Expanding Your Protection and Advocacyfor Assistive Technology (PAAT) Practice

Thinking Beyond the Traditional AT Devicesand AT Funding Sources

James R. Sheldon, Jr., Esq.National AT Advocacy ProjectNeighborhood Legal Services, Inc.

Buffalo, New York 14207716-847-0650 ext. 262jsheldon@nls.org www.nls.org/natmain.htm

Ron Hager, Esq.National Disability Rights Network202-253-5252ron.hager@ndrn.org

Prepared: June 2017

The ideas presented here are based on the experience of the National AssistiveTechnology (AT) Advocacy Project at Neighborhood Legal Services and NDRN in threekey areas related to AT advocacy: more than 20 years experience in providing trainingand technical assistance to P&A attorneys and advocates throughout the country andterritories; a dozen or more years experience in reviewing the Program PerformanceReports of all PAAT programs; and many years of direct representation of clients onAT-related issues.

I. Introduction

A. Every Protection and Advocacy (P&A) agency receives a Protection andAdvocacy for Assistive Technology (PAAT) grant from the Administrationfor Community Living (ACL) within the US Department of Health andHuman Services (HHS).

1. The PAAT grants enable P&As to provide a range of advocacyservices aimed at helping individuals with disabilities to obtainappropriate AT devices and AT services.

B. Other than specifying that our work be AT-related, neither the AT Act northe ACL grant awards specify:

1. The type of AT devices and services to be addressed (e.g.,wheelchairs, therapeutic tricycles, adapted computer keyboards, orspecialized software)

2. The funding sources or funding strategies to be addressed (e.g.,Medicaid, special education, your state tax code, or enforcement ofthe Fair Housing Act)

3. The types of advocacy services used (e.g., direct representation,training, preparation and dissemination of materials, or advocatingfor policy change)

C. This handout will look at these three key areas – AT devices andservices, funding sources and funding strategies, types of advocacyservices – and present a range of examples of what the PAAT programsare doing or could be doing to serve their client base, i.e., individuals withdisabilities. In doing so we hope this will be useful to P&As by:

1. Providing guidance for P&As as they prioritize their work for theirPAAT projects or their agencies in general

2. Providing guidance on where they might expand their PAAT

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practice to capture a different type of AT-related work, particularlyfor the P&A which has not traditionally experienced high caseloadsfor their PAAT project.

3. Helping P&As think through how other P&A programs, such as thePADD, PAIR, PABSS, or CAP programs, might combine forceswith their PAAT project to address issues that cross over to theother P&A programs.

II. Looking at the Definitions of AT Device and AT Service

A. The one thing that does govern the work we do as PAAT projects is thedefinitions of “assistive technology,” “AT device,” and “AT service” underthe AT Act at 29 USC 3202 (emphasis added):

* * * * *(3) The term “assistive technology” means technology designed to beutilized in an assistive technology device or assistive technology service.

(4) Assistive technology device

The term "assistive technology device" means any item, piece ofequipment, or product system, whether acquired commercially off theshelf, modified, or customized, that is used to increase, maintain, orimprove functional capabilities of individuals with disabilities.

(5) Assistive technology service

The term "assistive technology service" means any service thatdirectly assists an individual with a disability in the selection, acquisition,or use of an assistive technology device. Such term includes--

(A) the evaluation of the assistive technology needs of an individual with adisability, including a functional evaluation of the impact of the provision ofappropriate assistive technology and appropriate services to the individualin the customary environment of the individual;

(B) a service consisting of purchasing, leasing, or otherwise providing forthe acquisition of assistive technology devices by individuals withdisabilities;

(C) a service consisting of selecting, designing, fitting, customizing,adapting, applying, maintaining, repairing, replacing, or donating assistivetechnology devices;

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(D) coordination and use of necessary therapies, interventions, or serviceswith assistive technology devices, such as therapies, interventions, orservices associated with education and rehabilitation plans and programs;

(E) training or technical assistance for an individual with a disability or,where appropriate, the family members, guardians, advocates, orauthorized representatives of such an individual;

(F) training or technical assistance for professionals (including individualsproviding education and rehabilitation services and entities thatmanufacture or sell assistive technology devices), employers, providers ofemployment and training services, or other individuals who provideservices to, employ, or are otherwise substantially involved in the majorlife functions of individuals with disabilities; and

(G) a service consisting of expanding the availability of access totechnology, including electronic and information technology, to individualswith disabilities.1

B. Looking at the definition for AT device

1. The statutory language, “any item, piece of equipment, or productsystem . . . used to increase, maintain, or improve functionalcapabilities” allows us to think very broadly to consider a range ofequipment or product systems, including:

a. Mobility devices - wheelchairs, scooters, specialized strollers

b. Communication devices - including dedicated speechgenerating devices, and dual-purpose devices that alsofunction as a personal computer (most recently including thei-Pad and possibly similar devices)

c. Devices for hearing - hearing aids, a phonic ear, cochlearimplants

d. Devices for seeing - computer screen enhancements,magnification devices (such as the CCTV which would allowits user to read mail, books and magazines)

1The same definitions for AT device and AT service are used by the federalregulations governing special education programs, 34 CFR 300.5 and 300.6, and theregulations governing state vocational rehabilitation programs, 34 CFR 361.5(b)(7) and(b)(8).

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e. Adaptations to vehicles - including hand controls, hydrauliclifts, and equipment to help a wheelchair user store the chairand remove the chair from a trunk or roof rack

f. Devices to aid in therapy or medical treatment - a swimmingpool lift, a standing frame (to facilitate treatment known as“passive standing”)

g. Devices to assist with employment - a ramp, a speciallydesigned/modified desk or office chair, an optical scanner, abraille printer

2. Does it meet the AT device definition?

a. Sign interpreter?(1) No, not an “item, piece of equipment or product

system”; nor is it technology(2) However, the use of computer technology to allow the

individual to benefit from an interpreter who is at adistant location (e.g., an Internet video relay service)would fit the AT device definition as it is using both a“piece of equipment” (the personal computer) and a“product system” (video camera tied to the Internet) toallow the individual to increase their “functionalabilities” in the area of communication.

(3) Similarly, the use of a CART system or court reporterto transcribe a lecture for reader on a screen at thefront of the room or on the individual’s laptopcomputer would meet the AT device definition.

b. Guide dog or service animal?(1) This would not be an AT device as an animal is not

an “item, piece of equipment, or product system.” While some may argue that a dog is an “item,” itcertainly does not use “technology” to serve theindividual.

(2) However, many individuals who are blind, visuallyimpaired, or even cognitively impaired are now usinga range of AT devices, with voice output: such asGPS devices (including the GPS features orapplications on a smart phone) to follow directions; orhand-held devices, like the device that combines the

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personal digital assistant with a digital camera,2 thatwould allow the user to quickly scan items like busschedules or written directions.

c. What about the range of medical equipment which allowsthe individual to receive treatment at home, such as anebulizer (for treating asthma), portable oxygen (forrespiratory conditions), patient lifts (for individuals notcapable of independent transfers)?(1) Many of us might not think of items like this as AT

devices, as they were around for many years beforethe AT terminology found its way into federal law.

(2) However, since these devices are “equipment” or“product systems” that are used to “increase,maintain, or improve functional capabilities,” theywould all meet the AT device definition. They all use“technology” to provide the individual with the desiredtreatment or assistance.

3. Are your clients getting the AT device, but not all the adaptations oraccessories needed to fully benefit from the device?

a. Power wheelchair - could include tilt in space, programmablecontrols, a customized joystick, a horn and lights

b. Speech generating device - if individual is a wheelchair user,could include the mount needed to use the device on thewheelchair

c. Adapted personal computer, keyboard - is the school oremployer also considering the need for adapted seating thatthe individual may need?

d. Examples you can think of?

4. Examples of unique AT device cases/advocacy activities reportedby PAAT projects during past 10 years or so.

a. Cough assist machine to remove respiratory secretions fromthe airway. The New Hampshire PAAT program workedwith a 16 year old boy who has multiple disabilities, has

2That hand-held device, often referred to as the Kurzweil-National Federation ofthe Blind Reader, has been commercially available since 2006.

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significant muscle weakness and is too weak to cough wellenough to remove respiratory secretions from his airway. The client has frequent hospitalizations, many of which arerelated to his respiratory difficulties and the cough assistmachine is medically necessary to prevent airwayobstructions, lung collapse, and pneumonia. The PAATattorney successfully represented this client in an appeal tothe Department of Health and Human Services whichreversed its decision denying Medicaid payment for acough-assist machine.

b. Enclosed safety bed. The Iowa PAAT program representeda three-year-old child with congenital quadriplegia, profoundmental retardation and a seizure disorder. He was in fostercare, pending adoption. The child's foster family was waitingfor the positive outcome of the acquisition of an enclosedsafety bed before finalizing the adoption proceedings. ThePAAT assisted the client in obtaining the enclosed safetybed. Once the bed was acquired, the family was able tofinalize the adoption.

c. Power wheelchair with “seat to floor” function. The TexasPAAT program advocated on behalf of a eight year old girlwith cerebral palsy whose request for a power wheelchairwith a seat to floor function was denied by Texas Medicaid.The seat to floor function would help incorporate the childinto peer activities and would also enable the child totransfer independently to the floor, or any other surfaceindependent of where it was located. Following severaldemand letters and a meeting with Texas Medicaid'scounsel and an assistant Texas attorney general, however,Texas Medicaid reversed its decision and approved thepower wheelchair, with the robo seating system, asrequested.

d. Defective porch lift. The Connecticut PAAT program filed alawsuit against a Canadian company that had sold andinstalled a defective porch lift. After various attempts toresolve this case through negotiation, a lawsuit was filed andthe defendant company defaulted by failing to answer. Aftera damages hearing, the client was awarded full damages tocover the cost of the lift. A Canadian firm was then hired tocollect the funds and several months later the award wascollected, meaning the individual now has the money toreplace the lift or purchase alternative AT.

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e. Positioning chair to gain access to dining table or bathroomsink. The New York PAAT filed a lawsuit on behalf of an 11year old who needed a positioning chair in addition to hispower wheelchair. The power wheelchair did not provide himaccess to the dining table or bathroom sink. His medicalproviders stated that he needed the chair in order to developself-feeding, socialization and hygiene skills. After the lawsuit was filed, the Medicaid agency agreed these weremedical needs and agreed to provide an appropriate chair.

C. Looking at the “AT services” definition

1. While most of us have a general understanding of what an ATdevice is or can be, we tend to pay much less attention to the verybroad definition of AT services. The following examples are largelybased on actual cases that we learned of through technicalassistance or reviewing the annual reports submitted by PAATprograms.

2. Evaluations. In many instances, thousands of dollars are investedin AT that is not a proper match for the individual. When a fundingsource, like the special education system or a VR agency hasalready paid for an AT device, they may be against replacing it witha similar device just a short time later. Pushing for appropriateevaluations in the first instance will avoid a fight over “the wrongAT” later on.

3. Repairs. To the extent you deal with funding sources that use theAT devices and services definitions (i.e., special education and VRprograms), providing for repairs should go hand in hand withproviding the AT device. Certainly, the need to advocate forcoverage of repairs would be an appropriate PAAT activity nomatter what funding source you are dealing with.

4. Training or technical assistance (TA) to individuals with disabilities,family members. This need for training and TA is clearly neededfor those individuals with blindness or visual impairments who willbe using one of the voice dictation programs to enter informationinto their computer without the use of a keyboard. While gettingtraining or TA to the individual with a disability is key, in manycases it will be just as important to get those services to familymembers who will be very involved with the individual with adisability who is learning to use the new program or device.

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5. Training or TA to a range of providers, including educators,employers, and those providing employment services. Many ATadvocates are aware of cases in which the item in question, suchas the speech generating device or specially adapted computerequipment, sits unused for months because nobody at the publicschool program understands how the device is used. A similarphenomena could occur at the workplace. Those who advocate inthe special education or VR systems must be diligent to make surethat training is anticipated and included on individualized educationplans (IEPs) and individual plans for employment (IPEs) when thepurchase of AT is first identified.

6. Examples of unique AT service cases/advocacy activities reportedby PAAT projects.

a. Instruction in the use of a computer and software used forhome-based business. The New Mexico PAAT programrepresented a woman whose self-employment plan wassupported by her Department of Vocational Rehabilitation(DVR). Among other issues, this individual requested butwas denied DVR assistance to fund computer instruction forthe use of the computer and software that DVR hadpreviously purchased for use in her business. At theAdministrative Review, the PAAT advocate successfullynegotiated with DVR to pay for a computer technician toshow the individual how to set up and use her computer.

b. Assessing the need for a speech communication device. The Maryland PAAT reported that Medicaid recipients werenot able to get speech generating devices. They performeda thorough survey of the Medicaid Managed CareOrganizations' (MCOs) special needs coordinators andfound that most of the MCOs could not explain how theirmembers could obtain assessments for speech generatingdevices. Also, many special needs coordinators alsobelieved, incorrectly, that devices were not a covered servicefor individuals. The PAAT agency met with state Medicaidofficials and, after negotiation, settled on a policy thataugmentative communication assessments are theresponsibility of the MCOs but the devices would beprovided by Medicaid fee-for-service.

c. Training of aides to assist in transfer to standing device. InMinnesota, a man diagnosed with multiple sclerosis obtaineda standing device to use in his home therapy program.

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However, his home care agency refused to help him transferin and out of the device. As a result, he could not use hisstanding device. The PAAT program contacted the homecare agency. The home care agency agreed to train theirstaff and provide the necessary assistance for the client touse the standing device as recommended by hisrehabilitation therapist.

d. Purchase of program for PDA to assist man with traumaticbrain injury with scheduling, appointments, and prioritizing. The South Dakota PAAT program represented a 38 year oldman with a traumatic brain injury. He is employed at anon-resident facility serving people with disabilities. He wasunable to meet the job expectations of his position. PAATstaff advocated on the man's behalf to determine if theappropriate accommodations/modifications were provided bythe agency. They collaborated with VocationalRehabilitation Services and a program was purchased forthe individual’s personal digital assistant (PDA) to assist inscheduling, appointments, and prioritizing. A compatiblecomputer with the palm pilot programs was also purchased. With the appropriate accommodations/modifications, he wasable to remain employed. (Think about whether a state-of-the-art smart phone might even be better for this individualtoday.)

e. Right to use computer with a accessible software in acollege setting. The Oregon PAAT program assisted anindividual who needed help getting approval for accessiblesoftware for a required class in the Information Systemsprogram at a local university. The department refused toallow him to use alternative software that is accessible withJAWS screen reader. The PAAT advocate attended ameeting with the Disability Services Office at the school. Asa result the client was allowed to use the accessiblesoftware.

III. Are You Considering All the Potential Funding Sources and FundingStrategies That May Help Your Clients Obtain AT Devices and Services?

A. Statistically, for the reporting year that ended September 30, 2010, morethan 59 percent of closed cases from PAAT projects consisted of casesinvolving either health care (34 percent) or education programs (25

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percent).3

1. In the health care area, the highest percentage of all casesinvolved Medicaid and that has been the case every year we havelooked at data. A much smaller percentage of the health carecases involved either Medicare or private insurance.

2. Of the 25 percent of cases involving the “education” category, wecan assume that most of them involved special education oreducational issues within the public school setting, as there is aseparate category for post-secondary education.

3. While we recognize that Medicaid and special education issues willcontinue to be at the heart of what PAAT programs work on, andwe will continue to provide training and materials to support ATadvocacy as related to those issues, this part of the handout willfocus on issues that go beyond these two most common programs.

Looking Beyond Health Care and Education Cases:The following represents a variety of PAAT activity, as reported to the federal fundingagency, over the past several years.

B. Improving accessibility in a variety of environments

Most of these anecdotes involve enforcement of the ADA. In some cases,the P&A program used state anti-discrimination laws as well to obtain theresults described.

1. School buildings

a. The Illinois PAAT assisted a student's father who hasmultiple sclerosis and uses a wheelchair. The high schooland the district's administration building had multiplephysical access barriers. This prevented students withdisabilities, as well as family members and members of thepublic with disabilities, from accessing certain school anddistrict activities and events. The PAAT program filed acomplaint against the school district with the Department ofEducation's Office for Civil Rights (DOE-OCR) on behalf ofthe clients as well as on behalf of members of the public withdisabilities who wished to attend events held within schooldistrict facilities. A comprehensive settlement agreement

3These statistics have been similar in more recent years.

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between the school district and DOE-OCR was thenfinalized, which addresses widespread accessibilityconcerns.

b. The Alabama PAAT project worked with a private school thatutilized historic buildings to make those buildings accessibleto a child with physical disabilities. The school had beenunaware that they could alter the buildings for accessibility.

2. Courts

a. The Washington PAAT project negotiated an agreement tobring the courts into ADA compliance for physical andprogram accessibility, including improvements to courtroomAT. They have also negotiated installation of hardware tomake the toll-free hotline to report abuse and neglectavailable for the deaf or hard of hearing by TDD.

3. Health services, health facilities

a. In Oregon, a hospital would not permit a psychiatric patientto bring her motorized scooter into the facility. She was alsodenied the use of a wheelchair for most of her stay. ThePAAT attorney suggested revisions to the facility’s policy tospecifically incorporate ADA requirements and an interactiveprocess, including believing the patient who indicates he orshe needs a wheelchair or other AT. The hospital changedits policy and trained staff so that they would be incompliance with the ADA , meet patient needs and be morepatient focused.

b. In Hawaii, two persons with hearing impairments requestedreasonable accommodations from their medical group whilereceiving outpatient services. Through litigation broughtagainst the medical group by the PAAT project, policieswere established for all patients who require AT or otheraccommodations.

4. Domestic violence shelters

a. The Idaho PAAT participated in a year-long, interstateproject with Alternatives to Violence of the Palouse and theEastern Washington Council for the Deaf and Hard ofHearing, which addressed issues faced by people withdisabilities in rural counties of Idaho and Eastern

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Washington who live with or under the threat of domesticviolence (DV) or sexual assault. Many of the areasaddressed focused on the lack of available AT devices (ie.,phone systems for the hearing impaired, alternative formats,hand rails, magnfiers, keyboards) within DV shelters andservice centers. The group continues to work towardproviding resources, information and funding for requestedAT in area DV shelters and service centers.

5. Retail stores

a. Individuals who use wheelchairs or other mobility aids wereunable to shop or use restroom facilities in three sites of amajor department store in New Hampshire. As a result ofclass action litigation brought by the New Hampshire PAATproject, the department stores are now fully accessible.

6. Entertainment

a. The Tennessee PAAT program resolved a complaint againsta local entertainment venue and a nationally known speakerregarding the availability of assistive listening devices(ALDs) for individuals who are hard of hearing. As a resultof the PAAT's work, the arena agreed to provide appropriatetraining to staff and signage for patrons as to the location ofALDs provided by the arena in order ensure full access toALDs for patrons with hearing impairments. They have alsoimplemented procedures to ensure that the technologynecessary for the ALDs is used at all future events.

b. The Arizona PAAT project persuaded theaters in Phoenixand Tucson to purchase Rear Window personal captioningsystems for deaf and hard-of-hearing moviegoers, so thatthese individuals could access first-run movies.

7. Accessible fitness facility

a. In Elliott-Vandivier v. AquaHab LLP, the Pennsylvania PAATProgram represented the plaintiff, who has spina bifida andwas unable to use an inaccessible pool at her local fitnessfacility. The facility refused to install a pool lift. Afterlitigation was filed, pursuant to Title III of the ADA, the facilityagreed to install the pool lift and to allow the plaintiff to useits accessible rehabilitation center’s fitness room.

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C. Transportation

1. The Virgin Islands PAAT staff successfully advocated for a moreexpansive and accessible public transportation system in the U.S.Virgin Islands. As a result of this advocacy and intervention, theterritory's transportation system has brought more accessible publictransport vehicles to the territory, conducted a survey to determinewhat barriers still exist in public transportation, and will continue totrain its drivers in an effort to improve its delivery of services to thedisability community.

2. The Louisiana PAAT project urged the Baton Rouge transitauthority to repair its lifts on fixed bus routes so that passengerswith disabilities were able to use buses and trolleys. They alsoappeared at a City Council meeting and successfully advocated forincreased funding for paratransit services to make them ADAcompliant.

D. Employment discrimination.

1. In Alaska, the PAAT project has as a priority advocating forindividuals with developmental disabilities who faced discriminationthat jeopardized their income. They advocated for a young manwho is deaf and worked as a bagger at a grocery store. The storewould not consider promoting him to a cashier. With the PAATproject's intervention, he was hired as a cashier and provided withminimal AT so that he could effectively communicate withcustomers.

2. The Mississippi PAAT Project assisted an individual in shelteredemployment who uses an speech generating device. The man wasdenied his right to use the device while at work. The PAATsuccessfully advocated to have the workshop change its policy andprovide workshop staff training concerning use of the device.

E. Housing issues.

1. The Ohio PAAT represented individuals with disabilities who soughtdesignated parking spaces but those accommodations wererefused by their condominium association. The PAAT programthen assisted the clients in filing a charge of housing discriminationwith the Ohio Civil Rights Commission (OCRC) and prepared acomplaint to be filed in federal district court alleging discriminationunder the federal Fair Housing Act. At that point the condominium

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association agreed to provide the designated parking spaces forthe individuals and promptly installed a designated parking sign onthe space directly in front of their unit. The association entered intoa conciliation agreement under OCRC where it agreed to reservethe space in front of the clients' condo unit and place a "reserved"sign there.

2. The Iowa PAAT brought suit against a contractor who built adefective ramp to the entrance of the client's home. Despiterepresentations by the contractor that he was familiar with "ADAguidelines," the contractor built the ramp with a slope of 1:4, far toosteep to make it usable. At trial, the city's building inspector testifiedthat the ramp as built violated numerous building coderequirements. The court ruled in favor of the client, determining thatthe contractor had breached an express warranty that the rampwould be appropriate for her use and an implied warranty of fitnessfor a particular purpose. The court entered judgment for allpayments she had already made as well as the cost to have theramp removed.

3. The Pennsylvania PAAT project filed a lawsuit alleging violations ofthe federal Fair Housing Act when a landlord threatened to evict afamily from a mobile home park after the family installed atemporary ramp into the family's trailer. The family's son hadsuffered a traumatic brain injury and needed a ramp to access thetrailer. The family acquired funding for a permanent ramp in orderto appease the landlord, but the landlord insisted the ramp had tobe installed on the rear entrance. After the suit was filed, theparties entered into a settlement in which the landlord agreed topermit front entrance ramps.

F. AT in institutions

1. In Kentucky, a priority for the PAAT project is to assist individualswho reside in facilities to obtain AT. They reported on an individualwith a traumatic brain injury who resided in a nursing facility andused a laptop computer that doubled as a speech generatingdevice. The device was broken and the PAAT project wascontacted to help identify funding sources to pay for the repairs.After determining that the individual was entitled to specializedservices under the federal Pre-Admission Screening and ResidentReview (PASARR) mandates for nursing facilities, the PAATproject approached the facility's PASARR specialized servicescoordinator, who arranged to have the repairs made. The individualis now living in the community with a functioning communication

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device.

G. Voting access.

1. Due to the advocacy efforts of the Puerto Rico PAAT project, theElections Commission changed its policy toward persons withdisabilities by improving the accessibility of polling places.

2. The Colorado PAAT project worked closely with the Secretary ofState's Elections Division to ensure that fully accessible votingdevices will be available to voters with disabilities when the newvoter verifiable paper audit trail state statute is implemented.

3. As a member of the Elections Administration Council, charged withreviewing the accessibility of voting machines, the Wisconsin PAATproject has had input on the purchase of accessible votingmachines that could positively impact as many as 100,000 personswith disabilities.

H. Post-secondary education

1. In New Mexico, a priority for the PAAT project is to help studentswith disabilities obtain AT to enable them to achieve theireducational goals. It then reported a case in which a universitystudent who is blind needed class materials in Braille but theuniversity refused to provide them. The PAAT project intervenedand the school agreed to provide everything she needed in Braille.

I. Home modifications funded by Adoption Subsidy Program.

1. A case was referred to the Illinois P&A involving a family whoadopted a child who had lived with them as a foster child. Thechild has cerebral palsy and is a wheelchair user. The stateDepartment of Children and Family Services (DFCS) balked atproviding funding to make the home more accessible to the 12 yearold child. After prolonged negotiations, the DCFS agreed to fundmajor home renovations and pay for an accessible van for thefamily.

2. Comment: Significant numbers of children, in every state, gothrough adoption under the adoption subsidy program. Many ofthese children are in foster care before they are adopted. Whilethe right to specialized equipment may depend, in part, on state-specific options, we believe this represents a significant populationof children with disabilities whose AT-related needs are going

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unmet.

J. Accessible ATMs.

[Note: Although the reported activities are dated, the reported strategiesoffer an opportunity for both creative advocacy and the potential forcollaboration on similar issues.]

The P&As in both Massachusetts and Illinois, in collaboration with aprivate attorney from California, used a process known as “structurednegotiations” to convince a large banking institution to change existingATM machines so that they would now employ technology to allowcustomers who are blind to use these devices.

1. Enforcement of Americans with Disabilities Act (ADA): Theattorneys working on these cases believed they had meritoriouscases under Title III of the ADA and potentially under state laws aswell.

2. Use of structured negotiations: This approach, which has beenperfected by private attorney Lainey Feingold, involves detailedcorrespondence to the potential defendant, inviting them to engagein the negotiation process. By agreeing to negotiate, parties onboth sides save time and money, and the case can often movemuch more quickly to resolution since many of the litigation-relateddelays are not present.

3. Attorneys in these cases report obtaining settlements just as good,if not better, than those often obtained after years of hard-foughtlitigation.

IV. Could You Employ Any New Strategies for Training, Outreach andDissemination of Information?

A. Background. There are two primary reasons that P&As engage in theseactivities:

1. One reason is to get the information to our clients, family members,and agencies to make it more likely that they will obtain appropriateAT.

2. The other reason is to encourage those same clients, familymembers, and agencies to call the PAAT program when advocacyservices are needed to obtain AT.

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B. Creating Materials: Louisiana PAAT - Emergency Preparedness

1. In the aftermath of Hurricane Katrina, it became evident that to theextent that state and local organizations had emergency plans, theyoften did not consider the needs of individuals with disabilities,including those who use a range of AT devices.

2. Aware of some of the unneeded discomfort and suffering after themajor hurricane, the P&A program worked to put together anumber of materials to be used by organizations to plan for futureemergencies.

3. Examples of materials created:a. A sample emergency planning guide - encouraging owner of

items like wheelchairs and scooters to label them and havean extra set of batteries and chargers

b. A “Shelter Accessibility Tool,” asking a wide range ofquestions such as: whether bathrooms are accessible andwhether individuals with disabilities can shower safely.

c. A training outline for training shelter managers on theseissues.

4. Comment: Sadly, although this is example is dated, the impact ofnatural disasters on individuals with disabilities, including AT users,continues to be a challenge.

C. Training initiatives

1. Iowa PAAT: Training Third Year Law Studentsa. Every semester, professors at the University of Iowa Law

School teach second- and third-year students about key ATfunding sources, including Medicaid, Medicare, vocationalrehabilitation, special education programs, Section 504 ofthe Rehabilitation Act, the Americans with Disabilities Act,Workers' Compensation, and private insurance plans.

b. This weekly training prepares students to advocate for andrepresent people with disabilities.

2. Vermont PAAT: Training of State Legislatorsa. Vermont's PAAT Program project trained both newly elected

and returning state legislators on the state's health careprograms.

b. The purpose of the training was to increase the legislators'awareness of laws, regulations, policies, procedures,practices and organizational structures that facilitate the

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availability or provision of AT devices and services.

D. Serving Minority and Underserved Communities

1. South Carolina's PAAT Program conducted a training sessiontargeted specifically to the needs of persons with disabilities whowere members of rural or minority communities.

2. Wyoming's PAAT Program reached out to American Indians withinformation regarding AT and the availability of PAAT services topersons on the Wind River Reservation.

3. Texas' PAAT Program educated parents of children with disabilitieswho live in colonias, which are unincorporated, unregulated andunderserved areas along the U.S.-Mexico border. Topics includedspecial education, the ADA and how AT relates to a child's right toa free and appropriate public education.

4. Oklahoma's PAAT Program provided a basic-rights training onfunding of AT through Medicaid and special education programs toHispanic parents who had recently immigrated to the United States.

5. California's PAAT Program offered, to Cantonese-speaking parentsin San Fransisco's Chinatown, an intensive, two-day training onspecial education, language access and access to AT, whichemphasized parent empowerment and advocacy skills. Materialswere translated into Cantonese.

V. Are You Looking at All the Opportunities to Collaborate With Those FromYour Agency Assigned to Other P&A Programs?

A. Background on other P&A grants

1. Compared to some of the better funded P&A programs, such asProtection and Advocacy for the Developmentally Disabled (PADD)or Protection and Advocacy for Individual Rights (PAIR), thefunding for PAAT is very modest.

2. Some of the newer P&A programs, like the Protection andAdvocacy for Beneficiaries of Social Security (PABSS) orProtection and Advocacy for the Traumatically Brain Injured(PATBI), also have modest funding.

B. PAAT programs may wish to tap into any special expertise and theresources of the larger programs for collaboration on AT-related cases

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and projects.

1. For example, in most states the PADD program attorneys andadvocates have significant background and expertise in specialeducation cases. Where a special education case has a significantAT component or is only about AT, it may be appropriate for thePADD and PAAT programs to work on the case together.

2. At many P&As, the PAIR program attorneys and advocates havespecial expertise in enforcing the ADA. As examples aboveillustrate, many potential PAAT cases involve the right to ATthrough enforcement of the ADA. Where the ADA-related caseinvolves AT, it may be appropriate for the PAIR and PAATprograms to work together.

3. Comment: As many P&As have moved toward a model usingissue teams, rather than breaking up the office according to grantsources, the two examples above may take a different twist. Theissue may be whether the staff working through their educationteam, accessibility team, or employment team can legitimately billtime on a case to the PAAT grant.

C. At any given time and in any give state, one of the P&A programs (orissue teams) may have very limited resources or extensive resourcesrelative to the current demand for services. This need for help with casesor need for case referrals could be a basis for collaboration with the otherprogram.

1. For example, your state’s PABSS program is mandated to assistSocial Security and SSI disability beneficiaries to overcome barriersto employment. If the PAAT program is working on a caseinvolving the denial of funding for AT that will assist the individual inworking, that would be an appropriate PABSS case. Whereappropriate, the PAAT and PABSS program could collaborate onthe case or the case could be referred outright to the PABSSprogram. (Or, if this is an employment team case, those workingon the case may be able to bill work to either the PAAT or PABSSgrants.)

2. Another example might involve your state’s PATBI program. APATBI client with a traumatic brain injury may need computer-based AT that a funding source is refusing to provide. Here again,the PATBI and PAAT programs might work on that case together orthe PATBI program might refer the case outright to the PAATprogram. (Here again, who works on the case may be a give. If

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the client has a TBI diagnosis and the intervention sought involvesAT, the work on the case could be billed to either grant.)

VI. Are You Taking Advantage of Opportunities for Collaboration with YourState AT Project

A. The State AT Projects are also funded through the AT Act.

1. Originally, most referred to them as Tech Act Projects.

B. Examples of PAAT collaborations with a State AT Project

1. The Georgia PAAT project participated on the advisory council toassist Tools for Life, Georgia's AT Project, in accomplishing its goaland mission with measurable outcomes. The Council serves asareas of support for the Tools for Life program, to make ATaccessible, usable, timely, and more affordable for Georgians withdisabilities. The P & A attended council meetings and reviewed andprovided input on programs and services. The P & A supportedTools for Life to be a statewide voice for public awareness andadvocacy on increased access to AT.

2. Minnesota’s PAAT works closely with the System of Technology toAchieve Results (STAR) program, which is the state's AT Actprogram, and its Advisory Board. The P&A received funding to drafttwo new AT fact sheets. The P&A has three AT fact sheets that aredisseminated to other agencies and the public: (1) AssistiveTechnology Appeals: Medical Assistance; (2) Assistive TechnologyAppeals: Private Insurance; and (3) Will MA Pay for AssistiveTechnology. MDLC's general brochure, which includes theagency's contact information, is also distributed.

3. The South Carolina PAAT continues to collaborate with the SouthCarolina AT Program (SCATP). The P&A participates in theirexchange reuse listserv, which lists various AT needs, andresponds with an Information and Referral service; participates intheir annual South Carolina AT Expo.; and is also a member of theSC Assistive Technology Program Advisory Council (Council). TheCouncil meets semiannually to receive information about the latestSCATP activities and to provide input to SCATP's plan. Throughoutthe year, individual Council members are consulted about programactivities and plans. Members on the Council includerepresentatives from the SC Commission for the Blind, the USCSchool of Medicine, Walton Options, the Developmental DisabilityCouncil, Pro-Parents, the SC Independent living Council,

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Vocational Rehabilitation and the SC Department of Education.

4. The North Dakota PAAT staff serves on the IPAT (the State ATProject) Consumer Advisory Committee, attending two face-to-facemeetings a year. This committee is made up of people withdisabilities, parents and representatives from the education field,employment services, independent living, and aging services. TheCommittee reviews the programs and services provided throughIPAT, whose focus is on adaptive technology and its use to enablecontinued independence and the enrichment of lives. The inputprovided by consumers and agency stakeholders insures betterand more effective service delivery to people with disabilities inNorth Dakota who can benefit from AT.

VII. Looking Beyond the Traditional Approaches for AT Advocacy – The AT-Related Benefits Counseling Model

A. The New York PAAT program used this model on a small number ofcases over the years.

1. The model borrows from two other planning models:

a. The benefits planning model used by Work IncentivesPlanning and Assistance (WIPA) projects to guide SocialSecurity and SSI beneficiaries through the use of workincentives as they pursue work goals

b. The transition planning model used by school districts toguide planning for students with disabilities as they moveinto the adult world.

2. The New York PAAT advocate, with experience in both ATadvocacy and benefits planning in the Social Security/SSI context,realized that individuals who were contacting the agency typicallyhad more extensive AT needs than the individual case that broughtthem to the P&A agency.

3. With AT-related benefits counseling, the advocate used anextensive screening questionnaire and looked at all the apparentand potential AT needs over the next three to five years. Theadvocate then worked with the individual to identify a range offunding sources and funding strategies to meet all the identified ATneeds.

B. The Funding Sources:

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1. Disability advocates easily recognize the common funding sourcesfor AT such as Medicare, Medicaid, private insurance, your statevocational rehabilitative (VR) agency, and the special educationsystem.

2. Unfortunately, too little recognition is given to the vital ways inwhich other less commonly accessed programs can help to meetthe need for AT, both directly and indirectly. These include thework incentives provisions of the Social Security DisabilityInsurance (SSDI) and Supplemental Security Income (SSI)disability programs, subsidized housing, the Crime Victims Board,special needs trusts, the foster care system, local and communityfoundations, the Medicaid spend down program, low interest loanprograms, and the Department of Veterans Affairs just to name afew.

C. A Sampling of the Results of the Marriage of Benefits Advisement and ATAdvocacy:

1. John came to the office through a referral from his equipmentvendor. Medicaid had denied John’s prior approval request for apower wheelchair with special modifications. These modificationsincluded elevating seat and leg rests. John’s vendor advised himthat it was unlikely that Medicaid would approve the elevatingfeatures since they were not medically necessary.

John and his father attended a benefits advisement interviewwhere it was learned that he was attending college, with a goal tobecome an accountant. He has been receiving various servicesthrough the VR agency, including tuition assistance and room andboard costs while living on campus. In the end, a deal wasbrokered among the three parties (private insurance, Medicaid andVR) to share costs of the wheelchair, with VR paying for themodifications that were defined as vocationally related whichincluded the elevating seat and leg rests. Additionally, John’sparents had purchased a van and VR paid for the modifications tothe van. John had been struggling to make the payments on thevan since his parents had their own car payments to make. SinceJohn received both SSI and SSDI benefits, a Plan for AchievingSelf Support (PASS) was developed in order to pay for thecontinued van payments and other vocationally-related expenses. In the end, John received not only the requested wheelchair, butunexpected help with van payments and other financial supportswhile he finished college and moved into employment.

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2. Sam said he was literally a prisoner in his own home. He is awheelchair user but had no means with which to leave the home inhis wheelchair, i.e., a ramp. Sam casually remarked that he wishedhe could work part-time, but it seemed inconceivable not onlybecause he could not leave his home, but because he was afraidof losing his disability benefits as well. Sam was provided with theSSDI work rules wherein he learned he could, indeed, work part-time and still maintain his SSDI benefits and Medicare for anextended period. With the funds from part-time work, Sam learnedthat he could purchase a portable ramp, rather inexpensively, touse to enter and exit his home in order to work and enjoy socialactivities that previously were inaccessible to him.

3. Sarah slowly and painfully roamed the showroom of the medicalsupply store while on her arm crutches in hopes of finding amanual wheelchair she could afford. The salesperson asked aboutinsurance such as Medicaid but Sarah said she was not entitled toany SSI and Medicaid. After several more questions, thesalesperson speculated that the circumstances regarding herdisability benefits did not seem correct. She referred Sarah toNeighborhood Legal Services. It was determined during thebenefits advisement screening that Sarah was, in fact, entitled toSSI since SSA was not looking at her living arrangement correctly. She was provided assistance in attaining the benefits. Once SSI(and automatic Medicaid) eligibility was established, Sarah plannedto return to the vendor in order to submit a Medicaid prior approvalrequest for the wheelchair.

4. Lauren was receiving Social Security retirement benefits andworking part-time, struggling to make ends meet. She is hearingimpaired and needed a hearing aid, costing almost $1,200. SinceMedicare does not pay for hearing aids, Lauren wondered how shewould be able to afford the expense. During the benefitsadvisement interview, Lauren stated that her landlord was raisingher rent again. In the end, it was determined that Lauren met theage and disability criteria for the nearby subsidized apartmentcomplex. If approved, she would receive a subsidy to help pay herrent. This anticipated reduction in her monthly expenses wouldenable Lauren to enter into a monthly payment arrangement withthe hearing aid company.

5. Michael is developmentally disabled. His mother was trying toenroll him in a day rehabilitative therapy program. She is told hemust have Medicaid to qualify for enrollment. Michael oncereceived SSI and Medicaid but lost those benef its when his father

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died and he started to receive SSDI Childhood Disability Benefits(CDB, also known as Disabled Adult Child or DAC benefits). It wasdetermined that Michael should still be receiving his Medicaidthrough a special law that allows a person to continue Medicaideligibility if they lost their SSI due to receipt of SSDI DAC benefits. With Medicaid he could enroll in the day program and now had asource of funding for AT.

Updated: May 1, 2017

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