BSAS

Practice Guidance:  Access to Treatment Services 
for Persons with Disabilities

I.  Rationale:  

BSAS Principles of Care establish equitable treatment, responsive to the abilities and needs of the individual, as fundamental to substance abuse treatment.  For persons with disabilities, these principles mean more than prohibiting discrimination and removing physical barriers to entry and navigation of facilities.  Rather, they call for broad efforts to ensure that programs effectively reach, engage and serve persons with disabilities, efforts that are fully integrated into all agency programs and operations. This Practice Guidance addresses these efforts and the role of the Access Coordinator as practice leader in carrying these out.
Research documents high rates of substance use disorders (SUD’s) among persons with disabilities, ranging from 14% among persons with developmental disabilities to 50% among persons with traumatic disabilities, compared to 8.7% prevalence of SUD’s among the general population.  Tobacco use rates are also high:  in Massachusetts 24% of persons with disabilities smoke, compared to 17% of the general population. Excluded from these statistics are persons with disabilities who either have not been identified or assessed or who have not been reached by surveys omitting adaptive technology. SAMHSA estimates that 50% of persons with a substance use disorder and co-existing disability are not identified as such.  These factors can be catalysts of each other:  substance abuse increases risk of injury and disability, and disabilities increase risk of substance use. 
	Persons with disabilities are likely to report both poor health and difficulty in accessing health care.  Care for substance use disorders is no exception.  In a series of studies of access to treatment, as many as 8 out of 10 persons with disabilities who needed substance abuse treatment were unable to access it; and of the 431 treatment centers surveyed in the study year, only 5% of clients had an identified disability.  
	Improvements in rates of identification and treatment for persons with disabilities are important indicators of success in providing equitable, individualized care.  An active, clearly visible Access Coordinator is critical in achieving this success.  BSAS policy defines the Access Coordinator as a member of senior management, that is, serving in a leadership role. In addition to identifying barriers and needed accommodation required, the Access Coordinator:
•	Participates in programmatic, operational and fiscal decisions; 
•	Is knowledgeable about the agency’s clinical programs and administrative operations;
•	Identifies accommodations needed in policies, programs, procedures and methods of communication;
•	Responds to complaints and oversees grievances procedures, and

•	Promotes staff development.  
In other words, an active, knowledgeable and committed Access Coordinator is essential to equitable services for persons with disabilities.

II. GUIDANCE:  

A.  Organization: 
Policy
•	Policy states agency commitment to 
o	Serve persons with disabilities and to ensure that individualized assessments and treatment planning address disabilities; and to
o	Ensure that accommodations are made on by the agency, not by the individual with a disability.
•	Policy identifies Access Coordinator as a key leadership position who participates in decision-making about program design, resource development and finances.
Operations
•	Access Coordinator 
o	Serves in a senior management position;
o	Is knowledgeable about clinical programming as well as physical accessibility;
o	Is responsible for monitoring and reporting on agency accessibility improvements;
o	Is responsible for engaging community resources; and
o	Leads and participates in quality improvement efforts.
•	Agency establishes quality improvement systems to analyze service provision, e.g. to analyze admissions, reasons for discharge and referrals for persons with disabilities or secondary diagnoses.  
•	Agency conducts outreach and maintains links with resources such as Independent Living Centers, advocacy organizations and self-help groups.  
•	Senior management review Massachusetts Facility Assessment Tool annually. 
•	Agency ensures the annual access assessments encompasses:
o	Web and phone systems; 
o	Accessibility of agency procedures, forms and information; and
o	Efficacy of services for persons with disabilities. 
Supervision, Training & Staff Development
•	Agency designs and implements strategy to build a representative work force, including:
o	Targeted recruitment and retention;
o	Clearly defined essential functions of job;
o	Brochures and public information material depicting a diverse work force.
o	Ensuring staff are informed of their own rights in relation to accessibility and accommodation.
•	Workforce development efforts focus on:  
o	Understanding requirements of law, regulation and policies related to access and accommodation;
o	Value of and process for individualized assessment and treatment;
o	Effects of staff attitude and bias on identifying and serving persons with disabilities, and effects of disparate or disproportionate care;
o	Awareness of community resources; 
o	Importance of exploring the meaning of a disability to the individual; 
o	Understanding the culture and experience of disability; and
o	Adapting treatment methods to meet individual needs. 
•	Staff is trained in effective methods of making referrals and following up on referrals, and in making contact and building relationships with other providers, including prescribers.
B.  Service Delivery and Treatment:  
Assessment
•	Staff carefully review information gathered in assessments to identify reported disabilities, as well as indicators such as:
o	Accidents, injuries, combat experience;
o	Special education or poor school history;
o	Hospitalizations
o	Benefits the individual receives (or may be eligible for). 
•	Staff discuss meaning of disabilities with individuals, including:
o	Whether and to what degree the individual views the disability as a limitation;
o	Strengths demonstrated in coping with disability, including resources available from family, friends and community;
o	Losses related to disability, such as functional, life experience, health losses.
•	Staff consult with the individual and Access Coordinator to determine need for accommodations for full integration in treatment programming. 
Treatment Planning
•	Treatment plans describe 
o	The disability and accommodations needed so that the individual can participate fully in treatment;
o	The individual’s preferences in relation to accommodations.
•	Treatment plans describe referrals needed when an assessment indicates possibility of a disability, and record other care providers and plan for care coordination.

Service Provision
•	Services are adapted to individual capacities so individuals participate in an integrated way.
Education Individuals are:
•	Educated about risks related to substance abuse that are specific to persons with disabilities.
•	Provided information about community resources for persons with disabilities.
Transition and Aftercare:
•	Persons with disabilities are linked to ongoing supports such as Independent Living Centers, advocacy groups and primary health care.

III. MEASURES:  

Programs can assess their effectiveness by including specific queries in their data analysis, and by maintaining information about the community served.  Some examples of these related to serving persons with disabilities include:
•	Persons with disabilities participate in design and implementation of these assessments.
•	Management periodically assess program requirements to identify those which constitute (or might constitute) barriers, e.g. requirements for reading, for length of groups, or for performing chores; or aspects of the physical environment such as noise, lighting.  
•	Periodic, scheduled review of records where secondary diagnoses are recorded or where there is indication of undiagnosed disability.
•	Periodic surveys of staff and individuals served.  
•	Collecting and comparing demographic data with treatment population, including information on health disparities in community served.
•	Comparing outcomes or length of stay with characteristics identified in assessment, such as identified disability or special education history.
•	Tracking identification of disabilities in assessment and follow up.
•	Tracking use of assistance such as screen readers, American Sign Language  (ASL) interpreters and Communication Access Realtime Translation (CART).

IV. RESOURCES:  

DPH and BSAS:
Bureau of Substance Abuse Services Policy on Access for Individuals with Disabilities: Describes the authority and rationale, and details policy requirements.
BSAS and Massachusetts Commission for the Deaf and Hard of Hearing partnership:  A joint effort by BSAs and MCDHH to provide ASL and Communication Access Realtime Translation (CART) services for treatment programs and self-help groups (listed on website).  
DPH Office of Health Equity: Provides information and links to a range of resources and services related to health equity and health disparities, including links to Culturally and Linguistically Appropriate Services resources which include models for data collection and surveys.
DPH Healthy Aging and Disability Unit encompasses the Office of Healthy Aging and the Office on Health and Disability. The unit promotes the health and well being of older adults and people with disabilities across the lifespan in Massachusetts.  The ADA Checklist, tools for assessing accessibility, and sample policies are available at the HADU website (http://www.mass.gov/dph/healthyaging) 
The Massachusetts Department of Public Health Contractor Guidelines for Required ADA Compliance Programmatic Access	

Other Massachusetts Resources:  
Department of Disability Services, Adult Services, provides services for adults with intellectual disabilities.  The website includes descriptions of services as well as links to resources for individuals and their families.  
Massachusetts Commission for the Blind provides an array of services for blind individuals.
Massachusetts Commission for the Deaf and Hard of Hearing provides specialized services for individuals, as well as advocacy and technical assistance.
Massachusetts Rehabilitation Commission responsible for Vocational Rehabilitation Services, Community Services, and eligibility determination for the Social Security Disability Insurance (SSDI) and the Supplemental Security Income (SSI) federal benefits programs
Independent Living Programs and Services:  information and links to services supporting independent living, including a list of Independent Living Centers, private, nonprofit, consumer-controlled, community-based organizations providing services and advocacy by and for persons with all types of disabilities. 
Department for Interpreter/CART Services provides a statewide Interpreter and CART Referral Service.
National Resources:
Americans with Disabilities Act:  
Information and Technical Assistance Home Page:  a central link to an array of resources and information
2010 Standards for Accessible Design: Department of Justice regulations and guidelines on accessible design 
ADA Best Practices Tool Kit for State and Local Governments:  Contains helpful information about the role and responsibilities of the Access Coordinator
TIP 29:  Substance Use Disorder Treatment for Persons with Physical and Cognitive Disabilities: http://www.ncbi.nlm.nih.gov/books/NBK14408/
Office of Disability Employment Policy, US Department of Labor: http://www.dol.gov/odep/ Resources and information on building a diverse work force including job descriptions (see: Office of Disability Employment), accommodations, etc.    
Centers for Disease Control accessibility page provides resources and information on disability, health, accommodation, design and statistics.  
National Institute on Disability and Rehabilitation Research (NIDRR): and office of the US Department of Education, NIDRR supports applied research, training and development to improve the lives of individuals with disabilities. 
United States Access Board links page provides information about and links to resources for assistive devices, disability associations (advocacy and self-help), standards, and research.
Information about Assistive Devices: National Institutes of Health, MEDLine Plus
Census:  American Community Surveys:  to assess community composition, get data by zip code on right hand column link http://www.census.gov/acs/www/
World Health Organization: http://www.who.int/topics/disabilities/en/ Resources on classifications of disabilities, ‘e-accessibility’, assistive devices, etc. 
Training:
ADA National Network: A national website and network of 10 regional centers established by the National Institute on Disability and Rehabilitation Research (NIDRR), the network provides information, training (web training, usually free) and guidance.
WINDMILLS ATTITUDINAL TRAINING: Attitudinal training program developed by the California Governor’s Committee for Employment of Disabled Persons. http://www.miltwright.com/products/windmills.htm

FORMS:

Massachusetts Facility Assessment Checklist

BSAS welcomes comments and suggestions.  Contact: BSAS.Feedback@state.ma.us.