Change Is Slow: Acquisition of Disability-Accessible Medical Diagnostic Equipment in Primary Care Offices over Time.

Introduction: The lack of disability-accessible medical diagnostic equipment (MDE) in primary care impedes the receipt of quality medical care by people with mobility impairments. Cross-sectional surveys and observational studies have found <40% of medical offices have disability-accessible examination tables or weight scales. Although government agencies and advocates recommend primary care acquisition of the accessible MDE, the rate of acquisition is unknown. Methods: Using panel data, the research examined if primary care offices audited for disability accessibility increased accessible examination table and scale presence between the first and second audit. Data for 2006-2009 (Time 1 [T1]) and 2013-2016 (Time 2 [T2]) came from 1293 primary care practices associated with Medicaid managed care organizations. Permutations of presence or absence of a height-adjustable examination table and accessible weight scale were analyzed to assess rate of change across time periods. Results: More practices had disability-accessible examination tables or weight scales at the second observation, although total presence was low (12.9%, 7.9%). Practices added equipment between time periods; however, ∼60% of practices with accessible MDE at T1 no longer had it available at T2. Discussion: The acquisition rate of accessible MDE was low, despite prior auditing. Studying change in accessible MDE presence in primary care offices requires attention to equipment acquisition and its retention. Health Equity Implications: Stronger federal enforcement of Medicaid and Americans with Disabilities Act (ADA) access requirements, with regular standardized auditing of medical office accessibility, may be required to produce a more equitable health care experience for disabled people.

Accessible medical diagnostic equipment in primary care: Assessing its geographic distribution for disability equity.

BACKGROUND: Height adjustable examination tables, accessible weight scales, and lifts for transferring individuals on/off examination equipment enable delivery of equitable health care to persons with mobility impairment. Because most Medicaid-covered patients must utilize a managed care network, network providers with accessible medical diagnostic equipment (MDE) at proximate locations for travel time and distance are necessary. Network density and distribution of accessible MDE has not been studied. OBJECTIVE: This descriptive research examined geographic network adequacy by comparing the density of persons with mobility impairments and location of Medicaid managed care practices with accessible MDE in Los Angeles County. METHODS: Medicaid managed care practices with MDE were mapped by ZIP Codes shaded to indicate the number of persons with mobility impairment. Zero-inflated negative binomial regression examined ZIP Code population characteristics as potential predictors of accessible MDE presence. Data sources were: (1) 2013-2016 primary care facility audit of Medicaid managed care network providers in LA County, aggregated by ZIP Code, and (2) LA County ZIP Code characteristics from the 2016 American Community Survey. ArcGIS was used for mapping and MPlus for the regression analysis. RESULTS: No consistent association between the size of the mobility limited population, demographic characteristics, and presence of accessible MDE was observed or measured by regression. The observed low MDE density suggests network adequacy likely is not achieved in LA County. CONCLUSIONS: Actions by state and federal agencies are necessary to increase accessible MDE and network adequacy by enforcing existing non-discrimination law and Medicaid regulations.

The Impact of Nurse Delegation Regulations on the Provision of Home Care Services: A Four-State Case Study.

The objective of this study was to explore how home care workers and the agencies that employ them interact with their state's nurse practice act in the provision of care. Using a qualitative case study approach, we selected four states with varying levels of restrictiveness in their nurse delegation regulations. We conducted interviews (N = 45) with state leaders, agency leaders, and home care workers to learn how these policies affect the home care workforce's ability to perform care tasks for their clients in order to allow clients to remain in their own homes. We found that increased training and input from registered nurses is needed to identify appropriate health maintenance tasks to delegate to home care workers and support development of training strategies. The federal government could support the development of evidence-based guidelines for training and competency testing as well as for appropriate delegation of health maintenance tasks.

Can disability accommodation needs stored in electronic health records help providers prepare for patient visits? A qualitative study.

BACKGROUND: Embedding patient accommodation need in the electronic health record (EHR) has been proposed as one means to improve health care delivery to patients with disabilities. Accommodation need is not a standard field in commercial EHR software. However, some medical practices ask about accommodation need and store it in the EHR. Little is known about how the information is used, or barriers to its use. This exploratory-descriptive study examines whether and how information about patients' disability-related accommodation needs stored in patient records is used in a primary health care center to plan for care. METHODS: Four focus groups (n = 35) were conducted with staff of a Federally Qualified Health Center that asks four accommodation questions at intake for the EHR. Respondents were asked how they learned about patient accommodation need, whether and how they used the information in the EHR, barriers to its use, and recommendations for where accommodation information should reside. A brief semi-structured interview was conducted with patients who had indicated an accommodation need (n = 12) to learn their experience at their most recent appointment. The qualitative data were coded using structural coding and themes extracted. RESULTS: Five themes were identified from the focus groups: (1) staff often do not know accommodation needs before the patient's arrival; (2) electronic patient information systems offer helpful information, but their structure creates challenges and information gaps; (3) accommodations for a patient's disability occur, but are developed at the time of visit; (4) provider knowledge of a regular patient is often the basis for accommodation preparation; and (5) staff recognize benefits to advance knowledge of accommodation needs and are supportive of methods to enable it. Most patients did not recall indicating accommodation need on the intake form. However, they expected to be accommodated based upon the medical practice's knowledge of them. CONCLUSIONS: Patient accommodation information in the EHR can be useful for visit planning. However, the structure must enable transfer of information between scheduling and direct care and be updatable as needs change. Flexibility to record a variety of needs, visibility to differentiate accommodation need from other alerts, and staff education about needs were recommended.

Presence of Accessible Equipment and Interior Elements in Primary Care Offices.

Purpose: To describe the disability accessibility level of primary care office interiors and the presence of accessible examination equipment. Methods: Data from on-site audits of 3993 primary care offices in California for 2013-2016 are descriptively analyzed. Architectural access is assessed using an instrument based on ADA Accessibility guidelines (ADAAG), along with noting accessibility of examination equipment. Results: Compliance across architectural elements was ∼85%. Accessible examination tables and scales were observed in 19.1% and 10.9% of offices, respectively. Conclusions: Proactive accessibility auditing makes visible the infrequent presence of accessible examination equipment. It offers data for tracking progress to increase medical office disability access.

Physical accessibility in primary health care settings: results from California on-site reviews.

BACKGROUND: People with disabilities report physical barriers in doctors' offices that affect the quality of care. Whether most or few doctors' offices are accessible is not known. We address this gap with data on 2389 primary care provider facilities. OBJECTIVES: The analysis seeks to describe overall primary care office physical accessibility and identify (1) in which areas offices meet access criteria, (2) which accessibility criteria are most often not met, and (3) whether there are urban/non-urban differences. METHODS: Reviewers rated medical offices using a 55-item instrument that assessed parking, exterior access, building entrance, interior public spaces, doctor's office interior, and the presence of accessible exam equipment. Five health plans that serve California Medicaid patients conducted reviews of providers signed with their plans. Data from the plans were merged, coded, and a descriptive analysis conducted. RESULTS: An accessible weight scale was present in 3.6% and a height adjustable examination table in 8.4% of the sites. Other high prevalence access barriers were in bathrooms and examination rooms. Parking, exterior access, building access, and interior public spaces generally met the access criteria, except for van accessible parking. CONCLUSIONS: These findings provide a base for quantitative expectations about accessibility nationwide, and indicate significant barriers exist. They show it is possible to conduct a large number of accessibility site reviews, providing one model to meet the Affordable Care Act requirement for provider accessibility information. Physical access is important as it may affect the quality of care and willingness of patients to engage in preventive care.

Achieving accessible health care for people with disabilities: why the ADA is only part of the solution.

People with various disabilities encounter numerous physical and programmatic barriers to receiving health care of equal quality and effectiveness as that received by people without disabilities. Litigation and settlement negotiations under such federal laws as the Americans with Disabilities Act of 1990 have resulted in the removal of access barriers in specific instances, but have not yet resulted in the kind of systemic change needed in the health care delivery system. This article analyses some of the factors that make accessible health care so difficult to achieve. Accessible health care is viewed through a public health lens by which changes in public policy and social views of disability are necessary for achieving sustainable long-term success. The advantages and disadvantages of judicial policy making in the analogous contexts of tobacco cessation and Title VI medical discrimination in the United States is briefly discussed. The powerful but blunt tool of litigation is analyzed as only one tool among an array of public policy and legislative tools needed to effect barrier removal in the field of health care, especially among the smaller provider clinics and practices where a majority of outpatient visits take place. Lawsuits and other policy tools, such as enacting further legislation to link accessibility standards to federal agency enforcement, creating federally funded technical assistance centers that will disseminate practical policy and procedural tools to providers, and mandating the gathering of disability-specific disparities and effectiveness data, must work in concert to transform our health care system.