PRH Chapter 1 Part 2: Applicant File Review Your Role New Information Health Care Needs Direct Threat

Valerie R. Cherry, PhD Lead Mental Health Specialist Health Support Contract Humanitas, Inc. 2

ObjectivesObjectives Describe applicant outcomes due to the recent PRH Chapter 1 changes. Articulate your role in new information, health care needs and direct threat assessments. Identify the steps involved in the reviewing new information (re-review of eligibility factors), health care needs and direct threat assessments.

PRH 1 CHANGES Part 1—Center File Review Process Highlights 4

Essential Admission Requirements (EARS) Prior to conditional enrollment, OA assesses eligibility using EARS: – Criterion I: Program Suitability (Education and training needs) – Criterion J: Group Participation & Understanding Rules (participate successfully in group situation) – Criterion K: Interference with Other Students’ Participation (only EARS impacting center recommendations listed)

Once Eligible… ETA 6-53 & health documentation reviewed to determine if applicant is a direct threat and whether JC can meet applicant health care needs. If indicated, Health and Wellness staff reviews file, noting areas of potential concern (File Review Summary). FRT, including relevant health consultant and/or TEAP Specialist, interviews applicant and considers whether JC appropriate. How does the File Review Team (FRT) determine if JC is an appropriate setting?

Additional Steps… If applicant has disability, the RAC also interviews applicant and identifies accommodations, with input from applicant. FRT re-reviews file to see if concerns are ameliorated with identified accommodations. File is forwarded to Center Director, who completes “reasonableness” or “undue hardship” determination (if indicated) and forwards file to region. Reasonable Accommodations Committee (RAC)

Only Potential Application Outcomes Enrollment Applicant withdrawal Recommendation for denial – New information – Cannot meet basic health care needs – Direct threat 8

CENTER ROLE IN ELIGIBILITY REVIEW NEW INFORMATION 9

Revisiting Qualification for Admission Neither the center file review team nor its individual members may revisit the determination that an applicant is qualified for admission unless: – There is NEW INFORMATION presented that the AC could not have reasonably known at the time the applicant’s qualification for admission was established, and – This new information indicates that the applicant offered enrollment may not meet one of the Essential Admissions Requirements (EAR). 10

Very Limited Must identify the specific EAR Must use the exact questions from that EAR in Exhibit 1-1 to determine ineligibility Must document and send to the Regional Office 11

Scenario #1 AC certifies that applicant meets all admissions criteria and file is forwarded to the center for review. Applicant allegedly commits a crime after he receives a conditional offer of enrollment, and center learns of existing charges when health and wellness manager calls applicant to talk about a health care need. What should happen next? 12

DispositionDisposition Center received new information that the AC could not have known. Revisit EAR Criterion M: Court Involvement And/Or Agency Involvement. Applicant “may” not be eligible for enrollment. 13

Scenario 2 During the file review process you receive the following: – In the confidential health envelope there is a summary from group home that indicates applicant was terminated 3 months ago due to not following rules and engaging in arguments and fights with members in the group home. 14

DispositionDisposition Center received NEW INFORMATION that the AC could not have known. Contact the applicant for an interview. Revisit EAR. – Criterion J. Group Participation and Understanding of Rules Do you understand that if you come into Job Corps, you will be expected to comply with the rules and regulations of Job Corps? For example – if you live on center, you will have to follow curfew, your center may have rules about cell phone use, you may not be permitted to smoke on center, and you may be required to wear a uniform. Knowing this about Job Corps are you willing to go forward with your application? 15

DispositionDisposition Ask the specific EAR questions from Exhibit 1-1 – If applicant says Yes, then continues to be eligible – If applicant says No, then may be ineligible, document all of the above and forward to the RO – Health Care Needs Assessment Option 16

CENTER ROLE IN RECOMMENDATIONS FOR DENIAL TWO PRIMARY REASONS 17

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

Direct Threat Significant risk of substantial harm Threat is imminent: current specific behaviors, symptoms indicating instability Burden is on JC to prove direct threat exists With disability, must consider whether accommodations decrease threat to acceptable level

PROPOSED APPENDIX 610 HEALTH CARE NEEDS ASSESSMENT 20

Proposed Appendix 610 Health Care Needs Assessment A health care needs assessment should be completed whenever Job Corps believes that the health care needs of an applicant are beyond what the Job Corps’ Health and Wellness program can provide as defined as basic health care in PRH Exhibit 6-4: Job Corps Basic Health Care Responsibilities. This typically will occur after the applicant has received conditional assignment to a Job Corps center and has completed the 6-53 Health Questionnaire. – Applicant has health care needs beyond basic health services as defined in PRH 6 Exhibit 6-4. – Barriers to meeting health care needs cannot be eliminated or reduced by reasonable accommodation or modification. 21

Indicators for a Health Care Needs Assessment? Two or more ER visits or one or more hospitalizations for medical, mental health, oral health, and/or substance abuse reasons. 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.

Indicators for a Health Care Needs Assessment? 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).

Health Care Barriers Frequency and length of treatment Severe medication side effects Hourly monitoring required Medical needs requiring specialized treatment Therapeutic milieu required Complex full mouth reconstruction or 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)]

Review Process Health Care Needs Assessment The review should, at a minimum, be comprised of the following elements: – A review of specific condition(s) identified on ETA 6-53, or self- disclosed by applicant. – Review of health documentation in the file. – Request additional recent health information, to determine applicant needs, if appropriate and medically necessary. Collaborate with OA counselor. – Documented communication with treating provider, if possible and required if there are conflicting recommendations between the center health consultant and the treating provider. 25

Review Process Health Care Needs Assessment Interview with applicant, and parent/guardian if a minor, either face to face, videoconferencing, or via telephone. If unable to contact applicant, all attempts need to be clearly documented including collaboration with OA counselor. If condition rises to a level of a disability then refer to the reasonable accommodation committee (RAC) for consideration of accommodations and/or modifications for discussion with applicant. See Appendix 605 for definition of a disability. 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

Decision Tree Health Care Needs Assessment 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 (e.g., on-going community mental health treatment, specialized provider, etc.) to ensure continuity of care. – Center health provider works with HWM and applicant to arrange or at least identify community supports prior to entry. – On entry, student meets with center health provider for examination or additional assessment and care management plan is developed. – If condition rises to the level of a disability, refer to reasonable accommodation committee (RAC). 27

Decision Tree Health Care Needs Assessment If community support is not available near requested center, the center should do the following: – Contact the treating provider and discuss applicant’s needs to see if less frequent treatment or monitoring can be arranged. – If center is unable to make arrangements, applicant may be considered for center closer to home where health support and insurance coverage is available. – Documentation of efforts to arrange for less frequent treatment in home state and to secure community support near requested center should be included in the file (i.e., name of organizations/facilities and specific individual contacted). – File is forwarded to Regional Office for final determination. 28

Decision Tree Health Care Needs Assessment Health care needs exceed basic health care as defined 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. – Files forwarded to the Regional Office 29

Decision Tree Health Care Needs Assessment Accommodations or Modifications If the individual is a person with a disability, the center’s reasonable accommodation committee (RAC) must convene and consider accommodations and/or modifications that the individual may need. Once the accommodations and/or modifications have been identified, the qualified licensed professional who conducted the original assessment must review the previous findings giving consideration to the identified accommodations to determine whether or not the accommodations and/or modifications can remove the barriers to enrollment due to health care needs. 30

Decision Tree Health Care Needs Assessment Center Director Reasonableness Determination If the individual is a person with a disability and accommodations or modifications that could remove the barriers to enrollment due to health care needs have been listed by the center’s reasonable accommodation committee (RAC), the Center Director is responsible for making a determination as to whether such accommodations or modifications would be “reasonable” or pose an undue hardship and if so, she/he will then recommend denial of the accommodation to the Regional Office. 31

Scenario # 1 During the center file review process you receive the following: – In the confidential health envelope, the 6-53 indicates an applicant who has received mental health treatment in the past and diagnosis of bipolar. There is a summary from group home that indicates applicant was terminated 3 months ago due to not following rules and engaging in arguments and fights with members in the group home. CCMP indicates applicant is noncompliant with medication and prognosis is poor without medication. Indicates applicant can attend Job Corps with weekly counseling and weekly psychiatric follow-up. Applicant has state funded insurance and is applying to center out of state. 32

Proposed Health Care Needs Assessment Form 33 Within the past six months, two or more emergency room visits or one or more hospitalizations for medical, mental health, oral health, and/or substance abuse reasons. 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 (e.g., daily dialysis, only able to attend Job Corps 3 hours per day, hourly medication or behavioral monitoring, daily assistance with activities of daily living, long-term weekly on-center therapy provided by the CMHC, complex full-mouth reconstruction/rehabilitation). x Failure to follow previous treatment recommendations by licensed health providers that have adversely affected the applicant’s health, behavior, and/or adaptive functioning, and now requires significant health care management. (Note: Some students are non-adherent and experience adverse consequences but may still benefit from enrollment. Examples might include substance abuse relapse, poor diabetic control, poor asthma control, etc.) 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. x 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). What factors triggered review of the individual’s file for a health care needs assessment? [Please mark all that apply]

ETA 6-53—Indicates this 17 year old applicant has a diagnosis of bipolar and is receiving weekly mental health and medication management. Applicant also checked “lost control of your anger, or feared losing control of your anger, to the point of hurting yourself or someone else?” Applicant File Review Summary—Within the last year, applicant was removed from home due to fight with father and placed in a therapeutic group home. Three months ago applicant was terminated from group home due to unpredictable behavior resulting in verbal altercations with staff and 2 fights with group members. In addition, applicant did not consistently follow rules or complete assigned chores. He received a mental health assessment two months ago in which he is described as having a “serious” level of impairment and needs to “improve his ability to cope with stressors to decrease mood swings, anger and aggressive behaviors.” Specific symptoms within the last three months include: uncontrolled cycling behavior, poor relationships with others, difficulty sleeping, decreased motivation, and refusal to comply with “authority figures. 34

CCMP Provider Form (Does provider recommend applicant to enter Job Corps? X Yes □No) –The treating therapist indicated that applicant could likely participate in JC, as long as he was able to continue receiving weekly mental health treatment, medication management and additional support on center as needed. Because this recommendation appeared somewhat inconsistent with information in the applicant’s file and interview, a brief follow up call was made to the therapist on October 10 th. During that call, the applicant’s therapist expressed concern that applicant would have difficulty living in the dormitory as he becomes highly stressed and has “meltdowns” in social situations. Therapist also indicated that applicant is non-compliant with medications and there has been an increase in mood swings.. Therapist was under the impression that Job Corps was a therapeutic environment that employed full time mental health staff. Therapist indicated applicant must receive on-going weekly treatment at a minimum. 35

Applicant Interview Summary—The file review team, including the CMHC interviewed the applicant by telephone (he lives in another state and was unable to travel to center). The applicant acknowledged ongoing difficulty with emotional dysregulation and outbursts, but felt that he would be much happier “away from home.” Applicant currently reports feeling depressed, social withdrawal, and a lack of motivation. According to applicant he was doing better when he was on meds, but discontinued because he doesn’t like taking medicines. He seemed anxious during the phone call and became easily irritated when asked questions about specific mental health symptoms (particularly related to the cycling behavior); however, he answered all questions. 36

37 X Frequency and length of treatment Severe medication side effects Hourly monitoring requiredMedical needs requiring specialized treatment X Therapeutic milieu requiredComplex full mouth reconstruction/rehabilitation Complex behavior management system beyond Job Corps current system X Out of state insurance impacting access to required and necessary health care Daily assistance with activities of daily living Other (specify) What are the health care management needs of the applicant that are barriers to enrollment at this time?

38 In my professional judgment, health care needs are manageable at Job Corps as defined by basic health care services in PRH Exhibit 6-4, but require community support services to be in place on entry due to special care needs (e.g., on-going community mental health treatment, specialized provider, etc.) to ensure continuity of care. Community support services are available near center. If this box is checked, STOP FORM HERE and FILE REMAINS ON CENTER. If condition rises to a level of a disability, refer to RAC on center and applicant given start date. In my professional judgment, health care needs are manageable at Job Corps as defined by basic health care services in PRH Exhibit 6-4, 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 (i.e., name of organizations/facilities and specific individual contacted). 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. X 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. Based on your review above, does the named individual have health care needs beyond what the Job Corps’ Health and Wellness program can provide as defined as basic health care in PRH Exhibit 6-4: Job Corps Basic Health Care Responsibilities? [Please mark one below.]

39 RAC discussed the following accommodations with the applicant: Adjustments could be made to applicant’s schedule to allow him to attend therapy and psychiatry appointments off center, if available in the community. Applicant could be provided with set breaks during the day and encouraged to touch base with designated supports during those times if needed. Applicant could be provided with room in smaller dormitory.

Accommodations Modifications that will help applicant/ student participate in program (not treat impairment) 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) Case Management (not accommodations) – Brief, periodic check-ins with CMHC – Meet with MD for medication management – Educate student about stress reduction – Encourage participation in social skills group – Attend off-center therapy

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APPENDIX 609 DIRECT THREAT ASSESSMENTS 42

Appendix 609 Direct Threat Assessment A direct threat assessment should be completed whenever Job Corps believes that an applicant poses a direct threat to the health or safety of himself or others. – This typically will occur after the applicant has received conditional assignment to a Job Corps center and has completed the 6-53 Health Questionnaire. Poses a significant risk of substantial harm to the health or safety of the individual or others; and Cannot be eliminated or reduced by reasonable accommodation or modification. 43

Direct Threat Examples Imminence is key term – Suicidal behavior – Homicidal behavior – Impaired judgment – Paranoid thinking – Threat of violence/assaultive behavior – Risky behavior due to drug and alcohol use 44

Direct Threat Assessment 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 (New Section) 7.List below any accommodations or modifications that could either eliminate the risk or reduce it to an acceptable level (** see next slide for examples) 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

Accommodations Modifications that will help applicant/ student participate in program (not treat impairment) 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) Case Management (not accommodations) – Brief, periodic check-ins with CMHC – Meet with MD for medication management – Educate student about stress reduction – Encourage participation in social skills group – Attend off-center therapy

Direct Threat (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.

Review ( Pod Questions for Voting ) What are the three reasons that a center may recommend denial of enrollment? What is key in determining whether to do a Health Care Needs Assessment or Direct Threat Assessment? 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? 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? Can you recommend denial for health care needs due to non- compliance with medications or treatment? Until the Appendix 610 is released what should you do? 49

RESOURCESRESOURCES 50

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 52

Job Corps Disability Web Site 53

Job Accommodation Network (JAN) 54