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.

How do States Inform Nurses of Their Policies for Mandatory Reporting of Child Maltreatment?

Every state includes nurses as mandated reporters of suspected child maltreatment, and each state has its own law and policy regarding what is reportable and reporting requirements. These differences mean that generic training on child abuse and reporting needs to be augmented by practical state-specific information. In nearly every study of nurses, participants report having inadequate child abuse training. This paper presents an analysis of the information states post on their websites to educate nurses to appropriately identify and report suspected child abuse or neglect. Specifically, this study aims to answer the following questions: (1) how do mandated reporting laws that apply to nurses vary by state, (2) what information do states provide on their child protection and Board of Nursing websites about child maltreatment and mandatory reporting, and (3) what training resources do states make available on their websites to educate nurse mandatory reporters to ably fulfill their obligation? Data on state-by-state practices regarding mandated reporting of child abuse were gathered from the Rape, Abuse, & Incest National Network (RAINN) database, review of state statutes, Child Welfare Information Gateway, Board of Nursing sites, and the Nursing Licensure Compact (NLC) website. This analysis found that states provide little guidance or education about their child maltreatment laws, and few have resources targeted for nurses. Given rising membership in the NLC it is critical for nurses to have education about state specific mandated reporting requirements. States should consider adding mandatory reporting training as a requirement for licensure and for continuing education.

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.

Mandatory reporting for child protection in health settings and the rights of parents with disabilities.

This commentary considers the intersection of mandatory reporting in health settings and the public child protection system's treatment of parents with disabilities. Its impetus is the August 2015 technical assistance document issued jointly by the U.S. departments of Justice (DOJ) and Health and Human Services (HHS) that affirms the applicability of the ADA and Section 504 to child protection system (CPS) processes. The DOJ/HHS document speaks to actions of state child protection agencies and courts, without addressing the first step, mandatory reporting. Nonetheless, there are implications for how mandated reporters understand child risk in the presence of disability, and health settings are one venue where mandated reports initiate. This commentary seeks to provide medical professionals with greater understanding of the CPS process and its intersection with disability rights. It concludes that mandatory reporter training must include ADA principles for addressing disability so parents are not unnecessarily reported for investigation.

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.

Health care under the ADA: a vision or a mirage?

Problems in health care access are identified using recent studies documenting the health disparities experienced by people with disabilities. Some of these health care access barriers qualify as discrimination prohibited under the Americans with Disabilities Act. Focusing on the past decade of ADA enforcement, issues reported in the U.S. Department of Justice listing of resolved ADA complaints and settlements are compared to the profile of access problems. Key court case outcomes of the past decade also are presented. These sources indicate that the majority of resolved complaints and settlements involved failure to provide effective communication (often sign language interpretation). A smaller percentage of complaints and settlements addressed issues of refusal to provide treatment, physical access, equipment access, and provider procedures. Most of the key settlements involved hospitals and larger provider organizations, while many complaints also focused on individual physicians. Although the record indicates that the ADA can be, and has been, effectively used to increase access in many instances, other types of access problems have been lightly addressed through application of the ADA. This likely stems from enforcement choices made by the Department of Justice and the dynamics of the patient-doctor relationship. The broad challenge for the coming decade is to develop means to achieve effective communication and eliminate physical and programmatic barriers in more health care provider settings more consistently. The ADA can be a vigorous force in this effort as part of a multipronged strategy.

The prevalence of disability among children: paradigms and estimates.

Every examination of disability among children must first grapple with definition of disability. The challenges to identifying disability among children involve not only determining the appropriate paradigm for defining disability, but also applying that paradigm to children in a meaningful way. This discussion of the prevalence of disability among children starts by examining the various paradigms utilized to identify disability and how they are interpreted when applied to children. Estimates of the prevalence of childhood disability, under different definitions of disability are presented. The goal of the discussion is to illustrate the sensitivity of the estimates of disability prevalence to the particular definition and data set used. Finally, the potential influence of the choice of paradigm on further measurement and service delivery is outlined.