A research agenda for documenting disability status within healthcare organizations to address disparities in care

Identifying women with a disability in Australian maternity services: Time for a change

It is estimated that over 1 billion people worldwide have a disability. In Australia, 9% of women of childbearing age have a disability, but data on disability status for women accessing maternity services are not routinely collected and data collection processes are inconsistent. Maternal disability may affect perinatal outcomes, but to understand what factors might be amenable to interventions to improve outcomes, accurate data collection on disability status is essential. This opinion piece reflects on disability identification within maternity services in Australia, identifying areas for policy and practice change.

Documentation of Disability Status and Accommodation Needs in the Electronic Health Record: A Qualitative Study of Health Care Organizations' Current Practices

BACKGROUND

This qualitative study aimed to understand how early adopting health care organizations (HCOs) implement the documentation of patients' disability status and accommodation needs in the electronic health record (EHR).

METHODS

The authors conducted qualitative interviews with HCOs that had active or past initiatives to implement systematic collection of disability status in the EHR. The interviews elicited participants' current experiences, desired features of a standard EHR build, and challenges and successes. A team-based analysis approach was used to review and summarize quotations to identify themes and categorize text that exemplified identified themes.

RESULTS

Themes identified from the interviews included "why" organizations collected disability status; of "what" their EHR build consisted, including who collected, how often data were collected, and what data were collected; and "how" organizations were implementing systematic collection. The main purpose for collection of disability status and accommodation needs was to prepare for patients with disabilities. Due to this priority, participants believed collection should (1) occur prior to patients' clinical encounters, (2) be conducted regularly, (3) use standardized language, and (4) be available in a highly visible location in the EHR. Leadership support to integrate collection into existing workflows was essential for success.

CONCLUSION

Patients with disabilities experience significant disparities in the receipt of equitable health care services. To provide equitable care, HCOs need to systematically collect disability status and accommodation needs in the EHR to ensure that they are prepared to provide equitable care to all patients with disabilities.

Exploring disability prevalence among childbearing women attending a tertiary maternity service in Melbourne, Australia using an audit and cross-sectional survey

BACKGROUND

Although there is an estimated rate of 10% of women of childbearing age in Australia who have a disability, there is a lack of accurate prevalence data, with the true rate unknown. The timing and questions used to collect women's disability status in pregnancy vary, and there is limited knowledge on how women accessing maternity services in Australia would like to be asked about their disability status.

OBJECTIVE

To explore the prevalence of women with a disability receiving maternity care using a direct and indirect disability identification question. Secondary aims were to explore how women would like to be asked about their disability status and to examine the difference between self-reported and clinician-documented disability status within medical records.

RESEARCH DESIGN/SETTING

The study was conducted at a tertiary maternity hospital in Melbourne, Australia, and included two components. Component one used a cross-sectional survey with two different cohorts of women administered face-to-face on the postnatal ward (Cohort 1 - February 2019, Cohort 2 - December 2019). In Cohort 1, a specific disability identification question asked: 'Can you please tell me if you identify as someone who has a disability?'. In Cohort 2, an indirect disability identification question asked: 'Do you require additional assistance or support?'. Other questions explored women's views on disability identification. Component two consisted of an audit of the medical records to compare disability documentation in the medical records of the women who participated with women's disability self-identification status.

RESULTS

371/467 (79%) of eligible women that were approached participated in Cohort 1 and in Cohort 2, 295/346 (85%) of eligible women that were approached participated in the study. In Cohort 1, 5% (17/371) of women self-identified with having a disability. In Cohort 2 16% (46/295) of women reported needing additional assistance/support, however of these, only nine women viewed this as a disability. In Cohort 1, of the women who self-identified as having a disability, 82% had this recorded in their medical record. An additional 12% (43/354) of women in Cohort 1 who may have had a disability according to the Australian Bureau of Statistics classification, did not self-identify as having a disability. In Cohort 2, 37% (17/43) of women who self-identified as needing additional support did not have these needs documented in the medical record. Less than a quarter of women in both cohorts were asked about their disability status during their maternity care. Women with a disability or additional support needs suggested both direct and indirect ways of being asked about their disability status, and their responses were similar to women who did not self-identify with having a disability or additional support needs.

CONCLUSIONS

Disability prevalence data is highly dependant on the wording of the disability identification question. It may be appropriate to ask about disability both indirectly, in terms of additional support needs, and directly, to enable disclosure for those who do identify with a disability. Disability questioning should be routine and standardised guidelines around disability identification should be developed to allow for tailored adjustments to care on an individual level.

How are women with a disability identified in maternity services in Australia? A cross-sectional survey of maternity managers

BACKGROUND

Women with a disability have poorer perinatal outcomes, but little is known about the prevalence of women with a disability accessing maternity services, how they are identified and what care and services are available. Estimates suggest that nine percent of women of childbearing age have a disability.

AIM

To explore how public maternity services in Australia identify pregnant women with a disability, what (if any) routine disability identification questions are used, and to examine availability and adequacy of services for women.

METHODS

Cross-sectional online survey of maternity managers in Australian public hospitals.

FINDINGS

Thirty-six percent (70/193) of eligible hospitals responded including all states and territories. Overall, 71 % routinely asked women about disability status (usually as part of routine history taking), however there was wide variation in how this was asked. Most (63 %) did not have standardised documentation processes and two thirds (65 %) were unable to estimate the number of women with a disability seen at their hospital. Most (68 %) did not offer specialised services, with only 13 % having specialised training for staff in disability identification, documentation and referral pathways. Only a quarter of respondents felt that there were adequate services for women with a disability related to maternity care.

CONCLUSION

This is the first study to explore disability identification in maternity services in Australia. How women were asked was highly varied and documentation not standardised. National guidelines on disability identification for women accessing maternity services should be developed and collection of disability identification data should be routine.

Striving Toward Equity in Health Care for People With Communication Disabilities

PURPOSE

Approximately 10% of the U.S. adult population has a speech, language, and/or voice disability, collectively referred to as communication disabilities. An increasing number of studies demonstrate that persons with communication disabilities have worse health and health care outcomes as compared to those without communication disabilities. Understanding the state of the science, including potential contributing factors is critical to begin to address the disparities.

METHOD

Applying a historical lens and integrating multiple models of disability provide a comprehensive perspective of the health and health care outcomes of persons with communication disabilities.

RESULTS

Three phases for addressing health care disparities exist: detecting, understanding, and reducing. Results from a 2012 National Health Interview Survey provide compelling population-level results of the health and health care disparities experienced by persons with communication disabilities. To understand the disparities, factors within the health care system, such as availability of communication aids and services, as well as provider and staff biases, assumptions, and lack of knowledge need to be considered. To date, few interventions exist to address disparities in care for persons with communication disabilities. Consequently, researchers need to engage with stakeholders in innovative study designs and methods to facilitate the rapid development, implementation, and dissemination of interventions that address the disparities.

CONCLUSION

To ensure equity for the large and growing population of persons with communication disabilities, researchers, policy makers, patients, and health care systems need to collaborate in identifying and addressing the factors contributing to health and health care disparities. Presentation Video: https://doi.org/10.23641/asha.21215804.

Have Almost Fifty Years Of Disability Civil Rights Laws Achieved Equitable Care?

For almost fifty years, federal civil rights laws such as Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) of 1990 and the ADA Amendments Act of 2008, and Section 1557 and other provisions of the 2010 Patient Protection and Affordable Care Act have prohibited discrimination against Americans with disabilities, including in health care. Despite these laws, disabled Americans continue to experience disparities in health and health care, from preventive care to home and community-based services. In its 2022 Health Equity Framework for People with Disabilities, the National Council on Disability highlighted some of these disparities and recommended remedies. To explore these concerns, this article examines disability inequities and potential solutions within six areas. It concludes by recommending the ratification of the 2006 United Nations Convention on the Rights of Persons with Disabilities to reinvigorate US efforts to maximize the health and dignity of disabled Americans and support their full participation in the community.

Perspectives of Patients with Diverse Disabilities Regarding Healthcare Accommodations to Promote Healthcare Equity: a Qualitative Study

BACKGROUND

Patients with disabilities often require healthcare accommodations in order to access high-quality, equitable healthcare services. While attention has been paid to accommodation needs in specific disability populations, limited research to date has explored healthcare accommodations that cross-cut diverse disability populations.

OBJECTIVE

To identify a deeper understanding regarding accommodations in healthcare settings that could apply across disability populations and promote equitable healthcare.

DESIGN

We conducted qualitative focus groups with patients with disabilities and caregivers to understand their experiences and preferences for healthcare accommodations.

PARTICIPANTS

We recruited patients and caregivers across all major disability categories to participate in focus groups. Participants were recruited through advocacy organizations and healthcare settings in Southeastern Minnesota.

APPROACH

A total of eight focus groups were conducted with 56 participants. Participants described their healthcare experiences and desires for healthcare accommodations. The multidisciplinary research team recorded, transcribed verbatim, and coded all focus groups. The team thematically coded transcripts using content analysis within and across focus groups to identify major themes.

KEY RESULTS

Patients identified four challenges and corresponding steps healthcare team could take to promote equitable care: (1) consistent documentation of disabilities and needed accommodations in the medical record; (2) allowance for accommodations to the environment, including adapting physical space, physical structures, and scheduling and rooming processes; (3) provide accommodations for administrative tasks, such as completing paper or electronic forms; and (4) adapt communication during interactions, such as speaking slower or using terms that patients can easily understand.

CONCLUSION

These identified themes represent specific opportunities for healthcare teams to effectively provide accessible care to patients with disabilities. Many of the accommodations require minimal financial investment, but did require behavioral changes by the healthcare team to ensure equitable healthcare.

Using the web to increase access to oral health care for patients with special health care needs in South Carolina: A replicable model

AIM

To create an accessible web-based resource of providers willing to provide dental services for patients with special health care needs (SCHNs).

METHODS

With a grant from The Duke Endowment, surveys were sent to dentists in South Carolina RESULTS: Data showed that the majority of providers expressed willingness to treat patients with one or more mild SHCN, but fewer expressed willingness to treat those with one or more moderate or severe SHCN. Additionally, the data showed that among general practitioners specifically, only one-third were willing to treat mild and moderate/severe manifestations of all categories listed. The number of practitioners willing to treat moderate to severe manifestations of SHCN and accept Medicaid and willing to take new Medicaid patients dropped even further. These results demonstrated a need to increase the number of providers in South Carolina who are willing to treat patients with SHCN, and a need to provide an accessible resource for patients with SHCN to be able to find these providers. Data collected populated the web-based resource for the Special Adult Network of Dentists url:www.sandsc.org¹ CONCLUSION: This resource may be used by patients, caregivers, and health care providers and could be replicated in other states or designed as a national resource.

Development of Patient-Centered Disability Status Questions to Address Equity in Care

BACKGROUND

Patients with disabilities experience disparities in accessing and receiving high-quality health care services as compared to patients without disabilities. To address the disparities, health care organizations need to identify which of their patients have disabilities to track quality of care and provide appropriate health care accommodations. To date, no evidence-based sets of disability questions exist that serve these purposes. A study was conducted to identify patient-centered disability questions for health care organizations to determine which patients require health care accommodations and to track the quality of care experienced by patients with disabilities.

METHODS

In the first of three phases, a focus group with patients and caregivers (N = 54) and interviews with providers (N = 15) were conducted to explore the disability questions that they believed were important. In the second phase, nationally recognized experts (N = 17) participated in a modified Delphi panel to develop a set of disability questions. The third phase entailed cognitive interviews (N = 46) with patients with and without disabilities to refine the wording of the disability questions identified through the previous rounds.

RESULTS

Through the three phases, six essential questions and three additional recommended questions were identified. Questions addressed hearing, visual, motor, cognitive, communication, and learning disabilities, and the ability to conduct activities of daily living. An overall question for disabilities not included in the previous questions was also identified.

CONCLUSION

Through a rigorous, three-stage process that engaged multiple stakeholders, patient-centered disability questions were identified for health care organizations to use to identify disparities within their organizations and accommodations that address these disparities.

How do patients describe their disabilities? A coding system for categorizing patients' descriptions

BACKGROUND

To provide care that meets the values and preferences of patients with disabilities, health care providers need to understand patients' perceptions and understanding of their disability. No studies have explored patients' definitions of disability within the healthcare setting.

OBJECTIVE

The aim of the study was to understand how patients' define their disability in the healthcare setting and to develop a coding system for categorizing how they describe their disability.

METHODS

In 2000 all new outpatients at Mayo Clinic, Rochester, MN completed a form that inquired if they had a disability and if so, to write in the disability. The research team categorized the responses by disability type (e.g.: visual or physical) and how the patient described his disability or "disability narrative" (e.g.: diagnosis or activity).

RESULTS

Within 128,636 patients, 14,908 reported a disability. For adults, lower limb (26%) and chronic conditions (24%) were the most frequent disability type and activity limitations (56%) were the most frequent disability narrative category. For pediatric patients, developmental disabilities (43%) were the most frequently reported disability type and diagnoses (83%) were the most frequent disability narrative category. Patients used different disability narrative categories to describe different disability types. For example, most adults reporting a mental health listed a diagnosis (97%), compared to only 13% of those with lower limb disabilities.

CONCLUSIONS

Patients had diverse descriptions of their disabilities. In order for providers and healthcare organizations to provide high-quality care, they should engage patients in developing a consistent, patient-centered language around disability.

Silence in the EHR: infrequent documentation of aphonia in the electronic health record

Background

To begin to deliver patient-centered care, providers need to be aware of when a patient has a communication disability and what communication methods to use with the patient. The aim of the study was to describe if and how patients’ communication disabilities are documented within electronic health records (EHR).

Methods

A retrospective manual chart review of all inpatient and outpatient clinical encounter notes within the EHR for patients who had undergone a laryngectomy at Northwestern Memorial Hospital (Chicago, IL) between 2000–2013. We selected patients who had undergone a laryngectomy as the patient population as we were able to easily identify the patients through Common Procedural Terminology (CPT) codes.

Results

We identified 81 patient charts with 7484 encounter notes. Of the 81 patient charts, 58 (72%) had at least one encounter note with a communication notation. Excluding speech-language pathology notes, 1164 (16%) of all encounter notes included some notation of the patients’ communication abilities. We coded the communication notations into four categories. 1) Descriptions of communication abilities appeared in 663 (9%) of all encounter notes, 2) descriptions of communication methods appeared in 590 (8%) of all encounter notes, and the last two categories 3) medical management and 4) referrals to speech-language pathology services each appeared in 148 (2%) of all encounter notes. While all patients had the same type of communication disability, aphonia, providers used 39 different terms and phrases to describe aphonia.

Conclusions

Patients’ communication abilities were infrequently documented in the EHR. When providers did document a patient’s communication disability or method, they used inconsistent descriptions, suggesting a lack of standardized language. Further work is needed to determine how to consistently and accurately document patients’ communication abilities so staff and providers can quickly recognize how best to communicate with patients with communication disabilities.