# Presentation: 202180

## Create a Value Environment

-  Direct Threat
- Why, What, Who and How?

## Why?

- IT IS THE LAW
- Disability nondiscrimination law defines a “direct threat” as a significant risk of substantial harm to the health and safety of the individual or others that cannot be eliminated or reduced by reasonable accommodation or modification
- KEY POINT: the burden of proving “direct threat” is on Job Corps

**Notes:**
This means you:
must have specific, objective evidence to prove that this person poses a direct threat at this time
must assume that no direct threat exists where the evidence is:
equivocal or
insufficient to prove direct threat

## What?

- Factors for Determining “Significant Risk of Substantial Harm”
- Nature and severity of the risk
- Duration of risk
- Likelihood that the potential harm will occur
- Imminence of the potential harm

## What?

- Is the “significant risk of substantial harm” related to a disability?
- If yes, you must consider the availability of any accommodation(s) that would reduce or eliminate the risk
- If no, you do not have to consider accommodation

## What?

- Guiding Principles for Direct Threat Assessment
- Ultimate goal: Determining a specific applicant’s or student’s current ability to safely participate in Job Corps
- Assessment must be individualized
- Specific risk must be identified
- If psychiatric disabilities / conditions involved, must identify specific behavior that would pose threat

## What?

- Threat must be:
- Serious
- Likely to occur (not speculative)
- Allowable considerations:
- Objective factual evidence
- Input from the applicant or student
- Plus, if threat is related to disability or medical condition:
- Most current medical/mental health/substance abuse/oral health knowledge

## What?

- Objective medical evidence, such as:
- Applicant’s medical/mental health/substance abuse/oral heath history
- Opinions of experts
- Opinions of treating providers with direct knowledge of the applicant

## How and Who?

**Direct Threat Process**
- The Health and Wellness Manager does an initial review of the applicant’s health documentation in the file
- Information received  from the applicant or particular responses to the safety and risk questions on the ETA 6-53 indicates that the he/she may have a condition, disability, or behavior that poses a significant risk of substantial harm to the health or safety of the individual or others
- HWM forwards the applicant’s information to the appropriate licensed center health provider for a direct threat assessment
- The direct threat form and guidance has been released as Program Instruction 07-16

## Example 1

- B.C., age 19, is requesting admission to Job Corps
- She provides the following information to the admissions counselor (AC) on the 6-53:
- History of depression, currently in treatment with a community psychologist and on anti-depressant medications
- Hospitalized 3 months ago for suicide attempt (jumped in front of moving car and sustained minor injuries)
- Recent summary from treating provider indicates prognosis as poor

## Example 1 

- Health and Wellness Manager reviews file and forwards to CMHC
- CMHC conducts file review, possible direct threat, determines that interview with B.C. is needed
- Interview indicates that B.C. is currently having acute symptoms of depression, including flat affect, thoughts about death and hurting herself, hypoactive motor movement, tearfulness, and unable to concentrate on questions asked

## Example 1

- Interview also reveals that applicant has history of chronic depression, with 5 previous suicide attempts which required hospitalization within the past two years. Attempts have increased in severity each time. Applicant did not disclose this information during the OA process.
**Does this applicant present a direct threat?**

## What is the nature and severity of the risk?

- The type of potential harm is various types of injury to self (assessment form will list specific facts based on previous attempts - 20 Tylenol pills, severe cuts to the wrist requiring medical attention and hospitalization)
- The severity of the risk is serious with life threatening injuries

## What is the duration of risk?

- How long is the risk likely to last?
- The risk is present as long as the symptoms are acute (including thoughts about death and hurting herself)
- Because symptoms and attempts have continued over two-year period, the risk is likely to continue during entire time B.C. would be in Job Corps program

## What is the likelihood the potential harm will occur?

- The likelihood appears high given the history of previous attempts with increasing severity, recent attempt within the last three months, poor prognosis from treating provider, and results from current interview with the CMHC

## What is the imminence of the potential harm?

- How soon is the harm likely to occur?
- Unable to definitively answer, but due to history, current mental health status with thoughts of death/ hurting herself, and poor prognosis from treating provider, applicant may be vulnerable to a repeat suicide attempt at any time

## Is there a direct threat?

- Review of factors:
- Nature and severity: Various types of serious/life-threatening injury to self
- Duration: During entire time, B.C. would be enrolled in Job Corps
- Likelihood: High
- Imminence: At any time (immediate)
- Conclusion: Direct threat does exist

## Reasonable accommodation consideration

- If there is a direct threat, are there accommodations that might alleviate or reduce the threat?
- Process
- List possible accommodations
- Determine if each is likely to reduce threat
- If so, Center Director will conduct undue hardship analysis to determine reasonableness

## Possible Accommodations Considered

- Possible accommodation: Allow applicant to shorten training day to attend off center appointments with treating providers
- Will it reduce risk to acceptable level?
- Not at this time. It may take weeks for treatment with providers to produce improvement, lessen B.C.’s suicide risk

## Possible Accommodations Considered

- Possible accommodation: Provide intensive monitoring by staff, particularly after the training day
- Will it reduce risk to acceptable level?
- Possibly: constant monitoring could result in staff intervention before B.C. harms herself
- Because risk reduction is possible, Center Director must conduct undue hardship analysis

## Possible Accommodations Considered

- Possible accommodation: Consider factors listed in “undue hardship” definition in WIA nondiscrimination regs – largely cost-related
- If CD determines that constant monitoring would cause undue hardship, he/she must provide written statement of reasons for reaching that conclusion
- In this case, statement of reasons should indicate that no alternate accommodations would reduce risk level

## Conclusion

- Review of factors indicates that direct threat of harm to self exists
- Consideration of possible accommodations indicates that no accommodation that might reduce the risk is reasonable
- Therefore, B.C. will be recommended for denied admission at this time, based on direct threat

## Example 2

- K.C., age 19, is requesting admission to Job Corps and is conditionally assigned to a center.  During file review at the center, the following information is found:
- History on 6-53 - diabetes, asthma, depression, PTSD, and bipolar disorder
- Reports being sexually molested between the ages of 9-12
- Has been between 7 foster homes

## Example 2

- Current Meds – wellbutrin, trazedone, zoloft, insulin
- Treating providers indicate applicant is stable, needs to remain on medications and is able to come to Job Corps
- Center is concerned about “multiple medical and psychiatric issues” that are unidentified.
**Does this applicant present direct threat?**

## Example 2 - Conclusion

- Review of factors indicates that file contains no specific facts on which to base a direct threat determination
- Therefore, center may not recommend denial for K.C. based on direct threat

**Notes:**
What are some examples of accommodations that may reduce or eliminate direct threat?
As part of the focus on individualized assessment, it would depend on what the risks, safety concerns, or behaviors are? Let’s look at an applicant who has PTSD and reports being startled easily, which results in aggressive behavior.
Signs posted on dorm door please knock & try not to disturb 
Wear headphones to reduce noise 
Allow student to take a break and go to a place where s/he feels comfortable to use relaxation techniques
Sit at back of class where no one can come up behind  
Use a sensor mat, which will make an audible alert when someone steps on it. 
Sensitivity training for students and instructors

## Let’s Review

- What are the guiding principles for direct threat assessment?
- The ultimate goal of a direct threat assessment is to determine a specific applicant’s or student’s current ability to safely participate in Job Corps
- The assessment must be individualized and the specific risk must be identified
- If psychiatric disabilities/conditions are involved, you must identify specific behavior that would pose threat

## Let’s Review

- The threat must be serious and likely to occur (not speculative), not based on assumptions or stereotypes.
- The law makes clear that an individual does not pose a direct threat simply because he/she has a history of psychiatric disability, or is currently receiving treatment for a psychiatric disability.

## Let’s Play Jeopardy!

## Slide 28

| Minneapolis | Direct Threat | Region 5 |
| --- | --- | --- |
| 100 | 100 | 100 |
| 200 | 200 | 200 |
| 300 | 300 | 300 |
| 400 | 400 | 400 |
| 500 | 500 | 500 |

- This is the size of 78 football fields ---
- 9.5 million square feet.** **

## Mall of America

## Name two inventions created in Minneapolis.

## Inventions from Minneapolis 

- Inventions from Minneapolis

- 3M's Post It Notes and cellophane tape
- Cream of Wheat
- Totino's Frozen Pizza
-  Green Giant Vegetables
- Tonka Toys
- Rollerblades

## Minneapolis has more golfers per capita than any other city in the country.  

- Minneapolis has more golfers per capita than any other city in the country.
- True or False?

## True

## How many lakes exist within the city limits and afford Minneapolis the nickname 

- "City of Lakes?”

## 22

## Minneapolis was the location for 

- what famous movie by Prince and what famous sitcom in the 70’s about a career-oriented all American girl?

## Purple Rain

- Mary Tyler Moore Show

## Will centers be able to request additional information regarding a student’s current mental health?

## Yes, if the needed information is medically necessary information for the center to make a determination, then they may request additional information.  

- The request for information cannot be based upon “suspicions” or be a “fishing expedition.”

## What happens if DT situation occurs after student is on center? 

## For current students, an assessment may be conducted at anytime where there is a reasonable belief based on objective evidence that the student may have a condition, disability, or behavior that poses a direct threat.

- If the CMHC or health provider is not available to do a direct threat assessment or the situation is life threatening, the center should follow their SOP/COP for these situations and send the student to the nearest emergency room or contact local law authorities.

## Who can do direct threat assessments?

## Licensed health providers 

- Physicians
- Nurses
- CMHC
- TEAP
- Dentists

## What is an example of DT at center level that is not a disability? 

## Student has behavior problems that result in fighting, intimidation or threatening of students/staff but does not have a disability related to the behaviors.

## Name 4 factors in a direct threat assessment.

- Nature and severity of the risk
- Duration of risk
- Likelihood that the potential harm will occur
- Imminence of the potential harm

## How would the center document/deal with an individual who is self-injurious (cuts themselves) who has not disclosed the issue but it is obvious from marks on the

- body?

## There is a need to conduct a full assessment in order to determine if direct threat exists BUT, you would need more information in this scenario because there are different reasons for individuals who cut themselves — some who cut to relieve anxiety and others who cut in attempt to commit suicide.

- Name five centers in region 5.

## Region 5 Centers

- Paul Simon
- Atterbury/Indypendence
- Cleveland
- St. Louis
- Dayton
- Denison
- Detroit
- Pine Ridge
- Golconda

- Blackwell
- Cincinnati
- Flint-Genesee
- Excelsior Springs
- Mingo
- Joliet
- Flint Hills
- GR Ford
- HH Humphrey

## How many centers are there in Region 5?

## There are 18 centers.