crisis intervention as needed 32

Exhibit 6-4 Job Corps Basic Health Care Responsibilities Medical: – Assessment and diagnosis of injury and illness in clinic setting – Medical evaluation and examination – Primary emergency care for illness and injury – Treatment of urgent and other conditions not needing specialty care – Referral off center for specialized assessment regarding on- center management of asthma, diabetes, pregnancy… 33

Health Care Needs Assessment Appendix 610 Sections Initial review of 6-53 or information provided identifies red flags – potential areas of concern regarding health needs Involvement of file review team (including providers) Barriers identified to care on center Decision tree – Health care needs manageable at Job Corps as defined by basic health care services in PRH Exhibit 6-4, but may require community support services to be in place on entry due to special care needs. – Health care needs exceed basic health care as defined in PRH Exhibit 6-4 Refer to another more appropriate program Consider admission to another center Accommodations/Modifications Re-review of HCNA Center Director Reasonableness or Undue Hardship File Forwarded to Region

1. What Factors Triggered Review of the File for a HCN Assessment? 1. What Factors Triggered Review of the File for a HCN Assessment? Two or more ER visits or one or more hospitalizations for medical, mental health, oral health, and/or substance abuse reasons within past 6 months New diagnosis or recurrence of medical, mental health, extensive untreated oral health, and/or substance abuse condition that would require frequent medication adjustments, significant health resources and/or substantial change to the training day Failure to follow previous treatment recommendations by licensed health providers that has adversely affected the applicant’s health, behavior, and/or adaptive functioning, and now requires significant health care management Applicant has followed treatment recommendations by licensed health providers with no improvement in applicant’s health, behavior, and/or adaptive functioning which continue to place applicant in need of significant health care management Applicant’s condition or behavior has not been successfully managed in a similar academic, work, or group environment in the past year Applicant is in treatment for a condition that is not in the scope of Job Corps Basic Health Care Responsibilities (e.g., orthodontic braces for malocclusion, cancer)

2. What is Applicant’s History and Present Functioning to Support Statement of HCN? ETA 6-53 (Health Questionnaire) Applicant File Review Summary (Brief summary of relevant information from medical records, IEP, school records, etc.) CCMP Provider Form (does outside provider recommend applicant for Job Corps? If yes, must document discussion with provider about why you feel NOT appropriate) Applicant Interview Summary (Including clinical impression of applicant, e.g., mental status, behavioral observations, reported difficulties, etc.)

3. HCN: What are the Health Care Management Needs that are Barriers to Enrollment? Frequency and length of treatment Severe medication side effects Hourly monitoring required Medical needs requiring specialized treatment (possibly) Therapeutic milieu required Complex full mouth reconstruction/ rehabilitation Complex behavior management system beyond Job Corps’ current system Out of state insurance impacting access to required and necessary health care Daily assistance with daily living skills Other (specify)

4. Does the Applicant Have Health Care Needs Beyond What the Job Corps’ Health and Wellness Program Can Provide? In my professional judgment, health care needs are manageable at Job Corps but require community support services to be in place on entry due to special care needs to ensure continuity of care. If this box is checked, STOP FORM HERE and if condition rises to a level of a disability, refer to RAC on center. File remains with center and applicant given start date. In my professional judgment, health care needs are manageable at Job Corps, but require community support services which are not available near center. Documentation of efforts to arrange for less frequent treatment in home state and/or to secure community support near center included in the file. Applicant should be considered for center closer to home where health support and insurance coverage is available. File is forwarded to Regional Office for final determination. In my professional judgment, health care needs are not manageable at Job Corps as defined by basic health care services in PRH Exhibit 6-4. Applicant has health condition with current symptoms at a level that will interfere with successful participation in the program at this time. Deny entry and refer to other appropriate program/provider. File is forwarded to Regional Office for final determination.

Consider for Another Center Documentation of efforts to arrange for less frequent treatment in home state and/or to secure community support near center included in the file. Applicant should be considered for center closer to home where health support and insurance coverage is available. – Contact the treating provider and discuss applicant’s needs and see if treating provider (not HWC staff) recommends less frequent treatment or monitoring. – If treating provider does not recommend changes to frequency of treatment or monitoring, consider local community services with sliding fee scales for applicants without insurance or insurance in another state. – If community services not available, document name of local resource contacted and information provided by the resource. – Applicant may be considered for center closer to home where health support and insurance coverage is available. – File is forwarded to Regional Office for final determination. 39

5. If Student has Disability, RAC Must List Any Accommodations or Modifications Discussed with the Applicant That Could Remove or Reduce the Barriers to Enrollment After review of assessment considering the accommodations/modifications listed above, the barriers to enrollment can be eliminated or sufficiently reduced to allow for the applicant’s health care needs to be managed at Job Corps. After review of assessment considering the accommodations/modifications listed above, the barriers to enrollment cannot be eliminated or sufficiently reduced to allow for the applicant’s health care needs to be managed at Job Corps.

Section 6 Center Director Only If accommodations or modifications are listed in #7 above, you are responsible for making a determination as to whether such accommodations or modifications would be “reasonable” or pose an undue hardship. Complete the Accommodation Recommendation for Denial and Justification Analysis Documentation Form (See Program Instruction 11-16).

42 LET’S PRACTICE Recommend Denial Enroll Maybe HCNA Enroll but need more info Consider for different center

Mental Health Examples HCNA Decisions Hospitalized 9 months ago for psychotic episode. Currently receiving therapy once per week in addition to specialty group for abuse survivors and monthly med checks. Compliant with treatment and meds, no acute symptoms, treating provider recommends enrollment with maintenance of services. Out of state, but has Medicaid in state of residency. Contacted community mental health center near rural JC center – sliding fee scale and 3 month waiting list. Moderate mental retardation, autism or other cognitive deficit with recent difficulties in group setting impacting behavior and personal safety without supervision. Current binging or excessive use of substances which have resulted in recent risky behaviors. History of superficial cutting on arm that requires no medical attention Reports last incident 4 months ago and a decrease in anxiety since beginning meds 6 months ago. Feels Job Corps will help keep her mind off cutting because she will be busy. 43 Enroll Consider for different center Recommend Denial Recommend Denial Enroll

Medical Examples HCNA Decisions Applicant with chronic illness which is stable but requires IV infusion every 2 months; specialist in home state; no comparable provider in community and will lose payment method by moving to different state. Applicant with anorexia and BMI of 16; primary care physician recommending inpatient treatment. Applicant on Percocet twice daily for back pain and restriction of no lifting >20# or repetitive bending. 44 Recommend Denial OR Consider for different center? Recommend Denial Enroll with assessment essential duties/RAC

Medical Examples HCNA? T2D with hemoglobin A1C of 14; no recent hospitalizations or ER visits but has not consistently been taking medications History of allergies and asthma; no ER visits in past 6 months for exacerbation; rural center 45 Enroll

Direct Threat Versus Health Care Needs? Direct Threat – Imminence: Immediate safety concern Suicidal behavior Homicidal behavior Impaired judgment Paranoid thinking Threat of assault Health Care Needs – May have safety issues related to health needs, but threat is not imminent Mood swings Impulsive behavior Poor diabetes control and evidence of complications

Health Care Needs vs. Direct Threat Example Health Care Needs Recent (3 months) lethal suicide attempt, did not follow discharge treatment recommendations, on meds from hospital and reports sad mood along with poor sleep but no suicidal thoughts. Direct Threat Recent (3 months) lethal suicide attempt, did not follow discharge treatment recommendations, inconsistent with meds from hospital and reports intermittent suicidal thoughts. 47

What documentation do you need to submit? What happens to the file? 48

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52 Regional office forwards to regional disability support staff to conduct an administrative review. Process complete? Administrative reviewer returns file to center with instructions for completing. No Yes Center returns file and additional information to administrative reviewer. Administrative reviewer moves file to appropriate regional health specialist for clinical review (i.e. mental health, medical, dental or TEAP), Regional health specialist makes recommendation to regional director. RD or designee concurs with recommendation to deny? Center notified to accept applicant, inform applicant of acceptance, and schedule and arrival date. (See Note 1) No Applicant notified of denial decision, provided information on appeal/complaint process. Yes

ReviewReview Withdrawals, Direct Threat, and Health Care Needs Assessments 53

Review ( Pod Questions for Voting ) 1.If an applicant situation does not seem to fall within health care needs or direct threat, I can provide a cover letter stating instability or concerns with cognitive functioning? 2.What are the three reasons that a center may recommend denial of enrollment? 3.What is key in determining whether to do a Health Care Needs Assessment or Direct Threat Assessment? 4.What are the steps required if you request that an applicant be considered to a Job Corps center in their home state due to health care needs? 5.If you receive an applicant file with medical conditions listed on the 6-53 with supporting documentation and the applicant gives new medical information during the interview, what do you do? 6.Can you recommend denial for health care needs due to non- compliance with medications or treatment? 54

Review Pod/Poll Questions 1.If you receive an applicant file with medical conditions listed on the 6-53 with no supporting documentation and no evidence in the file that AC attempted to get information, what do you do? 2.If you are able to reach applicant and asks for additional information to be sent and you do not receive, what do you do? 55

Questions and Answers 56

Mental Health Examples Direct Threat Assessment? Repeated recent episodes of violence towards self or others when noncompliant with treatment and is presently noncompliant or inconsistently compliant. Current binging or excessive use of substances which may result in harmful behaviors Acute mental health disorder with self-harm incident within the last 6 months. Lacks insight, and/or is unresponsive to treatment. Applicant refuses to take responsibility for their own behavior or safety. History of lethal suicide attempt that required medical care, a year ago with treatment compliance and no further incidents Serious personality disorder predominately and currently characterized by chronic anger, hostility and impulsivity, negative attitude, unresponsiveness to treatment and lack of insight. These symptoms are associated with violent behaviors to others or self 57 MAYBE NO YES NO MAYBE

Mental Health Examples HCNA Decisions Personality disorder predominately and currently characterized by chronic hostility and impulsivity, negative attitude, unresponsiveness to treatment and lack of insight. Mild mental retardation, mild autism, or other mild cognitive deficit with history of living in a group setting. Minor impairments in social judgment. Some assistance needed in relating to peers A non-recent (over six months ago) non-lethal suicide attempt or gesture, which was an isolated incident. 58 Recommend Denial Enroll

ResourcesResources 59

– Tips for Reviewing Applicant Files – Sample Direct Threat and Health Care Needs Assessments – Direct Threat FAQs – Accommodation Examples for Direct Threat – Guide: Likelihood of Harm 60 Center Mental Health Desk Reference Guide

National Office Carol Abnathy, National Office of Job Corps (202) Johnetta Davis, National Office of Job Corps (202)

Regional Mental Health Specialists Region 1 Dave Kraft, MD Maria Acevedo, PhD Region 2/Lead Valerie Cherry, PhD Region 3 Suzanne Martin, PsyD, MPH Regions 4 and 6 Andrew Berger, PhD Vicki Boyd, PhD Region 5 Helena MacKenzie, PhD 62

Regional Medical Specialists Region 1 – John Kulig, MD, MPH Region 2 & 3 – Theresa Lowry, MD, MPH Region 4 – Drew Alexander, MD Region 5 – Gary Strokosch, MD Region 6 – Sara Mackenzie, MD, MPH 63

Job Corps Disability Web Site 64

Job Accommodation Network (JAN) 65