NBCOT Ch. 4 Professional Standards and Responsibilities

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TherapyEd

Age Discrimination in Employment Act

Prohibits practices that discriminate/unfairly affect workers 40+; prohibits mandatory retirement of older workers.

Reauthorization and Amendment of IDEA

IEPs; transitional planning begins at 14 or younger; transition services begin at 16 or younger; transition plan updated annually; Individual Family Service Plan (IFSP) for 0-2 y/o; OT=primary EI service.

Criteria for classifying individual as disabled -(part of ADA)

1- person with physical or metnal impairment that substantially limits 1+ major life activities; 2 - having record of such impairment; 3 - being regarded as having such impairment.

Omnibus Budget Reconciliation Act (OBRA) of 1981

Affirmed Section 504 of Rehab Act of 1973 (prohibits discrimination in fed. funded programs); provided MCD funding for community-based services for those with developmental disabilities when services were less expensive than institutional care.

legally mandated regulations for health care are set forth by

Centers for medicare and Medicaid services (CMS)

Accreditation is voluntary, however mandatory to receive...

Third party reimbursement and to be eligible for federal govt grants and contract

Beneficiary

The recipient of health care services. In a SNF, this is a "resident"

Capitation

Payment system. Provider is paid prospectively a specific amount for each member of a health plan regardless of services provided. (e.g. on a monthly basis). PMPM=per member, per month

co-insurance

percentage charged to a patient

clinical/critical pathway

standardized recommended intervention protocol for a specific diagnosis

diagnosis code

code that describe's a patient's medical reason or condition that requires health service

diagnostic related grops

descriptive category set forth by CMS that determines the level of payment at a per case rate.

fee for service

Payment system. The provider is paid the same rate per unit of service. Usually the payer pays 80%

health maintenance organization

(HMO). Most common form of managed care, requires enrollees to see only doctors within the HMO network, and be referred to specialists by the PCP

preferred provider organization

(PPO). Another form of managed care, typically with more selection of providers, however the more choices, usually the more expensive the rates.

managed care

Method of maintaining costs and services. Most common is HMO and PPO.

prospective payment system

PPS. Nationwide payment schedule that determines the medicare payment for each inpatient stay based on DRG.

usual and customary rate

UCR. Average cost of specific service and procedure in a geographic area .Max amount the insurer will pay for a service.

Largest source of insurance payment in U.S.

Private Pay

Intermediaries

Private insurance companies that contract with Medicare. Determine if services provided are within Medicare guidelines

insurers are regulated by

States in which they provide

largest single payer for OT services?

Medicare

Eligibility requirements for Medicare coverage

Over 65, been on social security for 24 months+, permanent kidney failure, black lung disease, other long-term disability specified in the law

Medicare Part A

Hospital, SNF, home health, hospice

Medicare Part B

Outpatient, under supplemental Medical insurance program, therefore patients must pay a monthly premium, usually 20% copayment

Primary difference between part A and B

Treatment schedule. Part A coverage requires minimum 5 days/week, Part B typically covers 3 days/week

OT is covered in SNFs if...

patient requires skilled therapy on a daily basis

Reimbursement in SNF is dependent on

resource utilization groups, which allows for maintenance plan design and reeval, caregiver training is part of this, must demo competence in training vefore discharge from OT

Home health OT is covered if

the patient is determined to be homebound

Homebound status criteria

confinement, based on necessity of adaptive equipment for mobility, need for assistance from others, or "considerable and taxing effort" to leave home. May leave home for medical appt and non-medical infrequent appts (hair, church, etc)

Home health agencies are reimbursed under...type of payment system

prospective payment system

Episode

60-day unit of payment for services

Home health assessment

outcome and assessment information set, which can be performed by an OT and places the patient into a home health resource group. Determines need for services. Must be completed within 48 hours of referral/return home

OT hospice care

covered if terminally ill (<6 months to live)

How can OT services be covered by a Medicare certified OT in independent practice, payment is according to

fee schedule: resource based relative value scale

Criteria for coverage of partial hospitalization (PHP)

OT services covered under general medicare guidelines, and the beneficiary would have otherwise required inpatient psychiatric care, active and individualized, multidisciplinary treamtnet must be provided

Durable Medical Equipment coverage by Medicare

repeated use can be withstood, primarily used for a medical purpose (w/c or walker) self help items not reimbursable

Medicaid is operated by...

States, however they receive 50% of their funding from the federal govt

Mandated medicaid services

Inpatient, outpatient, home health, Early Periodic Screening Diagnosis and Treatment (EPSDT) for children under 21, services identified under EPSDT

EPSDT

Early Periodic Screening, Diagnosis and treatment for children under 21. This includes hearing, vision, dental, periodic physical and developmental examinations

Optional Medicaid services

OT, PT, SLP

Pro Bono

Working for a free or reduced rate, paid for by therapist

HIPAA stands for...and ensures...

Health Insurance Portability and Accountability Act, ensures individual's right to continuity in healthcare coverage, privacy and security of records

Provider has ...days to respond to request for medical records

30-60

Hipaa does/does not require a guarantee of 100% confidentiality

Does not, just requires reasonable and vigilant safeguards

Medicare title 18

Medicare and Supplemental Security Income (SSI), a monthly income for persons with disabilities

Amendment to IDEA

IEP purpose - access education, including AT and behavioral interventions and supports, education should prepare for adult life and post-school

Transition planning and transition services begin...

Age 14 and 16 respectively, at which time the student is invited to the IEP meeting

Individualized Family Service Plan

IFSP, for parents of children aged 0-2 years, OT is a primary early intervention service.

IDEA improvement act of 2004

Directly addresses the student's FUNCTIONAL performance in addition to academic, also provided flexibility for IEP meetings, allowed members to be excused with written notice and authorization from parents, allowed parental revisions to IEP, requires that recs be evidence based, clarified that screening does not equal evaluation for eligibility, streamlined with No Child Left Behind Act, purpose of IDEA is to prepare children with disabilities (CWD) for further ed, job, ind. living

IDEA improvement act of 2004 allowed states to define...

developmental delay criteria, typically a percentage delay

No Child Left Behind

General education law
-Considers OTs to be pupil services personnel, sets no requirement for OT services
-requires schools to provide accommodations for mandated tests

Age discrimination in employment act

employers can't fix a retirement age, prohibits discrimination against workers 40 and up

Freedom to work act

allows social security beneficiaries to work without losing their income (65 years+)

Omnibus Budget Reconciliation Act of 1990 (OBRA)

-Nursing homes, improve QOL
-Minimum Data Set, coordinated annually by RNs
-psychosocial well-being emphasized
-resident assessment protocols (RAPS) guidelines for treatment of conditions found in MDS
-restraint reduction (ot and pt role)
-Resident choice in ADL

Medical Model of Service Delivery

-PWD has incurred physiological insult
-Focus on identifying disease/dysfunction
-Tx: performance components contributing to decreased functional skills
-OT ref: address pathological process, e.g. biomechanical, neurodevelopmental

Educational Model

-PWD lacks knowledge or skills
-Focus on learning and environmental interaction
-Bxs measured: obtaining skills, knowledge, adn competency to successfully meet the demands of the environment
-OT ref: adaptation in the environment (role acquisition, cognitive remediation)

Community Model

-PWD lacks skills/resources/supports for community integration
-OT ref: life-style performance, occupational adaptation

Early Intervention Programs (criteria, review frequency, OT role)

-Acceptance criteria "at risk" status: birth comp, suspected DD, failure to thrive, maternal subs abuse, teen mom, est. disability
-DD criteria typically 33% delay in 1 cat, 25% in 2+cats
-6 month reviews to determine continued service
-OT eval: cog, phys, soc-emot, adaptive, communication
-Evals written in strength-oriented, family friendly lang.

Schools (criteria, ot focus, scope)

-OT is a related service
-Criteria: child requires special ed and OT will enable the child to benefit from special ed
--OT will faciliate the child's participation in ed and improve functional performance
--School reviews referral and recs OT eval
-length determined by child's ability to benefit
-IEP annually
-Educational model, but includes functional performance
-corrective and compensatory methods
-ADL, play and school domains addressed
-addresses skills for adult life too, transition needs

prevocational programs

-develop skills that are prereq to work, d/c usually to voc program, OT focus on task skills, social skills, work habits

Vocational programs

specific voc skills, Person has good tasks skills but requires specific training to perform a job, OT focus on remediation, advocacy, ADA accommodations, referral to state offices

Residential programs continuum

24 hour, halfway group home, supportive apartments, etc.
-LOS ranges

Partial hospitalizations

-up to 5 days/week, with ongoing symptom treatment that does not require hospitalization, usually d/c to halfway or supported home setting

Program Development Steps

1. Needs assessment
2. Program planning
3. Program implementation'
4. Program evaluation

Capital expense budgets

permanent/long term purchases such as kitchen, new facilities, usually above a fixed amount (500+)

Operating expense budgets

daily financial activity, salary, housekeeping, marketing, rent

Productivity standards

"reimburseable" service each therapist is to provide each day

Continuous Quality Improvement

prevention emphasized, blame attributed to program, not persons.

Total Quality management

all employees contribute to environment of continuous improvement

Utilization review

review the resources, cost effectiveness, usually a part of CQI

Marketing, 5 ps

product, price, place, promotion, position

Research is...

kewl.
jk. Quasi exp: no randomization. True experimental: randomization

Ethical decision making

-Identify the ethical issues and potential dilemmas
-Gather relevant information
-Identify all individuals affected by the issue
-Determine prior history of the issue
-Analyze the dynamics and culture of the setting(s)
-Ask open ended questions to obtain descriptive data
-Determine conflicting values and areas of agreement
-A commitment to patient autonomy versus the principles of beneficence and nonmaleficence may need to be considered
-Identify as many relevant alternative courses of action as possible
-Consider who would take these actions and when these actions would need to occur
-Determine all possible positive and negative outcomes for each possible action
-Include outcomes for all participants in the dilemma. An ethical dilemma never involves just one person
-It can take time and thought to identify all those who may possibly have a "stake" or will be touched by a specific decision
-Weight, with care, the consequences of each outcome
-This step includes the process of reordering or rearranging parts of different decisions to arrive at a new alternative which may be the best possible course of action
-Seek input from others (ie. supervisors)
-Provide information in an anonymous fashion which enables the individual to give advice in a more objective manner and to provide recommendations that cannot be construed to be biased or prejudicial
-Apply best professional judgement to choose the action(s) to recommend
-Contact any and all agencies that have jurisdiction over a practitioner if there are questions about potential ethical violations that could cause harm or have the potential to cause harm to a person
-Determine desired and/or potential outcome of filing an ethical complaint

American Occupational Therapy Association (AOTA)

-The profession's official membership organization which develops, publishes, and disseminates the field's ethical code
-AOTA's Code of Ethics is a statement to the public that identifies the values and principles used to develop, endorse, and sustain high standards of behavior for OT practitioners
-A set of principles that apply to all levels of OT personnel
-All occupational therapy practitioners are obligated to uphold these standards for themselves and their colleagues
-Actions that are in violation of the purpose and spirit of AOTA's Code of Ethics are considered unethical by AOTA
-These ethical standards are often the guide by which other bodies judge professional behaviors to determine if malpractice has occurred
-As a voluntary membership organization, AOTA has no direct authority over practitioners (OTs and OTAs) who are not members, and no direct legal mechanism for preventing nonmembers who are incompetent, unethical, or unqualified from practicing
-Ethics commission: the component of AOTA that is responsible for the Code of Ethics, and the Standards of Practice for the profession; the Ethics Commission is responsible for informing and educating members about current ethical issues, upholding the practice and education standards of the profession, monitoring the behavior of members, and reviewing allegations of unethical conduct (Ethical complaints filed with the Ethics Commission initiate an extensive, confidential review process according to AOTA's established enforcement procedures for occupational therapy Code of Ethics

National Board for Certification in Occupational Therapy (NBCOT)

-The national credentialing agency for occupational therapy practitioners
-Certifies qualified persons as OTRs and COTAs initially through a written examination for entry-level practitioners
-NBCOT also maintains OTR and COTA certification through a voluntary certification renewal program
-Jurisdiction is over all NBCOT certified occupational therapy practitioners as well as those eligible for NBCOT certification
-As a voluntary credentialing agency, NBCOT has no direct authority over practitioners (OTs and OTAs) who are not certified by NBCOT, and no direct legal mechanism for preventing uncertified practitioners who are incompetent, unethical, or unqualified from practicing
-NBCOT has developed investigatory and disciplinary action procedures for NBCOT certified practitioners whose practices raise concern due to incompetence, unethical behavior, and/or impairment

Common law related to professional misconduct and malpractice

-Common law evolves from legal decisions and can impact occupational therapists
-Malpractice suits can be filed by individuals and/or their caregivers if the occupational therapist is viewed to be personally responsible for negligence or other acts that resulted in harm to a client
-Negligence: 1) failure to do what other reasonable practitioners would have done under similar circumstances 2) doing what other reasonable practitioners would not have done under similar circumstances 3) the end result was harm to the individual 4) every individual (OT, student OT, OTA or student OTA) is liable for their own negligence
-Supervisors or superiors may also assume the liability of their workers if they provided faulty supervision or inappropriately delegated responsibilities
-The institution usually assumes liability if an individual was harmed as a result of an environmental problem (falls resulting from slippery floors, poorly lit areas, lack of grab bars)
-The institution is also liable if an employee was incompetent or not properly licensed
-Personal malpractice insurance is advisable for all levels of OT practitioners

OT practitioner roles - general information

-OT practitioners include occupational therapists (OTs) and occupational therapy assistants (OTAs)
-Due to the implementation of the voluntary NBCOT certification renewal program, all OTs may not be OTRs and all OTAs may not be COTAs
-OT aides have an important role but are not considered OT practitioners
-OT practitioners can assume a variety of roles including entry to advanced level practitioner, peer and/or consumer educator, fieldwork educator, supervisor, administrator, consultant, fieldwork coordinator, faculty member, academic program director, researcher/scholar, and/or entrepreneur
-Role development and advancement depends on practitioner's experience, education, practice skills, and professional development activities (ie. self study, continuing education, advanced degrees)

OT assistant (OTA) information

-OTAs are graduates of ACOTE accredited technical educational programs which are generally 2 years in duration, resulting in an Associate's degree or a Certificate
-An OTA can expand their role by establishing service competency
-Service competency is the ability to use the specified interventions in a safe, effective, and reliable manner, (ie. the OTA and OT can perform the same or equivalent procedure and obtain the same results)
-OTAs who establish service competency do not become independent; they continue to work under the OT's supervision
-OTA's primary role is to implement treatment
-OTAs can contribute to the evaluation process but they cannot independently evaluate or initiate treatment prior to the OT's evaluation
-OTAs can contribute to development and implementation of the intervention plan and the monitoring and documenting of the individual's response to intervention under the OT's supervision
-OTAs can be activities directors in skilled nursing facilities (SNFs) and can supervise OT aides
-AOTA supports the independent practice of OTAs with advanced level skills who work for independent living centers (state licensure laws and scope of practice legislation may supersede this recommendation)

OT aide roles

-Although OT aides are not considered OT practitioners, according to AOTA Standards of Practice, the use of OT aides has increased in response to changes in the health care system (ie. pressures to control costs have resulted in the delegation of non-skilled tasks to aides)
-OT aides can be delegated non-skilled tasks by OTAs or OTs (non-skilled tasks aides may perform include routine maintenance and clerical activities, preparation of clinic area for intervention, and/or specified, supervised aspects of a treatment session [eg. contact guarding a client while therapist teaches transfers])

Methods of supervision

-Direct: face-to-face contact between supervisor and supervisee (includes co-treatment, observation, instruction, modeling, and discussion)
-Indirect: non face-to-face contact between supervisor and supervisee (includes electronic, written and telephone communications)

Guide for supervision of occupational therapy personnel

-Entry-level OT (working on initial skill development or entering new practice); supervision - not required. Close supervision by an intermediate-level or an advanced-level OT recommended; Supervises - aides, technicians, all levels of OTAs, volunteers, Level 1 fieldwork students
-Intermediate-level OT (working on increased skill development and mastery of basic role functions, and demonstrates ability to respond to situations based on previous experience); supervision - not required. Routine or general supervision by an advanced-level OT recommended; supervises - aides, technicians, all levels of OTAs, Level I and Level II fieldwork students, entry-level OTs
-Advanced-level OT (refining specialized skills with the ability to understand complex issues affecting role functions); supervision - not required. Minimal supervision by an advanced-level OT is recommended; supervises - aides, technicians, all levels of OTAs, Level I and Level II fieldwork students, entry-level and intermediate-level OTs
-Entry-level OTA (working on initial skill development or entering new practice); supervision - close supervision by all levels of OTs, or an intermediate or an advanced-level OTA who is under the supervision of an OT; supervises - aides, technicians, volunteers
-Intermediate-level OTA (working on increased skill development and mastery of basic role functions, and demonstrates ability to respond to situations based on previous experience); supervision - routine or general supervision by all levels of OTs, or an advanced-level OTA, who is under the supervision of an OT; supervises - aides, technicians, entry-level OTAs, volunteers, Level I OT fieldwork students, Level I and II OTA fieldwork students
-Advanced-level OTA (refining specialized skills with the ability to understand complex issues affecting role functions); supervision - general supervision by all levels of OTs, or an advanced-level OTA, who is under the supervision of an OT; supervises - aides, technicians, entry-level and intermediate-level OTAs, volunteers, Level I OT fieldwork students, Level I and Level II OTA fieldwork students
-Personnel other than occupational therapy practitioners assisting in occupational therapy services (aides, paraprofessionals, technicians, volunteers); supervision - for non-client related tasks, supervision is determined by the supervising practitioner. For client-related tasks, continuous supervision is provided by all levels of practitioners; supervises - no supervisory capacity

Specific OT roles and supervisory guidelines - Occupational therapist assistant (OTA)

-Functions to provide quality OT services to assigned individuals under supervision of OT
-Can range from entry level to advanced level depending on experience, education, and practice skills
-Development from entry level to advanced level is dependent upon development of service competency

Specific OT roles and supervisory guidelines - Educator (consumer, peer)

-Functions to develop and provide training or educational offerings related to OT's domain of concern to consumer, peer, and community groups or individuals
-Can be an OT or and OTA with appropriate supervision

Specific OT roles and supervisory guidelines - Fieldwork educator

-Functions as the manager of Level I and/or II fieldwork in a practice setting, providing students with opportunities to practice and implement practitioner competence
-Entry Level OTs and OTAs may supervise Level I fieldwork students
-OTs with one year practice-based experience may supervise OT Level II students
-OTAs with 1 year of practice experience may supervise OTA Level II fieldwork students
-Three years of experience are recommended for individuals supervising programs with multiple students and multiple supervisors

Specific OT roles and supervisory guidelines - Supervisor

-Functions as the manager of the overall daily operation of OT services in a defined practice area(s)
-Can be an OT or an OTA
-Experienced OTAs may supervise other OTAs administratively as long as service protocols and documentation are supervised by an OT

Specific OT roles and supervisory guidelines - Administrator

-Functions to manage department, program, services, or agency providing OT services
-Can be an OT with a graduate degree or continuing education relevant to management and experience appropriate to the size and scope of department and program(s) (ie. a minimum of 3-5 years of experience)

Team roles and principles of collaboration - overview

-A team is a group of equally important individuals with common interests collaborating to develop shared goals and build trusting relationships to achieve these shared goals
-Members of the team include the patient/client/consumer; his/her family, significant others, and/or caregivers; healthcare professionals; and the reimburser's gatekeepers
-Professional members on team will vary according to practice setting
-The consumer, family, significant other, and/or caregiver role on the team has become increasingly important. Collaboration with these individuals is even mandated by law (eg. OBRA, IDEA)

Principles of collaboration

-Factors that influence effective team functioning
-Member skill and knowledge
-Membership stability
-Commitment to team goals
-Good communication
-Membership composition
-A common language
-Effective leadership

Types of teams

-Intradisciplinary team
-Multidisciplinary team
-Interdisciplinary team
-Transdisciplinary team
-Team efficacy: interdisciplinary and transdisciplinary teams are the most common and considered the most effective in today's health care system

Lay team members and role responsibilities

-Consumer: the most important and primary member of the treatment team; the consumer's occupations, values, interests, and goals must be determined and used in all treatment planning (if the consumer and the therapist do not share a common language, an interpreter must be used)
-Family/primary caregiver: family's sociocultural background, socioeconomic status, and caregiving tasks, needs, and skills must be considered as they can impact on the outcome of intervention (if the family and the therapist do not share a common language, an interpreter must be used)

Para-professional team members and role responsibilities

-Personal Care Assistants (PCAs)/Home Health Aides (HHAs): individuals who provide primary care to enable a person with a disability to remain in his or her own home
-Most states require some minimum training and certification as a HHA/PCA. Standards and educational requirements can vary greatly from state to state
-Responsibilities: 1) personal care such as bathing, grooming, dressing and feeding 2) home management such as shopping, cleaning, and cooking 3) supervision of home programs as directed by a therapist
-Due to the tremendous importance this role has in maintaining a person with a disability in his or her own home, OT collaboration with HHAs/PCAs is critical
-OTs can also educate and train consumers on the hiring, training, and supervision of HHAs/PCAs

Professional team members and role responsibilities - Primary care physician (PCP)

-A physician who serves as the "gatekeeper" of services for consumers in managed health care systems
-Provides primary health care services and manages routine medical care
-Makes referrals, as needed, to other health care providers and services including specialty tests and examinations, rehabilitation services, and occupational therapy

Professional team members and role responsibilities - Physiatrist

-A physician who specializes in physical medicine and rehabilitation and is certified by the American Board of Physical Medicine and Rehabilitation
-Leads the rehabilitation team and works directly with occupational, speech, and physical therapists and others to maximize rehabilitation outcome for persons with physical disorders
-Diagnoses and medically treats individuals with musculoskeletal, neurological, cardiovascular, pulmonary, and/or other body systems disorders

Professional team members and role responsibilities - Psychiatrist

-A physician who specializes in mental health and psychiatric rehabilitation
-Leads the rehabilitation team and works directly with occupational therapists, psychologists, social workers, and others to maximize rehabilitation outcomes for persons with psychiatric disorders
-Diagnoses and medically treats individuals with psychiatric disorders
-Responsible for ordering transfers to long term care settings and for determining competence and the need for involuntary treatment

Professional team members and role responsibilities - Psychologist

-A professional with a Ph.D. in psychology
-Evaluates psychological and cognitive status with standardized and non-standardized assessments including intelligence/IQ (Standford-Binet, Wechsler), Projective (Rorschach), Personality (Minnesota Multiphasic Personality Inventory), Neuropsychological and Interest Inventories (Strong-Campbell)
-Provides individual, couple, family, and group supportive therapy, cognitive retraining, and behavior modification

Professional team members and role responsibilities - Respiratory therapy technician certified (CRT)

-A technically trained professional with an Associate's Degree who has passed a national certification examination
-Administers respiratory therapy as prescribed and supervised by a physician
-Performs pulmonary function tests and intervenes through oxygen delivery, aerosols, and nebulizers

Professional team members and role responsibilities - Physical therapist (PT)

-A licensed professional who is a graduate of an accredited physical therapy education program at a baccalaureate or graduate level
-Evaluates clients' physical motor skills
-Develops plan of care, and administers or supervises treatment to develop, improve and/or maintain client's physical motor skills to alleviate pain, an to correct or minimize physical deformity
-Delegates portions of treatment program to supportive personnel eg. physical therapist assistant (PTA)
-Supervises and directs supportive staff (PTA, PT aide) in designated tasks
-Re-evaluates and adjusts plan of care as appropriate
-Performs and documents final evaluation and establishes discharge and follow-up plans

Professional team members and role responsibilities - Physical therapist assistant (PTA)

-A skilled allied health care technologist, usually with a two year associate's degree
-Must work under the supervision of a physical therapist (if the supervisor is off-site, delegated responsibilities must be safe and legal practice with ready access to the supervisor; in home health, required periodic joint on-site visits or treatments with physical therapist)
-Able to adjust treatment procedure in accordance with the patient's status
-May not evaluate, develop, or change plan of care, or write discharge plan or summary

Professional team members and role responsibilities - Athletic trainer

-An allied health professional
-Assesses athletes' risk for injury, conducts injury prevention programs, and provides treatment and rehabilitation under the supervision of a physician when athletic trauma occurs

Professional team members and role responsibilities - Chiropractor (DC)

-A professional who is a graduate of an educational program in chiropractic who is usually licensed by state boards
-Assesses the individual's spinal column and intervenes to restore and maintain health, and decrease and elminate pain

Professional team members and role responsibilities - Certified orthotist (CO)

-Evaluates the need for orthotic equipment (spling, braces)
-Designs, fabricates, and fits orthoses for individuals to prevent or correct deformities and/or support body parts weakened by injury, disease, or congenital deformity
-Educates the client on purpose of orthoses, recommended care, and wearing schedule
-May be an OT, a PT, or an individual with specialized training

Professional team members and role responsibilities - Certified prosthetist (CP)

-Evaluates the need for a prosthesis
-Designs, fabricates, and fits prosthesis for an individual to ensure proper fit and to promote functional abilities
-Educate client and/or caregiver(s) about the use and care of the prosthesis
-Works directly with OTs, PTs, and physicians

Professional team members and role responsibilities - Biomedical engineer

-A graduate of an engineering program who specializes in the biomedical application of engineering theory and technology
-Serves as a technical expert to recommend commercial products, adapt available devices, and/or modify existing environments
-Develops, designs, and fabricates customized equipment, devices, and techniques

Professional team members and role responsibilities - Speech-language pathologist (SLP), or speech therapist (ST)

-A professional who is a graduate of an accredited educational program in speech-language pathology
-Assesses language and speech abilities and impairments
-Develops and conducts intervention programs to restore, improve, or augment the communication of persons with speech and/or language impairments
-May receive advanced training and specialize in oral-motor functioning (eg. the evaluation and treatment of dysphagia)

Professional team members and role responsibilities - Audiologist

-A professional who is a graduate of an educational program in audiology
-Administers assessments to determine an individual's auditory acuity, level of hearing impairment, and damage site(s) in the auditory system
-Provides recommendations for assistive devices (eg. hearing aids) and/or special training to enhance residual hearing and/or adapt to hearing loss

Professional team members and role responsibilities - Optometrist/vision specialist

-A professional who is a graduate of an educational program in optometry
-Examines the eye to determine visual acuity, level of visual impairments, and damage to or disease in the visual system
-Prescribes assistive devices (eg. corrective lenses) and recommends other appropriate treatment (eg. visual-motor training)
-Optometrist can refer individuals to outpatient OT

Professional team members and role responsibilities - Special educator/teacher

-A professional teacher certified to provide education to children with special needs (visual and/or hearing impairments; emotional and psychosocial disabilities; physical and sensorimotor disabilities; developmental disabilities; learning and cognitive disabilities)
-Assesses and monitors student learning, plans and implements instructional activities, and addresses the special developmental and educational needs of each student
-Advanced training in instructional methods for teaching children with special needs to develop to their full educational potential is required
-Additional training in teaching children with multiple disabilities is often needed
-May be assisted by teacher aides who provide direct care and "hands-on" support to students in the classroom (collaboration with aides is required for effective follow-through of OT programming in school setting

Professional team members and role responsibilities - Vocational rehabilitation counselor

-A professional who is a graduate of an educational program in vocational rehabilitation
-If certified, the counselor is able to use the credential of Certified Rehabilitation Counselor (CRC)
-Evaluates prevocational skills and vocational interests and abilities via standardized and non-standardized assessments to determine an individual's employability
-Provides counseling to maximize the individual's vocational potential
-Refers individual to appropriate vocational programming and/or job placement
-Serves as liaison between the individual and state educational and vocational departments for persons with disabilities to obtain funding for needed services

Professional team members and role responsibilities - Social worker

-A licensed/registered professional who is a graduate of an accredited educational social work program at a baccalaureate level (BSW) or at a graduate level (MSW)
-Upon passing a national certification examination, a social worker is eligible to use the credentials Certified Social Worker (CSW) (in states with licensure requirements, a social worker may have the credential of licensed clinical social worker [LCSW])
-Assesses client's social history and psychosocial functioning via clinical interviews and structured assessments
-Assists clients, families and caregivers with accessing social support services (eg. home care, support groups) and obtaining needed reimbursement/funding (eg. Medicaid, food stamps) through the completion of required application processes and through active advocacy
-Provides individual, couple, and family counseling
-Serves as a primary care manager, enabling individual to function optimally and maintain quality of life
-Provides crisis intervention and recommendation for additional services
-Contributes to discharge plan and completes tasks needed for implementation of discharge orders (eg. application to a SNF)
-Supervises and is assisted by social work assistants

Professional team members and role responsibilities - Substance abuse counselor

-A professional who may come from a diversity of educational backgrounds (psychology, social work, occupational therapy) who has completed a specialized training program
-Provides individual and/or group intervention
-Certified Alcohol Counselor (CAC) and Certified Alcohol and Drug Counselor (CADC) are the two main credentials designating this specialized role

Professional team members and role responsibilities - Recreational therapist/therapeutic recreation specialist

-A professional who is a graduate of a recreation therapy education program
-Conducts individual and/or group interventions to develop leisure interests and skills; to facilitate community, social, and recreational integration; to manage stress and symptoms; and to adjust to disability
-May be called an Activities Therapist but the two positions are not synonymous. Activities Therapists may only have on-the-job training

Professional team members and role responsibilities - Expressive/creative arts therapist

-Professionals who are graduates of specialized education programs
-Depending on the state, they may or may not be licensed or registered
-Includes art, dance/movement, music, horticulture, and poetry therapists
-Conducts individual and/or group interventions which use select expressive modalities to facilitate self-expression, self-awareness, social skills, symptom reduction and management

Professional team members and role responsibilities - Pastoral care

-Serves as the spiritual advisor to the individual, his/her family, caregivers, and the team
-Provides individual, couple, and family counseling in a non-denominational manner

Professional team members and role responsibilities - Alternative practitioners

-May include massage therapists, accupuncturists, Reiki practitioners, and others
-Training and licensure requirements vary greatly
-The roles and tasks of alternative practitioners will be determined by state practice regulations and reimburser's guidelines

United States health care system - overview

-A group of decentralized subsystems serving different populations
-Overwhelmingly private ownership of health care delivery
-Relatively small federal and state governmental programs work in conjunction with a large private sector; however, the government pays for a large portion of these private sector services through Medicare and Medicaid reimbursement
-Decentralization results in overlap in some areas and competition in others; therefore, health care is primarily a business that is market-driven (patients are viewed as consumers due to this economic focus; cost containment while maintaining quality of service is a delicate balancing act that is not always achieved)
-Primary care physicians have increased significance as the first line for evaluation and intervention, and the referral source for specialized and/or ancillary services

Health care regulations

-Health care is a highly regulated industry with most regulations mandated by law
-Legally mandated regulations are set forth by the Center for Medicare and Medicaid Services (CMS), a division of US Department of Health and Human Services (HHS)
-CMS is the federal agency which develops rules and regulations pertaining to federal laws, in particular the Medicare and Medicaid programs
-Facilities that participate in Medicare and/or Medicaid programs are monitored regularly for compliance with CMS guidelines by federal and state surveyors
-Facilities that repeatedly fail to meet CMS guidelines lose their Medicare and/or Medicaid certification(s)
-Long-term settings, ie. skilled nursing facilities (SNFs), are strongly influenced by CMS regulations since Medicare and/or Medicaid pays for all or most of the expense of long-term care
-CMS is divided into three centers: 1) the Center for Beneficiary Choices which focuses on Medicare Choice and Medigap 2) the Center for Medicare Management which focuses on traditional fee-for-service Medicare 3) the Center for Medicaid and State Operations which focuses on state administered programs like Medicaid and State Children's Health Insurance Program (SCHIP)
-Standards related to safety are set forth and enforced by the Occupational Safety and Health Administration (OSHA), a division of the US Department of Labor
-Structural standards and building codes are established and enforced by OSHA to ensure the safety of structures
-The safety of employees and consumers is regulated by OSHA standards for handling infectious materials and blood products, controlling blood borne pathogens, operating machinery, and handling hazardous substances
-State accreditation to obtain licensure for a health care facility is mandatory. Individual states develop their own requirements, with state agencies enforcing these regulations
-Local or county entities also develop regulations pertaining to health care institutions (eg. physical plant safety features such as fire, elevator and boiler regulation)

Voluntary accreditation

-Voluntary accreditation and self-imposed compliance with established standards is sought by most health care organizations
-Accreditation is a status awarded for compliance with establish standards
-Accreditation ensures the public that a health care facility is adequately equipped and meets high standards for patient care, and employs qualified professionals and competent staff
-Accreditation affirms the competence of practitioners and the quality of health care facilities and organizations
-Accreditation through an accrediting agency is voluntary; however, it is mandatory to receive third party reimbursement and to be eligible for federal government grants and contracts
-CMS and many states accept certain national accreditations as meeting their respective requirements for participation in the Medicare and Medicaid program and for a license to operate

Voluntary accrediting agencies

-Joint Commission on the Accreditation of Health Care Organizations (JCAHO): the voluntary agency that accredits health care facilities according to JCAHO established standards and conditions; JCAHO accredits hospitals, skilled nuring facilities (SNFs), home health agencies, preferred provider organizations (PPOs), rehabilitation centers, health maintenance organizations (HMO), behavioral health including mental health and chemical dependency facilities, physician's networks, hospice care, long term care facilities, and others
-Commission on Accreditation of Rehabilitation Facilities (CARF) is the voluntary agency that accredits free-standing rehabilitation facilities and the rehabilitative programs of larger hospital systems in the areas of behavioral health, employment and community support services, and medical rehabilitation
-Accreditation Council for Services for Mentally Retarded and Other Developmentally Disabled Persons (AC-MRDD) is a voluntary agency that accredits programs or agencies that serve persons with developmental disabilities
-Outpatient centers for comprehensive rehabilitation can be accredited by JCAHO, CARF, and/or AC-MRDD
-National Committee on Quality Assurance (NCQA) is a voluntary agency that accredits health maintenance organizations (HMOs), preferred provider organizations (PPOs), and managed behavioral health care organizations (MBHOs)
-National League for Nursing/American Public Health Association (NLN/APHA) is a voluntary agency that accredits home health and community nursing agencies that offer nursing and other health services outside hospitals, extended care facilities, and nursing homes
-National Adult Day Services Association (NADSA) is a voluntary agency, in affiliation with CARF, which accredits adult day services for person with functional and cognitive impairments

The accreditation process

-Accreditation is initiated by the organization submitting an application for review or survey by the accrediting agency
-A self-study or self-assessment is conducted to examine the organization based on the accrediting agency's standards
-An on-site review is conducted by an individual reviewer or surveyor or a team visiting the organization
-The accreditation and the re-accreditation process involve all staff. Tasks include document preparation, hosting the site visit team, and interviews with accreditors
-Once accredited, the organization undergoes periodic review, typically every three years

Value of accreditation to Occupational Therapy

-Self-study and self-assessment can be an opportunity to identify areas of strength, validated competence, and promote excellence
-Areas needing improvement can be identified (ie. procedures can be streamlined and additional resources can be obtained, team communication can be enhanced)
-Programs goals are clarified
-Practice is defined and documented
-Accreditors can share information regarding "best practice"
-An increased recognition of OT's contributions to the agency and identification of functional outcomes can result in increased visibility for OT and increased referrals

Capitation

-Payment system under which the provider is paid prospectively (ie. on a monthly basis) a set fee for each member of a specific population (ie. health plan members) regardless if no covered health care is delivered or if extensive care is delivered
-Payment is typically determined in terms of "per member per month" (PMPM)
-The healthier the enrollees (and the fewer services used), the more the provider retains of the total PMPM payment

Co-insurance

-The monetary amount to be paid by a patient, usually expressed as a percentage of total charge

Clinical/critical pathway

-A standardized recommended intervention protocol for a specific diagnosis

Deductible

-The amount a patient must pay to a provider before the insurance benefits will pay; usually expressed as an annual dollar amount

Denial

-The refusal by a payer to reimburse a provider for services rendered. Reasons for denial include benefits exhausted, duplication of services, and services not indicated

Diagnosis code

-A code that describes a patient's medical reason or condition that requires health service

Diagnostic related groups (DRGs)

-The descriptive categories established by CMS that determine the level of payment at a per case rate

Fee for service

-The payment system under which the provider is paid the same type of rate per unit of service. Traditionally, payer pays 80% and patient or provider is responsible for the remaining 20%

Health maintenance organization (HMO)

-The most common form of managed care. Maintains control over services by requiring enrollees to see only doctors within the HMO network and to obtain referrals before seeking specialty or ancillary care

Managed care

-A method of maintaining some control over costs and utilization of services while providing quality health care. Typically refers to HMOs and PPOs

Per diem

-A negotiated, per day fee for service. Typically used for inpatient hospital stays and skilled nursing facilities

Preferred provider organization (PPO)

-A form of managed care that is similar to an HMO but usually offers a greater choice of providers. However, as choices increase, percentage of payment decreases

Private payment

-The individual receiving services is responsible for payment

Procedure codes

-Codes that describe specific services performed by health professionals

Prospective payment system (PPS)

-The nationwide payment schedule that determines the Medicare payment for each inpatient stay of a Medicare beneficiary based on DRGs

Provider

-The entity responsible for the delivery and quality of services. Providers bill Medicare, HMOs, and PPOs for services rendered

Third party payers

-Agencies and companies who are the primary reimbursers for health care in the US (eg. Blue Cross). HMOs and PPOs are also third party payers

Usual and customary rate (UCR)

-The average cost of specific health care procedures in a geographic area. This is the maximum amount the insurer will pay for a service and covered expense

Vendor/supplier

-The entity which supplies services

Private Insurance and managed care plans

-Largest source of insurance payment in US (there are broad variations among plans and plan options; they can be for profit or not for profit)
-Many private insurers contract with Medicare to handle the day to day operations of Medicare. They are called intermediaries
-Insurers (eg. Blue Cross/Blue Shield, Aetna, MetLife, and Prudential), offer many insurance products including PPOs, HMOs, and managed care
-Coverage cannot be assumed based on the name of plan alone (co-insurance, deductibles and co-payments are common; most plans cover for OT in hospitals; outpatient coverage varies greatly; total number of visits and/or type and amount of services per diagnosis are limited)
-Insurers are not federally regulated. Each state determines its own requirements and regulations for insurers who operate within their borders
-Cost controlling payment strategies such as case management, precertification or preauthorization, mandatory second opinions, and preferred provider networks are often implemented
-Occupational therapists can join health care provider panels and/or a preferred provider network

Medicare - General information

-Largest single payer for OT services
-Administered by CMS
-Intermediaries determine if services provided are within Medicare guidelines
-Persons eligible for Medicare medical coverage for health care services: 1) persons 65 years or older 2) individuals with permanent kidney failure, black lung disease, and/or other long-term disability specified in the law 3) persons who have been on some social security program for 24 months
-The primary difference between Part A and Part B is the frequency in which the individual receives services. Inpatient Part A coverage requires services for a minimum of 5 days per week services. Part B typically covers 3 days a week outpatient services
-Medicare does not cover chronic illness, long term supportive care, or all medical expenses incurred when ill
-OT is covered as an outpatient service when provided by or under arrangements with any Medicare Certified provider (ie. hospital, SNF, home health agency, rehabilitation agency, a clinic) or when provided as part of comprehensive rehabilitation facility services (CORF)
-OT services can also be covered if provided by a Medicare certified OT in independent practice (OTIP) when services are provided by the OT in the OT's office or in the patient's home (payment is according to the fee schedule entitled the Resource Based Relative Value Scale (RBRVS)

Medicare Part A

-Pays for inpatient hospital, skilled nursing facility (SNF), home health, and hospice care
-Part A is automatically provided to all who are covered by the Social Security System that meet the coverage criteria
-Services provided in acute care hospitals receive a prospective, predetermined rate based on DRGs (Diagnostic Related Groups)
-The DRG per case rate covers all services including OT
-IT is a fixed dollar amount for patient care for each diagnosis regardless of length of stay (LOS) or number of services provided
-Treatment supplies (ie. adaptive equipment, splints) are included in this per case rate
-Individual hospitals determine the combination of services a patient will receive
-Part A covered services have specific time limits and also require deductible and coinsurance payments by the beneficiary: 1) annual deductible fees must be paid by patient 2) twenty percent of home health care must be paid by patient

Medicare Part B

-Pays for hospital outpatient physician and other professional services including OT services provided by independent practitioners
-Part B is considered a Supplemental Medical Insurance Program and therefore must be purchased by the beneficiary, usually as a month premium
-Part B services have no specific time limit and require 20% co-payment

Criteria for coverage of occupational therapy services by Medicare

-Prescribed by a physician or furnished according to a physician-approved plan of care
-Performed by a qualified OT or an OTA under the general supervision of an OT
-Service is reasonable and necessary for treatment of individual's injury or illness
-Diagnosis can be physical, psychiatric, or both. There are no diagnostic restrictions for coverage
-OT must result in a significant, practical improvement in person's level of functioning within a reasonable period of time

Medicare - OT in SNFs

-Is covered if the patient requires skilled nursing or skilled rehabilitation (ie OT, PT, SLP) on a daily basis (ie. minimum 5 days/week)
-Reimbursement is based upon resource utilization groups (RUGs)
-Reimbursement is also provided for the designing of a maintenance plan and for the occasional reevaluation of this plan's effectiveness
-Reimbursement is not provided for a therapist to carry out the maintenance plan
-Evaluation and training of caregivers is considered part of the design and reevaluation of a maintenance plan
-The competence of caregivers to carry out the maintenance plan must be documented prior to discharge from OT

Medicare - OT in home care

-Is covered if the individual is homebound and needed intermittent skilled nursing care, PT, or ST before OT began. OT services can continue after need for skilled nursing, PT, or ST has ended
-Homebound status criteria: 1) the person is typically not able to leave the home; ie. is "confined" to the home ("confinement" may be due to the need for the aid of ambulatory devices, the assistance of others, or special transportation; it considers medical, physical, cognitive, and psychiatric conditions) 2) if the person leaves the home it requires "considerable and taxing effort" 3) a person may leave his/her home for medical appointments (eg. kidney dialysis) and non-medical short-term and infrequent appointments/events (eg. trip to a hairdresser, attendance at religious services) 4) the need for adult day care does not preclude a person from receiving home health services
-Home health agencies (HHAs) are reimbursed under a prospective payment system (PPS): 1) this rate per episode of care reimbursement system applies to all home health services including all forms of therapy and medical supplies 2) durable medical equipment is excluded from HHA PPS 3) the HHA PPS uses a classification system called Home Health Resource Groups (HHRGs) to determine an episode payment rate 4) an episode is defined as a 60 day period beginning with the first billable visit and ending 60 days after the start of care
-An initial assessment visit and a comprehensive assessment using the Outcome and Assessment Information Set (OASIS) must be completed to verify the person's eligibility for Medicare home health benefits, the continuing need for home care, and to plan for the person's nursing, medical, social, rehabilitative, and discharge needs (OTs can complete the initial OASIS if the need for OT establishes program eligibility; the initial assessment must be completed within 48 hours of referral or within 48 hours of the person's return home; OTs can conduct follow-up. transfer, and discharge evaluations)
-AOTA is actively working to change federal legislation to have OT identified as an initial qualifying service for home health care, so barriers to OT home health services may be removed in the future

Medicare - OT in hospice care

-Is provided to persons who are certified as terminally ill (medical prognosis of fewer than 6 months to live) OT services are provided to enable a patient to maintain functional skills and ADL performance and/or to control symptoms

Medicare criteria for coverage of OT services rendered in a physician's office or in a physician-directed clinic

-The OT or OTA is employed by the physician or clinic
-The service is furnished under physician's direct supervision and the services are directly related to the condition for which the physician is treating the patient
-OT service fees are included on the physician's bill to Medicare

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