1. Serving People with Disabilities
Short Orientation PRIMARY AND SPECIALTY CARE PRACTITIONERS Medical Staff
Serving People with Disabilities
And Seniors
Prepared by
The Harris Family Center for Disability and Health Policy Western University of Health Sciences
Pomona, California
April 2011
NOTES FOR TRAINERS:
This PowerPoint presentation is intended to be used with primary and specialty care provider medical staff in a 15 to 30 min. orientation to providing care for people with disabilities and seniors.

2. TOPICS FOR PRIMARY AND SPECIALTY CARE PRACTITIONERS Medical Staff
Profile of Medi-Cal seniors and people with disabilities
Problems and barriers accessing care and priority solutions
Adopting policies and procedures
Coordinating accommodations with the front office staff

3. What is Disability?
The interaction of physical, sensory, or cognitive impairment with environmental factors
NOTES FOR TRAINERS:
THIS IS AN OPTIONAL SLIDETHAT CAN BE USED DEPENDING ON AVAILABLE TIME
The purpose of this topic is to convey the diverse disability definitions that are in use and establish a frame for the training that grows out of the group’s individual experiences with disability (including minor and temporary impairments).
Goals specifically include:
widening awareness that we all know people with functional limitations or have them ourselves, whether arising from age or disability
creating an understanding that disability exists along a continuum and is a function of the interaction of impairment with external, social, economic structural and other environmental factors
distinguishing disability from poor health, and
establishing that health care that includes cultural awareness of disability will benefit everyone.
Group discussion: Lead an open discussion on participants” understanding of disability, functional limitation, accessibility, and health maintenance. Begin by asking participants if they know someone with a disability, or if not, someone with a functional limitation (often an aging parent/grandparent; a friend or family member who broke a limb in an accident; someone who wears glasses; or has a learning disability). Broaden the discussion by asking what it does and does not mean to live with an impairment, and how different impairments interact with the environment, especially the ‘typical’ medical office environment.

4. Chronic conditions, diseases, disability
Definition of Disability Interaction of Impairment with Environmental Factors
Chronic conditions, diseases, disability
Functional
Limitation Accommodation
NOTES FOR TRAINERS:
Understanding disability means understanding how chronic conditions, diseases and diagnosis may relate to functional limitation that call for specific accommodations in the health care setting. For example:
Seniors diagnosed with chronic conditions (e.g., diabetes, dementia, heart disease, arthritis) may experience activity limitations such as difficulty walking, seeing, understanding, or communicating, which in turn, create the need for accommodations such as accessibility and steps to ensure effective communication.
People with a chronic condition such as diabetes may have activity limitations related to vision. But, regardless of the cause of the vision condition, effective health care requires accommodation of functional vision limitations such as providing care instructions in large print or audio formats.
People with a chronic condition such as intellectual or developmental disability may experience an activity limitation that affects understanding and/or communication. Identifying methods for effective communication ensure effective health care.

5. Profile of Medi-Cal Beneficiaries Who Are Seniors
Disability, functional impairment and chronic conditions co-exist and cut across age among Medi-Cal beneficiaries
NOTES FOR TRAINERS:
Source:
“State of California’s Concept for a Comprehensive Section 1115 Waiver to Replace the Current Medi-Cal Hospital/Uninsured Care Demonstration Project,” draft concept paper, California Department of Health Care Services, December 16, 2009.
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6. Profile of Medi-Cal Beneficiaries with Disabilities
70% who have disabilities live w/ two or more chronic conditions
About 25% have four or more chronic conditions
30% of beneficiaries with disabilities receive treatment for mental health conditions annually
NOTES FOR TRAINERS:
Source:
“State of California’s Concept for a Comprehensive Section 1115 Waiver to Replace the Current Medi-Cal Hospital/Uninsured Care Demonstration Project,” draft concept paper, California Department of Health Care Services, December 16, 2009.
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7. Profile of Medi-Cal Seniors
Seniors represent about 14% of Medi-Cal beneficiaries who have no other insurance who will experience mandatory enrollment into managed care during
NOTES FOR TRAINERS:
Source:
“State of California’s Concept for a Comprehensive Section 1115 Waiver to Replace the Current Medi-Cal Hospital/Uninsured Care Demonstration Project,” draft concept paper, California Department of Health Care Services, December 16, 2009.
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8. Profile of Medi-Cal Seniors—Activity Limitations
About two-thirds of seniors in Med-Cal, and who have no other insurance, have disabilities
Based on prevalence of disability among seniors, most seniors in Medi-Cal, who have no other insurance, are likely to have some type of activity limitation
NOTES FOR TRAINERS:
Source:
“State of California’s Concept for a Comprehensive Section 1115 Waiver to Replace the Current Medi-Cal Hospital/Uninsured Care Demonstration Project,” draft concept paper, California Department of Health Care Services, December 16, 2009.
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9. Health Disparities & Medi-Cal Beneficiaries with Disabilities
Among 70% with multiple chronic conditions -- 16% have diabetes compared with 7% of gen. pop.
30% are overweight or obese compared with 19% of gen. pop.
40% smoke compared with 22% of gen. pop
NOTES FOR TRAINERS:
Sources:
“State of California’s Concept for a Comprehensive Section 1115 Waiver to Replace the Current Medi-Cal Hospital/Uninsured Care Demonstration Project,” draft concept paper, California Department of Health Care Services, December 16, 2009.
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B. Altman and A. Bernstein, Disability and Health in the United States, , Hyattsville, MD: National Center for Health Statistics, 2008.
It is important to understand that poor health and disability are not naturally linked. Some disabilities may make maintaining one’s health more complicated, and some impairments increase one’s susceptibility to secondary conditions. However, the disparities mentioned here do not inevitably follow from the presence of a functional limitation. Consider how disparities can result from inaccessible medical equipment, inaccessible health screening and health maintenance procedures, health information that only comes in regular font English print, limited provider awareness, and the effort needed to self-advocate for the simplest changes in policies or procedures.

10. Health Care Disparities -- Medi-Cal Beneficiaries with Disabilities
Women – fewer Pap tests and mammograms
Overall -- Less participation in prevention programs
NOTES FOR TRAINERS:
One study of Medicaid beneficiaries concluded that women with disabilities were 24 percent less likely to have received a Pap test during the previous year than women without disabilities and were nearly three times more likely than women without disabilities to have postponed needed medical care. Outcomes for this group were substantially worse in terms of receiving necessary medical care and being able to obtaining prescription drugs. Women with disabilities who received Medicaid were more than twice as likely to have postponed taking medication they needed during the previous 12 months.
Sources:
Susan L. Parish and M. Jennifer Ellison-Martin, Health-Care Access of Women Medicaid Recipients: Evidence of Disability-based Disparities, Journal of Disability Policy Studies 18, no. 2 (2007), pp. 109–116.
Altman and Bernstein, in Health and Disability in the United States

11. Problems and Barriers Accessing Care
Physical (facility) barriers
Communication barriers
Equipment barriers
Practitioner awareness barriers

12. Priorities for Physical Accessibility
Access into the facility (for example, level entrance with no stairs)
Access to areas where services are provided such as exam rooms or lab areas
Access to restrooms
Tax incentives available for modification of existing facilities
NOTES FOR TRAINERS:
Modifications in existing facilities can be as simple as lowering a section of the reception counter to facilitate communication with wheelchair users and people of short stature; removing carpeting from pathways of travel to ensure smooth travel for mobility devices; installing grab bars in the restroom; or installing an electric door opener at the facility entrance.
Priorities for accessibility:
Access into the facility
Access to areas where services are provided, and
Access to restrooms.
Readily achievable, a standard under the Americans with Disabilities Act for accessibility in existing buildings, means without much difficulty or expense.
If a program can be made accessible by some method other than providing architectural access, providing architectural access is not required. Methods for achieving program access include:
Redesign of equipment
Reassignment to accessible buildings
Use of aides
Home visits
Delivery of services at alternative accessible sites
Alteration of existing facilities
For more information about the ADA, see the US Department of Justice website at:

13. Priorities for Effective Communication
People Who Are Deaf, Hard-of-Hearing
Qualified ASL interpreters
Relay service
Assistive listening device
Text message
Captioning
NOTES FOR TRAINERS:
Ensuring effective communication with people who have hearing, speech or vision impairments can be seen as a specific type of access. It may also involve the modification of policies, practices or procedures, and accommodations in the form of auxiliary aids and services.
There is a critical link between what needs to be communicated and whether communication is effective. For example, someone who is hard of hearing may be able to get by in a routine physical exam using handwritten notes. On the other hand, handwritten notes will rarely or never be adequate to convey the complex information needed to obtain informed consent from someone who is linguistically Deaf and therefore American sign language would likely be necessary for effective communication.
Wireless text communication are among the basic and commonly used communication methods in the deaf community. Through cell phones, wireless pagers or handheld communication devices, deaf and hard of hearing people are exchanging and instant messages. Ask the patient if they prefer to be contacted via or text messaging.
Alternative formats makes printed information usable for individuals unable to use standard print materials because they cannot read, manipulate, or process print due to a visual, physical or learning disability.
Federal Tax Credits available to small businesses to pay for auxiliary aids (and removal of architectural and transportation barriers).

14. Priorities for Exam and Diagnostic Equipment
People with Ambulatory/balance Impairments
Height adjustable exam tables
Wheelchair accessible weight scales
Adjustable mammography equipment
Moveable optometry chairs
NOTES FOR TRAINERS:
When you are meeting with the medical staff, ask if the practice has a height adjustable examination table and a wheelchair accessible weight scale available. If this equipment is not available, suggest that the practice consider purchasing such equipment. Mention that tax credits are available for such purchases. Be sure to suggest that the practice consider methods for assisting patients with disabilities onto and off of examination tables such as purchasing a portable lift.
NOTE: If your Plan is considering assisting primary care providers to acquire accessible equipment using group purchases, mention this to the medical staff. Be sure to indicate any other support your plan can provide to assist practitioners identify where accessible equipment such as wheelchair accessible weight scales are located that patients can use.

15. Priorities for Modification of Policies
People with Intellectual and Developmental disabilities
Flexible appointment time
Longer appointment time
Communication
Care coordination
Providing assistance filling out forms
NOTES FOR TRAINERS:
Briefly discuss the need for written policies and procedures to ensure that the practice has established a mechanism, for example, for providing flexible appointment times, longer appointment times, lifting assistance and so on.
NOTE––sample disability accommodation policies and procedures that spell out methods primary and specialty care practices can adopt to provide appropriate accommodations are available on the website at the end of this module in HANDOUTS.

16. Misinformation Can Affect Treatment Decisions
Common Misconceptions and Stereotypes
All deaf people can read lips
Some women with disabilities are not sexually active
People with developmental disabilities cannot contribute to their community
NOTES FOR TRAINERS:
Research has shown that sometimes misconceptions and stereotypes about disability affect medical decision-making. Studies have revealed that healthcare practitioners have little understanding of how people with hearing loss communicate or how to communicate effectively with them. Common misconceptions include the belief that people who are deaf can communicate effectively by lipreading or writing notes, and that people who are deaf are fluent English speakers.
Social misperceptions and stereotypes about disability can make it difficult for women with disabilities to obtain information, medical care, and services to ensure that the reproductive needs are met. Qualitative studies have revealed by healthcare providers sometimes expressed surprise that women with disabilities would be sexually active. Therefore, they frequently did not discuss the use of contraceptives or evaluate the women for sexually transmitted diseases.
Outmoded ideas about intellectual and developmental disability sometimes guide treatment decisions. Medical providers often lack training experience in treating individuals with intellectual and developmental disabilities
SOURCE: “The Current State of Health Care for People with Disabilities,” National Council on Disability, Washington, DC, September 30, 2009.

17. Other Priorities for Modification of Policies
People with Various Functional Limitations
Providing assistance filling out forms
Providing lifting assistance
Providing print materials in alternative, accessible formats
Allowing service animals
NOTES FOR TRAINERS:
Briefly discuss the need for written policies and procedures to ensure that the practice has established a mechanism, for example, for providing flexible appointment times, longer appointment times, lifting assistance and so on.
NOTE––sample disability accommodation policies and procedures that spell out methods primary and specialty care practices can adopt to provide appropriate accommodations are available on the website at the end of this module in HANDOUTS.

18. Sample Policies and Procedures
Accommodating Seniors and People with Disabilities–Model Policies and Procedures for Primary and Specialty Care Providers
Americans with Disabilities Act Compliance
Accommodations for Seniors and People with Specific Disabilities
Standard Patient Information Materials Produced in Alternative Formats
Disability Awareness Staff Training
Accommodations Check Sheet
Grievance Policy
NOTES FOR TRAINERS:
Briefly discuss the need for written policies and procedures to ensure that the practice has established a mechanism, for example, for providing flexible appointment times, longer appointment times, lifting assistance and so on.
NOTE––sample disability accommodation policies and procedures that spell out methods primary and specialty care practices can adopt to provide appropriate accommodations are available on the website at the end of this module in HANDOUTS.
NOTE—a checklist entitled, “Providing Healthcare for People with Disabilities: Capacity and Planning Checklists” is available in HANDOUTS and is an excellent resource that will help providers assess their capacity to serve patients with disabilities and areas for improvement

19. How the Health Plan Can Help
Assistance with arranging for Sign Language interpreters
Methods for providing print materials in alternative formats
Sources for equipment such as assistive listening devices, accessible weight scales, conversion of print material to Braille
NOTES FOR TRAINERS:
Trainers must be sure to identify the types of support and assistance their Plan can provide for primary and specialty care provider practices. For example:
Trainers must be aware if their Plan pays for Sign Language interpreters or requires that the provider negotiate payment as part of their capitated rates for service to Medi-Cal beneficiaries. If the Plan pays for interpreters directly, trainers should provide information about who to contact at the Plan to arrange for interpreter services. Trainers should provide examples of interpreter referral services if the provider hires interpreters directly.
Trainers must either provide information about who the provider should contact at the Plan to arrange for materials in alternative formats or to community organizations that provide this service.
If the Plan has a designated disability services coordinator, that person’s name should be provided to the medical staff as the point of contact within the Plan when they need assistance providing services to people with disabilities and seniors.

20. Coordinating with Front Office Staff
Communicate accommodation needs with front office staff
Ask front office staff to arrange accommodations IN ADVANCE
Sign Language interpreters
Print materials in accessible formats (for example, consent forms, insurance documents, brochures, diabetes education material)
Flexible exam time
NOTES FOR TRAINERS:
It is important for medical provider staff to communicate effectively with front office staff when patients with disabilities require accommodations that must be arranged in advance of the patient’s visit. For example:
A wheelchair user may require an exam room that has a height adjustable examination table
A person with a developmental disability may require a longer appointed time to ensure effective communication with provider staff.
These requirements must be communicated with front office staff and with those responsible for making the necessary arrangements in advance of the patient’s visit.
Medical staff should be aware of the office policies and procedures regarding providing accommodations for patients with disabilities and communication with medical staff regarding patients’accommodation needs.

21. Handouts/Resources
Accommodation Check Sheets for Patients with Disabilities
Accommodating Patients with Disabilities: Model Policies and Procedures
Tax Incentives for Providers
Videos and online training materials
NOTES FOR TRAINERS:
In addition to the handouts and resources listed in this slide, trainer should also tell the medical staff that the following material is available on the website:
Access to Medical Care: Adults with Physical Disabilities, a 22 min. video DVD that offers physicians, Dentists, nurses, social service and support staff an introduction to crucial areas that affect the quality of care for patients with disabilities in outpatient clinical settings. Available for purchase from the World Institute on Disability, Berkeley California.
Preservice Health Training Modules, designed to improve students’ and practicing clinicians’ comfort level and knowledge related to working with patients with developmental disabilities. The modules were produced in response to the continuing disparity access to quality healthcare experienced by this patient population. Available From the Human Development Institute, University of Kentucky, at
Reproductive Health Care for Women with Disabilities, and Internet-based slide program that assists women’s healthcare clinicians with office skills to assist with their care of women with physical, developmental or sensory disabilities and include specific information for reproductive health care. Available from the American Congress of Obstetricians and Gynecologists at