# Presentation: 673352

## APPLICANT FOLDER REVIEW 101

- David P. Kraft, MD, MPH
- Regional Mental Health Consultant
- Boston Region Health and Wellness Conference
- September 27, 2006

## 1. Regional Medical Review Process

- Admissions Counselors and center staff raise questions about whether eligible applicants are appropriate
- Center medical and mental health teams seek to allow equal access for all applicants into Job Corp and develop appropriate accommodations, when applicable
- The teams only raise questions when applicants do not appear to meet the additional factors for selection and enrollment as outlined in PRH 1.2 (education and training best met by JC, can use group training without threatening behavior, able to follow rules), “direct threat” as defined in Appendix 103, or when accommodations seem unreasonable.

## 1. Regional Medical Review Process (continued)

- Regional health consultant reviews questions about applicant appropriateness and accommodations (Table 1 shows number of charts reviewed by Region for past 6 years)
- Admissions Counselors can help expedite the review and should be familiar with the updates to PRH 1.2 and new Appendix 104, “Admission Counselor Guide for Evaluating Applicant Behavior and Court History”

## Table 1. MH Chart Review Boston and New York Sub-Regions, July 2000-June 2006 (PY00 to PY05)

- 1.  Recent increase in charts reviewed per year, after an initial
- decline in charts where accommodations were questioned
- 2.  General decrease in number of questionable applicants
- approved in past three years

## 2. Admissions Counselor Determines Appropriateness of Applicant for Job Corps, Based on Observations of Behavior (PRH 1.2)

- Are the applicant’s educational and training needs best met by Job Corps?
- Is the applicant reasonably expected to participate in group situations?
- Does the applicant fully understand that Job Corps centers have rules and the consequences of failing to observe those rules?

## 3. Review of Applicants with Mental Health Disabilities

- Providing equal access for qualified applicants with mental health disabilities and developing “reasonable accommodations” is the law
- Center convenes the Interdisciplinary Team (IDT), reviews folder, and makes contact with the applicant. If the center feels the applicant does not meet the “additional factors” (see previous slide), is a “direct threat” (safety concern) or  it cannot accommodate, it sends folder to Regional Office for review
- Regional Office sends to Regional Nurse Consultant to check for completeness, and then forwards complete file to Regional MH Consultant for final recommendation to RO

## 4. Examples of Major Mental Health Challenges 

- Limited Cognitive Abilities with poor adaptive skills
- Moderate to Severe Learning Disabilities, especially with low reading, writing, and math abilities
- Current or recent history of Behavior Control problems, especially poor anger management and impulsive disorders
- Psychiatric disorders, with poor medication compliance which results in disruptive or unsafe behaviors

## 5. Review Process Principles

- AC obtaining information very helpful
- Center generally responsible for direct contact with eligible student to review any items which might prevent enrollment
- Involve JAN or Vocational Rehab, as needed
- Identify referral resources for health needs

## 6. Reasons for Denying Admission - Appendix 103

- (1) Fundamental Alteration--accommodations are disruptive, or would alter the fundamental nature or operation of the program
- Needs 1-on-1 care for disruptive behavior or to remember to perform activities of daily living
- (2) Safety--person with disability poses “a direct threat”, defined as a significant risk to safety of self and/or others
- Resists taking medication without daily observation, in a student who became aggressive off medications in recent past, and appears unstable at this time
- (3) Undue Hardship--accommodations are extremely expensive [NOTE: legally hard to justify]

## 6. Reasons for Denying Admission-Appendix 103 (continued)

- NOTE:  Appendix 103 defines “a direct threat” as “a significant risk of substantial harm to the health and safety of the applicant or others that cannot be eliminated or reduced by reasonable accommodation or modification.”
- The determination of “direct threat” must be based on current “reasonable medical judgment” involving factual evidence for the individual, such as interview of the applicant, experience of the individual in a setting similar to Job Corps, and opinions of medical doctors, rehabilitation counselors or therapists with expertise in the disability involved and/or direct knowledge of the individual.
- Factors which must be considered include: (1) the imminence of potential harm, (2) the duration of the risk, (3) the nature and severity of potential harm, and (4) the likelihood that potential harm will occur.
- Typically, such an assessment is conducted by the Center Mental Health Consultant, Physician, Health and Wellness Manager, or TEAP Specialist, not by the Admissions Counselor.

## 7. Evidence for Possible Approval in Borderline or Questionable Cases

- Behavioral Stability for 3-6 months desirable, especially if successful in part-time work or school
- Evidence that low scores on old tests may be inaccurate--e.g., written statements on application, telephone contacts
- Follow-up MH visits not needed weekly
- Center can provide accommodations without disruption--e.g., separate bathroom for extremely germ phobic person who otherwise can succeed in program

## Summary

- AC assessment of appropriateness is important
- Assessment for accommodations can work
- Remember, direct contact by center staff or others reviewing needs for accommodations is crucial
- Many of accommodations make the program better for all students
- Doubtful cases can be sent through regional review for “second opinion”. (Feedback to Regional Health Consultants about problem cases is helpful)