Transcript Training for Care Managers (Click here)

LEGAL OBLIGATIONS AND BEST PRACTICS FOR WORKING
WITH PEOPLE WITH DISABILITIES:
A Training For Health Plan Care Managers
Center for Independence of the Disabled, NY © 2015
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Why is disability awareness important
to health plans?
Health plans that serve Medicare and Medicaid populations are more likely to have a
higher percentage of members who have disabilities.
People who have both Medicare and Medicaid have significant health needs, are more
likely than Medicare beneficiaries to be in fair or poor health, and have
significant functional limitations.
•
Within dual eligibles, four identifiable high needs groups:
(i) adults under age 65 with physical or sensory disabilities;
(ii) those 65 or older with multiple chronic conditions and functional limitations;
(iii) individuals with serious psychiatric disabilities and/or drug or alcohol
disorders; and
(iv) individuals with cognitive limitations including intellectual/developmental
disabilities or dementia.
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Why is disability awareness important
for care managers? (cont’d)
• One in five people in the U.S. have disabilities. That figure
increases as people age.
• In New York City, at least 887,640 people have disabilities (American
Community Survey).
– 11.0 percent of adults ages 35-64 (348,410);
– 27.0 percent of older adults ages 65-74 (145,147);
– 55.3 percent of older adults ages 75 and older (256,159).
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Why is disability awareness important
for care managers? (cont’d)
• Plans are required to conduct a disability accommodation needs
assessment, which includes the task of identifying any functional needs
and any accommodation needs as part of the Person Centered Services
Plan (PCSP).
• Care Managers and the Interdisciplinary Teams are charged with assessing
the need for reasonable accommodations. This includes collecting
information that impacts a person’s “health and well-being,” such
as“physical or cognitive limitations, communication styles, and language
barriers.”
• Care Managers also must ensure that members receive reasonable
accommodations.
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Why is disability awareness important
for care managers? (cont’d)
• The PCSP also requires that services are provided in the “most integrated
and least restrictive setting that will meet the needs of the member
safely.”
• You will likely have participants with disabilities who have invisible and/or
undiagnosed disabilities (learning disabilities, other cognitive disabilities,
hearing or vision disabilities that the person acquires as they age).
• You may have participants with disabilities who don’t know they have a
right to accommodations and therefore don’t ask for them.
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Why is disability awareness important
for care managers? (cont’d)
•
People with disabilities face physical and other barriers at plans and at provider
sites, such as architectural barriers, inaccessible exam tables and weight scales,
lack of interpreters, inflexible office procedures.
•
People with disabilities report being treated unfairly at practitioner offices because
of their disabilities. They report negative attitudes and lack of knowledge about
treating people with their type of disability.
•
A survey of primary care physicians found that almost 20 percent were unaware of
the Americans with Disabilities Act (ADA) and 45 percent were not aware of ADA
architectural requirements.
•
Physicians receiving training on disability issues were in the minority. Lack of
knowledge or disability-related education is consistent with other reports finding
inadequate preparedness to provide health services to people with disabilities.
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WHAT DOES THE LAW SAY?
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The Americans with Disabilities Act (ADA)
• The Americans with Disabilities Act (ADA), the landmark disability rights
law passed in 1990, prohibits discrimination against people with
disabilities in five major areas: employment, state and local government,
public accommodations, transportation and communication. Health care
plans are covered under the state and federal government provisions.
• The intent and spirit of the law is that people with disabilities have the
right to participate with their nondisabled peers in all aspects of society,
including access to health care.
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Defining Disability
There are many definitions of disabilities under various federal,
state and local laws. Disability is defined differently by the
Americans with Disabilities Act, New York State Human Rights
Law, and New York City Human Rights Law.
The ADA is a landmark disability rights law passed in 1990.
Because of its importance, courts often look to the ADA for
guidance about disability rights.
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The ADA Definition of Disability
Under the ADA, a person with a disability is:
• A person with a physical or mental impairment that
substantially limits one or more major life activities;
• A person with a record of such physical or mental impairment;
• A person who is regarded as having such impairment.
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Equal Treatment vs. Equal Opportunity
Basic distinction between the ADA and other civil rights laws based on
race, gender, other factors.
• Under most civil rights laws, nondiscrimination means “equal
treatment.”
• Because of the extent and nature of barriers for people with
disabilities, the ADA requires that affirmative steps (reasonable
accommodations, modifications or provision of auxiliary aids) be
taken to ensure that people with disabilities are given equal
opportunity to participate.
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What are examples of affirmative steps
to ensure equal opportunity?
• Architectural modifications
• Reasonable accommodations
• Auxiliary aids
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What are Health Plans’ Obligations Under ADA?
Plans are covered under Title II of the ADA and/or Section 504 of the
Rehabilitation Act when they contract with the government to provide
health care coverage.
•
Under Title II of the ADA, “no qualified individual with a disability shall, by reason
of such disability, be excluded from participation in or be denied the benefits of
the services, programs, or activities of a public entity, or be subjected to
discrimination by any such entity.”
•
Title II also states “All governmental activities of public entities are covered, even if
they are carried out by contractors. For example, a state is obligated by Title II to
ensure that services, programs, and activities of a state park inn operated under
contract by a private entity are in compliance with Title II’s requirements.”
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ADA Requirements
•
•
Programs must provide meaningful access to programs and services.
– Phil is 30 and a veteran – he takes medication that makes him slow in the
morning, so meaningful access for Phil may mean scheduling later
appointments with providers. What are some other examples you can think
of?
Reasonable modifications in policies and practices must be made when necessary
to avoid discrimination against individuals with disabilities.
– Tina has difficulty focusing because of her TBI. She needs help filling out
forms and understanding directions. How would you work with her so she can
get the accommodations she needs at her providers’ offices – what kinds of
accommodations might those be?
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ADA Requirements (cont’d)
•
Programs must provide an equal opportunity to participate in and benefit from
programs and services to people with disabilities.
– A prospective enrollee, Maria, calls to say that she has been sent a letter that
tells her she can apply for the plan online. She doesn’t have a computer and
needs help with forms. How can you accommodate her?
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ADA Requirements (cont’d)
•
Communication with people with disabilities must be as effective as
communication with others.
– Winnie, a 40-year-old woman with a mild cognitive disability tells you that she
doesn’t understand what the member services operator is telling her when
she calls. She’s also having trouble with instructions from her PCP’s staff.
How can you help her?
•
Auxiliary aids and services must be provided to individuals with disabilities when
necessary to provide an equal opportunity to benefit.
– Joe, a 60-year-old member who has diabetes, is taking the plan-offered
nutrition course. When you ask how the class is going, he tells you he’s not
sure he remembers what was taught in the first class. What would you ask
him and what kinds of things can you do to help him succeed in the class?
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The ADA & the Olmstead Decision
The Supreme Court Olmstead decision says care must be
provided in the most integrated setting – what does that mean?
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Olmstead Decision
Background: In Olmstead, Lois Curtis and Elaine Wilson, who had
mental illness and developmental disabilities, were voluntarily
admitted to the psychiatric unit in the state-run Georgia Regional
Hospital.
After the women's medical treatment there had ended, mental
health professionals determined that each was ready to move to
a community-based program. However, both women were
confined in the institution for several years after the initial
treatment was concluded. They filed suit under the Americans
with Disabilities Act (ADA) for release from the hospital.
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Olmstead Decision (cont’d)
• On June 22, 1999, the U.S. Supreme Court held that
unjustified segregation of persons with disabilities constitutes
discrimination under the ADA, Title II, and public entities must
provide community-based services when:
 such services are appropriate;
 the person receiving services are not opposed to community-based
treatment; and
 community-based services can be reasonably accommodated when
considering the available resources and the needs of others who are
receiving disability services from the entity.
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ADA standards are augmented by FIDA
requirements in the MOU, the 3-Way Contract,
and NYS DOH Guidance
In New York, Fully-Integrated Dual Advantage (FIDA) plans are subject to
disability rights requirements through other agreements, contracts, etc.
– The Center for Medicare & and Medicaid Services (CMS) and New York State
Department of Health (NYSDOH) negotiated a Memorandum of
Understanding (MOU) detailing requirements re: how programs must operate
with regard to people with disabilities.
–CMS, NYSDOH and FIDA plans have a 3-way contract that defines need to
ensure rights of people with disabilities.
–NYSDOH has issued a Letter to Providers about accessibility of their clinics
and practices.
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Plan Policies and Procedures
Plans should have internal policies and procedures that detail
care managers’ roles in the reasonable accommodations
process.
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HOW DOES THE LAWS AND OTHER REQUIREMENTS
AFFECT YOUR WORK?
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Common ADA Issues for Care Managers
• A common issue regarding people with disabilities is thinking too narrowly
about the types of disabilities that members might have. In plan
materials and trainings, sensory (blind/vision impaired, deaf/hard of
hearing) and mobility impairments are mentioned, but other less obvious
disabilities (e.g. speech impairments, cognitive impairments, mental
illness) are often not discussed.
• Care managers should be looking more broadly at disabilities when
completing the comprehensive assessments and reassessments for the
Person-Centered Service Plan (PCSP).
• You are key, as leaders of the Inter-Disciplinary Team (IDT), to ensure that
members are getting the assistance they need and to identify any gaps in
procedures that need to be filled.
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BEST PRACTICES:
IDT and Care Managers Assessing Need for
Reasonable Accommodation
The FIDA plans call for person-centered care, which includes care managers and
nurses who must have knowledge of the ADA. They also have the obligation to
provide and/or arranging for reasonable accommodations and modification of
policies, conducting participant assessments and reassessments.
Assessing Disabilities and Accommodation Needs:
– Using the NYS Department of Health Uniform Assessment System (UAS) or
AgeWell Environmental/Accommodation (EA) forms does not fully meet the
plan’s need to determine a disability and need for reasonable
accommodation for all plan services.
– Both the UAS and AgeWell EA focus on independent living skills at home and
does not adequately capture someone’s need for accommodations to access
services outside the home. Example – do you need help with accessible
transportation to your appointments? Do you need help understanding your
doctor’s instructions? etc.
– Also, be aware of what disabilities/accommodations fall in the “other”
category.
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BEST PRACTICES
IDT and Care Managers Assessing Need for
Reasonable Accommodation (cont’d)
– Plans should assess a person’s ability to understand information about
health care or health plans.
– Plans should assess a person’s ability to communicate: speech or
sensory impairments.
– The assessment should note any functional limitations outside the
home and any necessary reasonable accommodations.
– The assessment should note if the effect of medications or treatments
require reasonable accommodations.
– Reassessments are required every six months and if there is a
significant change in health status or needs, when requested by the
member, caregiver or provider, or other trigger events.
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BEST PRACTICES:
IDT and Care Managers Facilitating/Arranging
Reasonable Accommodations (cont’d)
In addition, under FIDA, the IDT coordinates care, including facilitating reasonable
accommodations.
• Everyone on the IDT should be working in a person-centered way. They need
to be proficient in cultural competence, disability, accessibility and
accommodations, independent living and recovery, wellness principals, and
ADA/Olmstead principals. Working in a person-centered way must include,
among other things, identification of:
• Participant’s preferred language
• Barriers or obstacles that need to be addressed
• Reasonable accommodations
• Care managers should be assigned based on individual needs, (e.g.,
communication, cognitive, or other barriers.) Participant has a right to choose
and change care manager.
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BEST PRACTICES:
IDT and Care Managers Facilitating/Arranging
Reasonable Accommodations (cont’d)
• How a plan member gets a reasonable accommodations must
be made clear to members by member materials and the IDT.
• Records of functional limitations and reasonable
accommodation needs should be kept so that requests for
reasonable accommodations, e.g., materials in alternate
formats, do not have be made repeatedly.
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Reasonable Accommodations:
Thinking more broadly to help your
participants with disabilities (cont’d)
When are reasonable accommodations available?
– Often the materials and training limit reasonable accommodation
discussions, e.g., communicating with the call centers or availability of
alternate formats, rather than clearly making known to staff and
members that reasonable accommodations are available at any stage
of interaction with the plan—e.g., call center, grievances, and advisory
boards.
– Understanding that each interaction or service for participants may
require reasonable accommodations.
– Train staff that reasonable accommodations are not limited to certain
times, e.g., call center or member materials.
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Areas where accommodations are critical
Providing Information/Communications:
– Call Centers
– Informational/Marketing Sessions
– Marketing Materials
Enrollment:
– Printed materials
– Online applications
– Telephone assistance with applications
Member Services
– Access to services
– Ensuring adequate network of ADA compliant providers
– Information Access
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Reasonable Accommodations
What types of accommodations are available?
– The reasonable accommodations mentioned in materials and trainings are
often limited to accessibility and accommodations for sensory impairments
(e.g., alternate formats, TTY). Examples of reasonable accommodations for
other disabilities, e.g., assistance filling out forms or scheduling flexible
appointments due to effects of medications, are often omitted.
– Think of reasonable accommodations as a question: what will make this point
of contact/service work for this participant? For example, training staff to
simplify or repeat information for a person with cognitive disability or provide
help filling out forms for someone who has a limitation (whether cognitive or
physical) that makes it difficult for them to fill out forms by themselves.
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Reasonable Accommodations (cont’d)
Things to keep in mind when working with a participant with a disability
–
–
–
–
People should be able to ask for help in plain language—no magic words.
A family member, friend or health professional may ask.
One size does not fit all-- reasonable accommodations are individualized.
Plan does not necessarily have to provide the specific accommodation asked
for, but the one provided must be effective, and consideration has to be given
to what the participant proposes.
– If you turn down a request, you must explain why. A denial of reasonable
accommodation is a decision that a member can file a grievance about.
– The accommodation process should be simple and quick.
– Sending a participant somewhere else for a reasonable accommodation does
not provide “an equal opportunity to benefit.”
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POSSIBLE REASONABLE ACCOMMODATION ISSUES:
CALL CENTER
TRAINING
– Call Center representatives, who are often the first and/or the main
contact for members, should be identifying accommodation needs, if
they do not, you should ensure that needs are identified and recorded
according to your procedures;
– Call Center representatives may need more support and training to
feel comfortable in providing a reasonable accommodation for the
interaction they themselves are having with the member and for
arranging reasonable accommodations for them for other plan
services.
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POSSIBLE REASONABLE ACCOMMODATION ISSUES:
Written Information & Communications
Information about rights to reasonable accommodations
– Members have to be clear that they have the right to ask for an
accommodation and that they can ask at any interaction point with
anyone representing the plan or plan providers;
– The right to appeal a decision about reasonable accommodations,
which can be grieved, must be clear to all members with disabilities.
Information about communication accommodations for non-sensory
disabilities, e.g., cognitive disabilities or speech impediments, should be clear
and delivered in simple language.
Each accommodation is a negotiation with the person with the disability, who
is an expert in their communication needs.
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POSSIBLE REASONABLE ACCOMMODATION ISSUES:
Written Information & Communication (cont’d)
The list of communication accommodations are often limited
with no indication that other appropriate accommodations may
be available.
– For example, the list of alternate formats are often limited
to Braille or large print.
– Other accommodations, such as reading materials to
members or electronic versions of materials, may be what
is necessary for effective communication.
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BEST PRACTICES:
Written Information & Communications (cont’d)
Provide assistance to participants with cognitive impairments; e.g.,
marketing, outreach and participant communications in simple, clear
language at a 4th to 6th grade reading and below, and, if necessary,
Individualized assistances to ensure materials are understood.
Provide reasonable accommodations needed to ensure effective
communication, including, but not limited to:
– Alternate formats, including, but not limited to:
• Large print in at least 16-point font;
• Braille;
• Materials in formats compatible with optical recognition software:
– Reading materials to members;
– Filling out forms upon request;
– Using different technology, such e-mail, telephone, text, video relay, etc.
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BEST PRACTICES:
Written Information & Communication (cont’d)
• Make available information on how to access oral
interpretation services and written materials in alternative,
cognitively accessible formats.
• Make available information on the availability of reasonable
accommodations and how they can be arranged and
delivered.
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POSSIBLE REASONABLE ACCOMMODATION ISSUE:
Grievances
• The right to grieve reasonable accommodation decisions
should be among the listed rights for members or made
readily known.
• Staff should also inform members of the right to reasonable
accommodations during the grievance procedure itself.
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BEST PRACTICES:
Accessibility of the complaint/grievance system
•
In NY, FIDA Plans must provide reasonable accommodations in the grievance
process including assistance in completing any forms or other procedural steps,
which shall include interpreter services and toll-free numbers with TTY/TTD/VP
and interpreter capacity.
•
The right to grieve reasonable accommodation decisions should be made clearly
known in the written materials and member materials.
•
The right to grieve to external agencies for adverse decisions about reasonable
accommodations should be clearly stated.
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Scenarios
• What will you say, what will you do?
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NY © 2015
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OTHER POTENTIAL PROBLEMS:
Network Adequacy (cont’d)
It is often unclear whether a provider network participant is
ADA-compliant.
– The provider directories only give information about
physical accessibility and is self-attested to by the provider.
– There is no clear way members can obtain information
about a provider’s ADA-compliance beyond basic physical
accessibility.
– Websites often lack a search feature for accessibility of
providers.
– What issues does this raise for Care Managers/IDTs?
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OTHER POTENTIAL PROBLEMS:
Network Adequacy (cont’d)
Provider ADA Attestation Forms do not capture all the
necessary information to ensure that a provider is ADA
compliant.
• The form lacks specific questions about the accessibility of exam tables
and medical equipment.
• No questions about whether the elevator has beeps or audio cues.
• Lacks specific questions about communication capacity of providers-TTY,
texting, video relay, alternate formats.
• Lacks questions about communication capacity of medical staff or
availability of qualified interpreters.
• Does not ask whether provider staff is trained to accommodate a full
range of disabilities, including cognitive or psychological disabilities.
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BEST PRACTICES: NETWORK ADEQUACY
Provider Physical Accessibility
Physical Barrier Removal
•
•
•
Providers are responsible for altering or modifying waiting, exam and changing
rooms to ensure access to persons with a range of physical, sensory and cognitive
impairments.
Providers are responsible for providing medical equipment that ensures that an
individual with a disability can receive the same health care services as others.
Examples include but are not limited to: adjustable exam tables, accessible weight
scales (platform/roll-on scales).
Providers responsible for safe and comfortable transfers without using patient’s
family member, friend, etc.
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BEST PRACTICES: NETWORK ADEQUACY
Provider Accessibility/Reasonable Accommodations
FIDA plans must train providers on accessibility and the ADA in the following
areas:
•
•
•
•
•
Reasonable accommodations to those with hearing, vision, cognitive, and
psychiatric disabilities;
Waiting room and exam room furniture that meets needs all participants,
including those with physical and non-physical disabilities;
Accessibility along public transportation routes and/or provide enough
accessible parking;
Clear signage and way finding , e.g., color and symbol signage, throughout
facilities; and
Any other requirements in the ADA Accessibility Attestation Form.
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BEST PRACTICES: NETWORK ADEQUACY
Provider Obligations
Providers are responsible for:
– Ascertaining the need for accommodation;
– Methods to ensure privacy during intake procedures;
– Transferring and positioning techniques;
– Sensitivity and awareness of the needs of individuals with various disabilities, including
cognitive disabilities;
– Identify and locate which examination and procedure rooms are accessible, where
accessible equipment is stored and how to use it;
– How to uses transfer and positioning aids and equipment, such as patient lifts, gait belts
and variety of stabilizing supports.
Their obligations are to:
– Have procedures to evaluate compliance with accessibility standards on an ongoing
basis.
– Inform patients of their rights in understandable formats and provide straightforward
methods for receive and resolving complaints.
– Have flexibility in scheduling as a reasonable accommodation.
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RESOURCES
• CIDNY Disability Etiquette
• Plan Forms
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Contact information
The Center for Independence of the Disabled, New York’s (CIDNY) goal is to
ensure full integration, independence and equal opportunity for all people with
disabilities by removing barriers to the social, economic, cultural and civic life
of the community.
CIDNY
841 Broadway
Suite 301
New York, NY 10003
212-674-2300 (Voice)
646-350-2681 (Video Phone)
www.cidny.org
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CIDNY – Queens
80-02 Kew Gardens Road
Suite 107
Kew Gardens, NY 11415
646-442-1520 (Voice)
347- 905-5088 (Video Phone)
www.cidny.org
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