You're listening to the Disability Law Lowdown podcast, show number
54, with your host, Jacquie Brennan.
Today, we're going to talk about a new Department of Justice
publication called "Access to Medical Care for Individuals with
Mobility Disabilities Under the Americans with Disabilities Act." The
ability to access doctor's offices, clinics, other healthcare
providers' offices, hospitals, that is essential to people with
disabilities getting good medical care. Because of architectural
barriers, individuals with disabilities are less likely to get things
that other people may take for granted, like routine, preventative
medical care, because they just don't have access to their doctor's
office. Ot they may be able to get access, but it's a real huge
hassle. Of course, accessibility is not only a legal requirement, but
it's important medically so that problems can be detected and treated
before they turn into a major and possibly life-threatening problems.
The ADA is a, as my listeners will know, is a federal civil rights law
that prohibits discrimination against individuals in everyday
activities, including medical services. The ADA requires medical care
providers have to offer their services in an accessible manner. So
this publication that the Department of Justice did, provides guidance
for medical care providers on the requirements of the ADA in medical
settings with respect to people with mobility disabilities. And that
includes people who use wheelchairs, scooters, walkers, crutches, even
get around without using mobility devides at all.
You can get a copy of this for your health care provider or if you are
a health care provider at our Web site at www.southwestada.org or at
ADA.gov. You can also get a copy there and the information that I'm
about to give you comes from that publication.
The ADA requires access to medical care services wherever the services
are provided. So, private hospitals are covered, medical offices are
covered, all kinds of medical offices, whether it's a free clinic, ora
neighborhood walk-in clinic, the clinics you find inside other stores
and so forth, dentist offices, optometrists, opthemologists, every
kind of doctor and medical office is covered by Title III of the ADA
as places of public accommodation. Now, public hospitals, publically
funded hospitals and clinics and medical offices, those that are
operated by state and local governments are also covered by the ADA.
They're covered by Title II of the ADA that covers programs of state
and local governments and public entities.
And both Title I and Title II require medical care providers provide
individuals with disabilities with full and equal access to their
health care services and facilities. And, they have to make reasonable
modifications to policies, practices and procedures when necessary to
make health care services fully available to individuals with
disabilities, unless the modification could fundamentally alter the
nature of the services. That is, the essential nature of the services.
The ADA has requirements for new construction and alteration to the
buildings and facilities, including all health care faciltities. And
those can be found at www.ada.gov/reg2.html. In addition, all
buildings, including those built before the ADA went into effect, are
subject to accessibility requirements for existing facilities. Now,
under Title III, existing facilities are required to remove
architectural barriers when such removal is readily achievable. A lot
of times, we will hear from doctors' offices and they say "Well, we're
grandfathered in to the ADA. We don't have to comply because our
office was here before the ADA was here." And there really is no
"grandfathering" provision in the ADA. Even those existing facilties
are required to remove architectural barriers.
Barrier removal is readily achievable when it is easily accomplishable
and able to be carried out without too much difficulty or expense. But
if barrier removal is not readily achievable, the health care entity
still has to make its services available through alternative methods.
The publication that that DOJ put out about this has some
frequently asked questions. And I'm going to go through those now.
Is it OK to examine a patient who uses a wheelchair in the wheelchair,
because the patient cannot get onto the exam table independently?
The answer is: Generally no. Examining a patient in their wheelchair
usually is less thorough than on the exam table, which is why anyone
has to get on the exam table, because that's the best way for a
thorough exam. So it doesn't provide the patient equal medical
services if you're examining them in their wheelchair. There are
several ways to make the exam table accessible to a person using a
wheelchair. One good option is to have a table that adjusts down to
the level of a wheelchair, like, about 17-19 inches from the floor.
What's important is that a person with a disability receives equal
medical services to those received by a person without a disability.
If the examination doesn't require that a patient lay down (for
example, an examination of the face, you went to a dermetologist who
is just looking at your face, or your arm), then the exam table is not
important to the medical care and the patient may remain seated.
Another question. Can I tell a patient that I cannot treat her because
I don’t have accessible medical equipment?
Again, generally no. You can't deny service to a patient whom you
would otherwise serve because she has a disability. You must examine
the patient as you would any patient. In order for you to do so, you
may have to provide an accessible exam table, an accessible stretcher
or gurney, or a patient lift, or have enough trained staff available
who can assist the patient to transfer.
Another question. Is it OK to tell a patient who has a disability to
bring along someone who can help at the exam?
No. If a patient chooses to bring along a friend or family member,
they can do that. However, a patient with a disability, just like
other individuals, can come to an appointment alone, and the provider
must provide reasonable assistance to enable the individual to get
medical care. This assistance can include helping the patient to
undress and dress, get on or off the exam table or other kinds of
equipment, and lie back and be positioned on the exam table or other
equipment. Once on the exam table, some patients may need a staff
person to stay with them to help maintain balance and positioning. The
provider should ask the patient if she needs any assistance and, if
so, what is the best way to help.
Question. If the patient does bring an assistant or a family member,
do I talk to the patient or the companion? Should the companion remain
in the room while I examine the patient and while discussing the
medical problem or results?
You should always address the patient directly, of course, not the
companion, just like you would with any other patient. Just because
the patient has a disability does not mean that she cannot speak for
herself or understand the exam results. It is up to the patient to
decide whether or not a companion remains in the room during your exam
or during the discussion with the patient. The patient may have
brought a companion to assist in getting to the exam, but would prefer
the companion to leave the room before the doctor begins any kind of
substantive discussion. Before beginning the examination or
discussion, you should ask the patient if he wishes the companion to
remain in the room.
Can I decide not to treat a patient with a disability because it takes
me longer to examine them, and insurance won’t reimburse me for the
additional time?
No, you cannot refuse to treat a patient who has a disability just
because the exam might take more of your or your staff’s time. Some
examinations take longer than others, for all sorts of reasons, in the
normal course of a medical practice.
Question. I have an accessible exam table, but if it is in use when a
patient with a disability comes in for an appointment, is it OK to
make the patient wait for the room to open up, or else use an exam
table that is not accessible?
Generally, a patient with a disability should not wait longer than
other patients because they are waiting for a particular exam table.
If the patient with a disability has made an appointment in advance,
the staff should reserve the room with the accessible exam table for
that patient’s appointment. The receptionist should ask each
individual who calls to make an appointment if the individual will
need any assistance at the examination because of a disability. This
way, the medical provider can be prepared to provide the assistance
and staff needed. Accessibility needs should be noted in the patient’s
chart so that the provider is prepared to accommodate the patient on
future visits as well. If the medical provider finds that it cannot
successfully reserve the room with the accessible exam table for
individuals with disabilities, then the provider should consider
acquiring additional accessible exam tables so that more exam rooms
are available for individuals with disabilities.
In a doctor’s office or clinic with multiple exam rooms, must every
examination room have an accessible exam table and sufficient clear
floor space next to the exam table?
Probably not. The medical care provider must be able to provide its
services in an accessible manner to individuals with disabilities. In
order to do that, accessible equipment is usually necessary. However,
the number of accessible exam tables needed by the medical care
provider depends on the size of the practice, the patient population,
and other factors. One accessible exam table may be sufficient in a
small doctor’s practice, while more will likely be necessary in a
large clinic.
Question. I don’t want to discriminate against patients with
disabilities, but I don’t want my staff to injure their backs by
lifting people who use wheelchairs onto exam tables. If my nurse has a
bad back, then she doesn’t have to help lift a patient, does she?
Staff should be protected from injury, but that doesn’t justify
refusing to provide equal medical services to individuals with
disabilities. The medical provider can protect his or her staff from
injury by providing accessible equipment, such as an adjustable exam
table and/or a ceiling or floor based patient lift, and training on
proper patient handling techniques as necessary to provide equal
medical services to a patient with a disability.
What should I do if my staff do not know how to help a person with a
disability transfer or know what the ADA requires my office to do?
Also, I am unsure how to examine someone with spasticity or paralysis.
To provide medical services in an accessible manner, the medical
provider and staff will likely need to receive training. This training
will need to address how to operate the accessible equipment, how to
assist with transfers and positioning of individuals with
disabilities, and how not to discriminate against individuals with
disabilities. Local or national disability organizations may be able
to provide training for your staff. And definitely, your local ADA
Center will be able to provide that training to your staff. And you
can get more information at ada.gov. And anyone can also call the ADA
Information Line at 1-800-514-0301 (voice) or 800-514-0383 (TTY). And
when you call that number, you can speak with an ADA Specialist to
get answers to questions about the ADA. Also, when preparing to assist
a patient with a disability, it is always best to ask the patient if
assistance is needed and if so, what is the best way to help. If the
provider is unsure of how to handle something, it is absolutely OK to
ask the patient what works best.
If I lease my medical office space, am I responsible for making sure
the examination room, waiting room, and toilet rooms are accessible?
Yes.Even if you lease, you're still responsible. Any private entity
that owns, leases or leases to, or operates a place of public
accommodation is responsible for complying with Title III of the ADA.
Both tenants and landlords are equally responsible for complying with
the ADA. However, your lease with the landlord may specify that, as
between the parties, the landlord is responsible for some or all of
the accessibility requirements of the space. Frequently, the tenant is
made responsible for the space it uses and controls, which is very
often in the lease it will say that the tenant is responsible for
abiding by all state, federal and local laws. And of course, the ADA
is a federal law.
Are there any tax breaks for making accessibility changes to my
medical office?
Yes. That's the really good news. Subject to IRS rules, federal tax
credits and deductions are available to private businesses to offset
expenses incurred to comply with the ADA. You can get Form 8836 at
irs.gov for additional information about the Disabled Access Credit,
which was established under Section 44 of the Internal Revenue Code.
You can get Publication 535 (Number 7: Barrier Removal) at irs.gov for
more information about the tax deduction, that was established under
Section 190 of the Internal Revenue Code. Both the tax credit and
deduction can be taken annually.
In the publication the DOJ put out that this information is taken
from, there are other parts to the publication. And they have a lot of
drawings, with the exact measurements that you need to use for
different things. The first part of this part of the publication talks
about accessible examination rooms because accessible examination
rooms must have features that make it possible for patients with
mobility disabilities, including those who use wheelchairs, to
receive appropriate medical care. These features allow the patient to
go into the exam room, move around the room and utilize the accessible
equipment provided.
The features that make this possible are an accessible route to and
through the room;
an entry door with adequate clear width, maneuvering clearance, and
accessible hardware;
appropriate models and placement of accessible examination equipment
and
adequate clear floor space inside the room for side transfers and use
of lift equipment.
New and altered examination rooms must meet requirements of the ADA
Standards for Accessible Design. Accessible examination rooms may need
additional floor space to accommodate transfers and for certain
equipment, like a floor lift.
The number of examination rooms with accessible equipment needed by
the medical care provider depends on the size of the practice, the
patient population, and other factors. As I said before, one such exam
room may be sufficient in a small practice, but more are probably
necessary in a large clinic.
Then this part of the publication actually goes into a lot of detail
about the features of an accessible exam room.
The next part is about accessible medical equipment. Availability of
accessible medical equipment is an important part of providing
accessible medical care, and doctors and other providers have to
ensure that medical equipment is not a barrier to people with
disabilities.
The right solution or solutions for providing accessible medical care
depends on existing equipment, the space available both within the
examination room and for storage of equipment, the size of the
practice and staff, and the patient population. What is important is
that a person with a disability gets medical services equal to those
received by a person without a disability. For example, if a patient
must be lying down to be thoroughly examined, then a person with a
disability must also be examined lying down. Likewise, examinations
which require specialized positioning, such as gynecological
examinations, must be accessible to a person with a disability. To
provide an accessible gynecological exam to women with paralysis or
other conditions that make it difficult or impossible for them to move
or support their legs, the provider may need an accessible height exam
table with adjustable, padded leg supports, instead of typical
stirrups.
However, if the exam or procedure does not require that a person lie
down (for example, an examination of the face or an x-ray of the
hand), then using an accessible table is not necessarily important to
the quality of the medical care and the patient can remain seated.
Then it goes on to describe in a lot of detail, with pictures, about
the exam tables and chairs, and the features of fully accessible exam
tables. And typical transfer techniques, and staff assistance, patient
lifts and that sort of thing. It goes into a lot of detail about
different kinds of patient lifts and what might work as well as
alternatives to that, like using stretchers or gurneys.
There's also a section about radiological equipment. There are a lot
of radiologic technologies and equipment that are associated, like
MRI, X-ray, CAT-Scan, bone densitometry, mammography, and ultrasound.
Most of these technologies require the patient to lie on a flat
surface that is part of the equipment. The accessibility issues
related to transfer to the surface are similar to those addressed
under the Examination Tables and Chairs and what we've talked about
before. But because the technology is often integrated into the table,
the table may not be able to be lowered sufficiently. In these cases,
use of a patient lift or another transfer and positioning technique is
particularly important for access to this equipment.
Many radiologic technologies also require the patient to keep still,
which may be very difficult for some individuals with a mobility
disability, including those with spasticity, tremor, or other
conditions. Patients may need a staff person to support them with
pillows, rolled up towels, wedges, or by holding onto them.
Mammography equipment is especially challenging, as those of us who
have had mammography can tell you. Individuals who use wheelchairs
will need to have an exam while staying in the wheelchair. The
mammography machine will need to adjust to their height and
accommodate the space of the wheelchair. People who walk with a
mobility device or who cannot stand for prolonged periods of time may
need to sit in a chair with adequate support, locking wheels, and an
adjustable back and, like people who use wheelchairs, need the machine
to adjust to their height. Additionally, some patients may not be able
to lean forward. But there is a section about that, as well as
accessible scales, and the importance of staff training.
A critical, but often overlooked, component to success is adequate and
ongoing training of medical practitioners and staff.
Purchasing accessible medical equipment will not provide access if no
one knows how to operate it. Staff must also know which examination
and procedure rooms are accessible and where portable accessible
medical equipment is stored. Whenever new equipment to provide
accessible care is received, staff should immediately be trained on
its proper use and maintenance. New staff should receive training as
soon as they come on the job and all staff should undergo periodic
refresher training during every year.
Finally, training staff to properly assist with transfers and lifts,
and to use positioning aids correctly will minimize the chance of
injury for both patients and staff. Staff should be instructed to ask
patients with disabilities if they need help before providing
assistance and, if they do, how best they can help. People with
mobility disabilities are not all the same - they use mobility devices
of different types, sizes and weight, transfer in different ways, and
have varying levels of physical ability. Make sure that staff know,
especially if they are unsure, that it is not only permissible, but
encouraged, to ask questions. Understanding what assistance, if any,
is needed and how to provide it, will go a long way toward providing
safe and accessible health care for people with mobility disabilities.
The Disability Law Lowdown is brought to you by the Disability
Business Technical Assistance Centers, which are a network of ADA
centers that provide training, technical assistance and materials on
the ADA and other disability-related laws. Funding for the centers is
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