General Management Considerations
Americans with Disabilities Act of 1990
The Americans with Disabilities Act (ADA) is a federal law the prohibits discrimination against a person with a disability who is seekig employment or access to services, including dental services. The law was enacted in 1990. Under Title 3 of this law, a private dental office is considered a place of publice accommodation. As of January 26, 1992, this law requires dentists to serve persons with disabilities.
According to the Americans with Disabilities Act, the following individuals are considered to have a disability;
- a person who has a physical or mental impairment that substantially limits one or more of that person’s major life activities (stroke, multiple sclerosis, mental retardation, spinal cord injury, etc.)
- a person who has a record of such impairment (history of alcoholism, mental or emotional illness, but is now free of impairment)
- a person who, while not actually being disabled, is “regarded” as having such an impairment (people misclassified as having mental retardation or mental illness)
You are under no obligation to make accomodations if a disability is not clearly discernable and the person does not inform you that he/she is disabled.
What does this mean to the private dental practitioner?
- The law requires that you treat the person with a disability on the same basis as you treat non-disabled patients. If, however, the disabled patient requires a procedure for which you would oridnarily refer a non-disabled patient, you may legally refer the disabled patient as well.
- You are required to make reasonable modifications to facilitate access to your office by persons with diabilities unless it can be shown that taking those steps would result in an “undue burden” or fundamentally alter the nature of the services you provide.
- What about hearing-impaired patients? The Act requires that you communicate in such a way that the person can understand what you are telling them. You may be able to use written notes, pictures, and models. The best approach would be to let the patient indicate which form of communciation to use. A sign language interpreter may, at times, be appropriate. You may not have to hire an interpreter; a family member or community service organization may provide this service. You may use a telephone relay service to communicate with a person who is deaf; contact your local phone company for information.
- The Act prohibits imposing a surcharge on disabled patients for the cost of auxiliary aids and services.
- Under the Act you must permit diabled persons to bring service animals into your office but not necessarily into the operatory.
- If the disabled person poses a “direct threat” (significant risk that cannot be eliminated using special procedures) to the health or safety of others, you may refuse to admit that person to your office. For example, an aggressive patient may have to be treated under general anesthesia.
Office Accessibility and Accommodation
Obviously, physical accessibility to the dental office is necessary to provide dental care to individuals with physical disabilities. Failure to provide access such as wheelchair ramps could be considered discrimination.
Architectural design considerations include:
- walkways, sidewalks and parking facilities
- entrance ramps, handrails, hallways and elevators
- door width and threshold height, door pressure or ease of opening,
- adequate space around door to maneuver a wheelchair, and elevator accessibility
- floor surface, carpets, and rugs
- telephone facilities,
- drinking fountains
- restroom facilities
- reception room design, furniture style, and lighting
- operatory design to allow for wheelchair transfer or in-wheelchair
If you are remodeling, you must make the remodeled area readily accessible to patients with disabilities, and if your are building a new office, then the entire office design must comply with ADA requirements.
Communication includes facial expression and body language as well as verbal expression. All available techniques should be used to help forge a bond between the patient and practitioner.
The primary rule in communicating with a person who has a disability is to address the patient directly. A caregiver, family member, or companion should be present to provide information that the patient cannot provide, however, an effort should be made to include the patient in the discussion.
People with disabilities may require assistance with activities of daily living, mobility, or specific tasks. The practitioner should discuss these needs with the patient and caregivers and provide assistance as needed.
A thorough medical history should be obtained for all patients. This should include; chief complaint, history of present illness, past medical history, review of systems, family and social history, thorough past dental history. (Some patients may not be able to provide the needed information; caregivers, family members or the patient’s physician may have to help.) Laboratory studies should be obtained when appropriate.
An assessment of the patient’s mental status or degree of intellectual functioning is important to allow appropriate communication to occur. In addition the patient’s competency should be determined so that appropriate legal consent can be obtained.
The patient’s physician should be consulted regarding:
- timing and sequencing of medical and dental treatment
- patient’s physical and mental disabilities
- use of restraints or sedation
- general anesthesia
- potential drug interactions
- mental competency
- antibiotic prophylaxis
All patients must be able to provide appropriate informed consent for dental treatment or have someone who can provide it for them. Informed consent must comply with applicable state laws and should include:
- the nature of the oral disease process and its impact on other body systems
- rationale for recommended dental treatment
- available treatment alternatives
- consequences of non-treatment
- possible complications or side effects
Consent is generally provided by a legally competent patient, or the legal guardian of a patient who is not competent. A natural or adoptive parent may provide consent for a minor, however, may not provide consent for a patient who is mentally incompetent and has attained legal age unless, of course, the parent has been appointed as the guardian by a court. Legal informed consent is necessary for all treatment. A determination needs to be made concerning whether an individual is competent to consent to a particular activity. State statutes may permit consent to be provided by designated representatives such as guardian advocates. A patient who does not communicate verbally, may legally provide informed consent in a variety of ways. This should be well documented in the dental record.If the provider is in doubt regarding the validity of consent, legal consultation should be obtained.
These guidelines are not intended to establish standards of informed consent but are designed to increase the provider’s awareness of the importance of consent issues.
Coordination of Care
Dental treatment should be coordinated with other therapy received by the patient, such as, kidney dialysis, physical therapy, occupational therapy and psychotherapy. The dentist should coordinate care via consultation with the patient’s other care providers, i.e., nurses, social worker or support coordinator, psychologist and physician. Vital signs, for example, may need to be obtained before and after treatment for some patients.
When indicated the primary care physician should be informed of the proposed treatment plan and anticipated complications. In addition, the physician should be consulted regarding medications, sedation, general anesthesia and special restrictions.
A common barrier to obtaining dental care for the person with a disability is a lack of financial resources. This problem may also dictate compromises in the treatment plan.
Frequently, Medicaid is the resource for reimbursement for dental services; the scope of services is limited and there are age limitations. In many states, adults are not eligible regardless of disability.
Potential funding resources that should be investigated include:
- Medicaid Waiver Program
- Supplemental Security Income
- Social Security Disability Insurance
- state or local Developmental Disabilities Councils
- advocacy organizations
- private foundations
- religious and fraternal groups
- relatives of the patient
- parent’s dental insurance
Affordable and accessible dental care may be available at:
- Public Health clinics
- institutional outpatient clinics
- regional treatment centers
- dental schools
Many individuals who are disabled have a social worker, support coordinator or case worker who may be able to assist in obtaining funding for dental services.