Medical File Review

1. Medical File Review APPENDICES 609 and 610 Gary Strokosch, MD Regions 3 and 5 Medical Health Specialist February 28, 2017

2. Goals • Support the success of Job Corps students • Ensure timely and productive file review process • The key components in a medical file review • Early identification and review of applicants with health concerns • Effective communication of review process and recommendations to Regional Office • Identification of when regional health specialist input may be helpful

3. Appendices 609 and 610 History • December 11, 2007 – Direct Threat Assessment Form via Program Instruction 07-16. • July 27, 2011 – Updated and added “Appendix 609 Individualized Assessment of Possible Direct Threat” to PRH via Job Corps PRH Change Notice No. 11-03. • November 16, 2011 – Added new “Appendix 610 Health Care Needs Assessment” to PRH via Job Corps PRH Change Notice No. 11-09. • July 1, 2013 – Revised Appendices 609 and 610 via Job Corps PRH Change Notice No. 13-02 (superseding 11-03).

4. Why Use 609 and 610 Forms? • Ensure recommendation for denial process is standardized and less likely to appear discriminatory. • Includes consideration of reasonable accommodation for applicants with disabilities. • Required forms in the Policy and Requirement Handbook (PRH).

5. Brief Relevant Background • The Only Potential Application Outcomes Are: • Enrollment • Applicant Withdrawal • Recommendations for Denial • New Information about Eligibility • Direct Threat (DT) • Cannot Meet Basic Health Care Needs (HCN) • Refer to more appropriate provider/program outside Job Corps • Consider for an alternate center Appendix 609: Individualized Direct Threat Assessment Appendix 610: Individualized Health Care Needs Assessment Complete within 30 Days!

6. Applicant Withdrawal • The applicant may request to withdraw his/her application. • If the center is unable to reach the applicant to conduct clinically related interviews, or to complete the reasonable accommodation process, then the center, in collaboration with the AC, would document the attempts to contact the applicant and if unable to do so, process the file as a withdrawal.

7. Recommendations for Denial • Two Primary Reasons to Recommend Denial: • Concern that an applicant is at significant risk of harming self or others • Complete the Direct Threat Assessment (Appendix 609) • Belief that Job Corps cannot meet an applicant’s health care needs • Complete the Health Care Needs Assessment (Appendix 610) • Third Reason to Recommend Denial: • New Information About Eligibility (Exhibit 1-1) • Revisit specific Eligibility (Admissions) Requirements (EAR→ER)

8. 609 (DT) Versus 610 (HCNA) Assessments • 609-Direct Threat • JC requires an applicant to not pose a threat to the health or safety of self, other students or staff, e.g. include • Suicidal behavior • Homicidal behavior • Threat of assault • Serious or life threatening medical condition • 610-Health Care Needs • Applicant’s needs exceed Basic Health Care • Frequent hospitalizations • Frequent ER visits • Uncontrolled seizures • Dialysis • Specialized treatment

9. 609 Direct Threat Assessment • Should be completed whenever a center believes that an applicant poses a direct threat to the health or safety of himself or others. • Poses a significant risk of substantial harm to the health or safety of the individual or others; and • The threat cannot be eliminated or reduced by reasonable accommodation or modification. • Assessment conducted by licensed clinician.

10. 609 Form Individualized Assessment of Possible Direct Threat • What is the nature and severity of the potential harm? • What kind of harm is posed? (15 check-boxes) • How serious is the harm? (e.g., death, incapacitation, or major/minor injury) • How long will the risk of harm last? • What is the likelihood that harm will occur? • How soon is the harm likely to occur? • Reasonable accommodation consideration by the DC • Decision Boxes

11. 610 Health Care Needs Assessment • The Health Care Needs Assessment should be completed if there is a concern that the center cannot meet the basic health care needs of the applicant. • The applicant’s health-care needs exceed those of basic care and cannot be met by the center. • The applicant’s health-care needs are manageable at Job Corps as defined by basic health-care services in Exhibit 6-4, but require community supports and services which are not available near center. • Assessment conducted by licensed clinician.

12. 610 Health Care Needs Assessment • An applicant’s health care needs are beyond what the Job Corps Health and Wellness Program can provide (as defined in Basic Health Care, PRH-6: Exhibit 6-4)

13. 610 Four of Six Trigger Factors • Recent ER visits or hospitalization • New diagnosis or recurrence of a condition requiring frequent med adjustments, significant health resources and/or substantial change to the training day • Failure to follow previous Rx recommendations or has followed Rx recommendations without improvement and now requires significant health care management • Applicant’s condition has not been successfully managed in a similar environment in past year

14. 610 Form Individualized Health Care Needs Assessment • Factors that triggered review of file (6 check-boxes) • Applicant’s history and functioning • ETA 653 (N.B. voluntary) • Applicant File Review Summary (available medical records) • CCMP Provider Form (Does the provider recommend applicant entry into JC?) • Applicant Interview Summary (preferable done with DC/HWM) • Functional limitations as barriers to enrollment (18 check-boxes) • Health management needs as barriers to enrollment (10 check-boxes) • Reasonable accommodation considerations if disabled, which parallel the functional limitations above (Disability Coordinator) • Decision boxes (2 check-boxes)…more to follow…7) To follow…

15. Two Item #6 Decision Boxes • Health care needs are manageable in JC, but require community support services which are not available near the center (see next slide). • Health care needs are not manageable in JC (see Exhibit 6-4). Symptoms are at a level that will interfere with successful participation in the program at this time.

16. #6 If Symptoms are Manageable • Required community support services are not available near your center. • Documentation of efforts to arrange for less frequent treatment in home state and/or secure community support near the center is required in question #7 (next slide). • Applicant should be considered for a center closer to home (TBD by Regional Office) where health support and insurance coverage are available.

17. #7 Question on HCNA • This question only gets filled out if health care needs are manageable, but not at your center. • If recommending a different center, document the failed efforts to arrange less frequent treatment in home state and/or secure community support near center. Include the name of the organization or facilities and specific individuals contacted and why access is not available at your center.

18. Scenario Medical Example Appendix 610 Health Care Needs Assessment

19. Appendix 610: Medical Example“Caitlin” • 20-year-old female • In reviewing health documentation, the HWM identifies concerns on the applicant’s Health Questionnaire (6-53) and associated medical documentation • History of significant medical illness: Poorly controlled diabetes with a HGB A1C of 12 • HWM forwards the file to the center physician for review and consideration of completion of a HCNA

20. Poll Question • At this point, what would you do? • Enroll • Recommend denial based on Direct Threat (DT) • Recommend denial based on cannot meet Basic Health Care Needs (HCN) • Call your regional health specialist • Not enough information to answer

21. #1: Triggers

22. #2: History and Present Functioning

23. #2: Continued

24. Poll Question • At this point, what would you do? • Enroll • Recommend denial based on Direct Threat (DT) • Recommend denial based on cannot meet Basic Health Care Needs (HCN) • Call your regional health specialist • Not enough information to answer

25. #2: Call to Primary Provider Re CCMP

26. #2: Call to Primary Provider Re CCMP

27. Do we have enough information yet? • No – We need to consider current functional limitations (symptoms/behaviors) that are barriers to enrollment. and whether accommodation can reduce symptoms.

28. #2: FRT Meeting / Applicant Interview

29. #3: Functional Limitations/Symptoms Barriers to enrollment

30. #4: Health Care Management Needs Barriers to enrollment

31. 605: What is a Disability? • It is a physical or mental impairment that substantially limits one or more major life activities. • A physical impairment is any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more body systems. • E.g., diabetes substantially limits endocrine function. • Reasonable accommodations are changes to the environment or in the way things are customarily done, that gives a person with a disability a opportunity to participate that is equal to the opportunity given to similarly situated people without disabilities.

32. #5: Reasonable Accommodations by Disability Coordinator

33. #5: Reasonable Accommodations

34. #5: Reasonable Accommodations

35. #5: Reasonable Accommodations

36. #5 Reasonable Accommodations

37. #6: Decision

38. #7: If Recommending Different Center

39. The Other Scenario • Student hospitalized 2 months ago due to stopping medication but with interview determine due to homelessness, no access to medications • Call to physician: MD still feels strongly will do well at Job Corps after description of program

40. Contact Your Regional Health Specialist • Anytime you are not sure what to do! • Conflicting data or lack of data – must make best guess – call and talk through options

41. Resources are Available • PowerPoint presentation • Word versions of Appendices 609 and 610 • Sample of completed Appendices 609 and 610 • Appendix 107 – Applicant File Review Guidance – Center Process • Exhibit 1-1: JC Eligibility Requirements