Accessible Healthcare: Rights and Responsibilities under the Americans with Disabilities Act

Michael Richardson, MPA

Learning Objectives

•	Learn about the resources available through the ADA National Network
•	Understand the basics of the Americans with Disabilities Act (ADA) and how it applies to healthcare  
•	Understand the requirements of ‘effective communication’ and physical access in healthcare facilities and programs

Where are the ten regional ADA Centers located?
Located throughout the United States in order to meet the specific needs of their regions.  

Congressional Purpose of ADA
"The purpose of the ADA ... is to provide a clear and comprehensive national mandate to end discrimination against individuals with disabilities and to bring those individuals into the economic and social mainstream of American life." 

 - A CIVIL RIGHTS ACT!
Who and what does the ADA cover?
Title I - Employment 
Title II - State and Local Governments and Transportation 
Title III - Public Accommodations (“Businesses”) 
Title IV - Telecommunications 
Title V - Miscellaneous 
Federal Disability Discrimination Laws
Title II of the Americans with Disabilities Act – applies to all public (state and local) healthcare providers.
Title III of the Americans with Disabilities Act – applies to all private healthcare providers.
Section 504 of the Rehabilitation Act of 1973 – applies to federal healthcare services and facilities; and healthcare providers who are also recipients of federal financial assistance, (such as federal Medicaid funds) or by federal research grants.  

How does the ADA view “aging?”
Some age-related impairments will meet the ADA definition of disability, others will not.

What makes a physical or mental impairment a disability under the ADA is that it:
•	Substantially limits one or more major life activities, or
•	There is a record of such an impairment, or
•	The individual is regarded as having an impairment.

Healthcare Providers under Title III
Hospitals, nursing homes, psychiatric and psychological services, offices of private physicians, dentists, health maintenance organizations (HMOs), and health clinics are included among the healthcare providers covered by the ADA. 

Common Scenario
One woman with low vision reported that she learned only after years of taking her thyroid medication at dinnertime that taking the medication with food weakened the drug’s effects, which may have compromised her treatment.
Effective Communication
Disabilities that affect hearing, seeing, speaking, reading, writing, or understanding may use different ways to communicate.

Information must be as clear and understandable to people with disabilities as it is for people who do not have disabilities. 

Effective Communication
Health care providers have a duty to provide appropriate auxiliary aids and services when necessary to ensure that communication with people with disabilities is as effective as communication with others.  
28 C.F.R. § 36.303(c)
Effective Communication

“Auxiliary aids and services” are devices or services that enable effective communication for people with disabilities.

Effective Communication: Who?
Customers, clients, and other individuals with disabilities who are seeking or receiving the services of the medical center.

May not always be "patients" of the healthcare provider – Auxiliary aids and services may need to be provided to spouses, partners, family members, etc. with disabilities.
Effective Communication
The means used to provide effective communication is determined on a case-by-case basis – person’s needs and situation.

Consult with the individual to determine what communication method or technology will be effective for him or her.

People with Visual Impairments
People with visual impairments often receive important health care-related information in standard print, which they can’t read. 

People with Visual Impairments
medical exam, test, and lab results
information explaining diagnoses or treatment 
prescription medication instructions
explanations of informed consent or end-of-life policies and procedures
physical therapy instructions and instructions for the management of chronic conditions
childbirth preparation resources, prenatal care materials

Visual Impairments
Where information is provided in written form, ensure effective communication for people who cannot read the text.
•	Consider the context,
•	the importance of the information,
•	the length, and
•	complexity of the materials.

Communication - Print materials
•	Alternative formats - Braille, large print text, electronic format, audio recordings. 
•	If little time to have it produced in an alternative format, reading the information aloud may be effective (Qualified Reader).
•	Example – reading what services you provide, etc.

Common Scenario
Confidentiality Issues

Individuals with vision loss report feeling frustrated and embarrassed after being forced to reveal their confidential financial information or details about highly personal and private physical and mental health concerns out loud in public, in front of strangers.

Common Scenario
Deaf woman giving birth: Her partner, who is also deaf, was also not provided an interpreter. He also was excluded from the delivery room during the birth because woman’s mother (who was attempting to provide basic ASL interpretation to her daughter) was counted as complainant’s choice of “companion” during the birth.

Cognitive Disabilities
•	Allow plenty of time to teach a new task.
•	Use repetition with precise language and simple wording.
•	Treat adults as adults and children as children. 
•	Do not pretend to understand if you do not. 

Cognitive Disabilities
•	Ask additional questions to clarify any information a patient may be sharing with you.
•	Reduce distractions.
•	Use pictures or objects to convey meaning, if appropriate.
•	Allow a “wait time” for the patient to process information or respond to a question or to make a comment.

Auxiliary Aids and Services for Individuals who are Deaf of Hard of Hearing
•	qualified interpreters 
•	note-takers 
•	written materials 
•	assistive listening systems/devices 
•	captioned media, transcripts, etc. 
•	Communication Access Real-time Translation (CART)
•	exchange of written notes

Communication - Simple situations
•	Brief or simple face-to-face exchanges - very basic aids are usually appropriate and effective. 
•	For example, exchanging written notes may be effective when a person asks for a copy of a form to fill out. 
•	Using a “smart phone” to write and exchange messages.

Communication - Complex situations
•	Complex or lengthy exchanges
o	an interpreter (sign language, oral, cued speech) or 
o	CART (Communication Access Real-time Translation)
•	Examples – interviews, counseling sessions, community events, meetings, etc.
•	Written transcripts or captions on video for pre-scripted situations such as speeches, presentations, etc.

Communication Access Realtime Translation
For individuals with significant hearing loss but do not rely on sign language for communication and who have good levels of reading comprehension, the appropriate auxiliary aid or service is usually the use of transcription services, such as Communication Access Realtime Translation (CART).  28 C.F.R. § 35.104. 
Undue Burden and Fundamental Alteration
•	The ADA does not require the provision of any auxiliary aid or service that would result in an undue burden or in a fundamental alteration in the nature of the goods or services provided by a health care provider.  

•	An individualized assessment is required to determine whether a particular auxiliary aid or service would be an undue burden.  
“But it Costs too Much!”
•	A health care provider is expected to treat the costs of providing auxiliary aids and services as part of the overhead costs of operating a business.  

•	As long as the provision of the auxiliary aid or service does not impose an undue burden on the provider’s business, the provider is obligated to pay for the auxiliary aid or service.
Accessible Exam Rooms, Chairs, and Medical Diagnostic Equipment

Common Scenario         
A woman with a significant disability, and a wheelchair user, was not able to get routine reproductive healthcare services due to physical and attitudinal barriers. Subsequently, she was discovered to have advanced endometrial cancer only after significant symptoms warranted attention.

U.S. Access Board
•	Clear floor space
•	Adjustable exam table
•	Space to assist with transfers
•	Floor space 
•	Accessible route 
•	Accessible entry
•	Maneuvering clearances at entrance

Accessible Medical Diagnostic Equipment
•	Examination Tables and Chairs
•	adjustable transfer surface height
•	transfer surface size
•	support rails
•	armrests
•	space for floor lift

Accessible Medical Diagnostic Equipment
•	Mammography equipment
•	breast platform height
•	space for approach
•	knee and toe clearance

Accessible Medical Diagnostic Equipment
•	Weight scales
•	minimum space for wheelchair
•	ramps
•	edge protection
•	support rails

Resources
•	Regulations, appendices, standards are available at DOJ’s ADA web site at  www.ada.gov 

For answers to specific questions, DOJ toll-free ADA information line:  
	800-514-0301 

•	U.S. Access Board www.access-board.gov

Contact the ADA National Network
Telephone
800-949-4232 
Website
ADAta.org