Tuesday, August 09, 2005

DISABILITY and WORKING; JAN (Job Accommodation Network) BEST RESOURCE for Disabled Workers!!!

JAN - the Job Accommodation Network is, without doubt, the absolute best resource and link for anyone who is disabled, who is facing becoming disabled, and who is still working! The purposes of this blog are:
  • to describe what this Resource is;
  • to give you an example of what types of information it can provide for you;
  • to give you an example (from my own experience) of how you can trigger the ADA (Americans with Disability Act) to continue working as your company provides you with "reasonable accommodations"; and,
  • to give you a link to this very valuable website.

OK, let's say that you have just been told by your Neurologist that the series of conditions that have been making you miserable for over the past 35 years really are the result of Multiple Sclerosis (MS). My first reaction was, OH DARN!!!

At this point in time, I was struggling to keep 2 kids in college, and was working in the best job that I had ever had! I was the Vice President of Human Resources for a Ship Repair Yard. My staff and I provided Human Resorces services to over 2,500 employees in 11 crafts (Unions) running a 24 (hour)/7 (days) week operations. (Note: you can see more about me by going to the "About Us" section of the www.disabilitykey.com website.)

My next reaction, since I am an ingrained "control freak", I decided to become an Expert Patient, even though I would not discover that phrase until over a decade later. If I was to become a Chronic Disease Self-Manager (again, I would not discover that phrase until over a dacade later) I needed to know all about Multiple Sclerosis, its symptoms, and, for whatever symptoms I had, their explicit impact on me. For, you see, my wonderful Doctor and I had been practicing Patient-centered health care (another yet-to-be-discovered concept) for years up to that point.

AND, since I still had bills to pay, two kids to keep in college (and those of you who have experienced this, you KNOW how expensive college is these days) I needed to keep working. But, my job skills were becoming increasingly more impacted by my MS symptoms. I knew that I must research, in addition to the disease, the concept of working while disabled.

Here, in a nutshell, is what I discovered. (By the way - I very much wish that there had been information like this for me to access when I needed it; that's one of the reasons that I am so passionate about providing the information to y'all, so that you can use it in your own unique situations.)

  • I learned that there was a federal law called "ADA". (OK, truth time; I already knew about this law as a Human Resources professional; what I mean to say, is that now I knew about the law as a DISABLED PERSON. Believe you me, the two "knowings" are as different as are night from day! One is academic, the other is experiential. It is the very nature of my experiential knowledge about disability and other "stuff" that fires me up to share the information with you so you don't have to recreate the wheel.)
  • Here is how the JAN describes WHAT the patterns and pracatices of a Company's employment nondiscrimination policies are under the ADA:

" The ADA prohibits discrimination in all employment practices, including job application procedures, hiring, firing, advancement, compensation, training, and other terms, conditions, and privileges of employment. It applies to recruitment, advertising, tenure, layoff, leave, fringe benefits, and all other employment-related activities."

  • This is how the JAN describes WHO is covered by the ADA:

"Employment discrimination is prohibited against "qualified individuals with disabilities." This includes applicants for employment and employees. An individual is considered to have a "disability" if s/he has a physical or mental impairment that substantially limits one or more major life activities, has a record of such an impairment, or is regarded as having such an impairment. Persons discriminated against because they have a known association or relationship with an individual with a disability also are protected."

  • Please note the sentence in red ink, and praticularly the words in bold that are larger. It is very important that you understand that you need not just "have" a physical or mental impairment, that/those impairment(s) must substantially limit one or more major of life's activities, and, furthermore, you must have documentation of that impairment ( and/or "be regarded as having such an impairment", which basically means that the impairment and it's limitations must be documented).
  • It is this information in red ink that made me realize the great truth about working and disability: I had to do the work myself to determine what my impairements were, and what activities they impacted; I had to become that Expert Patient who was also an Expert Disabled Worker! Here's how the JAN describes a "qualified individual with disabilities":

"A qualified individual with a disability is a person who meets legitimate skill, experience, education, or other requirements of an employment position that s/he holds or seeks, and who can perform the "essential functions" of the position with or without reasonable accommodation. Requiring the ability to perform "essential" functions assures that an individual with a disability will not be considered unqualified simply because of inability to perform marginal or incidental job functions. If the individual is qualified to perform essential job functions except for limitations caused by a disability, the employer must consider whether the individual could perform these functions with a reasonable accommodation. If a written job description has been prepared in advance of advertising or interviewing applicants for a job, this will be considered as evidence, although not conclusive evidence, of the essential functions of the job."

  • Next step, get a copy of the Job Description for your job. The job description should detail what is called "the Essential Duties (or Functions) of the Job". (Note: a copy of a Job Description that has such essential duties described, and the process of how to get one from your company's Human Resource department can be found at the www.disabilitykey.com website in the Disabilitykey Workbook. This Workbook is an "e-book" of over 100 pages with How-To's and lots of forms and examples. It can be purchased for a minimum cost.)
  • OK, you know your symptoms and their impacts upon you, and you have detailed them (once again, how to do this is covered in the Disabilitykey Workbook). Now you have to look at the Job Description for your own Job, and decide what you can and can't do.

OK, this is really hard stuff to do. That's where the JAN comes in that is so helpful! It has a link on the left hand column called "Accommodation Toolbox". If you click on this box, it will take you to a page with a wealth of information. Scroll down about an 15% of the page and you will find a section entitled "Accommodation Ideas". When you click on this section, you will find an index of illnesses/conditions, with some great information for you. You will need to understand accommodation ideas to

  • Here's what the JAN has to say about "Reasonable Accommodations", and about some accommodations applicants and employees may/can need.

" Q. What is "reasonable accommodation"?
A. Reasonable accommodation is any modification or adjustment to a job or the work environment that will enable a qualified applicant or employee with a disability to participate in the application process or to perform essential job functions. Reasonable accommodation also includes adjustments to assure that a qualified individual with a disability has rights and privileges in employment equal to those of employees without disabilities.
Q. What are some of the accommodations applicants and employees may need?
A. Examples of reasonable accommodation include making existing facilities used by employees readily accessible to and usable by an individual with a disability; restructuring a job; modifying work schedules; acquiring or modifying equipment; providing qualified readers or interpreters; or appropriately modifying examinations, training, or other programs. Reasonable accommodation also may include reassigning a current employee to a vacant position for which the individual is qualified, if the person is unable to do the original job because of a disability even with an accommodation. However, there is no obligation to find a position for an applicant who is not qualified for the position sought. Employers are not required to lower quality or quantity standards as an accommodation; nor are they obligated to provide personal use items such as glasses or hearing aids.
The decision as to the appropriate accommodation must be based on the particular facts of each case. In selecting the particular type of reasonable accommodation to provide, the principal test is that of effectiveness, i.e., whether the accommodation will provide an opportunity for a person with a disability to achieve the same level of performance and to enjoy benefits equal to those of an average, similarly situated person without a disability. However, the accommodation does not have to ensure equal results or provide exactly the same benefits. "

So, I now know my symptoms and their impacts; I know about the ADA, and about something called "reasonable accommocations". I have a copy of my Job Description, and am now trying to compare "ME" to the job's Essential Duties.

Again, here's where the JAN is soooooo valuable. Here's the information, copied directly from JAN about Multiple Sclerosis. Look at how detailed and varied the information is!

MULTIPLE SCLEROSIS

"Multiple Sclerosis (MS) is a chronic disease of the central nervous system. MS is often characterized by a pattern of exacerbation and remission. Symptoms may be mild, such as numbness in the limbs, or severe, such as paralysis or loss of vision. Possible symptoms include fatigue, loss of coordination, muscle weakness, spasticity, numbness, slurred speech, visual difficulties, paralysis, muscle cramps, bladder or bowel problems, and sexual dysfunction.

There are an estimated 250,000 to 350,000 people with MS in the United States. Because most people develop MS between the ages of 20 and 40, many are likely to be employed when first diagnosed. The following is a quick overview of some of the job accommodations that might be useful for people with MS. For a more in depth discussion, access our publication titled “Accommodating People with Multiple Sclerosis” at http://www.jan.wvu.edu/media/MS.html and the Searchable Online Accommodation Resource (SOAR) at http://www.jan.wvu.edu/soar/MS.html. To discuss an accommodation situation with a consultant, contact JAN directly at 800-526-7234 (V/TTY) or
jan@jan.icdi.wvu.edu.

QUESTIONS FOR THE COMPANY TO CONSIDER WHEN DETERMINING ACCOMMODATIONS
1) What symptoms or limitations is the individual with MS experiencing?
2) How do these symptoms or limitations affect the person and the person's job performance?
3) What specific job tasks are problematic as a result of these symptoms and limitations?
4) What accommodations are available to reduce or eliminate these problems?

5) Are all possible resources being used to determine possible accommodations?
6) Has the employee with MS been consulted regarding possible accommodations?
7) Once accommodations are in place, would it be useful to meet with the person with MS to evaluate the effectiveness of the accommodations and to determine whether additional accommodations are needed?
8) Do supervisory personnel and employees need training regarding MS, other disability areas, or the Americans with Disabilities Act?

EXAMPLES OF REASONABLE ACCOMMODATIONS USED BY OTHER COMPANIES TO ADDRESS A PRATICULAR MS LIMITATION

Activities of Daily Living:
· Allow use of a personal attendant at work
· Allow use of a service animal at work
· Make sure the facility is accessible
· Move workstation closer to the restroom
· Allow longer breaks
· Refer to appropriate community services

Cognitive Impairment:
· Provide written job instructions when possible
· Prioritize job assignments
· Allow flexible work hours
· Allow periodic rest breaks to reorient
· Provide memory aids, such as schedulers or organizers
· Minimize distractions and provide more structure
· Allow a self-paced workload
· Reduce job stress

Fatigue/Weakness:
· Reduce or eliminate physical exertion and workplace stress
· Schedule periodic rest breaks away from the workstation
· Allow a flexible work schedule and flexible use of leave time and work from home
· Implement ergonomic workstation design
· Provide a scooter or other mobility aid if walking cannot be reduced

Fine Motor Impairment:
· Implement ergonomic workstation design
· Provide alternative computer access
· Provide alternative telephone access
· Provide arm supports
· Provide writing and grip aids
· Provide a page turner and a book holder
· Provide a note taker

Gross Motor Impairment:
· Modify the work-site to make it accessible:
§ Provide parking close to the work-site
§ Provide an accessible entrance
§ Install automatic door openers
§ Provide an accessible restroom and break room
§ Provide an accessible route of travel to other work areas used by the employee
· Modify the workstation to make it accessible:
§ Adjust desk height if wheelchair or scooter is used
§ Make sure materials and equipment are within reach range
§ Move workstation close to other work areas, office equipment, and break rooms

Heat Sensitivity:
· Reduce work-site temperature
· Use cool vest or other cooling clothing
· Use fan/air-conditioner at the workstation
· Allow flexible scheduling and flexible use of leave time
· Allow work from home during hot weather



Speech Impairment:
· Provide speech amplification, speech enhancement, or other communication device
· Use written communication, such as email or fax
· Transfer to a position that does not require a lot of communication
· Allow periodic rest breaks"

At the bottom of the MS page, there's a link entitled: "Example Accommodations For People With Multiple Sclerosis". This link provides some actual situations.

OK: HERE'S THE LINK: http://www.jan.wvu.edu/

Stay tuned. Tomorrow we'll talk a little more about why and how you should/can put together a package yourself for your Human Resources department. And, as always, feel free to write comments, ask questions, seek clarification, etc. Particularly if you use this information, your questions can help others out there!

HEALTH PLAN Prescription "Prior Authorization" Compliance Example

Note: This blog is a real example of my own situation. I am continuing to use myself as a model of what I am bloging in the Disabilitykey Website. I passionately believe that we can only achieve the best quality of life for ourselves if we become an Expert Patient; a Chronic Disease Self-Manager; and participate with our Doctor in a "Patient-Centered" health care plan. BUT, I can't cajole, push, encourage y'all to accept these philosophies unless I first demonstrate that I too accept and follow them! So, here's a real life example describing the application of all of these philosophies!

"Prior Authorization required before this Plan will pay for this medication." How many of you have read this statement beside one of your medications when you check them out as your Company changes Health Insurance Plan coverage? Hopefully you did BEFORE you went to the Pharmacy expecting to get your medications, same as before, only to find out that you had to pay full amount for a needed medication (usually the most expensive one - ever wonder why this always happens?!?)

AND, if you, like me, are taking one of the "in the news" pain medications like Vioxx, Bextra (wait - we can't take these any more, even if we wanted to!!) or Celebrex, the Health Insurance Company REALLY DOES NOT want you to take these meds, as they don't want to be sued if there is a resulting problem.

So, you call the Plan, and they say that your Doctor has to fill out a document "justifying" your need for this medication, and obtain prior authorization before they will consent to pay for the medication. And by the way, we (the Health Insurance Plan) really don't think that anyone needs to take pain meds; they can just take OTC (Over The Counter) medications like the rest of the world. So, Doctor, do your best to justify for your patient, but...

Unfortunately for my Health Plan, I am VERY STUBBORN (gee - do you think that y'all might just have figured this out for yourselves by reading these blogs???). I know that the pain meds help me, I have been using them for over 4 years, and my Doctor prescribed them for me originally because I was taking 2X to 3X the "regularly approved" amount of OTC meds, and he was worried about the impact on my stomach and/or liver.

BUT, I have been taking the medication (in one form or another) for over 4 years, and I can't really remember (scratch that - I don't WANT to remember) what I felt like before I took pain meds!

OK self, I say, you claim to be an Expert Patient; to be a Chronic Disease Self-Manager; and you claim that you and your Doctor participate in the new "Patient Centered" Health Care (I promise to begin blogging about this tomorrow!) You know what you have to do!

Yes, I DO know what to do, and this is what, in fact, I did. Please, I ask all of you, keep your fingers crossed that it works! As I just completed the process today, I'll keep y'all informed on the outcome.

So, I needed to know exactly what the Paim meds did for me, and compile a document for my Doctor to assist him in documenting the Prior Authorization justification form. So....

1) I stopped taking the Pain medication the end of June! You see, as an Expert Patient and as a Chronic Disease Self-Manager, I am the only one who knows my body, my symptoms, and how the meds that my Doctor prescribes to my impact those symptoms. I can't ask my Doctor to write up something without my input. He is a fantastic Doctor, but he is not a mind-reader.

2) I spent the entire month of July off of the pain meds, trying to decrease the level of pain using OTC meds. You'll see the document that I wrote for my Doctor later on in this blog. I kept a daily diary about what was going on in my body.

As an aside, my family and some of my friends thought I was CRAZY! They watched the impact on me of being in constant pain, and thought that I should just pay the full price and take the meds! But, that would have defeated the point! Why have health plan insurance if it doesn't cover what it should? I can't let the Health Insurance company "win" on this; what about all those others out there in my same circumstances who can't afford to "just pay the money and get the meds"? AND, how can I "preach" to y'all to take chances and take responsibility for your body and your actions if I don't do the same first, and lead as an example?

3) At the end of the l-o-n-g month of painful July, I prepared a document of my situation and faxed it to my Doctor along with a request for him to prepare the Prior Authrization justification for me. I also called the Health Plan, gave them my Doctor's fax number, and asked them to fax a copy of the Prior Authorization justication form to my Doctor.

Now, there are some very key concepts demonstrated in what I just said above, and all relate to the concepts of control, self-reliance, and self-responsibility.

  • First of all, I took total responsibility for this process. I decided to stop taking the meds and to gather the documentation, because I needed to gather information. Now please I DO NOT RECOMMENDING THAT YOU STOP TAKING KEY MEDICATION THAT HAS BEEN PRESCRIBED BY YOUR DOCTOR THAT IS KEEPING YOU ALIVE. If you are unclear about what you need to do, you can always call your Doctor and run by him/her what you plan to do, and get his/her approval.
  • Secondly, I let a whole month go by so that I could gather as much information as I could.
  • Before i had anything sent to my Doctor, I called ahead and left a message for my Doctor through his Assistant to be on the look out for the incoming faxes.
  • Even though I had covered the who, what, why, when, over the phone to my Doctor's Assistant, I also documented that information into a cover memo attached to the justification documentation I sent to my Doctor.
  • Next, I was the one who called the Health Plan and had the document sent to my Doctor, as well as my documentation and cover memo. My Doctor's Assistant called me back to tell me that she had received both faxes.
  • I asked her to fax back to me what the doctor wrote on the form so that I can keep a copy in my files.

See, there is a process, and I, as the Expert Patient, kept control of it with my Doctor's help.

4) In the soon-to-be-blogged information about the Patient-Centered health care, the PCP (Primary Care Physician) Doctor treats the whole person, not just a symptom or two. And, s/he keeps in contact with any specialists that his/her patient sees, so that the PCP and the patient are like in the center of this web of contacts, treatments, and processes - TOGETHER. My Doctor and I have been working this way for over 10 years - long before I knew that it was really a process to be emulated! So, here's the document that I sent to him.

July 31, 2005
The following documents the pain that (I) suffer on a daily basis without a prescription of Vioxx, Bextra, or Celebrex. I have been on one of these three NSAIDS, Cox-2 inhibitor (selective) prescriptions for pain for over 4 years. As a result of a recent health insurance plan change, the plan requires that my Doctor justify my need for this prescription before its use can be approved, therefore, covered by the prescription coverage part of the health insurance.


When I called the health insurance company to ask about the justification, I was told that the Doctor needed to write out the justification on their appropriate form, justifying the need. The health insurance would review the justification, and determine if my need met their guidelines for coverage approval.


It is my understanding that the usage “justification” must demonstrate, to a medical necessity, that the need is greater than relief provided through use of OTC (over the counter) pain relief medications. Since my Doctor, needs to make this justification, I knew that I needed to supply him with evidentiary proof so that he could write the justification. Although (my Doctor) is the absolute best PCP (Primary Care Physician) possible, he is not a mind reader. Hence, he can only use what I provide to him.


Since I have been documenting my Multiple Sclerosis symptoms in the Attached Symptom Impairment Matrix while taking either Vioxx, Bextra or Celebrex, I knew that I had to get off of the pain medicine and actually take an OTC medication to be able to report on the impact that pain has on my Multiple Sclerosis symptoms to my Doctor. So, I ended my Celebrex medications on June 30th, 2005. I have now been relying solely on my other medications

[1] and the OTC pain medication of extra strength Non-aspirin Acetaminophen; caplets of 500 mg each. It took just 2 days without my daily Celebrex for the pain symptoms to begin to emerge. I have now had a month to document the results of my research into the impact pain without my prescription pain medication has on my Multiple Sclerosis symptoms. The following describes my symptoms and their impact on my body and my normal daily activities.


1) First of all, when I take the acetaminophen, I have to take 4 tablets, each time. This exceeds the recommended dosage, and, to even attempt to have any impact on my pain, I have to take 4 tablets every 4 hours, or a total of 24 tablets per each 24 hour period. This dosage level exceeds the recommended dosage level (the recommended dosage is not to exceed 8 tablets in a 24 hour period). I am concerned about the impact this level of dosage of acetaminophen is having on my stomach and liver. As of today, after 28+ days of this regime, I am experiencing daily stomachaches, cramps, and diarrhea.
2) As you can see in my attached Multiple Sclerosis Symptom Impairment Matrix, I deal with some level of pain on a daily basis, even while taking my prescription pain medication. However, I never realized just how well the prescription pain medication allowed me to better manage my other bodily functions until I went off of the prescription medication. Here are my ADDITIONAL PAIN IMPLICATIONS even taking the 4 acetaminophen tablets every 4 hours.
Ø My lower back aches all the time, with pain shooting down my legs. While on pain medication, this symptom occurred occasionally, NOT ALL THE TIME. My doctor says that this might be sciatica pain. This pain makes walking, climbing stairs, turning; all slow, jerky, and painful.
Ø My head, neck, shoulders, arms, hands, torso, back, hips, legs, knees, ankles, toes all ache, all of the time. The bones ache – deep; the muscles ache – throb; and, the muscles shake. This constant pain makes me clumsy, awkward, slow, and each movement hurts. As a result, I have fallen more often this past month then I have in the past 5 years! I have the bruises and scabs to document the falls. Even my son, with whom I live in a basement apartment, commented on my increased clumsiness.
Ø As a result of all of the pain, going to the bathroom is an event that is terribly painful. I have to move my arms and torso to carry out the activities, and each second hurts!
Ø I am more tired this past month than I have been in the past 4 years.
Ø Compensating for my constant pain increases my reaction to heat this past month.
Ø I have had tension headaches every day this past month; I had only about one or two per month on the prescription medicine.

Please approve my Doctor’s request for me to be able to once again take my prescription pain medication!
Thank you.


As you can see, there is lots of detail in the above document. I'll let y'all know what the result is.

Best of luck in your own documentation. Again, if you have questions or comments, please add to this blog, and we'll share with everyone!









[1] In addition to my pain medication prescription, I also take Gabapentin (300 mg capsules) 2 capsules by mouth 2X per day; Baclofen (20 mg tablets) one tablet 3X a day; and, Paroxetine (40mg tablets) one tablet 1X a day.