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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 provided by a grant from NIDRR, the National Institute on Disability and Rehabilitation Research. You can subscribe to the Disability Law Lowdown at our Web site at DisabilityLawLowdown.com or on iTunes.



The Southwest and Rocky Mountain ADA Centers are part of a program of Independent Living Research Utilization at TIRR - Memorial Hermann in Houston, Texas, and is funded by the National Institute on Disability and Rehabilitation Research. If you have questions about disability law or would like to request materials or training, please call 1-800-949-4232. This podcast is protected by the Creative Commons Attribution Non-Commercial No-Derivative-Works 2.5 License. For more information and transcripts, visit www.ada-podcast.com.