1. Let’s Figure It Out Together: Let’s Figure It Out Together: Increasing Understanding and Improving Efficiency with the Applicant File Review Process October 2015

2. Presenters Lead Mental Health Specialist, Humanitas, Inc. Valerie Rawls Cherry, PhDDebbie M. Jones, B.S. Disability Program Analyst Humanitas, Inc. 2

3. 3 Describe the process steps involved in making applicant file recommendations. Articulate ways to "think through" information presented in applicant files and applicant interviews to determine and subsequently support recommendations. Appropriately and thoroughly complete Appendices 609 and 610 assessments. Describe specific factors that trigger a reasonable accommodation review within the AFR assessment process. OBJECTIVES Identify at least 2 scenarios in which reasonable accommodation review would not need to be completed within the AFR assessment process.

4. 4 Policy Recommendations of Denial and Withdrawals

5. 5 Center enrolls applicant. ENROLLMENT Applicant’s health care needs exceed those of basic health care. RECOMMENDATI ON OF DENIAL Application Outcomes Applicant poses a direct threat to self or others. RECOMMENDAT ION OF DENIAL Applicant may no longer be eligible due to new information that the AC could not have reasonably known at the time of eligibility certification. RECOMMENDAT ION OF DENIAL

6. Application Outcomes Withdrawals  Applicant is processed as a withdrawal:  Applicant states or puts in writing that s/he is no longer wishes to enroll in the program.  The clinical team cannot reach the applicant, even with the AC’s assistance, to complete the clinical interview or the DCs cannot complete the required interactive reasonable accommodation process.  NOTE: If a file is in regional review when a withdrawal occurs, the file must be returned to the regional office or the regional representative who sent you the file to complete. 6

7. AC Requesting Return of Applicant File in Center Review  If the AC requests the center return an applicant’s file, should the center automatically do so?  It depends… The center has custody of the applicant file and responsibility for making a decision on that individual’s application to the program. So, the center should only release a file back to the AC when it has been requested via appropriate policy allowances.  Obtain written requests for the file via email that you can retain as documentation of why the file was returned. ACs may do the same of you when you return files to them! 7

8. Documenting Inability to Contact Applicant  “CMHC left message for applicant on 9/01/15 at 10:20 a.m. asking him to return call regarding his application to Job Corps.”  “CMHC left message for applicant on 2/14/14 at 12:40 p.m. asking him to return call by 9/21/15 regarding his application to Job Corps.”  “AC contacted via phone on 9/22/15 after center was unable to reach applicant and AC states he will make effort to contact applicant but that he has no new contact information available.”  “AC called HWM/DC on 9/26/15 and reports that he has attempted to reach the applicant and has been unable to do so as well.” 8

9. 9 Applicant File Tracking Records Department Responsibilities

10. Quick Check!  How many “official” logs must the center maintain?  Only one that contains all of the log requirements listed in the PRH!  Can you maintain more than one log?  Yes; however, if you maintain other logs, you must still have the one SINGLE log that has the stated PRH requirements documented.  Is it acceptable to delete entries once an applicant is accepted or a file has been returned to the AC or a submitted to the regional office?  No! The center must maintain ongoing records of its applicant file tracking documentation. May start a new log each PY but need to keep 2-3 years of records. 10

11. Applicant File Review Log  The log must contain:  The date the file arrived on center  To whom each file was sent and the position  How long a file has been with a particular department or staff member  How long the file has been on center  Notes/explanation of any delays in the process  The disposition of the file 11

12. 12 Sample Return to AC Memo

13. Sample Disposition Statements  Acceptable or not?  File requested by the AC.  File returned to the AC.  Applicant has been arrested and is in jail so the file was returned to the AC.  Returned to AC due to insufficient medical documentation (no subsequent entries).  Applicant sent email dated 8/20/15 and received by J. Moon, HWM, stating she no longer wished to enroll in Job Corps. File is being ret. to AC on this date to process as a w/drawal. 13

14. Sample Disposition Statements  Acceptable or not?  File sent to Regional Office (RO) on 8/30/15 as rec. of denial; File received back on 9/10/15 from RO to complete process; FRT nor AC could reach applicant so file is being ret. to AC on 9/20/15 to process as a w/drawal.  Applicant is hospitalized.  Applicant called center on 7/25/15 and spoke to N. Star, TEAP Counselor, stating that he had changed his mind and did not want to come to a smoke- free center. File returned to AC on 8/7/15 to process as a w/drawal. 14

15. 15 Center Applicant File Review Process PRH 1: 1.4, Appendix 107

16. 16 Applicant File Review Process 3. File is received on center by the records staff who record the file in the records log and tracks its movement. Records forwards the sealed medical, health, or disability-related information unopened to the Health and Wellness Manager (HWM). STEP 1 STEP 2

17. 17 3. Applicant File Review Process The HWM completes a review of the “Job Corps Health questionnaire (ETA 653)” and the medically related documentation to determine: The health care needs of the applicant and whether JC can meet those needs, and If the applicant presents a direct threat to self or others. The HWM determines who else may need to review the protected information based upon the determination of “need to know.” This is your File Review Team (FRT)! STEP 3 STEP 4

18. Identification of the File Review Team  Who should be the typical participants of the file review team?  Center Mental Health Consultant (CMHC) reviews mental health-related information  Center Physician reviews medical information  Center Dentist reviews dental information  TEAP Specialist reviews substance-related information  Academic Manager reviews IEPs, 504 plans, educational reports including special education assessments 18

19. Identification of the File Review Team  Which center positions should have a limited and infrequent role, typically, on the FRT team?  Center Standards Officer (CSO or sometimes referenced as CSIO or SPO on some centers)  Which center positions should not have a role on the center’s FRT related to the decision-making process of accepting an applicant or not?  Counseling Manager  Records Manager 19

20. 20 Applicant File Review Process Applicant File Review Process If there is no health-care needs or a direct-threat assessment necessary, schedule the applicant for enrollment. The members of the FRT determine if a health care needs or a direct threat assessment is necessary or if there is a need to revisit the eligibility factors. STEP 5

21. 21 How do we Decide if Job Corps is Appropriate for Applicant?

22. How do We Decide if JC is Appropriate for Applicant?  Individualized consideration  Current stability  History of stability  Current behaviors  History of behaviors  Medical risks and health care needs  SAFETY  Failure to comply with an outside provider’s recommendation does not automatically mean a recommendation of denial. 22

23. Important Information to Review  ETA 6-52 (Outreach and Admissions Applicant Information Sheet)  ETA 6-53 (Health Questionnaire)  CCMP Provider Forms  Inpatient psychiatric or medical hospitalizations or Emergency Department visits (if relevant), treatment summaries  IEP, 504, and other educational information provided  Psychological Assessment  Background Check  Individual Statement from Applicant 23

24. Applicant Interview is KEY!  Interactive in-person or telephone  Only ask specific questions regarding any behaviors or information of concern that has been disclosed or documented in the applicant file.  Document specific behavioral or clinical observations from interview.  If center H & W staff (including TEAP specialist) disagrees with the opinion provided by outside professional on CCMP, try to contact professional to resolve or explain difference of opinion. Document contact or lack of response. 24

25. Applicant Interview is KEY if:  Center has concerns regarding cognitive ability and adaptive functioning of applicant.  Ideal:  Provide in depth tour noting how well applicant functions during time on center.  Document specific behaviors that arise indicating applicant might be vulnerable in group setting or have difficulty with training environment.  Focus on applicant’s adaptive living and social skills. Not solely on IQ! 25

26. 26 Appendices 609 – Direct Threat Assessment (DTA) and 610 – Health Care Needs Assessment (HCNA) How to appropriately and thoroughly complete Appendices 609 and 610 assessments

27. Type in one challenge you have when completing Appendix 609 Direct Threat Assessment or Appendix 610 Health Care Needs Assessment. 27

28. Why use Appendices 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).  July 1, 2013 –Revised Appendices 609 and 610 via Job Corps PRH Change Notice No. 13-02 28

29. Appendix 609 – Direct Threat Assessment  A direct threat assessment should be completed whenever center believes that an individual:  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  cannot be eliminated or reduced by reasonable accommodation or modification.  Assessment conducted and signed by licensed clinician. 29

30. Appendix 609 Direct Threat Assessments (DTA) What Factors Trigger a Review of Individual’s File for Direct Threat? 30

31. 31 6-53 Health Questionnaire

32. Additional Triggers Interview, CCMPs, and Other Documents  History of suicide attempts and expresses current suicidal thoughts with imminent risk.  Active hallucinations and/or delusional thinking which places them or others at imminent risk.  Significant history of inappropriate sexual impulses, assaults, recency or increased violent episodes. Non-compliant with tx.  Homicidal thoughts  Expresses harm to self or others  Impaired judgment  Paranoid thinking  Threat of violence/assaultive behavior  Self-harm behavior due to drug and alcohol use  Medical condition with imminent high risk 32

33. Appendix 609 – Direct Threat Factors 1.What is the nature and severity of potential harm? a)What kind of harm is posed by the individual’s medical condition or disability? b)What is the seriousness of the potential harm (e.g., death, serious injury, minor emotional distress? 2.What is the duration of the risk (e.g. how long will risk last)? 3.What is the likelihood that the potential harm will occur (e.g. high, moderate, low)? 4.What is the imminence of the potential harm (e.g. how soon likely to occur)? 33

34. Reasonable Accommodation in the Assessment Process Policy, Process and Considerations 34

35. 35 Applicant File Review Process When completing the DTA or HCNA for an applicant with a disability, the reasonable accommodation committee (RAC) must convene to consider reasonable accommodation (RA). STEP 6

36. 36

37. Appendix 605 Reasonable Accommodation (RA) Process  Who is a person with a disability?  Has a physical or mental impairment that substantially limits a major life activity.  Some conditions essentially always considered a disability.  Term “substantially limits” should be construed broadly in favor of expansive coverage.  Does not require extensive documentation.  ONLY talking about RA related to the denial assessment process here!! 37

38. RA in the Assessment Process  The DC and the applicant MUST be involved in the RA review as per the PRH.  The DC is the coordinator of the reasonable accommodation process; therefore, this individual must lead this portion of the assessment process.  Other clinicians may participate/make recommendations as they wish and as time permits and are strongly encouraged to do so. 38

39. RA in the Direct Threat Assessment – What must be Considered?  Review any behaviors/functional limitations checked with an affirmative answer in item #1 of the DTA.  Go to item #5 and identify related appropriate accommodations that may assist the applicant based upon the behaviors/functional limitations checked in item #1!  Review only those appropriate for the functional limitations identified or as requested and applicable by the individual applicant. 39

40. 40

41. RAC has been unable to ID any RA  True or False: When do you think you should be checking this box? (Must always make the determination on a case by case basis.)  The DC or RAC is able to identify RA but does not think they will be sufficient?  Applicant is experiencing symptoms which impairs his/her judgment such that they could not reasonably participate in the decision-making process to determine RA even if given RA to assist with participation.  Applicant has significant history of self-harm or self-harm attempts coupled with recent events that have been increasing in either frequency and severity or both.  Applicant has single incident of self-harm with ER visit but no resulting hospitalization and no previous history. 41

42. 42

43. 43 For illustration purposes only.

44. Yes/No Boxes in #5 of Assessment Form  Completing the check boxes:  Checking “yes” means that the applicant was offered the specific accommodation and accepted it.  Checking “no” means that the applicant was offered the specific accommodation and rejected it.  Leaving the box blank means the accommodation was not offered and/or discussed because it was not appropriate or necessary. 44

45. Decision Time: Recommendation to Enroll or Recommend Denial Policy, Process and Considerations 45

46. 46 Applicant File Review Process Then the licensed clinical professional completing the assessment considers whether or not accommodations would sufficiently remove the barriers to enrollment. The licensed clinical professional makes a final decision based upon the findings of the assessment. STEP 7 STEP 8

47. 47

48. 48 Applicant File Review Process Any applicant file recommended for denial is to be forwarded to the Regional Office for review and final determination of the application status. STEP 9

49. DTA Mental Health Examples DTA Considerations and Review 49

50. Direct Threat Assessments  Higher clinical standard than HCNA.  Imminent risk, not speculative.  Active harm behaviors to self or others.  Can be used for behaviors, such as sexual offense histories, assaultive histories, other significant behavioral safety concerns.  Cannot revisit behavioral (criminal) clearance done by ACs, this is clinically driven.  Discuss with Regional Mental Health Specialists.  SAMPLE AVAILABLE FOR DOWNLOAD. 50

51. Mental Health Examples Qualify for Possible Direct Threat Assessment?  History of superficial mutilation that requires no medical attention (cuts, burns, pinches, scratches) on body. Not in treatment.  History of chronic impulsive suicidal/homicidal behavior with injury to self or others or threats when off meds. Reports being currently stable (in the past 3 months). Stopped treatment and meds two weeks ago. Has never had more than 3 months of symptom free behaviors without meds.  Serious personality disorder predominately and currently characterized by chronic anger, hostility and impulsivity, negative attitude, unresponsiveness to treatment and lack of insight. These symptoms are associated with violent behaviors to others or self. 51 NO YES Maybe

52. Appendix 610 Health Care Needs Assessment HCNA Considerations and Review 52

53. Appendix 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.  The center must document efforts to arrange for less frequent treatment in home state and/or to secure community support near center and include this information in the health-care needs assessment.  Assessment conducted and signed by licensed clinician. 53

54. Consider for Another Center  Documentation of efforts to arrange for less frequent treatment in home state and/or to secure community support near center included in the file. Applicant should be considered for center closer to home where health support and insurance coverage is available.  Contact the treating provider and discuss applicant’s needs and see if treating provider (not HWC staff) recommends less frequent treatment or monitoring.  If treating provider does not recommend changes to frequency of treatment or monitoring, consider local community services with sliding fee scales for applicants without insurance or insurance in another state. 54

55. Consider for Another Center  If community services not available, document name of local resource contacted and information provided by the resource.  Applicant may be considered for center closer to home where health support and insurance coverage is available.  File is forwarded to Regional Office for final determination. 55

56. Appendix 610 – Health Care Needs Assessment  Health care needs beyond Job Corps basic health care responsibilities (PRH Exhibit 6-4)  Red Flags:  Frequent recent ER visits  Newly diagnosed or uncontrolled health issue  Symptoms/condition not well managed in similar environment as Job Corps  Require extensive resources/intervention 56

57. Exhibit 6-4 Job Corps Basic Health Care Responsibilities  Mental Health and Wellness Program:  Assessments (not psych testing)  Short-term counseling  Collaboration with center physician and health and wellness staff on psychotropic medication monitoring  Psycho-educational groups as needed in collaboration with counseling  Crisis intervention as needed  Referral to off center services 57

58. 58 Appendix 610 - PRACTICE! Applicant File Review Case Studies

59. Health Care Needs Scenario  During the center file review process you receive the following:  In the confidential health envelope, the 6-53 indicates an applicant who has received mental health treatment in the past and diagnosis of bipolar. There is a summary from group home that indicates applicant was terminated 3 months ago due to not following rules and engaging in arguments and fights with members in the group home.  CCMP indicates applicant is noncompliant with medication but prognosis is good with medication. Indicates applicant can attend Job Corps with weekly counseling and weekly psychiatric follow-up.  Applicant has state funded insurance and is applying to center out of state. SAMPLE AVAILABLE FOR DOWNLOAD 59

60. 60

61. 61

62. 62

63. 63

64. 64

65. 65

66. 66

67. 67

68. 68

69. HCNA Mental Health Examples HCNA Considerations and Review 69

70. Mental Health Examples Possible HCNA Decisions  Hospitalized 10 months ago for brief psychotic episode. Currently receiving therapy once per week in addition to specialty group for abuse survivors and monthly med checks. Compliant with treatment and meds, no acute symptoms, treating provider recommends enrollment with maintenance of services. Out of state, but has Medicaid in state of residency. Contacted community mental health center near rural JC center – sliding fee scale and 3 month waiting list. 70 Enroll Consider for different center

71. Mental Health Examples Possible HCNA Decisions  Moderate mental retardation, autism or other cognitive deficit with recent difficulties in group setting impacting behavior and personal safety without supervision.  History of panic attacks, most recent 1 month ago. Recently stopped meds due to insurance problem. Able to articulate coping strategies to reduce attacks.  Personality disorder predominately and currently characterized by chronic hostility and impulsivity, negative attitude, unresponsiveness to treatment and lack of insight. 71 Recommend Denial Recommend Denial Enroll

72. 72 Direct Threat or Health Care Needs Assessment? Review of the Decision- making Process

73. DTA versus HCNA 609 – Direct Threat  Imminence: Immediate safety concern  Suicidal behavior  Homicidal behavior  Paranoid thinking  Threat of assault 610 – Health Care Needs  May have safety issues related to health needs, but threat is not imminent  Mood swings  Impulsive behavior  Impaired judgment 73

74. DTA versus HCNA Example 609 – Direct Threat  Recent (3 months) lethal suicide attempt, did not follow discharge treatment recommendations, inconsistent with meds from hospital and reports intermittent suicidal thoughts. 610 – Health Care Needs  Recent (3 months) lethal suicide attempt, did not follow discharge treatment recommendations, on meds from hospital and reports sad mood along with poor sleep but no suicidal thoughts. 74

75. 75 Appendix 610 - Practice!

76. Type in one challenge you have when trying to make a recommendation on an applicant file. 76

77. Scenario #1 Applicant - Jennifer  18-year-old applicant who reports current treatment for diagnoses of ADHD since age 13 and reports Learning Disability on the ETA 6-53 Health Questionnaire  Recent ADHD CCMP documentation by treating psychiatrist describes applicant as stable, medication compliant over past year, and good prognosis.  IEP (a year old) – No behavior intervention plan (BIP), academic accommodations, good effort in classroom.  What happens now ? 77

78. Scenario #1 (cont.) Applicant - Jennifer  Should CMHC review this file?  Should CMHC interview this applicant? Clear for enrollment, HWM contacts applicant regarding medications, if appropriate, and CMHC provides DC with potential accommodations to discuss with applicant. 78

79. Scenario #1, version 2 Applicant - Jennifer  18-year-old applicant who reports current treatment for diagnoses of ADHD since age 13 and reports Learning Disability on the ETA 6-53 Health Questionnaire.  Recent ADHD CCMP documentation by treating psychiatrist describes applicant as stable, medication compliant over past year, and good prognosis.  IEP – Social Emmotional Disturbance (SED) with or without BIP.  What happens now ? HWM and CMHC contact applicant for interview and participate in RAC. 79

80. Scenario #1, version 3 Applicant - Jennifer  18-year-old applicant who reports current treatment for diagnoses of ADHD since age 13 and reports Learning Disability on the ETA 6-53 Health Questionnaire.  Recent ADHD CCMP documentation by treating psychiatrist describes applicant as stable, medication compliant over past year and good prognosis.  IEP – SED with or without BIP.  Interview reveals hospitalization for serious suicide attempt 2 months ago with new diagnosis of Bipolar Disorder.  What happens now ? 80

81. Scenario #1, version 3 Applicant - Jennifer  HWM and CMHC contact applicant for interview, may request additional health information, may contact treating psychiatrist, considers health care needs, participates in RAC, makes recommendation for enrollment or denial. 81

82. 82 Red Flags Actions that “Possibly” Trigger Further Review

83. Red Flags Applicant files are returned to the AC for additional medical documentation or insufficient medical documentation or the information is requested without returning the file. In either situation, the information is not received and file never retrieved by the center, if applicable, and processed to a final disposition. If the center has requested additional documentation about an applicant and it does not receive that information, the center must make a decision on the information that is available to it. The applicant file cannot be returned to the AC and/or processed as a withdrawal. AC requests applicant file to be returned to Outreach office without appropriate justification. An AC may only request files back from a center for allowable reasons within the PRH. The center should not release custody of the file without knowing why it is being requested and that it is for a PRH allowable reason. 83

84. Red Flags Lack of applicant file recommendation of denial submissions to the respective regional office. The center has not submitted any files or a very limited number of applicant files to the regional office for review over an extended period of time. Lack of dates and details included in the disposition column of the Applicant File Review Tracking Log. Failure to include dates, names of individuals involved and their titles, details of the situation or conversation and to maintain copies of any supporting documentation (e.g., emails received, sent, etc.) leads to additional review and time spent on identifying dispositions of files. 84

85. 85 Resources Upcoming Webinars, Websites, Regional Specialists and Coordinators

86. 86 Upcoming webinars! Coming October 21, 2015! 11 am ET and 3 pm ET Upcoming Webinars! Applicant File Review: Conducting the Interview of Applicants with Mental Health Histories Dr. Valerie Rawls Cherry, PhD Lead Mental Health Specialist

87. Job Corps Disability Website https://supportservices.jobcorps.gov/disability/Pages/default.aspx 87

88. Job Corps Health & Wellness Website https://supportservices.jobcorps.gov/Health/Pages/default.aspx 88

89. Job Accommodation Network http://askjan.org 89

90. Regional Mental Health Specialists  Region 1 - David Kraft, MD, MPH  dkraft@external.umass.edu dkraft@external.umass.edu  Region 1 (Puerto Rico)- Maria Acevedo, PhD  mmacevedo@onelinkpr.net mmacevedo@onelinkpr.net  Region 2 - Valerie Cherry, PhD  vcherryphd@gmail.com vcherryphd@gmail.com  Region 3 - Suzanne Martin, PsyD, MPH  suzannempsyd@gmail.com suzannempsyd@gmail.com  Region 4 - Lydia Santiago, PhD  lydia.v.santiago@att.net lydia.v.santiago@att.net  Region 5 - Helena MacKenzie, PhD  helena.mackenzie530@gmail.com helena.mackenzie530@gmail.com  Region 6 - Vicki Boyd, PhD  vdelboyd@aol.com vdelboyd@aol.com 90

91. Regional Medical Specialists  Regions 1 and 2 – John Kulig, MD  jwkulig@gmail.com jwkulig@gmail.com  Regions 3 and 5 - Gary Strokosch, MD  gstrokosch@aol.com gstrokosch@aol.com  Region 4 - Drew Alexander, MD  cyvoc@yahoo.com cyvoc@yahoo.com  Region 6 - Sara Mackenzie, MD, MPH  saramack17@msn.com saramack17@msn.com 91

92. Regional Disability Coordinators  Boston and Philadelphia Regions – Kristen Philbrook kristen.philbrook@humanitas.com  Dallas Region – Laura Kuhn laura.kuhn@humanitas.com  Atlanta and Chicago Regions – Sharon Hong sharon.hong@humanitas.com  San Francisco Region – Kimberly Knodel Kimberly.Knodel@humanitas.com 92

93. THANK YOU