Emergency Management and Preparedness-Inclusion of Persons with Disabilities
Health Care and the ADA-Inclusion of Persons with Disabilities
Pacific ADA Center 
Thursday, February 24, 2022	1:15-3:00 P.M. CT

* * * * * * * * 

>> LEWIS KRAUS: Welcome to the Healthcare and the ADA Inclusion of persons with Disability Webinar Series.  I'm Lewis Kraus ‑‑

>> LEWIS KRAUS:  ‑‑ from the Pacific ADA Center, your moderator for this series.  This series of webinars is brought to you by the Pacific ADA Center on behalf of the ADA National Network.  The ADA National Network is made up of 10 regional centers that are federally funded to provide training, technical assistance and other information as needed on the Americans with Disabilities Act.  You can reach your regional ADA Center by dialing 1‑800‑949‑4232.  Realtime captioning is provided for this webinar.  The caption screen can be accessed by choosing the CC icon in the meeting control toolbar.  To toggle the meeting control toolbar permanently on, press the alt key and then if you need to, press it a second time.  We also have ASL interpreter, but at the moment I'm not seeing the ASL interpreter... okay, there we are.  We have ASL interpreters as well.  As always in our sessions, only the speakers will have audio.  If you do not have sound capabilities on your computer or prefer to listen by phone, you can dial 1‑669‑900‑9128 or 1‑646‑558‑8656 and use the webinar ID of 837‑2204‑3591.  And all of those numbers are in the chat.  This webinar is being recorded and will be able to be accessed on ADApresentations.org in the archives section next week.  This Webinar Series is intended to share issues and promising practices in healthcare accessibility for people with disabilities.  The series topics cover physical accessibility, effective communication, and reasonable modification of policy issues under the Americans with Disabilities Act of 1990, the ADA.  Upcoming sessions are available at ADApresentations.org under the Schedule tab.  Then follow to healthcare.  These monthly webinars occur on the fourth Thursday of the month at 2:30 eastern, 1:30 central, 12:30 mountain, and 11:30 a.m. Pacific time.  By being here, you are on the list to receive notices for future webinars in this series.  Those notices go out two weeks before the next webinar and open that webinar to registration.  You can follow along on the webinar platform with the slides.  If you are not using the webinar platform, you can download a copy of today's PowerPoint presentation at the healthcare schedule we page at ADApresentations.org.  And that also is in the chat.  At the conclusion of today's presentation, there will be an opportunity for everyone to ask questions.  You may submit your questions using the chat area within the webinar platform.  The speakers and I will address them at the end of the session.  So feel free to submit them as they come to your mind during the presentation.  To submit your questions, you can use the chat area text box as shown on the screen or if you are using keystrokes press alt‑H and enter your text.  If you are listening by phone and not logged into the webinar, you may ask your questions by emailing them to adatech@adapacific.org. 

If you experience any technical difficulties during the webinar, you can send a private chat message to the host by typing in the chat window.  Again, you can type your comment directly in there and hit enter or use alt‑H to access the chat box via your keyboard keys.  You can also tell us any technical difficulties at adatech@adapacific.org or you can call 510‑285‑5600. 

Today's ADA National Network Learning Session is titled "Learning from Patients to Provide Accessible Healthcare and Effective Communication for Patients Who Are Blind Or Have Low Vision."  In this presentation, the American Foundation for the Blind will share experiences of people who are blind or have low vision when seeking healthcare based on focus group research on patient health experiences.  And these experiences, they identify ways providers can operationalize the ADA requirements for healthcare accessibility to provide better care for those patients.  Medical professionals and healthcare administrators will come away with techniques for working directly with patients as well as understanding where training and facility design can contribute to high quality accessible patient care.  Today's speakers are Dr. Arielle Silverman.  Arielle is a research specialist at AFB with 15 years’ experience.  Before joining AFB, Dr. Silverman was an independent consultant who conducted research on the experiences of people who are blind and low vision and provide trainings with organizations on effective communication with people with disabilities.  Dr. Carlie Rhoads is the program metrics and evaluation specialist with the American Foundation for the Blind, where she is part of a team that engages in research on a wide variety of topics and provides program evaluation support.  Prior to joining AFB, Dr. Rhoads was the director of the Oregon deafblind project where she supported children with deafblindness from birth to age 22.  So Arielle and Carlie, I will now turn it over to you. 

>> ARIELLE SILVERMAN: Thank you very much.  This is Dr. Arielle Silverman.  Can we go to slide 9, please? 

I want to begin this discussion today by telling a couple of stories that we have heard from patients who are blind or have low vision, and the first story was shared by a middle‑aged woman who was having surgery about a year ago and she needed to get a preoperative COVID test and she had her father give her a ride to the testing center and she reported that when she arrived to get the test done, the medical staff assumed that she could not speak directly to them and they spoke to her dad instead of to her.  She said they just asked my dad for my name and birth date, which I gave quickly, providing my name in case it was needed.  They asked my dad, not me, if I was coming for a procedure in the hospital, and I again answered quickly.  So that's just one example of the type of experience that people who are blind or have low vision can have with healthcare professionals that they feel is disrespectful.  Another example that was shared, someone said, "Before leaving me to get ready for the procedure, the assistant asked me if I needed helped getting undressed.  I felt so belittled."  That's an example where someone felt like it was presumed that because they couldn't see, that they also had trouble dressing and undressing themselves.  So those are just a couple of examples of ways in which people may feel disrespected by healthcare professionals and, of course, those are situations that we would want to avoid.  Next slide. 

So, about AFB.  The American Foundation for the Blind is a national nonprofit working to create a world of no limits for people who are blind or visually impaired.  We mobilize leaders, advance understanding, and champion impactful policies and practices using research and data.  And Dr. Rhoads and I are both presenting from the Public Policy and Research Institute at American Foundation for the Blind.  The PPRI produces research to understand the experiences of people who are blind or have low vision, advocates for federal policies that create opportunities, and publishes the Journal of Visual Impairment & Blindness, which includes peer‑reviewed research findings.  Next slide. 

So about people who are blind or low vision, we just have statistics here that according to the American Community Survey, 2019, approximately 7.5 million people living in the community report having a vision‑related disability.  So that that means they answered yes to a question asking, are you blind or do you have trouble seeing, even when wearing glasses?  And so that description describes a really wide spectrum of experiences, all the way from people who are totally blind who cannot see light, all the way to people who have enough vision that they might be able to read standard size print with aides, with a magnifier, for example, and they might be able to travel without use of a mobility aide.  So it's a really wide spectrum.  Next slide. 

Some impacts of blindness and low vision on daily living, I think the two we are going to focus on most are impacts on access to information, to written information, and navigating in the environment.  So in terms of access to written information, there's a picture here of a woman who is reading Braille.  And most people have a preference about how they read.  So some of the methods that people who are blind or have low vision might use to read include large print, Braille, using an electronic device to access text, and so that might be, for example, on a smartphone or a computer or a tablet.  The device will have software loaded on it that will convert the text into speech, so that a person can listen to the information, or it might be connected with a Braille display, so they can read the information in Braille, or a large computer monitor so that they can read the information in a large print format.  People might listen to text via a reader, a person, a live person, who is reading information to them, or an audio recording that somebody has read on to a recording.  So those are some of the ways that people might access information.  Next slide. 

And then considering some of the ways people that are blind or have low vision navigate through their environments, we have a picture of someone walking on a sidewalk holding a white cane.  The white cane is a method that many blind or low‑vision individuals might use to get around.  Some people might use a guide dog, which we'll talk about service animals a little bit later, and some people might not use either, a cane or a guide dog.  If they have enough vision they might be able to navigate without that or they might choose to use a human guide where they're holding on to the elbow of another person in order to navigate through space.  And a lot of people use more than one of these methods. 

So, now I will pass it to Dr. Rhoads. 

>> CARLIE RHOADS: All right, next slide, please.  So there are three big pieces of legislation that cover the issue of discrimination against individuals with disabilities with, of course, the main one being the Americans with Disabilities Act or ADA.  The ADA is nothing new.  It was first implemented in 1990 and it was the United States Government's first step towards addressing the needs of citizens living with disabilities.  We also had Section 504 of the Rehabilitation Act of 1973, which as amended is a civil rights law that prohibits discrimination on the basis of disability.  This law applies to public elementary and secondary schools among other entities.  Finally Section 1557 of the Affordable Care Act prohibits discrimination on the basis of race, color, national origin, age, disability or sex, including pregnancy, sexual orientation and gender identity. in covered health programs or activities.  Together, the ADA Section 504 and Section 1557 ultimately prohibit discrimination on the basis of disability, specifically also in healthcare facilities, programs and activities.  People with disabilities must be able to fully benefit from healthcare programs and services.  The ADA in particular applies to employers, public entities and public accommodations.  Today we are specifically discussing the obligations of healthcare providers as public entities and public accommodations, but also in insuring that programs and services are accessible to patients that will be beneficial to employees with disabilities as well.  Next slide, please. 

Healthcare organizations that provide services to the public are covered by the ADA.  The ADA requires that healthcare entities provide full and equal access for people with disabilities.  This can be done in several ways.  First, reasonable modifications of policies, practices and procedures.  Adjusting policies, practices and procedures if needed to provide goods, services, facilities, privileges, advantages, or accommodations.  Second, effective communication.  Making communication in all forms easily understood.  This includes making sure that communication needs such as interpreting services are being met.  Third, accessible facilities, which means insuring physical accessibility such as for individuals with physical disabilities.  Covered healthcare facilities include but are not limited to hospitals, doctors offices, pharmacies, dentist offices, etc.  As a result healthcare providers are required to ensure that facilities and equipment are accessible to a wide variety of individuals with and without disabilities.  Providers engage in effective communication with people with disabilities which may include an American Sign Language or ASL interpreter or pro tactile interpreter, someone who interprets for an individual with deafblindness.  Healthcare providers must ensure that policies, programs and procedures are modified when necessary to prevent discrimination, which can mean access to an ongoing conversation that must be periodically updated to ensure all needs are being appropriately met.  Next slide, please. 

The American Foundation for the Blind conducted a large project that served to help a specific hospital located in Huntington, West Virginia to better serve the needs of individuals with visual impairments in healthcare settings.  We started off with literature review and focus groups.  Two focus groups were conducted with individuals who are blind or have low vision specifically in Huntington, West Virginia.  Participants of the focus groups tended to be older, white, college educated, and to have had limited incomes at the time of the study.  Once these initial stages were completed, the research team developed a 40‑minute long recorded webinar about meeting the needs of individuals with visual impairments, which included individuals who were blind with low vision or who were deafblind specifically in healthcare settings.  Along with the presentation, a pretest and post‑test were developed to test the knowledge of viewers prior to the presentation and after viewing the presentation.  The research team additionally created five handouts, each tailored to meet the specific needs of various staff members such as those including working the registration desk for when they would encounter and need to assist an individual with a visual impairment.  At the time of the presentation, we had had almost 30 individuals complete the pre‑quiz and nearly 20 individuals complete the post‑quiz.  Many individuals scored quite low prior to viewing the presentation, with 42% of individuals scoring zero.  By contrast, after viewing the presentation, nearly 50% of all individuals scored 80% or higher.  Next slide, please. 

For the focus groups, questions were specifically developed based on findings from if literature review.  The first question was:  How would you define healthcare quality?  We wanted to know exactly what the participants considered to be high and low quality healthcare.  Our next question involved communication with medical and non‑medical staff.  We wanted to find out typically how the population communicated with staff in healthcare settings such as positives, negatives and above all else, what their personal experiences included. 

Access to the hospital services was the third topic.  We wanted to know if the participants, based on their own experiences typically had access to hospital services or if there were barriers to getting appropriate healthcare services.  Getting to and around the hospital was the fourth topic where we asked about participants experiences with transportation and physically arriving at the hospital and their experiences with traveling within the healthcare facility.  We also asked participants about training doctors and hospital staff, such as what do staff need to know about working with individuals with visual impairments?  What would be helpful for them to be trained on and for them to be knowledgeable about?  Our final topic was designing hospital procedures for people with blindness, low vision and deafblindness.  We asked focus group participants about current hospital procedures, which ones were helpful, and which were harmful, and what could be done to help improve procedures overall to better meet the needs of individuals with visual impairments.  Next slide, please. 

The research team also conducted a study called flatten inaccessibility.  This was anonymous online survey conducted in April of 2020 that explored the experiences of individuals who are blind or have low vision during the beginning of the COVID‑19 pandemic.  For this study we had 1,921 respondents who answered questions on transportation, employment, education, social experiences, access to food, meals and supplies, loading, and most pertinent for us today, 1,010 of the participants answered questions about healthcare.  While our research did not specifically examine ADA standards, it did explore the impact on patients of having accessible facilities, effective communication, and appropriate modifications to some policies and practices.  Some snapshots from the Flatten accessibility report include the following.  54% of participants have concerns about healthcare.  59% felt their underlying health conditions made them particularly vulnerable to COVID‑19 complications.  30% of participants reported meeting with their healthcare provider using telehealth, but 29% of participants reported that the telehealth platform was not accessible.  And overall report recommendations included that healthcare facilities must recognize that people with visual impairments may need someone to accompany them to visually interpret the environment when necessary and advocate on their behalf.  Recommendations also included the medical provider should make written information accessible to individuals who are visually prepared by providing electronic Braille and large print options, and a final recommendation included that electronic health records, secure video platforms and other telehealth systems should meet the highest accessibility and usability standards.  Next slide, please. 

We found that some similar themes and findings emerged across both of these research projects.  In general, patients who are blind or have low vision want the same things from their care as any patient.  That is medical professionals who are respectful practice good communication and assume competence on the part of the patient.  Information about their care and treatment plan and effective care.  The literature review revealed patterns of inaccessibility, especially in access to information, communication, transportation, navigating facilities and privacy, as well as a lack of staff training on disability.  To provide the full benefits of quality care, medical professionals, their staff, and the care facility often need to improve their facilities and provide modifications to typical practices and policies.  Notably in our research we also found that while participants generally are their own self‑advocates, self‑advocacy is much more difficult when they are sick.  Having medical and non‑medical staff ask the patient what their needs are can open the door to building strong communication and trust between the doctor and patient.  And I will pass it back to Dr. Silverman, and the next slide, please. 

>> ARIELLE SILVERMAN: Okay, so slide 20.  The 2010 ADA standards specify that healthcare facilities must be accessible to people with disabilities and medical equipment should also be accessible to patients with disabilities.  Examples of facility features that the standards cover include passive travel, signage, transportation facilities, removal of protruding objects that could create a safety hazard, and also elevators.  So, for example, regarding accessibility for people who are blind and have low vision and providing Braille or large print signage, Braille or large print numbers on elevator panels and removing overhead objects.  Next slide, please. 

So we have a picture on the slide of a hospital directory sign.  And the photo has been blurred so that it simulates what someone might see if they are looking at the photo with a visual acuity of 20/200.  So individuals with that level of visual acuity might have difficulty reading details on signs, maps and other wayfinding tools.  So providing accessible signage, maps and wayfinding will promote navigation for people who are blind or have low vision, whether they are the patient or a visitor.  Next slide, please. 

Effective communication.  Healthcare providers are generally required to take the necessary steps to effectively communicate by providing auxiliary aids or services.  Exceptions to this rule are limited and public entities are required to give primary consideration to the type of communication requested.  So if a patient or someone else in hospital requests access to information in a certain format, like Braille, large print or digital format, efforts should be made to accommodate that request.  The goal is to find a practical solution that provides communication, and some examples of what we mean by auxiliary aids and services include qualified readers, so, again, those are human beings who provide access to print by reading materials aloud to the individual and possibly also writing down the individual's information if they're filling out a form, for example.  Braille or large print materials.  Accessible electronic and information technology.  So accessible patient portals, for example, and healthcare records apps that patients can use to access their medical information.  Next slide, please. 

So check‑in and registration is one specific area where access to accessible information is really important.  Forms and documents should be provided in the patient's preferred format, which, again, can include Braille, large print, electronic, or providing a human to read the material to the patient.  The materials are presented on a website or kiosk, the digital platform needs to be fully accessible.  Patients should not be expected to bring their own reader or assistant with them.  So many people who are blind or have low vision go to medical appointments alone, and don't necessarily have someone or want to bring someone with them to help them with reading and filling out forms and the like.  Protecting patient privacy is also critical.  So if the patient is requesting or needing to read forms and fill them out, it's important to provide a private area where they can do that without sensitive information being overheard by others.  Accessible formats and devices also provide privacy to the individual by allowing them to fill out the form independently without having to rely on another person.  Some of the findings I found in the focus groups, focus group participants expressed gratitude when a private room was provided to fill out forms, etc.  Some people were told that they had to bring a person with them, which, again, is not always desired or practical by the individual.  When staff assisted the form, some people experienced longer wait times, needing to wait for an individual to be available to assist them with the forms, and so some of those things interfered with full access to healthcare services.  Passing back to Dr. Rhoads. 

>> CARLIE RHOADS:   I think we are a slide behind, so if we can go to Slide 25, please.  Thank you.  For inpatient stays, staff should explain that a meal tray has arrived, what is on the tray and provide menus and ordering slips in a format that is accessible or provide a qualified reader to read the menu and fill out the order form.  This allows individuals with visual impairments to fully access the meal delivery service and ensures they receive their meals in accessible manner.  It is also suggested that staff let the patient know that a meal has arrived.  We have a quote from one of or our focus groups on this topic, and the individual says, "I hate when someone says, it's over there, or in the hospital they will say, here's your tray, and plop it down and you don't know what is on the tray."  Another participant shared that," Sometimes they will bring you a little slip and put it on your tray and you get to choose what you want for the next meal, but you don't know it's there and you can't read it anyway, so they just give you whatever.  If they could help you fill the slip out, that would be great." so, by making meal delivery accessible, patients with visual impairments will be able to exercise autonomy over meal choices equal to that of patients with visual impairments.  Next slide, please. 

In our focus groups, the most common negative discharge experience was that documents were not provided in accessible format.  Often documents were given to the patient without explanation.  Sometimes the patient is still sedated and cannot fully understand even when the documents are read to them.  One focus group participant shared that his wife was given the documentation and that no one explained to him the steps that he needed to take.  He stated, "They gave the prescriptions to my wife and figured that was all they needed to do." another participant from the focus groups explained," I had outpatient surgery, and when I woke up, they handed me a bunch of papers and said, this is what you need to do to take care of yourself, and I couldn't read them.  I asked them to read them to me, and they said, is there anyone at home to help you?  Well, I'm alone.  I have nobody to help me.  So they hand you those papers and send you home and you don't know how to take care of yourself ." 

So based on the experiences of the focus group participants and research conducted within the accessibility study, it is recommended that staff provide discharge documents DME the patient's preferred formats.  This could include large print Braille or electronically.  If documents are read aloud, ensure that the patient is in an appropriate state to receive the information and ask follow‑up questions.  And I will pass it back to Dr. Silverman.  Next slide, please. 

>> ARIELLE SILVERMAN: We should be on Slide 27, digital accessibility.  Healthcare services and information are increasingly being available online, and using digital tools, for example, electronic health records, websites, and telehealth platforms.  And accessible digital materials, as mentioned previously, can facilitate access to healthcare, for example, by allowing people to fill out forms independently, but when those tools are inaccessible, they can create barriers.  Digital diagnostic and remote monitoring is also something that is becoming more and more prevalent.  Ensuring accessibility upfront reduces costs involved in remediating barriers.  So insuring that accessible tools are procured, testing those tools to be sure that they are accessible, and providing accessible customer support for users who are blind or have low vision.  Next slide, please.  So prescriptions.  And we have an image of a pill bottle that is on its side and I just want to share a little quick anecdote in addition to being a research specialist at AFB, I am a totally blind person, and I had an experience a few years ago where I was traveling and I had packed a couple of different medications, and I took out what I thought was a Tums and put it in my mouth and started chewing it, and I soon realized that it was actually an Advil.  And if you have not had the experience of chewing Advil, I really do not recommend it.  And that was a relatively harmless experience and I can laugh about it, but, of course, depending on the medication, the consequences of mixing up medications can be serious or even deadly.  So access to prescriptions and medication label is extremely important.  Mis‑identifying medication can have serious consequences when people cannot read the medication labels.  And we have a link here to the prescription labeling guidance from the Access Board, so we encourage you to look at that link to learn more about how to make prescriptions and medication labels accessible.  Next slide, please. 

Service animals.  So some people who are blind or have low vision use a guide dog, which is a type of service animal, to get around.  And so a service animal is an animal that has been specially trained to perform a specific task for a person with a disability.  A service animal is not the same thing as an emotional support animal.  Emotional support animals can provide emotional support to individuals, but they are not subject to the same regulations as service animals.  Service animals are allowed in any part of the healthcare facility where the public is allowed to go.  So they're allowed in patient rooms, ambulances, and any other public spaces in hospitals.  Basically anywhere except sterile facilities where the public is not allowed to go.  We have a link here to the Department of Justice Q&A on service animal policies, and we encourage you to look at that for more detailed information about service animals.  I will pass back to Dr. Rhoads. 

>> CARLIE RHOADS: Thank you.  Next slide, please.  So disability awareness training.  Our focus group participants really emphasize the need for staff to be knowledgeable about disability.  Staff should understand enough about the various disabilities and should treat patients with disabilities with full respect and confidence.  These are some action items that we think would be very helpful.  The first one is announcing themselves and providing verbal instructions, and we have some quotes from our focus groups to kind of back this up.  One of our participants had to say, "The doctor should say their name when they come in.  The other day someone came in and grabbed me and turned me around.  I had to say, who are you?  And he acted like I was acting kind of silly.  I said, I can't see you, you need to tell me who you are. 

The next item is speaking directly to the patient unless otherwise indicated.  And we have a quote here from one of our focus group participants.  "I am there with my wife, but she is not my interpreter or my mommy.  I had a nurse one time who said to her, you're going to have to come in and help him get undressed.  The nurse just ignored me and spoke to her.  They should talk to me."  Another participant had to share that," Oftentimes you get talked down to.  I can understand what everyone else can understand.  They assume you can't hear because you're blind.  They ask someone else about you, how much can she see, what would she like to eat?  Another item that we suggest is understanding that blindness and low vision is a progressive scale.  And one of our participants had to say that, when I see something and comment on it, they think I see.  They don't understand the differences in what people see.  It's very hard to describe.  Once they see that you have a little vision, they think you are either blind or not blind.  They should ask, what are the deficits and how can we work around them? 

The next item is communication between staff and remembering patient needs.  And a quote from one of our participants is... "A lot has to do with the patient's approach.  Some after advocates with them and others don't.  When I was at one hospital, the first thing they asked me was if I would need a guide.  Will you need someone to accompany you or read to you?  They were extremely good.  They knew why I was coming in before I got there and it was an extremely seamless process.  When I got to write needed to go, I was less anxious and more focused on my issues.  That was important to me at the time.  Communication should go both ways, given and received.  Open communication is really important for ensuring patients receive the accommodations that are most useful.  Next we have assisting with orientation.  Some focus group participants reported that the most efficient way for them to travel within the hospital was with sighted assistance.  Hospitals may want to train volunteers and security staff in the human guide technique so these non‑medical personnel can be available to provide assistance.  It is extremely important that all hospital personnel understand that they must ask the person if they want assistance.  If the person does, the guide needs to offer an arm and allow the person to hold their arm above the elbow. 

Orientation to the patient's room is also important.  Participants wanted to be able to independently move around in their room if their medical condition permitted.  They appreciated a brief orientation to their room layout.  They also wanted to know how to use the call button to require assistance when needed.  Additionally, controllers can be easily marked with masking tape or other tactile markings to help discern what their functions are for.  Next slide, please. 

Respondents to our flattened accessibility study about the COVID‑19 pandemic expressed fears about being discriminated against on account of their disability.  The concern statement reads as follows:  "I am concerned that if I need care due to COVID‑19 I will be denied access to care, such as a vented later, because of my visual impairment."  968 participants answered this question with a mean score of 3.41 meaning most of the respondents agreed or strongly agreed with the concern statement, meaning that the bulk of participants had concerns that because of their disability they would be denied proper care if they were to contract COVID‑19.  The ADA and Section 1557 prohibit discrimination on the basis of disability.  People who are blind or have low vision must not be denied care or receive insufficient treatment based on their disability.  Next slide, please. 

As discussed earlier in the presentation, AFB has several resources that may be helpful and we encourage dissemination of these items. first we have provided a website link on this slide where you can gain access to any of these resources.  On this list of resources we have the handouts that we created for the healthcare professionals.  There are five which are geared towards registration staff, guest services, food services, support staff, and then that general handout for all staff members.  Each handout is tailored to specific needs of the staff members and typical responsibilities within the healthcare setting.  We also have our training videos, Part 1 and Part 2, created by three AFB research staff members, and that includes myself and Dr. Silverman, who took what we learned through our research and coupled it with personal.  Two of the researchers are visually impaired and professional experiences, together this research team designed a 40‑minute training presentation that has short activities embedded within.  It's not just death by PowerPoint.  Rest assured, there are fun quizzes and interactive features.  The information provided is practical and has lots of examples shown with photos in short illustrated video clips.  Finally, with the website link you also have access to the pre‑ and post‑test presentation to test your knowledge and see if you learned anything new.  Next slide, please. 

We thank you for your time today and willingness to learn more about this very important topic.  If you have additional questions or concerns or would just like to reach out, Dr. Silverman and myself are both available via email posted on the screen.  We are very happy to discuss this topic 

So COVID‑19 restrictions have eased more recently and many Americans are beginning to venture out to shop, socialize, work and just return to some sense of normality.  We know that the COVID‑19 pandemic has had a very profound impact on all of our lives, and this is especially true of individuals with blindness or low vision who are still facing accessibility adversity when navigating the mic arena.  We want to be sure that we are adequately prepared with resources such as those we created at AFB to better edge skate to have who work in healthcare.  We need to ensure the needs of individuals with visual impairments are being met.  We strongly feel that together we can keep striving for a world with no limits.  Thank you. 

>> LEWIS KRAUS: All right, thank you so much, Arielle and Carlie.  Appreciate that fantastic presentation.  All right, everyone, this is a time, if you have not submitted your questions, you can submit your questions in the chat window, and we're going to go through them now. 

The first one is a comment, and maybe you can both respond to this comment.  Discharge instructions in Braille can take a lot of time to be produced.  Most hospitals do not have a Braille printer on site and need to outsource services, which can take several business days.  I don't know if you have a comment about that or not. 

>> CARLIE RHOADS: I think that is a really great point, that the production of Braille is very time‑consuming.  I think when it's possible to have pre‑Brailled items, that's always a great thing.  Such as you know, if the hospital has a menu they regularly use, having that automatically already available in Braille would be great.  Or hospital policies and procedures that are not going to be changing, that could be pre‑made into Braille as well.  I think it's just important for us to keep in mind that we need to make sure we're offering different avenues so that things are accessible.  So while it might be out of the realm of possibility to get quick Braille for an individual specific treatment plan for home, we can offer things like large print.  That doesn't take long to print out.  Or we can offer electronic offers or have someone to read to them.  So thank you. 

>> ARIELLE SILVERMAN: Yeah, I completely agree with that.  I definitely agree with pre‑Brailling information that doesn't change frequently, and I think also just working with the patient to find out ‑‑ or the visitor, whoever it is, to find out if there is another way, if they need immediate access to the information and it's individualized, if there's another way to make that available.  So, for example, some people who use Braille might also have a Braille display at home.  And so if the information is emailed to them, they can read it in refreshable Braille.  So that might be another way of giving them access. 

>> LEWIS KRAUS: Those are great answers.  I do like to reemphasize on that that a lot of accessibility issues can be solved by planning.  So if you don't leave it to be something that you have to do at the moment, you're in a better situation.  So I agree that if you can plan ahead to have the documents available or make them available electronically, that will be helpful. 

All right, next question... has there been any effort to educate patient advocates regarding medical care access for people with disabilities?  Would such education to patient care advocates be helpful? 

>> CARLIE RHOADS: Go ahead, Dr. Silverman.

>> ARIELLE SILVERMAN: Yes, I think it definitely would be helpful. 

>> CARLIE RHOADS: As far as I know, there hasn't been, to my knowledge, an effort to educate patient advocates, but as Dr. Silverman said, I think that would be helpful.  I think anyone that is touching the healthcare setting definitely needs proper training and education about how to best meet the needs of individuals with disabilities, because access to healthcare is a right that everyone should have access to and we need to make sure that it is accessible and inclusive. 

>> LEWIS KRAUS: All right, thank you.  Next question...

... any suggestions for delivery of virtual care to patients? 

>> CARLIE RHOADS: Actually, I have some very strong opinions about that question.  You know, we really found in flattened accessibility, as well as a new study that we're in the process of putting the report together, it's the sequel to Flatten Accessibility, it's called Journey Forward, and that report should be out at the end of March or early April, and we have found that largely the telehealth applications and platforms have been very inaccessibility to individuals with visual impairments.  So I think the really big thing is just making sure that these apps and platforms and websites are actually accessible to these patients.  Another big thing is, you know, when they're sending out emails, you know, making sure that if it's really image heavy or something like that, that we're including alt tags, that they are readable with a screen reader, that they're accessible with screen enlargement software.  You know, just being really mindful from the beginning and making sure these things are accessible.  I think a really consistent theme that we found with a lot of this research is that we're in the middle of a pandemic, and we're kind of in a disaster crisis situation, and so many things that were problems to begin with have been magnified to become even bigger problems.  So we need to make sure that we are including the needs of individuals with disabilities, and specifically those with visual impairments from the beginning and not trying to bootstrap Band‑Aids on really, really big situations. 

>> ARIELLE SILVERMAN: Yeah, I agree with that, and I think one way just generally for all these situations of increasing accessibility is to provide multiple ways that someone can access the platform.  So making it available on the web and through an app and maybe having a telephone option for meeting with a provider, for example, instead of relying on requiring the person to log in and use a video access method can ensure that people who can't access the video for whatever reason can still get care. 

>> LEWIS KRAUS: That's great.  That's such an important area, because of all the increasing use of virtual meetings.  So thank you for those responses.  And the next person says ‑‑ and this may be referring back to the last question.  Being sure to allow a patient to record or write notes from read instructions is important.  The unfortunate part is that it does not appear that there are patient advocate organizations to which to provide outreach.  Any feedback on that or comments on that? 

>> CARLIE RHOADS: Yeah, I think that's a really important point.  First of all, if the patient is by themselves, you need to make sure that they're not sedated, that they are, you know, cognitively aware of what is going on so that they can actually take in important information that you're giving to them.  So making sure that they have a way to record what you're saying on their phone or that they have a way to write notes, that is really, really critical, and we need to make sure that that accommodation is also being made. 

>> ARIELLE SILVERMAN: And that's an easy way, too, if somebody desires it, it's a pretty easy way to give people access to information, like the names of providers that ‑‑ or information that is written on their whiteboard in their hospital room, for example, or important phone numbers.  Allowing someone to record it for them is a really good way for them to have access to that information whenever they need it. 

>> LEWIS KRAUS: All right.  Thank you.  Next question.  How do we make sure our telehealth platforms are accessible to patients?  Is there a checklist of features we should look for, or is it more training of clinicians that is needed? 

>> ARIELLE SILVERMAN: I think much of ensuring accessibility is being sure that they are tested by either professional accessibility testers or by multiple users who are blind or have low vision, instead of just doing automated accessibility checks. 

>> CARLIE RHOADS: I agree with Dr. Silverman.  You know, it also is helpful if you have IT staff who have been properly trained on accessibility features so that they're able to provide support in those arenas.  So, you know, just making sure that the platforms and apps are accessible, that they have been tested by people who would actually know what to look for, know how to use those things.  There's not really, like, a checklist, per se, just because platforms and apps can really vary so much.  You know, depending on what features are included, but, you know, some of the real basics are, you know, if there is a photograph, you need an alt tag.  If you have a video, it needs audio description.  And, of course, closed captioning and those sort of things.  You know, things like having buttons on the screen for clicking through to next on a slide or something like that, those typically aren't accessible with a screen reader.  So just being mindful about things like that and making sure that you have properly test it and that it's hopefully not going to break when other people who really, really need the service, so that they can use it. 

>> LEWIS KRAUS: All right.  We have run to the end of the questions that people have.  If you have any more questions, this is a good time to put them in the chat box, so that we can ask Dr. Silverman and Dr. Rhoads.  If not, just letting you know, while you're thinking about that, letting you know that you will be receiving an email with a link to an online session evaluation.  You can complete that evaluation for today's program, because we value your input and want to make sure that our funder is aware of the importance of these webinars.  So, having said that, another question came in.  So much has been tested already in the last year or more.  You are using Zoom.  Does this mean that this is a properly tested format you have selected for webinar use? 

So I think a little bit of that I'm going to ‑‑ let me start with that.  Dr. Silverman and Dr. Rhoads, this is our system, and, yes, we have looked at this and we have put in the accessibility features and have worked with the manufacturers to make sure that the accessibility features are there.  And you can see that we have included captioning, we have included ASL interpreters, we are putting the slides up in in large format.  So we have done as much as we can, and we have been monitoring the kind of correspondences that have come back to us about whether this is accessible to people or not, and so far this has been, I feel, well‑received.  Having said that, Dr. Silverman and Dr. Rhoads, any response? 

>> ARIELLE SILVERMAN: Yeah, as a member of the blind community, I've experienced and heard that Zoom is probably one of the best platforms. 

>> CARLIE RHOADS: I will say at AFB we tend to use a mix of Zoom and Google Meet.  So I hesitate to say that Zoom is like the be‑all‑end‑all, because of course there's always room for improvement, but I think at this point in the pandemic, when we all have gotten pretty savvy at online learning, online meetings, online connections, you know, Zoom is a really solid option, and I think every time of accessibility feature has been very thoughtfully considered, specifically for this webinar.  We submitted our slide deck and all of the pictures have alt tags, and, you know, there's interpreting services, closed captioning.  So I think this organization has done a very nice job of considering all the angles. 

>> LEWIS KRAUS: And I think there is someone who replied to that and said there is Zoom for telehealth, which I have known blind people to have a good experience.  So anyway... and just to be clear, we are not endorsing this as the only or be‑all of services, and I think over time all the services are starting to learn about the features that they need to have.  So I think as time goes on, we probably are going to find that things are going to be getting better. 

All right, the next question... what are ‑‑ what are your thoughts on accessibility for those with low vision/blindness on technology, especially smartphones, game systems, laptops, etc.?  Additionally, do you think there are any ways, companies such as Apple, Google, Amazon and Microsoft could improve their accessibility?  This might be a little out of your range, Dr. Silverman and Dr. Rhoads, and let me know, and I can answer if you would like. 

>> ARIELLE SILVERMAN: I will just mention that AFB recently published a report on workplace technology.  I know that's not all of what you were asking about, but some of what you were asking about is definitely part of that report.  So you can learn more about that project at www.AFB.org/wts. 

>> CARLIE RHOADS: That is a really, really big talk.  I think we could probably have a whole webinar just on that topic, actually. 

So, accessibility, with just like technology in general you know, I was a TBI ‑‑ I got my TBI license years and years ago, and even since then I think ‑‑ TBI is a teacher of students with visual impairments, for those that don't know the acronym.  I used to work with students with visual impairments and students who were deafblind, and even just ten years ago the technology we were using was so different.  Like we have come such a far, far away from where we initially started.  Like there are so many wonderful apps on the phone for reading currency, for converting print to speech, and all kinds of wonderful things.  AFB has a really great resource called Access World located on our website that talks about all of the newest technology and apps and wonderful things that are out there that have been reviewed and talked about by people who actually use those services.  So if you're looking for specifics about technology and accessibility, that is a really great place to look. 

>> LEWIS KRAUS: And I'm going to add that in general there are standards that are ‑‑ that have been put out by the WCAG, the world web accessibility initiative.  And those do cover these other elements, like smartphones, etc.  Game systems are coming.  Laptops and whatnot, that's all in existence.  So people are to follow those, or should be following those, and the companies you have mentioned tend to have accessibility staff who are monitoring things, although sometimes it's internal, sometimes it's external.  But if you would like to learn more, I'm going to put into the chat here the ADA National Network as another Webinar Series that you can look at that has to do with technology, and you can go and look at those websites if you have an interest in that area and would like to look at that some more.  And there is a couple more comments in the chat that are related to this.  One person said, I have also known at least one blind person to have noticed improvement to the Doxy.me app for iOS.  And there is also someone who said there are resources for communication access, including checklists for improving communication access for individuals who are blind or have low vision that is at the CMS.gov address.  And I'm going to put that in the chat, because I'm not sure if everybody can see that. 

So there are a few resources that are available to everyone about that particular topic.  So, any other questions about Dr. Silverman and Dr. Rhoads, go ahead and put them in the chat.  In the meantime I do want to remind you that if you did ‑‑ if you do have a question that is ADA related, and you think of it after this is done, and you would like to ask that, feel free to contact Dr. Silverman and Dr. Rhoads, as they said right there, or you can contact your regional ADA Center at 1‑800‑949‑4232, and also you can find us at the ADA national website.  Our next webinar, just to let you know, our next webinar will be on March 24th and will feature a presentation by the National Council on Disability on lessons learned from the COVID‑19 pandemic and how to improve equitable healthcare for people with disabilities.  And so given that, we are ‑‑ I want to thank Dr. Silverman, Dr. Rhoads, thank you so much for your presentation and your time.  It was a great presentation.  And for sharing your time and knowledge with us.  And for all of you listening, just a reminder that today's session was recorded and will be available for viewing next week at ADApresentations.org in the Archives section of Healthcare area. 

All right, so thank you for attending today's session, and I think we will end there.  Thank you again, Dr. Silverman and Dr. Rhoads. 

>> CARLIE RHOADS: Thank you for having us today.  It was a wonderful opportunity and we were glad to talk to everyone. 

>> ARIELLE SILVERMAN: Yes, thank you.

>> LEWIS KRAUS: Have a great afternoon, everyone! Bye‑bye!

>> AUTOMATED VOICE: Recording stopped.