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Caring for patients with disabilities

How to stay compliant with ADA guidelines while treating patients with disabilities


Caring for patients with disabilities

How to stay compliant with ADA guidelines while treating patients with disabilities


By Emily Margosian, assistant editor

In July 2020, the Americans with Disabilities Act (ADA) celebrated its 30th anniversary. Its passage is attributed to years of activism from disability rights advocates, and the landmark piece of legislation protects nearly 40 million Americans currently living with a disability (MMWR. 2016; 65(38); 1021-1025).

However, despite accounting for over 12% of the United States’ population, individuals with disabilities often experience poorer health outcomes due to stigmatization and lack of access to both basic and specialized care. In turn, physicians may be unprepared or uncomfortable treating disabled patients, and feel overwhelmed at the often-complex regulations surrounding their care.

This month, DermWorld consults with legal, compliance, and disability rights experts for advice on treating patients with disabilities in accordance with federal regulations. 

What does the law say?

According to Rachna Chaudhari, MPH, AADA director of practice management, some of the most common questions the Academy’s practice management staff receive involve how practices should comply with the complex rules regarding patients with disabilities.

The Americans with Disabilities Act (ADA) is a comprehensive federal civil rights law designed to ensure equal access and protection for individuals with disabilities. Under the ADA, medical practices are considered public accommodations and are therefore required to ensure that their products and services are equally accessible to patients with qualified disabilities. This includes full access to the office space, exam rooms, medical equipment, and practice website.

Regardless of the type of payment accepted, all practices must comply with ADA requirements, explained Rob Portman, JD, MPP, a health care attorney with Powers Pyles Sutter & Verville in Washington, D.C., and general counsel for the AAD/A. “The ADA is not tied to Medicare or Medicaid, so it doesn’t matter whether a physician practice accepts payment from these programs — it must comply with the ADA as a public accommodation.”

Additionally, Section 504 of the Rehabilitation Act states that public accommodations and state entities are required to provide American Sign Language interpreters, and other auxiliary aids, to ensure effective communication with deaf and hard of hearing individuals.

Get ADA compliance help

Visit the AADA Practice Management Center for more resources to help dermatologists understand and comply with the requirements of the ADA.

Adjustments to the clinical space

As a “public accommodation” under the ADA, dermatology practices must be prepared to provide service and access to people with disabilities on an equal basis with the rest of the public. As per the law, “regulations require that architectural and communication barriers that are structural must be removed in public areas of existing facilities where their removal is readily achievable,” — in other words, “carried out without much difficulty or expense.” However, the law does not define precisely how much effort and expense are required for a facility to meet its obligation.

To assess their current level of compliance, practices can consult the following checklist to identify accessibility problems and solutions in order to meet their ADA obligations:

Accessible approach/entrance

Is there a route of travel that does not require the use of stairs?

Is the route of travel slip-resistant?

Is the route at least 36 inches wide to accommodate wheelchairs?

Can objects protruding into the circulation paths be detected by a person with a visual disability using a cane?

Is there an adequate number of accessible parking spaces available? Are there designated parking spots near the accessible entrance?

Access to goods and services

Does the accessible entrance provide direct access to the main floor, lobby, or elevator?

Are accessible routes and doors to all public spaces at least 36 inches wide to accommodate wheelchairs?

Is there a 5-foot circle or a T-shaped space for a person using a wheelchair to reverse direction?

Do signs and room numbers feature brailled text of the same information?

Access to restrooms

Is at least one public restroom (either one for each sex or unisex) fully accessible?

Is there tactile signage identifying restrooms?

Does the restroom doorway have at least 32 inches of clear width?

Staff training

Are all staff trained in compliance with appropriate measures that welcome patients with disabilities, such as compliance with “auxiliary aids and services?” Basic disability awareness training helps staff interact in a relaxed manner.

Visit the ADA website for a more comprehensive checklist.

Service animals in the office?

Learn more about ADA requirements for service animals and which species qualify. 

Basic care considerations for patients with disabilities

While compliance with the ADA and other federal regulations may be at the forefront of many physicians’ minds when treating patients with disabilities, Marsha Saxton, PhD, director of research at the World Institute on Disability, and lecturer in disability studies at the University of California, Berkeley, emphasizes the importance of stepping beyond the law when providing quality care to these patients.

“My concern about starting with the law is that the best way to learn and understand accommodating people with disabilities is through relationships. When you know people who use wheelchairs, or have cognitive disabilities or hearing impairment, the rules make sense in context of people’s lives. Just focusing on the law makes people think it’s all about not getting sued,” she said. As an advocate for increased education in treating patients with disabilities, Dr. Saxton says that disabled peoples are often undercounted and thus ignored or excluded in daily life. “Everybody has someone in their family with a disability. Somewhere between 15-20% of the global population is covered by disability law. If physicians have that broader picture, it becomes much easier in terms of complying with the law and providing the best quality care.”

Communication: Ask and listen

While physician-patient communication can prove challenging during any patient visit, dermatologists need to be particularly mindful when treating patients with disabilities. “Often it’s very common for the physician to be nervous, particularly if they’re treating someone with a disability they haven’t encountered before. They’re going to be tense, and not know what to do or say,” explained Dr. Saxton. “What physicians need to do is rely on the patient as an expert and ask questions. Do not assume you know, because you don’t. That person is an expert in dealing with the sometimes-awkward interactions with non-disabled people who are unfamiliar with their disability.”

Dermatologists should also take time to clearly communicate each aspect of the visit — what they are doing and why — particularly if it involves a close physical exam. “It’s a very charged area, because of the need for personal assistance or clothing removal. There’s a very high rate of sexual abuse among children with disabilities, just because access is easy, and physicians must take care to not be thoughtless,” said Dr. Saxton. “The patient may be anxious and/or confused, and may not be able to adequately communicate everything they want and need. Adequate time is needed for that physician to establish some degree of rapport, to explain what they are doing, and perhaps have another person as an assistant.”

Caregiver etiquette

If a patient does bring a caregiver or assistant with them to their appointment, physicians should keep the patient as their primary focus when communicating, advised Dr. Saxton. “A bad habit in the broader culture is that the companion or caregiver will be ascribed the role of a guardian, which is profoundly patronizing and insulting to that disabled person who can likely speak for themselves. This turns up in medical settings as well, with the assumption being that the person accompanying the patient is in charge of that person, and again, sets up the rapport to be very awkward. The physician and the staff have to pay attention to the dynamic.” At the same time, according to Portman, if a parent or guardian who accompanies a patient to an office visit requests an accommodation for a disability, the ADA requires the physician to honor that request or provide an accommodation that will meet the ADA accessibility standards.

Time

According to Dr. Saxton, allowing adequate time to see patients with disabilities is an essential accommodation, and critical to quality care. “In the case of someone who needs assistance with undressing or transferring from a wheelchair to the exam table — or someone with a communication impairment, maybe they’re deaf or have a cognitive disability — the physician needs to figure out how to have time to make the communication work. In fact, studies are showing that hearing-impaired people are the least well-served in medicine because that communication is so important to everything — from diagnosis, to functional issues, to treatment,” she said. “That deaf or mobility-impaired person who requires assistance is entitled by law to have appropriate accommodation, including enough time.”

Training staff

From the front desk to the exam room, preparing staff to anticipate and accommodate disabled patients is also a key care consideration for practices. Dr. Saxton suggests incorporating language about any potential accommodations during the appointment-making stage. “People with disabilities sometimes forget to say, ‘I need someone to help me onto the exam table,’ or ‘I’m bringing a friend, or I need an interpreter.’ Have the receptionist who’s doing the scheduling ask that question. They can then communicate that to the nurse or the physician so that everybody knows what’s happening and is aware of what changes are necessary in addressing this patient.”

Interpreter services for deaf or hearing-impaired patients

Both the ADA and HHS under Title VI of the 1964 Civil Rights Act require practices to ensure that staff can communicate with patients by providing interpreter services to the patient free of charge. “Physicians have been legally liable in cases where they did not offer to pay for interpreter services for patients with hearing and speech disabilities,” said Chaudhari.

All practices are expected to comply. While HHS has stated that physicians can use a variety of tools to communicate with disabled patients, including handwritten notes or telephonic translation services to communicate with deaf patients, physicians must work with patients to ensure that the form of communication allows for equal accessibility to the information being provided. “In practice, if patients want an interpreter, a practice may need to accommodate that request to avoid being the subject of litigation,” said Portman. While Medicare will not reimburse for interpreter services, Chaudhari recommends that dermatology practices reach out to private insurers as some contracts will reimburse for these services. If not, practices could consider building this service into their budgets.

Physicians should be aware that they may not charge the patient for the cost of interpreter services. Additionally, the ADA prohibits practices from dismissing patients on the basis of their disability.

Website accessibility

While most dermatologists are familiar with ADA’s physical accessibility requirements for their office, some may be unaware that ADA standards also apply to their practice websites. “While the internet as we know it today did not exist when the ADA was enacted in 1990, several courts and the U.S. Department of Justice have interpreted the ADA’s accessibility requirements to apply to websites of public accommodations,” explained Portman in his September 2019 Dermatology World Legally Speaking column. “Given that the internet is increasingly becoming a popular mode of communications among doctors and patients, it is essential that your practice ensure that its website is accessible to individuals with disabilities.”

Often trouble arises when medical practice websites are incompatible with assistive technology, such as screen recognition software or screen readers. Blind individuals, for example, may struggle with PDF documents, as the format is incompatible with most text-based screen readers. To avoid alienating or denying services to disabled patients, dermatology practices should at minimum consider:

  • Adding written captions/text equivalents to every image
  • Posting documents in text-based formats
  • Structuring the website to allow users to alter the color and font size through their web browser
  • Including captions on any videos
  • Including an accessibility statement on how patients can request information in a compatible format

“Unfortunately, there is no clear guidance available for establishing ADA compliance for websites,” said Portman. “The safest way to comply with the ADA is to ensure that your website meets the applicable Web Content Accessibility Guidelines (WCAG).” While WCAG guidelines are not explicitly required under the ADA, they can provide a safe harbor for website accessibility. Learn more about WCAG guidelines here.

Failure to take action may result in a complaint letter — and serious legal consequences. “There is a cottage industry of attorneys seeking to sue practices for non-compliant websites,” warned Portman. “In the event you are contacted with concerns about your website’s accessibility or a demand letter, we recommend taking the complaint or demand letter seriously and speaking with an attorney with ADA expertise as quickly as possible.”