NBCOT-CH. 2-Professional Standards and Responsibilities

Occupational Therapy Code of Ethics – Principle 1
-Occupational therapy personnel shall demonstrate a concern for the safety and wellbeing of the recipients of their services (beneficence)
-Occupational therapy personnel shall:
-Provide services in a fair and equitable manner. They shall recognize and appreciate the cultural components of economics, geography, race, ethnicity, religious and political factors, marital status, sexual orientation, gender identity, and disability of all recipients of their services
-Strive to ensure that fees are fair and reasonable and commensurate with services performed. When occupational therapy practitioners set fees, they shall set fees considering institutional, local, state, and federal requirements, and with due regard for the service recipient’s ability to pay
-Make every effort to advocate for recipients to obtain needed services through available means
-Recognize the responsibility to promote public health and the safety and well-being of individuals, groups, and/or communities
Occupational Therapy Code of Ethics – Principle 2
-Occupational therapy personnel shall take reasonable precautions to avoid imposing or inflicting harm upon the recipient of services or to his or her property (nonmaleficence)
-Occupational therapy personnel shall:
-Maintain relationships that do not exploit the recipient of services sexually, physically, emotionally, financially, socially, or in any other manner
-Shall avoid relationships or activities that interfere with professional judgement and objectivity
-Refrain from any influences that may compromise provision of service
-Exercise professional judgement and critically analyze directives that could result in potential harm before implementation
-Identify and address personal problems that may adversely impact professional judgement and duties
-Bring concerns regarding impairment of professional skills of a colleague to the attention of the appropriate authority when or/if attempts to address concerns are unsuccessful
Occupational Therapy Code of Ethics – Principle 3
-Occupational therapy personnel shall respect the recipients to assure their rights (autonomy, confidentiality)
-Occupational therapy practitioners shall collaborate with recipients, and if they desire, families, significant others, and/or caregivers in setting goals and priorities throughout the intervention process, including full disclosure of the nature, risk, and potential outcomes of any intervention
-Occupational therapy practitioners shall obtain informed consent from participants involved in research activities and ensure that they understand potential risks and outcomes
-Occupational therapy personnel shall respect the individual’s right to refuse professional services or involvement in research or educational activities
-Occupational therapy personnel shall protect all privileged confidential forms of written, verbal, and electronic communication gained from educational, practice, research, and investigational activities unless otherwise mandated by local, state, or federal regulations
Occupational Therapy Code of Ethics – Principle 4
-Occupational therapy personnel shall achieve and continually maintain high standards of competence (duty)
-Occupational therapy practitioners shall hold the appropriate national and state credentials for the services they provide
-Occupational therapy practitioners shall conform to AOTA standards of practice and official documents
-Occupational therapy practitioners shall take responsibility for maintaining and documenting competence in practice, education, and research by participating in professional development and educational activities
-Occupational therapy practitioners shall be competent in all topic areas in which they provide instruction to consumers, peers, and/or students
-Occupational therapy practitioners shall critically examine and keep current with emerging knowledge relevant to their practice so they may perform their duties on the basis of accurate information
-Occupational therapy practitioners shall provide appropriate supervision to individuals for whom the practitioners have supervisory responsibility in accordance with Association official documents, local, state, and federal or national laws and regulations, and institutional policies and procedures
-Occupational therapy practitioners shall refer to or consult with other service providers whenever such a referral or consultation would be helpful to the care of the recipient of service. The referral or consultation process should be done in collaboration with the recipient of service
Occupational Therapy Code of Ethics – Principle 5
-Occupational therapy personnel shall comply with laws and Association policies guiding the profession of occupational therapy (procedural justice)
-Occupational therapy personnel shall familiarize themselves with and seek to understand and abide by applicable Association policies; local, state, and federal/national/international laws
-Occupational therapy practitioners shall be familiar with revisions in those laws and Association policies that apply to the profession of occupational therapy and shall inform employers, employees, and colleagues of those changes
-Occupational therapy practitioners shall encourage those they supervise in occupational therapy-related activities to adhere to the Code
-Occupational therapy practitioners shall take reasonable steps to ensure employers are aware of occupational therapy’s ethical obligations, as set forth in the Code of Ethics, and of the implications of those obligations for occupational therapy practice, education, and research
-Occupational therapy practitioners shall record and report in an accurate and timely manner all information related to professional activities
Occupational Therapy Code of Ethics – Principle 6
-Occupational therapy personnel shall provide accurate information when representing the profession (veracity)
-Occupational therapy personnel shall represent their credentials, qualifications, education, experience, training, and competence accurately. This is of particular importance for those to whom occupational therapy personnel provide their services or with whom occupational therapy practitioners have a professional relationship
-Occupational therapy personnel shall disclose any professional, personal, financial, business or volunteer affiliations that may pose a conflict of interest to those with whom they may establish a professional, contractual, or other working relationship
-Occupational therapy personnel shall refrain from using or participating in the use of any form of communication that contains false, fraudulent, deceptive, or unfair statements or claims
-Occupational therapy practitioners shall identify and fully disclose to all appropriate persons errors that compromise recipients’ safety
-Occupational therapy practitioners shall accept the responsibility for their professional actions which reduce the public’s trust in occupational therapy services and those that perform those services
Occupational Therapy Code of Ethics – Principle 7
-Occupational therapy personnel shall treat colleagues and other professionals with respect, fairness, discretion, and integrity (fidelity)
-Occupational therapy personnel shall preserve, respect, and safeguard confidential information about colleagues and staff, unless otherwise mandated by national, state, or local laws
-Occupational therapy practitioners shall accurately represent the qualifications, views, contributions, and findings of colleagues
-Occupational therapy personnel shall take adequate measures to discourage, prevent, expose, and correct any breaches of the Code and report and breaches of the Code to the appropriate authorities
-Occupational therapy personnel shall use conflict resolution and/or alternative dispute resolution resources to resolve organizational and interpersonal conflicts
-Occupational therapy personnel shall familiarize themselves with established policies and procedures for handling concerns about his Code, including familiarity with national, state, local, district, and territorial procedures for handling ethics complaints. These include policies and procedures created by the AOTA, licensing and regulatory bodies, employers, agencies, certification boards, and other organizations who have jurisdiction over occupational therapy practice.
Ethics in practice
-Ethics guide the behavior and decision making of occupational therapy practitioners to help them determine the morally right course of action
-Occupational therapy practitioners are often faced with issues and events that challenge their personal values and beliefs and professional ethics
-Decisions about what are the right and wrong courses of action are based on our profession’s Code of Ethics
Ethical distress
-When a therapist knows the correct action to take but an existing barrier prevents the therapist from taking this course of action
-For example, when an admissions policy to a day treatment program excludes persons with substance abuse histories, yet this program would provide appropriate intervention for a client who is mentally ill and chemically addicted (MICA)
Ethical dilemmas
-When there are two or more potentially morally correct ways to solve a problem. However, these solutions are exclusive; therefore, choosing one course of action prohibits acting on the other choices
-For example, a group of occupational therapy private practice practitioners has the opportunity to bid on a lucrative contract for the provision of services in a school system. However, none of the OTs has pediatric experience. Their options may include not bidding on the contract or bidding on the contract and if the contract is won, incurring the expense of hiring pediatric-trained therapists
Patient/client abuse
-Ethical responsibility of occupational therapy practitioners
-In accordance with Principle 1 of the AOTA code of ethics occupational therapy personnel must act to ensure “the safety and well-being of the recipients of their services”
-As a result, practitioners are obligated to report any observed or suspected incidents of patient/client abuse or neglect: 1) the party to whom reporting is required varies from state to state, as does the penalties for not reporting 2) minimum reporting standards require reporting to one’s immediate supervisor
-Occupational therapy practitioners should also provide interventions to victims of abuse and/or neglect. These can include: 1) treatment for physical and emotional injuries 2) development of a trusting relationship 3) provision of support to family and loved ones 4) referral to appropriate disciplines and agencies 5) contributor to staff training programs to prevent abuse
-Facts and figures: all ages are at risk for abuse; facts and figures for patient/client abuse are subsumed into institutional elder abuse and abuse of the mentally ill
Definition of abuse
-Abuse is defined as deliberately hurting a patient physically, mentally, or emotionally
-Neglect is defined as deliberately withholding services that are necessary to maintain an individual’s physical, mental, and emotional health
-Definition vary from state to state
Signs of patient/client abuse
-Individual’s report of abuse and/or neglect
-Frequent unexplained injuries or complaints of pain without obvious injury
-Burns or bruises suggesting the use of instruments, cigarettes, etc
-Passive, withdrawn, and emotionless behavior
-Lack of reaction to pain
-Sexually transmitted diseases or injury to the genital area
-Unexplained difficulty in sitting or walking
-Fear of being alone with caretakers
-Obvious malnutrition
-Lack of personal cleanliness
-Habitually dressed in torn or dirty clothes
-Obvious fatigue and listlessness
-Begs for food, water, or assistance (especially in regard to toileting)
-In need of medical or dental care
-Left unattended for long periods
-Bedsores and skin lesions
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
State Regulatory Board (SRB)
-Public bodies created by state legislatures to assure the health and safety of the citizens of that state
-Their specific responsibility is to protect the public from potential harm that might be caused by incompetent or unqualified practitioners
-State regulation may be in the form of licensure, registration or certification
-Each state has legal guidelines that usually specify the scope of practice of the profession, and the qualifications that must be met to practice in that state
-Ethical jurisdiction
-SRBs usually provide a description of ethical behavior. In many instances, SRBs have adopted AOTA’s Code of Ethics for this purpose
-By the very nature of their limited jurisdiction (ie. only over therapists practicing in their state), SRBs can monitor a profession closely
-SRBs have the authority by law to discipline members of a profession if the public is determined to be at risk due to malpractice
-SRBs also intervene in situations where the individual has been convicted of an illegal act that is directly connected with professional practice (ie. fraud or misappropriation of funds through false billing practices)
-Since SRBs are primarily concerned with the protection of the public from harm, they will limit their review of complaints to those involving such a threat
Disciplinary actions for ethical violations and professional misconduct
-When the AOTA, NBCOT, and/or a SRB determine that a person has violated their standards for ethical practice, different actions can be used as a disciplinary measure
-These actions are based on agency internal investigations to determine the severity of an infraction and can include: 1) reprimand – the private communication of the respective agency’s disapproval of a practitioner’s conduct 2) censure – a public statement of the respective agency’s disapproval of a practitioner’s conduct 3) ineligibility – the removal of eligibility for membership, certification, or licensure by the respective agency for an indefinite or specific time period 4 probation – the requirement that a practitioner meet certain conditions (eg. further education, extensive supervision, individual counseling, participation in a substance abuse rehabilitation program) to retain membership, certification, or licensure by the respective agency 5) suspension – the loss of membership, certification, licensure for a specific period of time 6) revocation – the permanent loss of membership, certification, or licensure
-All the above actions (except reprimand) are made public by the respective agencies
-Disciplinary actions that are made public by one agency (eg. NBCOT) can trigger an investigation into a practitioner’s professional conduct by other practice jurisdictions (eg. SRBs)
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])
General supervision information
-Supervision is the process in which two or more individuals collaborate to establish, maintain, promote, or enhance a level of performance and quality of service
-It is a mutually respectful joint effort between supervisor and supervisee
-It promotes professional growth and development and facilitates mentoring
-It ensures appropriate training, education, and use of resources for safe and effective service provision
-Supervision facilitates innovation, supports creativity, and provides encouragement, guidance, and support while working toward attainment of a shared goal
-Only OT practitioners can supervise OT practice, OT aides cannot supervise OT practice
-Occupational therapists can practice autonomously and do not require any supervision to provide OT services (occupational therapists are responsible and accountable for all aspects of OT service delivery; to develop best practice competencies and foster professional growth, occupational therapists should use supervision and mentorship)
-OT assistants must be supervised by occupational therapists for any and all aspects of the OT service delivery process
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)
Supervision continuum
-Supervision occurs along a continuum that includes close, routine, general, and minimum
-Close: daily, direct contact at the site of work
-Routine: direct contact at least every 2 weeks at the site of work, with interim supervision occurring by other methods such as telephone or written communication
-General: at least monthly direct contact with supervision available as needed by other methods
-Minimal: provided only on a needed basis, and may be less than monthly
-Formal supervision can be supplemented by functional supervision, which is the provision of information and feedback to coworkers (a sharing of expertise)
-The degree, amount, and pattern of supervision required can vary depending on the practitioner’s competence, service demands, state laws and licensure requirements, facilities procedures, complexities of client needs, and caseload characteristics and demands (ie. an OT assistant providing services to an acutely ill person with rapidly changing status on an inpatient until will require a closer OT/OTA partnership than an OT assistant providing services to a more stable client in a long-term care residential facility)
-The supervising occupational therapist determines the type of supervision that is most appropriate
-Ethically, the OT supervisor must ensure that the type, amount, and pattern of supervision match the supervisee’s level of role performance
-OT aide supervision may be intermittent or continuous depending on the task being performed (intermittent supervision is sufficient for non-patient related tasks. It requires periodic discussion, demonstration, or contact between the supervisor and aide on at least a monthly basis; continuous supervision is required for patient-related tasks. A supervisory OTA or OT must be within auditory and/or visual contact in the immediate area of the aide during the aide’s task performance
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 (OT)
-Functions to provide quality OT services (assessment, intervention, program planning and implementation, discharge planning, related documentation and communication)
-Can be direct, indirect, or consultative in nature, and can range from entry level to advanced level depending on experience, education, and practice skills
-The OT has ultimate responsibility for service provision
-OTs who do not have access to formal supervision are advised to seek mentoring to facilitate professional growth and develop best practice skills
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)
Specific OT roles and supervisory guidelines – Consultant
-Functions to provide OT consultation to individuals, groups, or organizations
-Can be an OT or an OTA at the intermediate or advanced practice level
-The OT and OTA are responsible for obtaining the appropriate level of supervision to meet regulatory and professional standards
Specific OT roles and supervisory guidelines – Academic setting fieldwork coordinator
-Functions to manage fieldwork within the OT academic setting
-Can be an OT or an OTA with a recommended three years of practice experience and experience in supervising fieldwork students
-General supervision by the OT academic program director is recommended
-Close to routine supervision is recommended for new faculty
Specific OT roles and supervisory guidelines – Faculty
-Functions to provide formal academic education to OT or OTA students
-Can be an OT or an OTA with an appropriate advanced professional degree and intermediate to advanced skills in teaching
-General supervision is recommended by academic program director
-Close to routine supervision for new, adjunct, and part-time faculty by program director
Specific OT roles and supervisory guidelines – Program director (academic setting)
-Functions to manage the OT or OTA education program with an appropriate advanced professional degree, experience as a faculty member, and experience or continuing education in academic management
-General to minimal administrative supervision from designated administrative officer (eg. Academic Dean)
Specific OT roles and supervisory guidelines – Researcher/scholar
-Functions to perform scholarly work of the profession ie. examining, developing, refining, and/or evaluating the profession’s theoretical base, philosophical foundations, and body of knowledge
-Can be an OT or an OTA with additional self study, continuing education, experience and formal education related to research and scholarly activities
-OTAs can contribute to research process
-Additional academic qualifications are needed for OTAs to be principal investigators
-Supervision needs range from close to minimal depending on skills of researcher/scholar and scope of project
Specific OT roles and supervisory guidelines – Entrepreneur
-Functions as a partially or fully self-employed individual who provides OT services
-Can be an OT or an OTA who meets state regulatory requirements
-OTAs who provide direct service have the responsibility to obtain appropriate supervision from an OT
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
Intradisciplinary team
-One or more members of one discipline evaluate, plan, and implement treatment of the individual
-Other disciplines are not involved; communication is limited, thereby limiting perspectives on the case
-This “team” is at risk due to potential narrowness of perspective
-Comprehensive, holistic care can be questionable
Multidisciplinary team
-A number of professionals from different disciplines conduct assessments and interventions independent from one another
-Members’ primary allegiance is to his/her discipline. Some formal communications occur between team members
-Limited communication may result in lack of understanding of different perspectives
-Resources and responsibilities are individually allocated between disciplines; therefore, competition among team members may develop
Interdisciplinary team
-All disciplines relevant to the case at hand agree to collaborate for decision making
-Evaluation and intervention is still conducted independently within defined areas of each profession’s expertise. However, there is a greater understanding of each discipline’s perspective
-Members are directed toward a common goal and not bound by discipline line-specific roles and functions
-Members tend to use group process skills effectively (eg. during team treatment planning meetings)
-The exchange of information, prioritization of needs and allocation of resources and responsibilities are based on members’ expertise and skills, not on “turf” issues
Transdisciplinary team
-Characteristics of interdisciplinary teams are maintained and expanded upon
-Members support and enhance the activities and programs of other disciplines to provide quality, efficient, cost-effective service
-Members are committed to ongoing communication, collaboration, and shared decision making for the patient/client’s benefit
-Evaluations and interventions are planned cooperatively, yet one member may take on multiple responsibilities. Role blurring is accepted
-Ongoing training, support, supervision, cooperation, and consultation among disciplines are important to this model, ensuring that professional integrity and quality of care is maintained
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 – Physician’s assistant (PA)
-A professional who is a graduate of an accredited physician’s assistant educational program and who has passes a national certification examination
-Performs routine diagnostic, therapeutic, preventative, and health maintenance service
-Specializations can include family medicine, geriatrics, pediatrics, obstetrics, emergency care, and orthopedics
-Must work under the direction of and be supervised by a physician
Professional team members and role responsibilities – Registered nurse (RN)
-A licensed professional who is a graduate of an accredited nursing education program
-Serves as the primary liaison between the individual and physician. Also, often serves as the primary case manager
-Monitors vital signs, symptoms, and behaviors
-Dispense medications and assists the physician with the titration of medications
-Performs or supervises bedside care and assists with ADL in collaboration with the OT
-Conducts group and individual interventions related to wellness and prevention and disease and symptom management (eg. medication education)
-Performs patient, family, and caregiver education to facilitate recovery and maximize quality of life
-Supervises and is assisted by licensed practical nurses (LPN), certified nursing assistants (CNAs), and aides
-Due to the major role LPNs, CNAs, and aides have in providing direct care to individuals. OT collaboration with these team members is essential
Professional team members and role responsibilities – Dietitian/Clinical nutritionist
-A licensed professional who is a graduate of an accredited educational program and who passed a national registration examination
-Practitioners who pass this registration examination are credentialed as Registered Dietician (RD) or Dietician Technician Registered (DTR), depending on the level of education
-Evaluates individuals’ nutritional status and dietary needs
-Provides nutrition therapy for diseases such as diabetes and preventive counseling for issues such as obesity
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
Beneficiary
-A person receiving services. In skilled nursing facilities (SNFs), the term “resident” is used
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
Medicare criteria for coverage of partial hospitalization (PHP) services in a hospital-affiliated or community mental health psychiatric day program
-The beneficiary would otherwise have required inpatient psychiatric care
-OT services are covered under general Medicare guidelines (ie. MD’s prescription, reasonable and necessary, function expected to improve)
-Active treatment incorporating an individualized multi-disciplinary intervention plan to attain measurable, time-limited, medically necessary, functional goals directly related to the reason for admission must be provided
-Pyschosocial programs that provide structured diversional, social, and or recreational, services or vocational rehabilitation do not meet the criteria for active treatment in a PHP and are not reimbursable under Medicare
Medicare coverage of durable medical equipment, prostheses, and orthoses
-Rental or purchase expense for durable medical equipment (DME) are covered if used in beneficiary’s home and if necessary and reasonable to treat an illness or injury or to improve functioning
-A physician’s prescription is needed and must include diagnosis, prognosis, and reason for DME need
-Criteria for durable medical equipment: 1) repeated use can be withstood 2) primarily and customarily used for a medical purpose (eg. a wheelchair or walker) 3) generally not useful to a person in the absence of injury or illness
-Self help items, bathtub grab bars, and raised toilet seats are not reimbursable because other people can use them and they are not considered medically necessary
Medicaid – general information
-A state/federal health insurance program for persons who have an income that is below an established threshold and/or have a disability
-States administer the program but receive at least 50% of their funding from federal government
-Includes federally mandated services and state optional services
-Mandated services must be provided if a state receives federal funds
-Coverage of optional services varies greatly from state to state
Mandated Medicaid services
-Inpatient and hospital services
-Outpatient (eg. laboratory work, x-rays, skill nursing) and physician’s services
-Home health (level and amount of care can vary)
-Early periodic screening diagnosis, and treatment services (EPSDT) for persons 21 years-old and younger
-Services identified as needed to treat a condition during EPSDT (including OT) must be provided
-SNFs receiving Medicaid must provide skilled rehabilitation services (including OT) to residents who require them
Optional Medicaid services
-Occupational therapy, physical therapy, speech language therapy
-Durable medical equipment
-Services provided by independently practicing licensed professionals including psychologists, psychiatric social workers, and other mental health professionals
-Targeted case management
-Prescription medication
-Dental care, eyeglasses
-Crisis response services
-Transportation
-Psychiatric inpatient services for persons aged under 21 or over 65
-Related services (including OT) provided by school systems to children with disabilities (note: this provision overlaps IDEA legislation and has led to questioning as to whether services to individual children should be funded as an educational or a health care service)
Medicaid reform
-Due to rapidly rising costs there is an increased press for cost containment
-States are examining ways to reformulate Medicaid benefits
-Reform options may include placing caps or other limitations on types and length of therapy, reducing or eliminating optional benefits, and/or developing and implementing managed care approaches
-Individual states can apply to the federal government for a waiver which gives the state flexibility in the types of services and delivery systems they provide under Medicaid
Workers’ compensation
-Designed to compensate employees who have job-related illness or injuries
-Funded jointly by individual employers or groups of employers and state governments
-Each state has a workers’ compensation commission board which determines regulations for employer participation, benefit provision, employee coverage, and insurance administration
-Administration can be through contract with private insurance companies or through individual employers or groups of employers who administer their own programs. This is known as self-insuring
-Coverage varies from state to state, with many states initiating cost-containment measures including limits on choice of providers, use of set fee schedules, utilization review, and managed care
-Workers compensation programs include cash benefits and medical benefits. OT services may be included
-Rehabilitation and disability management to return the person to gainful employment is a primary focus
Personal payment and “Pro Bono” care
-Individuals whose health insurance has discontinued coverage of OT services may elect to pay for these services personally, providing that benefit can be derived from continued services
-Individuals without health insurance or with no coverage for rehabilitative services may also pay for OT personally
-The services of OTs practicing in non-medical settings, (ie. wellness and prevention programs) are generally not covered by insurers so their clients must private pay
-“Pro Bono” or free or reduced rate care may be supported by the individual therapist’s personal donation of services or through philanthropic donations
Federal legislation related to occupational therapy
-Historically, the opportunities available to and the roles afforded to persons with disabilities have been influenced by federal legislation
-Federal laws establish numerous standards and provide funding for health benefits, medical services, rehabilitation, early intervention, education, vocational programming, professional training, and research
-These laws directly affect the profession of occupational therapy by establishing practice guidelines and reimbursement standards
-Major social movements that have precipitated federal legislation and/or have resulted from federal legislation include deinstitutionalization, early intervention, mainstreaming, and full inclusion
-State laws also influence OT practice but, due to their variability, would not be included in a national examination
-To ensure best possible practice, OTs have an ethical responsibility to know federal and state laws and regulations
Health Insurance and Portability Accountability Act (HIPAA)
-Set standards and safeguards to assure the individual’s right to continuity in healthcare coverage and to ensure privacy and security of health care records
-All persons must be informed of the setting’s privacy policies and a good faith effort must be made to obtain written acknowledgement from each person about his/her attainment of this knowledge
-If the person refuses to sign, the provider should document the efforts made, failure to obtain written acknowledgement is not a violation of the rule
-Written consent must be obtained from a person before any personal health information is used or disclosed in the provision of treatment, obtainment of payment, or the carrying out of any healthcare related operations (exemptions to the written notification/acknowledgement are allowed if the attainment of this will prevent or delay timely care [ie. emergency care]. Written acknowledgement must be obtained as soon as possible; if language barriers preclude signed acknowledgement, treatment can occur if the physician believes consent is implied)
-Prior to discussing a person’s status with a family member/significant other or other provider, the provider must obtain the person’s permission, or give the person the opportunity to object (providers can use their clinical judgement to determine whether to discuss the person’s case with others if the person cannot give permission or objects – documentation for this decision is essential [eg. person is at risk of harming self due to lack of judgement; consultation with a specialist is essential to ensure quality of care]; all information used or disclosed about a person’s status must be limited to the minimum needed for the immediate purpose
-The HIPAA Privacy Rule requires that all providers protect patient confidentiality in all forms (ie. oral, written, and electronic) and implement appropriate physical, technical, and administrative safeguards to assure this privacy
-An individual has the right to access all of his/her records
-HIPAA does not exclude treatment from occurring in group settings or open clinics (discussion regarding treatment should be done quietly and, if possible, behind a screen/room divider)
-HIPAA does not require a guarantee of 100% confidentiality; it does require reasonable and vigilant safeguards
-HIPAA guidelines for research are complex but they are congruent with the established guidelines for human subject research and Institutional Review Board (IRB) standards (a “limited data set” that does not include identifiable patient information can be used in research without patient approval [eg. diagnosis, age, length of stay])
-The Administrative Simplification rules also provide standardization of codes and formats for medical data
-HIPAA does not override state laws that further restrict privacy and it defers to state laws governing minors
HIPAA Privacy Rule
-Requires that all providers protect patient confidentiality in all forms (ie. oral, written, and electronic) and implement appropriate physical, technical, and administrative safeguards to assure this privacy
-Settings must reduce the physical identifiability of patient information; ie. door tags and white boards can only list last names, no diagnoses or treatment procedures may be listed, sign-in sheets with names only are allowed
-Charts and any documentation with patients’ names or other identifiers must be stored out of public view and in secure locations
-Opaque covers should be used for clipboards that contain paperwork with patient information
-All computers that are used to record, document, or transmit patient information should be equipped with monitor privacy screens
-All faxes must contain cover sheets noting confidentiality of accompanying information and be sent only to dedicated fax machines in secure locations
-All e-mails must use password protection and encryption if going over the internet
-All faxes and computer printouts must be immediately destroyed or placed in the person’s chart, as most appropriate
-All conversations regarding a person’s health status must be done in private areas, in low tones, and with minimal disclosure
Individual’s right to access all of his/her records
-Providers can charge reasonable copying costs and have 30-60 days to respond
-Individuals have the right to request that information in their record by amended
-The provider can refuse the request, providing his/her rationale
-The provider can comply with the request by documenting the request and the reason for compliance. The original documentation should not be removed/excised
Medicare Title 18-PL 89-97
-Established Medicare and Supplemental Security Income (SSI)
-SSI enables a person with disabilities to receive a monthly income enabling them to live in the community
Rehabilitation Act of 1973
-Prohibits discrimination on the basis of disability in any program or activity that receives federal assistance
-Required all federal agencies to develop action plans for the hiring, placement, and advancement of persons with disabilities
-Required contractors who received federal contracts over a pre-set amount to take affirmative action to employ persons with disabilities
Fair Housing Act
-Prohibits discrimination on the bases of disability, religion, sex, color, race, national origin, and familial status
-Required owners of housing to make reasonable exceptions to their standard tenant policies to allow individuals with disabilities equal housing opportunities (eg. allowing a seeing eye service dog in a “no-pets” apartment)
-Required that tenants with disabilities be allowed to make reasonable modifications to common use areas and to their private living space to enable access (the housing owner is not required to fund these modifications)
-Required that newly constructed multifamily residences (4 or more apartments) be built to meet established accessibility standards
Omnibus Budget Reconciliation Act (OBRA) of 1981
-Affirmation application of Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination in federally funded programs to a diversity of services (ie. Head Start programs, block grant programs, community development programs)
-Provided Medicaid financing for community-based services for people with developmental disabilities when services were demonstrated to be less expensive than institutional care
American with Disabilities Act (ADA)
-Prohibits discrimination against qualified persons with disabilities in employment, transportation, accommodations, telecommunications, and public services
-Criteria for classifying an individual as disabled: 1) a person with a physical or mental impairment that substantially limits one or more major life activities 2) a person having a record of such an impairment 3) a person regarded as having such an impairment
-Individuals who are actively abusing substances or compulsively gambling or persons who have kleptomania, pyromania, or sexual behavior disorders are not protected by ADA
-Title I – Employment
-Title II – Public Services
-Title III – Public Accommodations and Services operated by Public Entities
-Title IV – Telecommunications
ADA Title I -Employment
-Prohibits employers from discrimination against persons with disabilities in any aspect or phase of employment including recruitment, hiring, working conditions, hours, promotion, training opportunities, termination, social activities, and other privileges of employment
-Allows questions about one’s ability to perform a job but prohibits inquires as to whether one has a disability
-Prohibits employment tests that tend to screen out people with disabilities
-A “qualified individual with a disability” means a person with a disability who is able to perform the “essential functions” of a job (that is, the tasks fundamental to the position) with or without reasonable accommodations
-“Reasonable accommodations” must be provided by businesses with 15 or more employees to persons with disabilities to enable them to perform essential job functions unless such accommodations would impose an “undue” hardship on the business
-Types of reasonable accommodations: 1) acquisition or modification of equipment or devices 2) modification or adjustments to examinations, training materials, or publications 3) provisions of ancillary aids or services 4) modified or part time work schedules, job restructuring, or reassignment to a vacant position 5) improvement of existing facilities used by employees so they are usable by and accessible to persons with disabilities and/or other similar accommodations
-Types of auxiliary aids and services: 1) taped texts, qualified readers, or other methods that can effectively make visually delivered materials accessible to persons with visual impairments 2) qualified interpreters or other methods that can effectively make aurally delivered materials accessible to persons with hearing impairments 3) modification or acquisition of devices or equipment 4) similar actions or services that increase accessibility
-Undue hardship is defined as action that would be significantly difficult or overly expensive given the financial resources of the employer, its size, and major functions
-The United States Government, Indian Tribes, religious groups and/or private tax-exempt membership clubs are exempt from ADA employer guidelines
ADA Title II – Public Services
-Mandates that state and local governments and their departments, agencies, and/or component parts may not discriminate against, exclude, or deny persons with disabilities participation in or benefit from the services, programs, or activities of these public entities (this includes transportation, public education, employment, recreation, social services, health care, courts, town meetings, and voting)
ADA Title III – Public accommodations and services operated by public entities
-Mandates that places of public accommodation (ie. hospitals, health care providers’ offices, schools, day care centers, and other places of accommodation) may not discriminate against persons with disabilities with respect to their participation in or ability to benefit from the service, goods, facility, use or other programming aspects
-All new construction of public accommodations must be accessible
-Public transportation systems must be accessible
-Physical barriers in existing facilities must be removed if removal is able to be carried out without much difficulty or expense
-Private services that serve the public (eg. restaurants, stores, and theaters) cannot discriminate in the provision of services
-Private transportation systems must be accessible and non-discriminatory (eg. livery services, taxis, tour bus companies)
ADA Title IV – Telecommunications
-All television must include closed captioning
-Telephone companies must provide telecommunications relay services (TRS) to persons with hearing or speech impairments 24 hours per day, 7 days per week
Ticket to Work and Work Incentives Improvement Act (TWIIA)
-Strives to make it more realistic and easier for a person with a disability to work
-Removes a major disincentive to work by allowing individuals with disabilities to maintain their Medicare or Medicaid health care benefits (allows an individual with a disability to keep Medicare benefits for an additional 54 months after starting work; eliminates limits on Medicaid “buy in” options)
-Enables consumers to have a choice in their service provider beyond public assistance programs
-Establishes community-based vocational planning and assistance programs
-Increases consumer choices for accessing employment support services
-All states can design their own program
Work Investment Act (WIA)
-Established a federally sponsored national employment and vocational training system
-Established a “One-Stop” delivery system for all adults aged 18 or older seeking access to employment and training services. This means traditionally separate “unemployment” offices and “vocational rehabilitation services” are now available at a “One-Stop Center”
-Availability of all employment and training services at a One-Stop Center is aimed to allow for “universal access” for people with disabilities – a core principle of WIA
-Categories of One-Stop services: 1) core services, which include outreach intake and orientation; initial assessment; eligibility determination for services; assistance with job search and placement; job market information and career counseling 2) intensive services for individuals who do not attain successful employment after receipt of core services. Services can include comprehensive assessments of service needs and skill level, development of individualized plans for employment, case management, and counseling 3) training services for individuals who do not attain successful employment after receipt of core and intensive services. These services are typically provided off-site from the One-Stop Center and can include adult education and literacy training, on-the-job training, and individualized vocational training
-The One-Stop system of services is provided through a network in each state. The names of these systems can vary from state to state
-Persons determined to be eligible for WIA services receive an Individual Training Account (ITA) which is used to obtain services from any approved provider. Specific ITA procedures can vary from state to state
-Services for youth (aged 14-21) with disabilities are also provided for in the WIA to assist in a successful transition from school to work
Technology Related Assistance for Individuals with Disabilities Act
-Funded the development of technology and technologic aids for persons with disabilities to improve communication, mobility, self-care, transportation, and education
Telecommunications Act of 1996
-Required providers of telecommunication systems and manufacturers of telecommunication equipment to make services and equipment usable by and accessible to individuals with disabilities, if at all possible
Child Abuse Prevention and Treatment Act
-Defines child abuse and neglect as mental or physical injury, negligent treatment, maltreatment, or sexual abuse of a child less than 18 years of age by a person responsible for the child’s welfare under circumstances that indicate that a child’s welfare or health is being threatened or harmed
-Mandates professionals to report abuse and neglect to law enforcement officials
-Occupational therapists are included in this list of mandated reporters
-OT practitioners can also serve as child welfare advocates
-Direct OT intervention may be needed to remediate the emotional or physical disorders that result from abuse
Early Intervention and Education Acts
-Multiple acts have provided the foundation for current early intervention and education services. These include:
-Mandates for free and appropriate education (FAPE) for all children regardless of ability or disability, (aged 3-21) in the least restrictive environment (mainstreaming [ie integrating children with disabilities into classrooms] was the means to ensure education is provided in the least restrictive environment)
-Requirements that public schools provide OT to special education students if OT is needed for the student to benefit from the special education
-The designation of occupational therapy as a primary early intervention service
-Funding for family support services and programs to train professionals in early intervention
-Recommendations for states to develop infant and toddler programs (birth to 3 years) (programs are voluntary and vary from state to state but all states participate to some degree; OT is considered a primary developmental service)
Reauthorization and Amendment of Individuals with Disabilities Education Act
-Emphasizes that the purpose of the Individualized Education Plan (IEP) is to address the child’s unique needs as related to his/her disability and decide how these needs can be served so the child has full access to the general education curriculum and can participate in the general education classroom
-Clarifies that the individual education plan (IEP) can include consideration of assistive technology and behavioral interventions, strategies, and supports (an area in which OT can offer a great deal)
-States that IEP planning team is open to related personnel at the request of the parent or school, in addition to the regular education teacher, if the student is in a regular education class
-States that the education the student receives should prepare him/her for independent living and employment in adult life: 1) transitional planning begins at the age of 14 (or younger if indicated) to help the student plan a course of study that will lead to post-school goals 2) transition services begin at the age of 16 (or younger if indicated) to provide student with a coordinated set of services to attain post-school goals (these services can include community experience, specific instructions, and/or ADL and vocational assessment and intervention) 3) the student must be invited to attend IEP meetings that discuss his/her transition planning and services to allow for self-advocacy and self determination 4) this transition plan must be updated annually with appropriate service revision provided
-Maintains the established definition of related services (including OT)
-Expands orientation and mobility services by broadly interpreting them to include all children with disabilities
-Students with disabilities may be punished in the same manner as other students for serious offenses (ie. carrying illicit drugs or a weapon). However, disciplinary prevention measures are stressed
-Educational and related services still must be received by the child even if he/she is removed to an alternative placement
-Clarifies early intervention services and systems (mandates an Individual Family Service Plan (IFSP) for children 0-2 years of age; OT is identified as a primary early intervention service
Individuals with Disabilities Education Improvement Act (IDEA 2004)
-Directly addresses the student’s functional performance along with academic performance: 1) requires that evaluation for IDEA eligibility include relevant functional and developmental information, not just academic achievement data 2) expands the IEP’s annual goals to include academic and functional goals 3) specifies that accommodations must be provided as needed to measure the functional performance and academic achievement of all students with disabilities
-Provides for the piloting of a multi-year (not to exceed 3 years) IEP to allow for long-term planning and to coincide with a child’s ‘natural’ transitions (eg. pre-school to elementary school, middle school to high school)(plan is optional for parents)
-Provides for increased flexibility in IEP meetings: 1) allows IEP team members to be excused from IEP meetings if their area of concern is not being addressed or modified at the meeting or if a written report is submitted prior to the meeting (District and parental approval for a team member’s absence is required; parental approval must be in writing) 2) allows IEP revisions and/or amendments to be made by parents and districts after an annual IEP meeting (parents must be provided with a written copy of the revised/amended IEP) 3) allows the use of technological alternatives to face-to-face IEP meetings (ie. video conferences, conference calls)
-Requires that recommendations for early intervention, special education, related and supplementary services and aids be made based on peer-reviewed research to the extent that this is practical: 1) this requirement raises concern that established intervention methods may be questioned due to a real or perceived lack of evidence supporting their efficacy 2) this requirement may spur research on early intervention and school-based OT to support evidence-based practice
-Clarifies that a screening done by a specialist is not equivalent to an evaluation for eligibility for IDEA services: 1) OT practitioners can conduct informal classroom-based screenings and provide consultations for classroom modifications and other teaching strategies without completing a formal evaluation according to IDEA procedures
-Requires that all students with disabilities be assessed in compliance with the No Child Left Behind Act: 1) the IEP team determines if the student should take an alternative assessment or the standard assessment with or without accommodations
-Provides for early coordinated intervening services for general education students from kindergarten through 12th grade who do not require special education services but who do need additional supports to succeed in school
-Clarifies that the purpose of the IDEA is to prepare children with disabilities for further education, employment, and independent living
-Allows school personnel to individually consider each case of a student with a disability who violates the school’s code of conduct: 1) students with disabilities who are disciplined must: be provided with services to continue to progress towards achieving their IEP goals; receive appropriate functional behavioral assessments and interventions and service modifications as needed to address their conduct violation(s)
-Allows each state to define developmental delay criteria to determine if an infant or toddler is eligible for early intervention in that state: 1) typically, states define developmental delays quantitatively (eg. percentage of delay according to a standardized developmental assessment)
-Requires that an IFSP be completed to include: 1) the infant’s or toddler’s developmental level 2) family priorities, concerns, and resources 3) the infant’s or toddler’s natural environments 4) measurable outcomes 5) projected, length, frequency and duration of research-based services 6) transition plans to pre-school or other services, as appropriate
-Clarifies the role of the parent and IFSP team in determining the site for service provision: 1) requires states to maximize the provision of early intervention services in the infant’s or toddler’s natural environments, as appropriate
-Requires states to establish procedures for the referral of infants and toddlers who are victims of abuse and/or neglect to early intervention services: 1) this provision was also included in the Keeping Children and Families Safe Act
No Child Left Behind Act (NCLB)
-A general education law which emphasizes standards-based education
-Considers occupational therapists to be pupil services personnel and sets no requirements for OT services
-Requires schools to provide accommodations, if needed by students, for mandated tests (OT practitioners can recommend testing alternatives and/or classroom accommodations
Age Discrimination in Employment Act
-Prohibits employment practices that discriminate or unfairly affect workers 40 years and older
-Prohibits mandatory retirement of older workers. Employers cannot fix a retirement age
Freedom to Work Act
-Amended the Social Security Act to enable Americans receiving retirement Social Security (SS) benefits (currently 65 years old) to be able to work without affecting their SS income (there are no income restrictions in this amendment)
Omnibus Budge Reconciliation Act (OBRA) of 1990
-Applied to all nursing homes that receive federal money for Medicare or Medicaid patients
-Emphasized attending to residents rights, autonomy, and self determination; providing quality of care; and enhancing quality of life within nursing homes
-Mandated a comprehensive resident assessment system, the Minimal Data Set (MDS), which is administered upon admission and thereafter on an annual basis, unless there is a significant change in the resident’s condition (MDS is coordinated by an RN. OTs can contribute information)
-Psychosocial wellbeing and activity pursuit patterns must be considered along with the resident’s physical condition and cognitive abilities (this has broadened OT’s role in nursing homes)
-Mandated that the evaluation and treatment of conditions found during the MDS follow specific guidelines called the Resident Assessment Protocols (RAPS): 1) the structured approach to assessment is called the Resident Assessment Instrument (RAI) 2) individualized care plans must be established within specific time frames
-The enhancement of quality of life through restrain reduction and the provision of restraint-free environments are strongly emphasized: 1) nursing homes must show evidence of consultation by an OT or PT for consideration of interventions that are less restrictive than restraints 2) OTs are frequently consulted for ADL treatments, seating adaptations, positioning ideas, environmental modifications, psychosocial interventions, and activity programming
-Aims to guarantee that residents have the right to choose how they want to receive care and live their lives: 1) residents should have a choice in determining their ADL, including community activities 2) residents should be able to function as independently as possible
-Post discharge plans must meet specific criteria including client or caregiver education
Service delivery models and practice settings – overview
-A working knowledge of service delivery models and practice settings ensures that OT practitioners make educated decisions about their employment and competent referrals for their clients
-As a result of legislative initiatives and health care system changes, services delivery models and practice settings are evolving from medical-based models and settings to more community-based models and settings (eg. IDEA has solidified schools as a practice setting)
-Implications for OT practice: 1) fewer practitioners are working in hospitals and long term care facilities 2) more practitioners are working in community based settings (eg. day treatment, home care, school settings)
Models of practice
-Criteria for determining a model of practice:
-The type of setting
-Philosophy and mission of the particular setting and department
-The role the therapist plays as a team member within that particular setting
-Medical model
-Education model
-Community model
Medical model
-Views the individual with a disability as a person who has incurred a physiological insult that has resulted in reduced functional capacity
-Focus is placed on identifying the disease or dysfunction
-Treatment addresses the disease or dysfunction (performance components) contributing to decreased functional skills
-OT frames of reference address the pathological process of the disease or dysfunctions (eg. biomechanical, neurodevelopmental)
Education model
-Views the individual with a disability as lacking knowledge or skills
-Focus is placed on learning and making the behavioral changes needed to interact successfully in the environment
-An individual’s skill deficits are determined, and related goals are established, to promote learning to adequately perform within a particular environment
-Behaviors are measured in terms of obtaining skills, knowledge, and competency to successfully meet the demands of the environment
-OT frames of reference are based on learning theories to facilitate adaptation in the environment (eg. role acquisition, cognitive remediation)
Community model
-Views the individual with a disability as lacking skills, resources, and supports for community integration
-Focus is placed on identifying and developing the skills needed for one’s expected environment
-If skills cannot be developed, community resources and supports are identified and developed to enable functioning within one’s chosen environment
-OT frames of reference promote development of performance components and/or performance areas within the individual’s performance contexts (eg. life-style performance, occupation adaptation)
Acute care hospitals
-Admission is for a medical or psychiatric diagnosis that cannot be treated on an outpatient basis
-Initial onset of a new illness or major health problem
-Acute exacerbation of a chronic illness
-In psychiatry, a person may be involuntarily admitted to an acute unit if he/she is considered to be a danger to self or others, or as having a grave disability
-Length of stay (LOS) is determined by diagnosis and presenting symptoms
-LOS can be limited to 1-7 days
-Longer LOS requires significant documentation to justify need for further hospitalization
-Ongoing need for acre frequently results in discharge to another setting
-OT evaluation process focuses on quick and accurate screening of major difficulties impeding function (eg. cognitive status, home safety skills)
-OT intervention focus: 1) stabilization of client’s status 2) engagement of the client in the therapeutic relationship and purposeful activities/meaningful occupations so that he/she can see that change is possible, thereby increasing motivation to pursue follow-up 3) discharge planning and after-care referrals 4) family, caregiver, and consumer education
-The role of an acute care OT can be a generalist or a specialist (eg. neonatology, burns) (specialized practice roles require advanced knowledge and skills and therefore would not be evaluated on the NBCOT examination)
Sub-acute care/intermediate care facilities (ICFs)
-Admission is for a medical or psychiatric diagnosis that has progressed from an acute stage but has not stabilized sufficiently to be treated on an outpatient basis
-Length of stay (LOS) is determined by diagnosis and presenting symptoms
-LOS can range from 5-30 days
-Longer LOS requires significant documentation to justify need for further hospitalization
-Ongoing need for intervention or long-term care frequently results in discharge to another setting
-OT evaluation can include more in-depth assessments and more thorough observations of client’s functional performance
-OT intervention focus: 1) functional improvements in performance skills and areas of occupation 2) active engagement of the client in the treatment planning, implementation, and re-evaluation process 3) discharge planning to expected environment
-Sub-acute care and ICFs can be housed in hospitals or skilled nursing facilities (SNFs)
Long-term acute care hospital (LTAC)
-Admission is for chronic or catastrophic illnesses or disabilities that require extensive medical care and/or dependency on life support or ventilators (patients often have multiple diagnoses with major complications)
-The average length of stay is greater than 25 days to maintain Medicare certification
-OT evaluation and intervention is often limited by the population’s severe and complex medical needs: 1) for all clients, evaluation and intervention is concerned with palliative care and the prevention and treatment of complications (eg. positioning to prevent decubiti and contractures) 2) for individuals who are cognitively intact, the focus of evaluation and intervention is mastery of the environment and the attainment of client-centered goals
Rehabilitation hospitals
-Admission is for a disability that is medically stable but which has residual functional deficits requiring skilled rehabilitation services
-Length of stay (LOS) is determined by presenting deficits and rehabilitation potential: 1) LOS can range from a week to months 2) documentation requirements supporting the need for an extended LOS are dependent upon institutional, state, and third party payer guidelines 3) LOS ends when coverage is expended. The client is then discharged to the appropriate environment (skilled nursing facility; a supportive community residence; home/independent living)
-OT evaluation can be extensive and focus on all performance skills and patterns, areas of occupation, and occupational roles that will be required in the expected environment (environmental assessments of planned discharge environment must be completed)
-OT intervention focus: 1) functional improvement in performance skills and patterns, areas of occupation, and occupational roles 2) development of compensatory strategies for residual deficits and client factors 3) provision of adaptive equipment and training in use of the equipment to promote independent function 4) modification of the discharge environment, as needed, to enhance function 5) education of the individual, family, and caregivers on abilities, limitations, compensatory techniques, and advocacy skills
Long-term hospitals
-Admission is for a medical or psychiatric diagnosis that is chronic with the presence of symptoms that cannot be treated on an outpatient basis
-Length of stay (LOS) is determined by diagnosis and presenting symptoms: 1) LOS can range from a month to years 2) documentation requirements supporting need for increased LOS are dependent upon institutional, third-party payer, and/or state guidelines 3) LOS in private long-term hospitals is determined by insurance coverage. When coverage is expended, an alternative discharge environment is needed for the client (a state run long-term hospital; a skilled nursing facility; home or supportive residence)
-OT evaluation can be extensive due to increased LOS
-OT intervention focus: 1) functional improvements in performance skills and patterns and areas of occupation 2) development of compensatory strategies for residual deficits and client factors 3) maintenance of quality of life 4) development of skills for discharge to the least restrictive environment
Skilled nursing facilities (SNFs)/extended care facilities (ECFs)
-Admission is for a medical or psychiatric diagnosis that is chronic and requires skilled care, but the individual’s illness is stable with no acute symptoms
-Due to managed care constraints on acute hospital stays, many individuals are being admitted to SNFs for medical care and rehabilitation
-Length of stay (LOS) can range from 1 month to the individual’s lifetime. Several factors influence LOS: 1) the progression of the illness 2) availability of family or community supports 3) insurance coverage
-OT evaluation and intervention is guided by Medicare standards: 1) for individuals with rehabilitation potential, the focus of evaluation and intervention is the same as identified under Rehabilitation Hospitals 2) for individuals without rehabilitation potential, evaluation and intervention is more concerned with palliative care and the maintenance of quality of life
Forensic settings
-Admission is due to engagement in criminal activity by a person. The person can be remanded to a variety of settings depending on the nature of the crime and if he/she has a psychiatric diagnosis: 1) jail – a city or county facility which is the individual’s first entry into the criminal justice system and the placement for those convicted of crimes with sentences of less than a year 2) prison – a state or federal facility for individuals found guilty of crimes with sentences greater than a year 3) forensic psychiatric hospital or unit – a specialized hospital or unit within a hospital which provides inpatient psychiatric care for individuals convicted of a crime and found guilty but mentally ill or not guilty by reason of insanity
-Length of stay (LOS) is determined by court-ordered directives and criminal sentences
-The availability and quality of services varies greatly from none in most jails to extensive in some forensic hospitals
-Due to serious gaps in mental health services, the incarceration rate of persons with mental illness has increased significantly (eg. a homeless person with schizophrenia steal food due to hunger)
-OT evaluation and intervention focus: 1) determination of individual’s competency to stand trial, in forensic psychiatry settings 2) areas similar to those described under Rehabilitation Hospitals to develop community living skills needed for successful community reintegration upon release 3) facilitation of skills and provision of structured programs to enable the person to function at his/her highest level within their current environment since discharge may be delayed or not possible, depending on the nature of the crime 4) restoration of competency to stand trial in forensic psychiatry settings
Outpatient/ambulatory care
-An individual who does not require hospitalization but has functional deficits requiring evaluation and intervention may receive OT services on an outpatient basis in private clinics, medical offices, and/or hospital satellite centers
-Focus of outpatient care is diagnostic evaluation, interventions to increase functional performance, consumer education, and prevention
Community-based practice settings – early intervention programs
-Acceptance criteria for an early intervention evaluation are based on “at risk” status of the infant or toddler who is under the age of three: 1) birth complications 2) suspected delays in development 3) failure to thrive 4) maternal substance abuse during pregnancy 5) birth to an adolescent/teen mother 6) established disability/diagnosis
-Acceptance criteria for early intervention services are based on the following criteria: 1) the extent of the developmental delay (typically a 33% delay in one area of development or a 25% delay in two areas) 2) an established diagnosis/disability
-Length of service provision: 1) if the infant/child qualifies for services, an infant family service plan is completed by the service coordinator after a review of all assessments and in collaboration with the family and early intervention team 2) six month reviews are submitted by all professionals to determine if services should continue
-Occupational therapy evaluation: 1) assessment of five developmental areas (cognitive; physical; communication; social-emotional; adaptive) 2) determination of the effects of current development on the occupational areas of play and activities of daily living 3) evaluations need to be written in a strength-oriented manner 4) functional goals must be written in family friendly terms and include levels of functioning, unique needs, and recommended services
-Occupational therapy intervention process: 1) development of cognitive/process, psychosocial/communication/interaction, and sensorimotor skills 2) development of play and activities of daily living skills 3) provision of family education 4) provision of advocacy and advocacy training 5) transition planning from early intervention to preschool is essential
Community-based practice settings – schools
-Acceptance criteria for OT services as related service in an educational setting: 1) the child requires special education services, and OT will enable the child to benefit from special education 2) OT will facilitate the child’s participation in educational activities and enhance the child’s functional performance 3) referrals are received from the previous agency that provided early intervention services, the child’s teacher, and/or school’s child study team 4) the school reviews the referral and, if indicated, recommends an OT evaluation (if an OT evaluation has already been completed, the need for OT intervention services is discussed; the frequency, length of sessions, and duration of the intervention are also determined)
-Length of services is dependent upon the impact of OT services on the child’s abilities and prevention of loss of abilities: 1) if OT services can improve the child’s ability to participate in education-related activities and allow full access to the general education curriculum, services can be continued 2) a review of services and progress made towards the child’s individualized education plan (IEP) is conducted on an annual basis
-OT evaluation: 1) assess client factors, performance skills and patterns and areas of occupation, that impact on the educational and functional performance of the child within the school (findings are used to contribute to the IEP, in which goals and objectives are formulated to address the overall educational needs of the students) 2) assess the child’s functional and developmental level to contribute to the Functional Behavioral Analysis
-OT intervention focus: 1) based on educational model versus a medical model 2) addresses the student’s functional performance along with academic performance 3) activities are utilized to address the goals and objectives documented in the IEP using both corrective and compensatory methods 4) assistive technology and transition services, in accordance with the regulations of IDEA, are provided 5) performance skill deficits and client factors (ie sensorimotor, cognitive/process, and psychosocial/communication/interaction) are treated to improve the child’s ability to participate in and perform education-related activities within a school setting 6) skills in the performance areas of ADL, school, and play are developed to improve the child’s ability to participate in and perform education-related activities within a school setting 7) skills for adult life post-school are developed in accordance with the student’s transition plan
-The OT practitioner needs to know the school district’s and state’s funding source and regulations and interpretations of the federal laws regarding education
-The role of OT practitioners in school-based practice has expanded beyond IDEA education-related services to include programs that address students’ psychosocial needs and prevent school violence: 1) Behavioral Intervention Plans which include Response to Intervention (RtI), Early Intervening Services (EIS), and Positive Behavioral Supports (PBS) may be a component of school-based OT service provision (Response to Intervention (RtI) is an evidence-based, structured intervention approach that uses Early Intervening Services (EIS) to address academic difficulties and Positive Behavioral Supports (PBS) to address behavioral problems early in a child’s education)
Community-based practice settings – Supported education programs
-Participant criteria include adolescents or adults who require intervention to develop skills that are needed to succeed in secondary and/or post-secondary education (the person may have never developed these skills or lost them due to a psychiatric disability or mental health problems)
-Length of stay is determined by agency’s funding and person’s attainment of goals (discharge is upon entry into, or completion of, an educational program or the attainment of a graduate equivalency degree [GED])
-OT evaluation is focused on the individual’s client factors, performance skills and patterns that impact on the occupational role of student
-OT intervention focus: 1) improvement in performance skills and patterns that are needed for the occupational role of student (eg. time management and task prioritization) 2) education and training in compensatory strategies to support academic performance (eg. studying in a quiet room) 3) exploration of participant’s educational interests and aptitudes to ensure self-determined engagement in a school, college, technical training program, or community-based adult-education class(es)
Community-based practice settings – Prevocational programs
-Participant criteria include adolescents or adults who require intervention to develop skills that are prerequisite to work: 1) the person may have never developed these skills due to developmental delays, environmental insufficiencies, illness, or disability 2) the person may have lost these skills due to illness or disability
-Length of stay is determined by agency’s funding and person’s attainment of goals: 1) discharge is usually to a vocational program 2) discharge to a work setting can occur if sufficient abilities are developed
-OT evaluation is focused on the individual’s task skills, social interaction skills, work habits, interests, and aptitudes
-OT intervention focus: 1) improvement in task skills and social skills that is prerequisite to vocational training or work 2) development of work habits and abilities 3) exploration of work interests and aptitudes to ensure discharge to a relevant vocational training program, school, or work setting
Community-based practice settings – Vocational programs
-Acceptance is for the development of specific vocational skills: 1) person has the prerequisite abilities to work (eg. good task skills and work habits) but requires training for a specific job and/or ongoing structure, support and/or supervision to maintain employment 2) person has to develop his/her work capacities to a level acceptable for competitive employment (eg. strength and endurance)
-Length of stay is determined by agency’s funding and attainment of goals: 1) in rehabilitation workshops (formerly called sheltered workshops) and supportive employment programs, discharge is not always a goal (maintenance of the person in these structured work environments can be the desired objective for some individuals while others will be discharged to other programs or to work) 2) transitional employment programs (TEPs) are generally time limited (3-6 months) with discharge to competitive employment, supportive employment, or rehabilitation workshops 3) Employee Assistance Programs (EAPs) provide ongoing support, intervention, and referrals as needed to a company’s employees to enable these individuals to maintain this employment
-OT evaluation is focused on the individual’s functional skills and deficits related to work in his/her current and expected vocational environment
-OT intervention focus: 1) remediation of underlying performance skill deficits and compensation for client factors that affect the work performance area 2) development of general work abilities and specific job skills 3) consultation to and/or supervision of vocational direct care staff 4) identification and implementation of reasonable accommodations in accordance with ADA 5) referral to state offices of vocational and educational services (eg. “One-Stop Centers”) for persons with disabilities for further evaluation, education and training
Community-based practice settings – Residential programs
-Admission for a developmental, medical or psychiatric condition that has resulted in functional deficits that impede independent living but are not severe enough to require hospitalization: 1) residential programs are on a continuum from 24 hour supervised quarter way houses, halfway houses, or group homes, to supportive apartments with weekly or biweekly “check-in” supervision 2) the degree of functional impairment determines the residential level of care needed
-Length of stay for transitional living programs (eg. quarter way and halfway houses programs) is determined by agency’s funding (long-term and permanent housing options [ie group homes and supportive apartments] are available and are funded through the individual’s social service benefits)
-OT evaluation is focused on assessment of the individual’s skills for living in the community and determination of the social and environmental resources and supports needed to maintain the individual in his/her current and expected living environment
-OT intervention focus: 1) consultation to and/or supervision of residential program staff 2) remediation of underlying performance skill deficits and compensation for client factors that affect independent living skills 3) ADL training, activity adaptation, and environmental modifications to facilitate community living skills 4) referral to appropriate residential services along the continuum of care as individual’s functional level improves 5) education about ADA, the Fair Housing Act, and Section 8 Housing
Community-based practice settings – Partial hospitalization/day hospital programs
-Admission is for a medical or psychiatric condition that has been sufficiently stabilized to enable an individual to be discharged home or to a community residence (eg. halfway house or supported apartment); however, the individual still has symptoms remaining which require active treatment
-Treatment is up to 5 days per week with multiple interventions scheduled each day
-Length of stay (LOS) is determined by diagnosis, presenting symptoms, and response to treatment: 1) LOS can vary from 1 week to 6 months 2) documentation requirements supporting the need for an extended LOS are dependent upon institutional, state, and/or third party payer guidelines 3) once LOS is expended, discharge is usually to a less intensive community day program
-OT evaluation is focused on the individual’s functional skills and deficits in his/her performance areas and the occupational roles that are required in his/er current and expected environments
-OT intervention focus: 1) functional improvement in areas of occupation and occupational role functioning 2) remediation of underlying performance skill deficit and compensation for client factors that affect functional performance 3) development of skills for community living and identification of community supports for community integration
Community-based practice settings – Clubhouse programs
-Membership is open to adults and elders with a current mental illness or a history of mental illness: 1) all members have equal access to all clubhouse functions and opportunities regardless of functional level or diagnosis 2) individuals who pose a significant and direct threat to the safety of the clubhouse community are the only persons excluded
-Services are provided by staff and members with the responsibilities of operating the clubhouse shared equally by staff and members under the oversight of a director: 1) due to his role equality, it can be difficult to distinguish between members and paid staff 2) staff’s main role is to engage membership and provide needed support and structure
-Individual schedules will vary to meet each person’s unique needs and interests: 1) clubhouses are open at least 5 days per week. Many are open 7 days per week 2) the daily schedule is organized around the “work-ordered” day, which parallels typical working hours to engage members and staff in the running of the clubhouse 3) evening and weekend schedules are focused on avocational interests and recreational pursuits 4) additional services that can be provided include literacy and education programs, transitional employment placements, independent employment assistance, community support and outreach services, housing programs, and legal and financial advisement
-Length of stay is indefinite and members can exit and re-enter a clubhouse community at will
-OT evaluation and intervention is not provided in a formalized manner (the role of the OT is integrated into the clubhouse model which has staff acting as generalists who contribute to the development and enrichment of members’ abilities
Community-based practice settings – Adult day care
-Admission is for adults and elders with chronic physical and/or psychosocial impairments, and/or for individuals who are frail but semi-independent
-Services are provided in a congregate or group setting
-Individual schedules will vary: 1) flexibility in scheduling is provided to address daily caregiver needs and allow for planned respite 2) schedules can range from one afternoon per week to 5 full days
-Length of stay is indefinite (ongoing services are provided to individuals with chronic conditions who might otherwise be institutionalized or to individuals who are frail and need ongoing support (eg. cooked meals, socialization opportunities)
-OT evaluation is focused on the individual’s functional skills and deficits in the areas of occupation, his/her home environment, and the adult day center’s environment
-OT intervention focus: 1) maintenance of the healthy, functional aspects of the individual and facilitation of adaptation of impairments 2) engagement in purposeful activities that provide appropriate stimulation, reflect lifelong interests, develop new interests, and foster a sense of community with other participants 3) caregiver education, support groups, home visits, consultations, and referrals to community resources 4) modifications to the day care center’s environment and the individual’s home environment to maximize the person’s comfort in, and mastery and control of, these environments
Community-based practice settings – Outpatient/ambulatory care
-Admission is for a medical or psychiatric condition that is not serious enough to warrant hospitalization or for a condition that has sufficiently stabilized to enable the individual to be discharged from a hospital but remaining symptoms require active treatment
-Treatment is usually provided in short 30-60 minute sessions once a day for up to 5 days a week
-Length of stay is determined by diagnosis, presenting symptoms, response to treatment, and insurance coverage or ability to pay a fee for service
-OT evaluation focused on the individual’s client factors and functional assets and deficits in his/her performance skills and patterns, areas of occupation, and his/her home, work and leisure environments
-OT intervention focus: 1) active engagement of the client in the treatment planning, implementation, re-evaluation, and discharge process 2) remediation of underlying performance skill deficits that affect functional occupational performance 3) functional improvements in performance areas and occupational roles 4) compensatory strategies for remaining performance skill deficits and client factors 5) consumer, family, and caregiver education
Community-based practice settings – Home health care
-Acceptance criteria for home health services: 1) presence of a medical or psychiatric condition that is not serious enough to warrant hospitalization or for a condition that has sufficiently stabilized to enable the individual to be discharged from a hospital but that still has remaining symptoms requiring active treatment 2) reimbursers can have strict and variable criteria for qualifying for home health care
-Treatment is usually provided in 60 minute sessions, once a day for up to 5 days a week, as determined by insurance coverage
-Length of stay is determined by diagnosis, presenting symptoms, response to treatment, insurance coverage, or ability to pay a fee for service
-OT evaluation is focused on the individual’s client factors and functional skills and deficits in his/her performance skills and patterns, areas of occupation, and the occupational roles that are required in the current and expected environment(s)
-OT intervention focus:1) active engagement of the client, family, and caregivers in the treatment planning, implementation, and re-evaluation process 2) functional improvement in areas of occupational role functioning within the home 3) remediation of underlying performance skill deficits and compensation for client factors that affect functional performance within the home 4) education of the family, caregivers, and/or home health aides to provide appropriate care and/or assistance as needed 5) environmental modifications and activity adaptations that maintain optimal functioning and improve quality of life 6) increasing ability to resume occupational roles outside of the home 7) prevention of hospitalization and avoidance or delay of residential institutional placement
Community-based practice settings – Hospice
-Acceptance criteria for hospice services: terminal illness that has a life expectancy of 6 months or less
-Services are most often provided in the home with the type and quantity of services determined by the needs of the individual, his/her family, significant others, and caregivers (hospice services may also be provided in an independent facility or in a special unit of a SNF or a hospital)
-Length of stay is determined by the person’s terminal outcome
-OT evaluation is focused on determining the individual’s occupational functioning and his/her physical, psychosocial, spiritual, and environmental needs that are most important to him/her
-OT intervention focus: 1) maintenance of the individual’s control over his/her life 2) facilitation of engagement in meaningful occupations and purposeful activities that are consistent with the individual’s roles, values, choices, interests, aspirations, abilities, and hopes and that contribute to a satisfactory quality of life 3) reduction or removal of distressing symptoms and pain 4) environmental modifications and activity adaptations that maintain optimal functioning and improve quality of life 5) caregiver and family education and support to maintain optimal functioning and improve quality of life for all
Community-based practice settings – Case management programs
-There are two different focuses to case management programs: one is clinical, one is administrative
-Clinical case management provides individualized support and intervention to a client with a serious illness which significantly limits his/her ability to access and/or engage in existing community services and/or therapeutic programs, ensuring that the person is able to remain in the community and not be re-hospitalized
-Administrative case management connects a person with a serious illness to the appropriate and needed community services and/or therapeutic programs, overseeing this service provision to ensure that quality of care in a cost-effective manner is achieved
-Services can be provided in an office and/or in the individual’s home and community
-Length of stay is determined by the individual’s ability to independently access needed services and by funding availability
-OT evaluation is focused on the individual’s client factors and functional skills and patterns, areas of occupation, and the occupational roles that are required in his/her current expected environment (assessment of the individual’s supports and barriers for community integration is critical)
-Case management interventions can be purely referral-based in the administrative model or encompass the full range of interventions in the clinical model (eg. one-on-one counseling, family education, ADL training, community re-entry, etc): 1) both models aim to prevent regression and re-hospitalization and promote optimal functioning and quality of life 2) both models actively engage the individual and family in treatment planning, implementation, and the re-evaluation process 3) both models plan discharge, if appropriate, to an environment that will best serve an individual’s needs
Community-based practice settings – Wellness and prevention program
-Acceptance is most often by individual’s self-referral to meet a personal need or by an institution’s provision of a program to its members or employees (eg. a parenting skills class for pregnant teens in a school)
-Programs have been developed to serve populations considered at risk and are held in offices or individual’s residences and/or at community sites
-Length of stay is determined by the individual. It is usually influenced by program’s planned length (eg. a six-week joint protection program) or by individual’s achievement of a desired outcome (eg. smoking cessation)
-OT evaluation focuses on risk factors for illnesses and disabilities and the individual’s functional skills and deficits in the occupational roles that are required in his/her current and expected environment
-OT intervention focus: 1) disease prevention and health promotion 2) interventions can range from the traditional domain of OT (eg. home safety and environmental modifications), to contemporary areas of concern (eg. stress management, life coaching)
Private/Independent practice
-In any and all community and institutional settings, the OT practitioner can work in an entrepreneurial manner by negotiating a fee for service agreement and/or a long term contract
-Private practitioners can also open their own free-standing clinics
-A provider number is required for a private practitioner to receive third-party payment
-Private practitioners must abide by all state and third party payer regulations for evaluation, intervention, and documentation
Management principles, functions, and strategies
-Management that has a positive attitude about change and innovation fosters best practice
-Successful management supports open communication, team building, decentralization of resources, and the sharing of power
-Management that utilizes strategic thinking in a systems model can respond proactively to market demands and changes
-The use of different management styles (ie. the manager’s characteristic way of performing management tasks) has a significant impact on productivity, change and growth
-Management’s understanding and application of theories of motivation and behavior facilitates appropriate and effective responses to situations, fosters program efficacy, and promotes employee satisfaction
-Administrative functions of management include program development, fiscal and personnel management, and program evaluation
-Management by Objective (MBO): a complete system of management based upon a core set of goals to be accomplished by a program – 1) mission and goals are established 2) measurable objectives are quantified 3) specific time frames for accomplishment of objectives are established 4) staff training needs and deterrents to progress are identified 5) program evaluation is instituted
Program development – purposes of developing specific programs
-To directly meet the needs of a specific population(s) or group(s)
-To clearly focus evaluation and intervention efforts and activities
-To increase visibility and use of available services (eg. offering an outpatient cardiac rehabilitation program is more visible than individual referrals, resulting in increased recognition and utilization of this service)
-To convert an idea into a practice reality
Program development – Four basic steps of program development
-Needs assessment
-Program planning
-Program implementation
-Program evaluation
Program development – Four basic steps of program development – Needs assessment
-Describe the community; its physical, social, cultural and economic factors; and populations at risk
-Describe the target populations demographics, disorder(s), functional level(s), and presenting problem(s)
-Identify specific needs of target population: 1) perceived needs of the population as reported by others (eg. family, physicians, other professionals) 2) felt needs as stated by the individual members of the target population 3) real needs, which are the actual disabilities and functional limitations of the target population
-Determine discrepancy between real needs and felt needs -Establish unmet needs according to priority
-Identify resources available for program implementation: 1) formal or institutional resources such as staff, supplies, money, space 2) informal resources such as family, friends, cultural or religious figures, self-help/consumer groups
-Needs assessment methods: 1) survey, interview, or self report of target population. A representative sample is required 2) key informant, which involves the surveying of specific individuals who are knowledgeable about the target population needs 3) community forums to obtain information through public meetings or panels 4) service utilization reviews of records and reports 5) analysis of social indicators to identify social, cultural, environmental, and/or economic factors that can predict problems
Program development – Four basic steps of program development – Program planning
-Define a focus for the program based on the needs assessment results: 1) problem areas, functional limitations, and unmet needs that are relevant to the majority of the target population are the priority focus 2) program level of difficulty as determined by the range of population’s functional levels and the level required by the current and expected environment
-Adopt a frame or frames of reference that are most likely to successfully address and meet the needs that are program’s focus
-Establish objectives and goals of the program specifically related to primary focus: 1) individual goals which will be met by the program are set 2) programmatic goals which establish standards for program evaluation are determined
-Describe integration of program into existing system of care: 1) establish realistic timetable for program implementation 2) define staff roles, responsibilities, and assignments 3) identify methods for professional collaboration 4) determine the physical setting and space requirements 5) consider potential barriers to program implementation 6) develop methods to effectively deal with identified obstacles before program implementation
-Develop a system of referral for entry into, completion of, and discharge from the program: 1) evaluation protocols to standardize information to be obtained from each person referred to the program and to assess the type of program services needed 2) criteria for acceptance into the program and for movement through program levels 3) discharge criteria to determine when an individual has achieved maximum gain from the program, usually defined as the achievement of program goals
-Describe the fiscal implications of program plan: 1) determine projected volume or service demand to estimate revenue 2) identify resource utilization and projected expenses to estimate costs 3) directly compare estimated revenue and estimated expenses to determine financial viability of program
Program development – Four basic steps of program development – Program implementation
-Initiate program according to timetable and steps set forth in the program plan
-Document program activities, procedures, and use
-Communicate and coordinate with other programs within the system
-Promote program to ensure it reaches target population
Fiscal management – purpose of fiscal management
-To ensure cost-effective services and programs are planned and implemented
-To meet the demands of a managed health care system
-To remain competitive in a market-driven practice environment
Fiscal management – Major fiscal management tasks
-Develop revenue and volume projections
-Use cost-effective charging procedures and fee structures
-Manage payroll and staffing budgets
-Schedule staff in a cost-effective manner that meets productivity standards
-Plan for short and long term program needs including capital expenses
-Manage general, administrative, and operating expenses
-Meet organization’s revenue expectations
Fiscal management – Budget terms and concepts
-A budget financially projects, for a specified time period, the costs of managing a program and the anticipated revenue from service provision
-Budget periods vary from multi-year (5-10 years) for capital expenses to annual for personnel and supply expenses
-Budget revisions may be needed as program(s) or service(s) change due to ongoing program evaluation
Fiscal management – Budget terms and concepts – Capital expense budgets
-Permanent or long term purchases such as an ADL kitchen or for new facilities, such as a new wing for a work hardening program
-Typically any item or action above a fixed amount (eg. $500.00) is considered a capital expense
-Capital items are separated from other expenses due to depreciation of value and possible tax credits for purchases and investments
Fiscal management – Budget terms and concepts – Operating expense budgets
-The daily financial activity of a program or service
-Information on revenue, volume, and direct and indirect expenses: 1) direct expenses include costs related to OT service provision, such as salaries and benefits (eg. vacation and sick time), office supplies (eg. pen, paper), and treatment equipment (eg. ADL materials) 2) indirect expenses include costs shared by the setting as a whole such as utilities, housekeeping, and marketing 3) fixed expenses remain at the same level even when there are changes in the amount of services (eg. rent) 4) variable expenses change in direct proportion to the amount of services provided (eg. splinting materials)
Fiscal management – Budget terms and concepts – Full-time equivalent (FTE)
-The amount of time a full-time staff employee works; in the US, 8 hours/day, 5 days/week
-A budget formula used to determine the number of personnel providing direct care: 1) two practitioners who do administrative tasks half of the day and direct care half of the day would equal one FTE 2) three part-time employees would equal 1.5 FTEs
Fiscal management – Budget terms and concepts – Productivity standards
-Establishes the amount of direct care and reimbursable service(s) each therapist is to provide per day
-Managed care pressures have increased productivity expectations in some practice areas resulting in ethical dilemmas and/or ethical distress
Fiscal management – Budget terms and concepts – Break-even analysis
-Also called cost-volume-profit analysis
-Determines the volume of services needed to be provided for revenues to equal cost and profits to equal zero
Fiscal management – Budget terms and concepts – Accounts payable
-The debts within a budget
-Indicates payments that are due for purchases or services rendered (eg. to an equipment supplier, a landlord)
Fiscal management – Budget terms and concepts – Accounts receivable
-The assets within a budget
-Indicates payments that are owed to the program, setting, or institution (eg. consultation fees)
Personnel management
-The oversight of OT practitioners and support personnel and the services they provide
-Purposes of personnel management: 1) to serve as the link between the individuals working for an organization and the larger organizational structure 2) to attain best practice from personnel
Personnel management – Major personnel management tasks
-Design work roles and write job descriptions
-Recruit, select, and orient personnel to perform the roles
-Supervise and evaluate personnel to ensure adequate role performance and the attainment of organizational goals
-Support personnel’s ongoing professional development
-Deal with difficult personnel issues as they arise
Personnel management – Job description
-A statement of the job’s expectations, duties, and purpose and its supervisory relationships. It should include:
-Position’s title and department
-Skilled and non-skilled requirements of the job including education, physical demands, and licensure requirements
-Specific responsibilities, duties, and performance standards in detail
-Supervisor(s) and supervisory relationships: decision making authority and degree of autonomy
Personnel management – Recruitment
-The process of determining staffing needs, predicting turnover and vacancies, and identifying and recruiting potential replacements to maintain the staffing levels required to meet program objectives
-Identify the position available and determine its job description
-Attract potential qualified applicants: 1) advertise in trade publications, state and national OT association newsletters and/or on-line 2) network internally within own organization and externally at local, state, and/or national OT meetings and conferences and through established OT contacts 3) conduct open houses, job fairs, and workshop 4) direct mail recruitment information to OT practitioners 5) use placement agencies 6) train and educate fieldwork students
-Screen interested applicants for an interview: 1) review applications and resumes 2) check references
-Interview screened applicants to determine suitability for position: 1) obtain information about relevant experience and career goals 2) verify knowledge and skills 3) use open-ended semi-structured questions to facilitate discussion 4) ask the same question of ever candidate 5) take notes of applicant’s responses 6) questions to the applicant that violate civil rights legislation or ADA should not be asked (age; sexual orientation; marital status or family composition; race or national origin, religion, or political beliefs; physical, mental or cognitive disabilities) 7) share information about the position’s salary, benefits, work hours, job description, and advantages and limitations of the organization
-Make job offer: 1) contact selected applicant to offer position 2) upon applicant’s acceptance of position, confirm terms of employment, starting date, salary, and licensure requirements
Personnel management – Orientation of staff
-The process of providing specific information to a new employee to increase the ease and effectiveness of his/her transition into his/her new position
-Introduce key coworkers, managers, and department heads
-Provide specific information about the organization’s and department’s mission, policies, and procedures
-Distribute manuals, checklists and/or handouts with recommended standards on how to perform required tasks competently
-Tour the facility and department to learn locations of resources, support services, equipment, and materials
Personnel management – Performance evaluation/appraisal
-The process of evaluating staff performance according to established performance expectations
-Steps in performance appraisal: 1) articulate specific and clear expectations for performance 2) document positive performance to substantiate quality care and to support recommendations for merit pay, raises, bonuses, and/or promotions 3) document substandard performance to identify areas requiring quality improvement, further training, increased supervision, and/or disciplinary action 4) meet privately with employee to discuss written performance appraisal, allow employee feedback, and develop a plan for remediation, if needed, and a plan for ongoing professional development
Personnel management – Disciplinary action
-The process of informing an employee that his/her job performance is unacceptable, the organization’s procedures for an administrative review of disciplinary actions and the organization’s employee grievance procedures
-Criteria for fair disciplinary action: 1) written documentation of problem behaviors and expectations for improvement 2) referral to counseling and/or other services needed to improve performance 3) clear and documented warnings of consequences for unremediated behavior 4) consequences that are impersonal, immediate, and consistent 5) continuous documented monitoring of employee’s behavior until the employee achieves satisfactory job performance, resigns voluntarily, or is terminated
Personnel management – Retention and motivation of staff
-The process of identifying understanding, and meeting employees’ needs, expectations, and desired rewards
Personnel management – Motivating job characteristics
-A fair and competitive salary and benefits package
-Job security, realistic performance expectations, and fair employment policies
-A good working environment with a relaxed, friendly atmosphere, adequate physical space, and sufficient current equipment and supplies
-Challenging, satisfying work and diverse caseloads
-Competent supervision with adequate feedback on job performance
-Active mentorship and support for professional development
-Tuition reimbursement and financial support for conferences, workshops, and /or post-professional education
Personnel management – Staff development steps
-Assess employees’ development needs and interests
-Assess organization’s strategic plan to identify existing and new areas planned for OT service that may require staff training
-Provide mentorship and supervision
-Provide educational in-services, workshops, and practical on-site experiences
-Support self-directed learning, such as journal reviews, self-study courses, on-line networking, teleconferencing, off-sire workshops, and/or post-professional education
Program evaluation and quality improvement
-The systematic review and analysis of care provided to determine if this care is at an acceptable level of quality
Program evaluation and quality improvement – Purposes of program evaluation
-To measure the effectiveness of a program; that is, were program goals accomplished
-To use information obtained in the evaluation to improve services and assure quality
-To meet external accreditation standards
-To identify program problems/limitations and to resolve them
Program evaluation and quality improvement – Major types and terms: Continuous quality improvement (CQI)
-A system-oriented approach that views limitations and problems proactively as opportunities to increase quality
-Prevention is emphasized
-Blame is not attributed to persons; problems are related to organizational improvement needs
Program evaluation and quality improvement – Major types and terms: Total quality management (TQM)
-The creation of an organizational culture that enables all employees to contribute to an environment of continuous improvement to meet or exceed consumer needs
Program evaluation and quality improvement – Major types and terms: Performance assessment and improvement (PAI)
-A systematic method to evaluate the appropriateness and quality of services
-Utilization of an interdisciplinary systems focus
-A client-centered approach which focuses on the rights, assessment, care, and education of the person
-Organizational ethics, improved organizational performance, leadership and management are emphasized
Program evaluation and quality improvement – Major types and terms: Utilization review
-A plan to review the use of resources within a facility
-Determination of medical necessity and cost efficiency
-Often a component of a CQI or PAI system
Program evaluation and quality improvement – Major types and terms: Statistical utilization review
-Reimbursement claims data are analyzed to determine the most efficient and cost-effective care
Program evaluation and quality improvement – Major types and terms: Peer review
-A system in which the quality of work of a group of health professionals is reviewed by their peers
Program evaluation and quality improvement – Major types and terms: Professional review organization (PRO)
-Groups of peers who evaluate the appropriateness of services and quality of care under reimbursement and/or state licensure requirements
Program evaluation and quality improvement – Major types and terms: Prospective review
-Evaluation of proposed intervention plan that specifies how and why care will be provided
-Used by third party payers to approve proposed occupational therapy intervention program
Program evaluation and quality improvement – Major types and terms: Concurrent review
-Evaluation of ongoing intervention program during hospitalization, outpatient, or home care treatment
-Method to ensure appropriate care is being delivered
-Often a component of a CQI or PAI system
Program evaluation and quality improvement – Major types and terms: Retrospective review
-Audits of medical records after intervention were rendered
-Method to ensure appropriate care was given
-A UR tool for third party payers that can be time consuming and costly
Program evaluation and quality improvement – Major types and terms: Risk management
-A process that identifies, evaluates, and takes corrective action against risk and plans, organizes and controls the activities and resources of OT services to decrease actual or potential losses
-Potential risks are client or employee injury and property loss or damage with resulting liability and financial loss
-OTs are responsible to ensure proper maintenance of equipment and a safe treatment environment
-Staff education and training (eg. annual certification/recertification in CPR) is required
-Effective communication with consumers (eg. informed consent) and with team members is required
-Risk management is an integral part of program evaluation
-If risk management fails and an incident occurs, completion of an incident report according to setting’s standards is required
Methods of program evaluation
-Describe program objectives and goals to determine program outcome criteria
-Identify measurable indicators based on objectives and goals
-Describe population, staff, services provided, intervention methods, scope of care, and length of treatment
-Design an evaluation study
-Select methods to collect data: 1) direct observation and/or review of client charts 2) safety checklists, incident reports, and/or client/family complaints 3) surveys of clients, families and/or staff 4) review of treatment sessions and missed treatments 5) initial, discharge, and follow-up assessments 6) review of statistics on costs and service volume
-Collect and organize data
-Evaluate and analyze results and limitations of the study
-Report results, highlighting information to determine program’s efficacy
-Use results to initiate appropriate program actions: 1) continue and/or expand programs that have demonstrated good efficacy/positive outcomes 2) change or modify programs that have demonstrated limited efficacy/satisfactory outcomes 3) discontinue programs that have demonstrated poor efficacy/unsatisfactory outcomes
-Evaluate effectiveness of actions
Marketing/Promotion
-A managerial process that analyzes consumer need(s), plans and designs a service or product to meet the identified market need(s), and implements strategies and actions to promote consumer use of the service or product
Marketing/Promotion – Major marketing tasks
-Analyze market opportunities: 1) conduct a self audit to assess the strengths and weaknesses of oneself and/or one’s organization 2) conduct a consumer analysis to determine consumer need(s) and desire(s) for services or products 3) Identify potential competitors to clarify areas of service overlap/product similarity and to identify areas that are underserved or unserved 4) assess the environment to determine political, sociocultural, economic, and/or demographic factors that may impact on product(s) or service(s)
-Analyze the market to be targeted for purchase of product(s) or service(s): 1) research selected target market(s) to determine validity of perceived market needs and wants 2) divide market into segments to identify groups of consumers with similar characteristics, interests, and needs that will influence their purchase of the product(s) or service(s)
-Develop marketing strategies to address the 5 P’s (product, price, place, promotion, and position) of a market plan for the OT service: 1) product – the service or thing that is being offered to the market (eg. a work hardening program, adaptive equipment) 2) price – the financial, physical, and psychological cost of doing business 3) place – the distribution method for getting a product or service to the target market for providing the target market with access to the product or service 4) promotion – all efforts to communicate information about the product or service to the target market or market segment that makes the product or service visible and desirable 5) position – the place the product or service holds in relation to similar products or services available
-Implement and evaluate the marketing plan: 1) the implementation and evaluation of marketing efforts must always consider ethics (ie. truth in advertising) 2) undifferentiated marketing – the use of the same marketing strategies and activities with the complete market (eg. promoting the OT profession to the general public) 3) differentiated marketing – the design and use of marketing strategies and activities for different market segments (eg. promoting OT specialties to different consumer self-help groups) 4) concentrated marketing – the design and use of specific marketing strategies and activities to concentrate on one market segment (eg. the elderly) 5) ongoing assessment and periodic review is needed to determine market plan’s effectiveness and to modify, as needed
Marketing/Promotion – Methods
-Marketing instruments that can be employed to address the 5 P’s include: 1) advertising and publicity release 2) sales promotions, discounts, and bonuses 3) personal contact welling and networking 4) work of mouth recommendations
Fieldwork eductation
-A key service management function is to develop, implement, and support clinical fieldwork education for OT and OTA students
-ACOTE guidelines for Level I and Level II fieldwork education are to be followed
-Fieldwork education managerial tasks: 1) collaboration with the academic education program to develop specific fieldwork learning objectives and activities consistent with the facility’s and school’s philosophies and missions 2) development of professional development plans and activities for the students’ clinical supervisors to ensure adequate fieldwork supervision 3) establishment of departmental policies and procedures for a student program and its supervision 4) assurance of quality of care provided by student(s) according to established program standards and professional ethics 5) evaluation and supervision of students’ performance and completion of ACOTE’s evaluation tool 6) completion of cost-benefit analysis to collect data for institutional support of clinical education
Purpose of research
-Critical evaluation and consumption of research literature enhances one’s theoretical and philosophical foundations, improves clinical reasoning and critical thinking, increases professional knowledge and skills, and facilitates evidence-based decision-making
-Application of research literature ensures practice is current, meaningful, and competent which ultimately improves the quality of life of individuals receiving OT services
-Knowledge of research provides opportunities to address questions that arise daily in professional practice
-The development and implementation of research projects that test and establish the efficacy of OT evaluation and intervention is essential to the provision of evidence-based practice (EBP): 1) establishment of the relevance and efficacy of OT can influence public health, social and educational policy, thereby impacting on the delivery of OT services 2) recent legislation (eg IDEA 2004 and No Child Left Behind) place increase emphasis on the provision of EBP
-Acquisition of scientific knowledge can provide answers to practice questions and help solve problems encountered in practice
-Development of a body of professional research contributes to the science of a professional and provides a body of knowledge to guide practitioners
-Participation in research to evaluate program outcomes is a requirement of most practice settings and accrediting bodies
Quantitative Methodology/Design Types – True experimental
-The classic two-group design which includes random selection and assignment into an experimental group that receives treatment or a control group that receives no treatment. All other experiences are kept similar
-The two levels of treatment (some and none) together constitute the independent variable being manipulated
-The comparison of their status on some variable (ie. outcome) that might be influenced by treatment constitutes the dependent variable
-A cause and effect relationship between the independent and dependent variable is examined
-In human subject research, it is often difficult to design pure experimental designs
Quantitative Methodology/Design Types – Quasi-experimental
-An independent variable is manipulated to determine its effect on a dependent variable but there is a lesser degree of researcher control and/or no randomization
-Used often in health care research in which it is unethical to control or withhold treatment
-Used to study intact groups created by events or natural processes
Quantitative Methodology/Design Types – Non-experimental/correlational
-There is no manipulation of independent variable; randomization and researcher control are not possible
-Used to study the potential relationship between two or more existing variables (eg. attendance at a day program and social interaction skills)
-Describes relationships, predicts relationships among variables without active manipulation of variables
-Limitations: 1) cannot establish cause and effect relationships; limits interpretation of results 2) may fail to consider all variables that enter into a relationship
-Degree of relationship is expressed as correlational coefficient, ranging from -1.00 and +1.00
-Examples of correlational research: 1) retrospective – investigation of data collected in the past 2) prospective – recording and investigation of present data 3) descriptive – investigation of several variables at once; determines existing relationship among variables 4) predictive – used to develop predictive models
-Can be “ex post facto” (after the fact) research because variables may be studies after their occurrence (eg. post-diagnosis adjustment)
Qualitative Methodology/Design Types –
-A form of descriptive research that studies people, individually or collectively, in their natural social and cultural context
-A systematic, subjective approach to describe real-life experiences and give them meaning
-It is rich in verbal descriptions of people and phenomena based on direct observation in naturalistic settings
-The process of the study is considered as important as the specific outcome data
-Types of qualitative research: 1) phenomenological 2) ethnographic 3) heuristic 4) case study
Qualitative Methodology/Design Types – Phenomenological
-A study of one or more persons and how they make sense of their experience
-Minimal interpretations by the investigator
-Meanings can only be ascribed by participants
Qualitative Methodology/Design Types – Ethnographic
-Patterns and characteristics of a cultural group, including values, roles, beliefs, and normative practices, are intensely studied
-Extensive field observations, interviews, participant observation, examination of literature and materials, and cultural immersion are used
-Used in health care to understand an insider’s perspective to develop meaningful services (eg. a study of a nursing home)
Qualitative Methodology/Design Types – Heuristic
-Complete involvement of the researcher in the experience of the subject(s) to understand and interpret a phenomenon
-Aim is to understand human experience and its meaning
-Meanings can only be understood if personally experienced
Qualitative Methodology/Design Types – Case study
-A single subject or a group of subjects is investigated in an in-depth manner
-Purpose can be description, interpretation, or evaluation
-This method is easy to use in most practice settings
Essentials of the research process
-Formulation of a philosophical foundation to reflect researcher’s view of, and assumptions about, learning, human behavior, and other phenomena related to health and human services
-Identification of a broad issue, topic or problem of interest and relevance that warrants scientific investigation
-Review and synthesis of research literature related to identified area of interest
-Utilization of a theoretical base to frame the research problem or area of concern to ensure that the resulting research contributes to, or build upon, theory
-Development of a specific question or focus for research (in quantitative/experimental research this is very specific, detailing the exact variables to be studied; in qualitative/naturalistic research, this is a broad question called a “query” that will develop specificity over the course of the study)
-Selection of a research design (in quantitative/experimental research, the design is highly standardized; in qualitative/naturalistic research, the design is more fluid)
-Formulation of methodology
-Determination of study’s length
-Identification of study’s participants/population sample
-Collection of data using established principles for collecting research information
-Methods of data collection (observation; interview; written questionnaire; survey instruments; artifact and record review; hardware instrumentation; tests and assessments)
-Analysis and interpretation of data using descriptive statistics (measures of central tendency; measures of variability)
-Analysis and interpretation of data using inferential statistics (standard error of measurement; tests of significance; parametric statistics; nonparametric statistics; correlational statistics)
-Report and dissemination of research findings (results section, conclusion section, summary)
Review and synthesis of research literature related to identified area of interest
-Conduct a comprehensive and systematic literature search: 1) define the parameters and boundaries of the search according to the research question’s main concepts and constructs 2) use databases, indices, and abstracts along with the support of a reference librarian 3) organize literature obtained according to relevance and concepts and take notes to summarize content 4) critically evaluate literature reviewed 5) recognize that the literature may need to be re-visited and/or re-searched as the study progresses and/or when its results are analyzed
-Critique of published research: 1) analyze the purpose, relevance, and meaningfulness of the study 2) assess the comprehensiveness of the study’s literature review 3) examine the congruence between the purpose, literature, methodology, findings, and conclusions 4) assess the adequacy of the research procedures to address the study’s question or focus 5) analyze the comprehensiveness of data analyses, interpretation, conclusions, and limitations
Identification of study’s participants/population sample
-Based on literature review, the study’s hypothesis and goals, determine a target population’s desired characteristics
-Describe criteria for selecting a sample of the population to be study’s participants
-Determine sampling method: 1) random – individuals are selected through the use of a table of random numbers 2) systematic – individuals are selected from a population list by taking individuals at specified intervals (eg. every 10th name) 3) stratified – individuals are selected from a population’s identified subgroups based on some pre-determined characteristic (eg. by diagnosis) that correlates with the study 4) purposive – individuals are purposefully and deliberately selected for a study (eg. all consumers of a program for a CQI study) 5) convenience – individuals are selected who meet population criteria based upon availability to the researcher 6) network/snowball – study subjects provide names of other individuals who can meet study criteria
-Obtain informed consent from all participants
Collection of data
-Information obtained must be relevant and sufficient to answer the specific research question or query
-The method of data collection selected must be realistic given the practical limitations of the researcher, the type of research design, and the nature of the research problem
-Use of a combination of data collection methods can be useful and more fulling answer a research question or query
Methods of data collection
-Methods range along a continuum from unstructured observations to highly structured, fixed choice questionnaires
-Most methods are used in both qualitative and quantitative research
-Most methods are used in conjunction with other data collection techniques
Methods of data collection – Observations
-In quantitative research, observations are structured and formalized
-In qualitative research, observations are unstructured and ever-changing according to the contexts and results of the observations
-Observations may be made of nonhuman objects, such as equipment, or human subjects during actual performance or via videotapes
Methods of data collection – Interview
-Used to gather information in ethnographic and survey research
-In survey research, interviews can be face-to-face or by telephone
-In ethnographic research, interviews are always face-to-face
Methods of data collection – Written questionnaires
-In quantitative research, questionnaires must be structured
-In qualitative research, questions may be unstructured
-Distribution may be by mail, e-mail, or in person, with instructions to complete at that moment or at the respondent’s convenience and with directions to return the completed questionnaire to researcher by a specific date
-Surveys are a major type of questionnaire used in research
Methods of data collection – Survey instruments
-Surveys are nonexperimental instruments designed to measure specific characteristics
-Survey questions can be open-ended questions or closed-ended questions: 1) semantic differential – a point scale with opposing adjectives at two extremes, measuring affective meaning 2) Likert scale – respondents indicate their level of agreement, usually on a five point scale 3) Guttman scale rank ordering – the respondent places a number alongside a list of items, indicating their order of importance. Sometimes only 2-3 items are asked for, other times a whole list may be prioritized. It is difficult (and irrelevant) to prioritize more than 10 4) multiple choice – a statement is provided, sometimes in a question format, and the respondent selects the item most reflective of their opinion. Used to elicit opinions or attitudes 5) incomplete sentences – a phrase is provided to indicate a certain domain of concern and the respondent completes the sentence. Used to find out opinions, attitudes, knowledge, styles of behavior, personality traits
-Survey design research typically uses large samples through mail, telephone, or face-to-face contact
-Benefits of survey research: 1) the ability to obtain a large number of participants at a relatively low cost 2) the ability to measure numerous variables with one instrument 3) the ability to use the data obtained in multiple ways through statistical manipulation during data analysis
-Disadvantages to survey research: 1) limited or poor response rate 2) missing or inaccurately completed data 3) most disadvantages to survey research can be minimized with the development and use of a good survey instrument; therefore, it is advisable for all researchers to carefully critique and pilot their survey before its use in a research study
Methods of data collection – Artifact and record review
-Used to gather information in all types of research
-May be the sole data collection method in historical research
-A review of written records can include medical records, publications, letters, and/or minutes of meetings and conferences
-A review of artifacts may include physical items such as personal objects in a person’s home, adaptive equipment and/or audiovisuals
Methods of data collection – Hardware instrumentation
-Mechanical or physical instruments with established reliability and validity that measure independent variables (eg. goniometers)
Methods of data collection – Tests and assessments
-Use to measure independent variables (eg performance components, interests and values)
-Published tests with established reliability and validity are preferred
-If there are no existing tests or assessments available to collect information sought by the research, an instrument can be constructed in accordance with established test construction guidelines
Analysis and interpretation of data using descriptive statistics
-Measures of central tendency: a determination of average or typical scores: 1) mean – the arithmetic average of all scores (the most frequently used measure of central tendency; appropriate for interval or ratio data) 2) median – the midpoint, 50% of scores are above the median and 50% of scores are below; appropriate for ordinal data 3) mode – the most frequently occurring score; appropriate for nominal data
-Measures of variability: a determination of the spread of a group of scores: 1) range – the difference between the highest score and the lowest score 2) standard deviation (SD) – a determination of variability of scores (difference) from the mean (the most frequently used measure of variability; appropriate with interval or ratio data) 3) normal distribution – a symmetrical bell-shaped curve indicating the distribution of scores; the mean, median, and mode are similar (half the scores are above the mean and half the scores are below the mean; most scores are near the mean, approximately 68% of scores fall within +1 or -1 SD of the mean; frequency of scores decreases further from the mean; distribution may be skewed (not symmetrical) rather than normal; scores are extreme, clustered at one end or the other; the mean, median, and mode are different) 4) percentiles and quartiles: describe a score’s position within the distribution, relative to all other scores (percentiles – data is divided in 100 equal parts; position of score is determined; quartiles – data is divided into 4 equal parts and position of score is placed accordingly)
Analysis and interpretation of data using inferential statistics
-Determines how likely the results of a study of a sample can be generalized to the whole population
-Standard error of measurement: an estimate of expected errors in an individual’s score; a measure of response stability or reliability
-Test of significance: an estimation of true differences, not due to chance; a rejection of the null hypothesis 1) alpha level – pre-selected level of statistical significance (most commonly 0.05 or 0.01: indicates that the expected difference is due to chance, eg. at 0.05, only 5 times out of every 100 or a 5% chance, often expressed as a value of P; there are true differences on the measured dependent variable) 2) degrees of freedom: based on number of subjects and number of groups; allows determination of level of significance based on consulting appropriate tables for each statistical test 3) errors: a) standard error – expected chance variation among the means, the result of sampling error b) Type I error – the null hypothesis is rejected by the researcher when it is true eg. the means of scores are concluded to be truly different when the differences are due to change c) Type II error – the null hypothesis is not rejected by the researcher when it is false, eg. the means of scores are concluded to be due to chance when the means are truly different
-Parametric statistics: testing is based on population parameters; includes tests of significance based on interval or ratio data: 1) T test – a parametric test of significance used to compare two group means and identify a difference at a selected probability level (eg. 0.05) 2) Analysis of variance (ANOVA) – a parametric test used to compare two or more treatment groups or conditions at a selected probability level 3) Analysis of covariance (ANCOVA) – a parametric test used to compare two or more treatment groups or conditions while also controlling for the effects of intervening variables (covariates), eg. two groups of subjects are compared on the basis of upper extremity functional reach using two different types of assistive devices; subjects in one group have longer arms than subjects in the second group; arm length then becomes the covariate that must be controlled during statistical analysis
-Non-parametric statistics: testing not based on population parameters; includes test of significance based on ordinal and nominal data 1) used when parametric assumptions cannot be met; less powerful than parametric tests, more difficult to reject the null hypothesis 2) chi square test – a nonparametric test of significance used to compare data in the form of frequency counts occurring in two or more mutually exclusive categories, eg. subjects rate treatment preferences
-Correlational statistics: used to determine relationships between two variables; eg. compare progression of radiologically observed joint destruction in rheumatoid arthritis and its relationship to demographic variables (gender, age), disease severity and exercise frequency 1) Pearson product-moment coefficient (r) – used to correlate interval or ratio data 2) Spearman’s rank correlation coeficient (rs) – a nonparametric test used to correlate ordinal data 3) Intraclass correlation coefficient (ICC) – a reliability coefficient based on an analysis of variance 4) strength of relationships – positive correlations range from 0 to +1.0; indicates as variable X increases, so does variable Y (high correlations – 0.70 to +1.00; moderate correlations – 0.35 to 0.69; low correlations – 0 to 0.34; 0 means no relationship between variables; negative correlations range from -1.0 to 0; indicates as variable X increases, variable Y decreases; an inverse relationship) 5) common variance – a representation of the degree that variation in one variable is attributable to another variable
Report and dissemination of research findings
-Results section: 1) in quantitative/experimental research, report all factual data with no interpretation 2) in quantitative/experimental research report all findings with no bias towards reporting only results supportive of the study’s hypothesis 3) in qualitative/naturalistic research, results, conclusion and interpretations are discussed in an integrated manner (descriptions, illustrative quotations, and brief examples are used; writing format used depends on the qualitative/naturalistic design of the study)
-Conclusion section: 1) interpretation of the results 2) comparison of study’s findings to those presented in the literature review 3 ) analysis of findings supportive and non-supportive of the hypothesis
-Summary: 1) major contributions, practical or theoretical implications that can be drawn from the study 2) brief suggestions for improvements to the study’s design and procedures 3) proposals for new research based on study’s findings
Ethical considerations
-Participants must be provided with full disclosure of study’s purpose, methodology, and the nature and scope of expected participation
-Participants must be informed of any potential risk or discomforts and a plan to remediate risk or discomfort must be developed and provided to participants
-Participation in the study must be voluntary: 1) participant’s right to withdraw from a study must be protected 2) participant’s refusal to answer certain questions and/or participate in a specific procedure must be respected and honored
-Confidentiality of all participants identifying information must be ensured at all times
-Institutional Review Board (IRB) approval must be obtained for all human subject research: 1) IRBs (or Human Subjects Boards) are mandated by the government to be established at all institutions that are involved in research. This includes educational and health care settings 2) IRB approval is required to receive federal (and most other) research grants 3) proposals for research must be submitted to, and approved by, an IRB prior to implementation of the research study 4) IRBs review research proposals to ensure that all ethical standards for research have been considered by the researcher